Central Manchester University Hospitals NHS Foundation Trust Annual Report and Summary Accounts - 1 April 2015 to 31 March 2016

Transcription

1 CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST ANNUAL REPORT AND SUMMARY ACCOUNTS 1 April 2015 to 31 March 2016

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3 Central Manchester University Hospitals NHS Foundation Trust Annual Report and Summary Accounts - 1 April 2015 to 31 March 2016 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006.

4 2016 Central Manchester University Hospitals NHS Foundation Trust

5 Contents Welcome and overview by our Chairman and Chief Executive 6 1 Performance Report Overview of performance Performance analysis Accountability Report Directors Report Remuneration Report Staff Report Activity Reports Sustainability Report Equality Report Research Report Statement of Compliance with NHS Foundation Trust Code of Governance Regulatory ratings Statement of Accounting Officer s responsibilities Annual Governance Statement Quality Report Part One Welcome and Overview Part Two - Statements of Assurance from the Board and Priorities for Improvement Part Three Other information Auditors Report Foreword to the financial statements Summary financial statements

6 Welcome and overview by our Chairman and Chief Executive We are very proud to be able to share with you the highlights of a year when delivering excellent patient care has continued to be at the heart of everything we do. Colleagues across the Trust have worked tirelessly to make sure patients and their families have a good experience in our hospitals and community services. In spite of the financial pressures and increasing demand faced by our Trust and the rest of the NHS, our focus has remained on improving the quality and safety of care across our services, while also increasing efficiency. One way we have been able to do this is by investing in modern, state of the art facilities. Milestones in 2015/16 included the opening of the new 17m Altrincham Hospital in April The purpose-built hospital provides a modern and spacious healthcare environment, and the opportunity to introduce new and extended services for local people. At Manchester Royal Infirmary, the Emergency Department (ED) resuscitation unit was enlarged and refurbished, boosting care for some of the one thousand patients on average who visit the department each day. Work is also underway on a new Mental Health Assessment Room in the ED. The CMFT Charity has made a significant contribution to creating patientfriendly hospitals, enhancing care and funding research. Money raised has paid for arts projects, additional equipment and facilities for patient and their families to use. Our charity team has also raised over 1.7m towards the 3.9m cost of building a helipad to enable the safe and rapid transfer of seriously ill or injured patients to hospital, the first in the city centre. We are very grateful for the 1.1 million from banking fines which the Chancellor, George Osborne, allocated to the appeal in his March 2016 budget. Our Transforming Care for the Future strategy has also gone from strength to strength since its launch in February Staff have embraced the idea of working with colleagues, patient and carers to identify ways to improve quality, leading to a number of major initiatives. For example, October 2015 saw the Embedding the SAFER Standards Week across Manchester Royal Infirmary and Trafford Hospital. These standards are designed to improve patient experience, quality and flow by ensuring Senior review, Assessment, Flow, Early discharge and Regular review. Benefits included improved A&E performance and reduced waiting times, an increase in discharges and fewer patients staying in hospital for 14 days or more when this wasn t necessary. An assessment of our Trust s elective (non-emergency) surgery standards had shown that a number of patients are cancelled on the day of their operation for a variety of reasons. Our Surgery Division launched a rapid improvement initiative called Project PAtTH (Perfect Admission to Theatres) in November and December

7 The key objective was to improve performance, ensure patients are kept safe and that they get their surgery on time, without unnecessary delays or cancellations. The results in terms of fewer cancellations and more patients ready on time for theatre were very encouraging. You can read more about these and other transformation initiatives from page 52 onwards. We know that not everything goes right every time, but our culture at CMFT is to encourage people to be open about things that go wrong. We were very pleased to see our Trust awarded a good rating in the 2015/16 Learning from mistakes league table ( compiled by Monitor and the NHS Trust Development Authority. The table identified levels of openness and transparency within 200 NHS trusts and foundation trusts. Listening to patients, their families and our staff - and sharing what we learn across the organisation - is essential to improving quality and safety. You can read about 'Tell us Today', our new initiative to respond to patient concerns or complaints, on page 56. We now have a dedicated telephone service operated by a senior nurse or manager, who will listen to concerns and put patients or their relatives in touch with a senior member of staff within one hour. Patients and their families play an important role in shaping our services and making sure we respond to the needs of the community we serve. That may be through being a member of our Trust, taking part in surveys or attending meetings. We also have many expert patient groups who share their experience of managing long term conditions. And of course both patients and healthy volunteers make a huge contribution to our research and innovation programme. CMFT is one of the top Trusts in the country for recruiting patients to clinical research studies, working closely with our academic colleagues at The University of Manchester. Major breakthroughs in 2015/16 included the first use in the world of a bionic eye artificial retina to help a blind man with wet age related macular degeneration (AMD) to recover some of his central vision. Other milestones include pioneering a new heart scanning technique to reduce radiation risk for patients; a trial at Trafford Hospital which is the first in the world to investigate the potential of a new drug for chronic pain associated with conditions like diabetes; and a significant discovery in the fight against membranous nephropathy, a rare kidney disease which can lead to kidney failure. Research teams at CMFT are part of a dynamic and growing collaboration which is increasingly attracting national funding. The team at Greater Manchester NHS Genomic Medicine Centre, based at Saint Mary s Hospital, have made great strides forward with the 100,000 Genomes Project. 7

8 The project, which involves collecting and decoding 100,000 complete sets of people's genes, will transform the way that doctors and scientists approach the care and treatment of patients with cancer and rare diseases. Since the launch in late 2014, our researchers have recruited over 450 people to the study. It is also expanding beyond Saint Mary's, with plans well underway to recruit patients at our partner hospitals of Salford Royal, Wythenshawe and the Christie. Our Trust is also a collaborator in the complementary government funded Catapult for Precision Medicine based at Citylabs 1.0, the biomedical centre on the former Royal Eye Hospital site. The Catapult is designed to develop treatments tailored to the different characteristics of individual patients. Science and technology businesses linked to our hospital campus are giving patients access to the latest technology and treatments. They are also boosting economic growth and bringing jobs and investment to Manchester. To capitalise on these opportunities, CMFT has joined forces with health and academic partners to create Health Innovation Manchester, a collaboration of research, clinical and commercial expertise. Our city is truly a driving force within the Northern Powerhouse, a national initiative to tackle inequalities in health, employment and infrastructure across the North of England. A new era for Greater Manchester started on 1st April 2016, as our region became the first in the country to take control of its combined health and social care budgets a sum of more than 6 billion per annum. For the first time leaders and clinicians will be able to tailor budgets and priorities to directly meet the needs of local communities and improve the health and wellbeing of 2.8 million residents. This devolution presents a unique opportunity to tackle some of the health inequalities that currently affect our region. During the past year, CMFT colleagues have worked hard alongside politicians, senior health and social care officials and other partners, to establish a system of governance that will allow Greater Manchester to prosper. More than ever in 2015/16, we have seen the importance and benefits of partnership working, including with commissioners and other Trusts. In January 2015, the Manchester Health and Wellbeing Board launched the City of Manchester Single Hospital Service Review. Hospital services in Manchester are facing many challenges around staffing, workload pressures and financial viability, and standards of care are not consistent across the city. The first stage of the independent review, led by respected clinician Sir Jonathan Michael, demonstrated that closer collaborative working across CMFT, University Hospital of South Manchester NHS FT and North Manchester General Hospital (run by Pennine Acute Hospitals NHS FT), could help to address these issues. The review has now considered the organisational and governance arrangements needed to achieve this in stage two, and published its proposals in June The stage two report recommends that the creation of a new organisation, which would take responsibility for the full range of services currently provided by CMFT, UHSM and NMGH, provides the best opportunity to deliver the benefits of a Single Hospital Service. 8

9 You can read more about all these changes and what they will mean on pages 18 and 19. Our staff will play a vital role in developing the future shape of healthcare across Greater Manchester. CMFT is committed to recruiting the best people, and helping everyone to reach their potential through providing high quality training, education and mentoring. We also encourage staff to take advantage of wellbeing services, from stress management and smoking cessation to zumba classes and lunchtime walking sessions. The dedication of our staff is showcased through our annual We re Proud of You and Extra Mile awards, and is always a cause for celebration. Numerous CMFT staff have also won regional, national and international recognition during 2015/16, and you can read about their achievements on pages 35 and 36. The dedication of our staff was also recognised in the outcome of our Care Quality Commission (CQC) inspection in November In its final report released on 13th June 2016, the CQC praised our staff for being proud of their services, caring and compassionate, going the extra mile for patients and families, open when things go wrong and willing to learn. Everyone at CMFT was absolutely delighted to be given a CQC rating of Good, putting us in the top ten per cent of Trusts across the country. Over coming years our aspiration is to move from Good to Outstanding, the top rating. We would like to end by thanking our staff, Governors, volunteers, fundraisers, and members for all you have done to make CMFT a place where everyone is committed to giving outstanding care to our patients and their families. Steve Mycio OBE Chairman Sir Michael Deegan CBE Chief Executive 9

10 1. Performance Report 1.1 Overview of performance Chief Executive s Statement Sir Michael Deegan As Chief Executive, I see on a daily basis just how busy we are as a group of hospitals and community services and just how demanding the financial environment is. There are many pressures on our services, particularly urgent care, and during the past year we have faced significant challenges to our clinical, operational and financial performance. Against this backdrop, the majority of our clinical teams have delivered consistently high quality care in a timely way, with excellent outcomes and patient experience. However, across some of our services there is still scope to improve outcomes and use NHS resources more efficiently. Our Transformation Programme team is leading a range of initiatives to identify and share opportunities to achieve this. Our Performance Report and Quality Report provide wide-ranging details about CMFT s performance. My personal highlights for the year include: 9,267 babies were safely delivered at Saint Mary s, up from 8,928 in 2014/15. Manchester Royal Infirmary's transplant team broke the UK national record for a single transplant centre, carrying out 317 life-changing transplants in The new, state of the art Altrincham Hospital, part of our services in Trafford, opened on time and on budget. innovative work by our colleagues in the University Dental Hospital of Manchester to develop the first ever method to mark teeth for extraction. A neurosurgery team at Royal Manchester Children s Hospital carried out the first operation in the country on a child under 12 using a fluorescent drug to pinpoint a brain tumour. Experts at Manchester Royal Eye Hospital carried out the world s first trial of the bionic eye artificial retina to treat dry age-related macular degeneration (AMD). Our Research & Innovation teams involved more than 8,700 patients and volunteers in research studies and clinical trials, with many of our patients being the first to benefit from access to the latest drugs, diagnostics and therapies. We delivered a comprehensive programme of sepsis awareness raising, training and education, supported by a communications campaign and practical measures such as sepsis trolleys and stickers on wards. 10

11 We introduced an enhanced screening programme for Carbapenemase-Producing Enterobacteriaceae (CPE) as part of our infection control work and, together with the addition of extra isolation facilities and environmental changes, we are seeing a reduction in the transmission of CPE. Having a motivated, well-trained workforce is key to operational effectiveness, and our HR team have been working across the Trust to ensure vacancies are filled as quickly as possible, sickness absence rates are reduced and mandatory training targets are met. Significant achievements in 2015/16 included: Increasing our staff retention rate from 80% to 88% A successful international recruitment campaign which has seen the employment of 118 nurses with further staff due to arrive during This work has contributed to reducing the overall number of nursing vacancies, supporting the reduction in the cost of using temporary staff and ensures that clinical areas have the right staff numbers and skills to provide care to our patients. As part of the 2015 NHS staff survey, we saw an increase in our overall staff engagement score from 3.76 to This was better than average for Acute and Community Trusts and in the top 20% for all acute Trusts. The first student from Manchester Health Academy (sponsored by CMFT) who joined us as a Healthcare Support Worker graduated as a qualified nurse. This excellent performance does need to be seen in the context of the increasing financial pressures facing the NHS. Foundation Trusts across England have recorded significant deficits this financial year and CMFT has not been immune to this. Particular factors which have affected our financial stability include: Increasing demand for services, particularly emergency care which saw a rise in A&E attendances to 311,134, up just over 3.8% from 299,685 in 2014/15 Costs related to safely managing CPE infection across our hospitals The additional costs associated with using agency staff to fill medical and nursing vacancies Not achieving all the planned productivity improvements to our clinical services. Therefore the Board adopted an internal turnaround approach, which meant greater challenge and scrutiny of all our spending. A programme of efficiencies and improvements is also well underway and generating results. It is a credit to everyone at CMFT that we have managed to reduce a forecast operating deficit of 30 million to one of 18.5 million in 2015/16. By focusing on providing the best possible patient care in the most efficient way, I m certain that we can continue to meet the challenges ahead in 2016/17 and achieve even higher standards of safety and quality while also balancing the books. 11

12 I do also want to reflect briefly on CMFT s inspection by the Care Quality Commission (CQC) in November This is an independent review by the regulator of our services and performance, and we were delighted to be given an overall rating of Good, with our Child and Adolescent Mental Health Services (CAMHS) being awarded Outstanding. The CQC s findings included that CMFT staff had been warm and welcoming and that there had been good patient feedback. It was particularly noted that many teams were enthusiastic in meeting the inspectors eager to demonstrate their services and describe how proud they were of the care they were providing for our patients and families. You can read more about the inspection in the Quality Report, from page 183. About us Central Manchester University Hospitals NHS Foundation Trust (CMFT) is the leading provider of hospital, community and specialist health services for Manchester and Trafford. We treat more than a million patients every year, and our hospitals are home to an outstanding team of clinicians, nursing and support staff, all committed to providing safe, high quality and compassionate care. We are also proud to be a major teaching hospital, training the health professionals of the future, and to be among the country s leading trusts for research and innovation excellence. Our vision is to be recognised internationally as leading healthcare; excelling in quality, safety, patient experience, research, innovation and teaching; dedicated to improving health and well-being for our diverse population. Our values underpin everything we do. We have a framework that sets out the core behaviours and attitudes that we expect of our staff, recognising how important these are to delivering a positive patient and staff experience. Our values are: Pride - showing pride by being the best in everything we do. Respect - showing regard for the feeling, rights and views of others. Empathy - showing empathy by understanding the emotions, feelings and views of others. Consideration - showing thoughtfulness and regard for others, showing consideration for their feelings and circumstances. Compassion - showing understanding, concern and contributing to providing a safe, secure and caring environment for everyone. Dignity - showing respect and valuing all individuals and their diverse needs. Our hospitals CMFT was established in 2009, although we can trace our roots back to The Trust s main campus is on Oxford Road, two miles south of Manchester city centre, which is home to five hospitals and a range of other services. We also run Trafford hospitals, acquired in 2012, which include a general hospital situated in Urmston, and the new purpose-built Altrincham hospital. 12

13 The Trust also provides adult and children s community services for central Manchester, and city-wide services for children, dentistry and sexual health. Manchester Royal Eye Hospital Central Manchester University Hospitals NHS Foundation Trust Manchester Saint Trafford Royal Mary s Hospitals Infirmary Hospital Royal Manchester Children s Hospital University Dental Hospital of Manchester Specialist eye hospital Emergency care Complex secondary & tertiary services Specialist children s hospital Specialist hospital for women, babies and genetics Secondary services in Trafford and Altrincham Specialist dental hospital Integrated community services More detailed information about our individual hospitals and community services can be found on page 259 onwards of the Quality Report. Research and teaching are a fundamental part of our activities. We have a long-established and very successful relationship with The University of Manchester, together forming the country s largest clinical-academic campus. Both organisations are founding members of the Manchester Academic Health Science Centre (MAHSC) and Health Innovation Manchester (HInM). Together, we are ambitious to make Manchester a leading centre for applied health research, innovation and education, to the benefit of our patients and the wider community. See our Research Report on pages for more information. Since gaining foundation status in 2009, the Trust has expanded its facilities, workforce and range of services to meet growing demand for complex and specialist treatments. Working in close partnership with local Clinical Commissioning Groups, other NHS trusts, social care colleagues, our members and the local community has enabled us to shape and develop our vision and strategy to meet this demand. Our key priorities for the coming year are summarised in our plan on pages The fundamental principles that underlie all our clinical activity are to provide safe, high quality care, delivered in an efficient and productive way. Activity summary The tables below give an indication of the number of patients we treated during 2015/16 compared with the previous year, and details of waiting times for treatment. 13

14 Accident & 2014/ /16 emergency attendances Attendances 294, ,033 Clinic attendances 5,060 5,101 Total 299, ,134 In-patient/day case 2014/ /16 activity In-patient (Non- 84,386 84,192 elective) In-patient (elective) 19,437 18,791 Day cases 76,256 78,135 Total 183, ,118 Day cases as a % of elective activity Day cases as a % of total activity 76.8% 80.6% 41.5% 43.1% In-patient waiting list As at 31 st March 2015 As at 31 st March 2016 Inpatient Day case Total Inpatient Day case Total Total on waiting list 2,832 10,478 13,310 3,347 11,424 14,771 Patients waiting 0-12 weeks Patients waiting weeks Patients waiting over 26 weeks 1,709 6,959 8,668 1,745 6,359 8, ,707 2, ,117 2, ,812 2, ,948 3,786 Out-patient activity 2014/ /16 Out-patients first attendances 282, ,532 Out-patients follow-up 787, ,707 attendances Total 1,069,841 1,113,239 Bed usage 2014/ /16 Average in-patient stay 4.5 days 4.5 days 14

15 How our performance is regulated and monitored CMFT s performance is regulated by two national statutory bodies: the Care Quality Commission and Monitor (Monitor is now part of NHS Improvement). We were inspected by the CQC in November 2015, and given a rating of Good. You can read much more about this on page 183 onwards of the Quality Report. Locally, CMFT sits within both the Manchester and Trafford local health economies (LHEs). The Central Manchester LHE comprises Central Manchester Clinical Commissioning Group and Manchester City Council. The Trafford LHE is made up of Trafford Clinical Commissioning Group and Trafford Local Authority. The Manchester and Trafford LHEs also operate within the broader Greater Manchester health system, which is striving to achieve consistently high standards of care across the board, regardless of where patients live. Central Manchester LHE Manchester is served by three Clinical Commissioning Groups CCGs; North, Central and South CCGs. It is covered by one local authority; Manchester City Council. We have long-standing and well developed engagement arrangements in place with Central Manchester CCG and across the city of Manchester. During 2015/16 they included: Central Manchester Integrated Care Board (CICB) chaired by the Chair of Central Manchester CCG, it brings together health and social care providers and commissioners within central Manchester and reports to the Manchester Executive Health & Well Being Group. Central Provider Partnership (CPP) chaired by the Deputy Chief Executive of CMFT, it brings together all nine of the provider organisations across Central Manchester including GoToDoc (the out of hours provider), North West Ambulance Service (NWAS) along with the Carers Forum and the voluntary sector. Manchester Executive Health & Well Being Group chaired by Manchester City Council CEO it brings together Manchester City Council, Manchester CCGs and the key health and social care providers in the city. Manchester Health & Well Being Board chaired by the leader of Manchester City Council it brings together CEOs of the health and social care providers and commissioners across Manchester. Trafford LHE We have well-established working relationships with senior colleagues at Trafford CCG and Local Authority. More formal engagement mechanisms in place include: Trafford Integrated Care Redesign Board (ICRB) - oversees the programme to develop integrated ways of providing healthcare in Trafford. 15

16 Trafford Health and Wellbeing Board (HWB) - CMFT is represented on the statutory Health and Wellbeing Board which is a sub-committee of Trafford Council. The implementation of GM Devolution means that the local regulatory and governance mechanisms changed from 1 st April 2016, and you can read more about this on pages Key issues and risks for CMFT and how we manage them During 2015/16, the Trust identified a number of issues and risks that could affect the delivery of our services. These are listed below and covered in greater detail in the Annual Governance Statement (page 130 onwards) The Trust s Risk Management Committee, chaired by the Chief Executive, meets bi-monthly to ensure these risks are monitored and addressed. Key risks in 2015/16 Risk Category Current / New 1. A&E performance and Emergency Clinical 15/16 Department capacity 2. Infection control - CPE Clinical 15/16 3. Regulatory framework Clinical 15/16 4. Patient records Organisational 15/16 5. Never events Clinical 15/16 6. Major Trauma Organisational 15/16 Downgraded 7. Communication of diagnostic test and Clinical 15/16 screening test results 8. ICE Order Communications Implementation Clinical 15/16 Downgraded 9. Compliance with Building Regulations - Fire Stopping Organisational New 15/ Financial control and failure to deliver trading gap savings / financial challenge for future years Financial 15/ Equality and Diversity Programme Organisational 15/16 Downgraded 12. Stretford Memorial Hospital Organisational New 15/16 Downgraded 13. Corporate and clinical mandatory training Clinical New 15/16 compliance 14. Nurse staffing Clinical New 15/ Management of the Mental Health Act Clinical New 15/ Diagnostics Adult Endoscopy Clinical New 15/ End of Life Care Clinical New 15/ Community Services: Building Fabric Organisational New 15/ Nutrition Royal Manchester Children s Hospital Clinical 15/16 Downgraded 20. Nutrition Patient Dining Experience Organisational New 15/16 16

17 Risk Category Current / New 21. Transition of care Clinical New 15/16 Downgraded 22. Obstetric capacity Clinical New 15/16 Managing external risks CMFT is also part of the wider Greater Manchester (GM) health and social care system, and this has an impact on the services we deliver and the risks we have to manage. GM faces some very significant challenges: People die younger than people in other parts of England. Cardiovascular and respiratory illnesses mean people become ill at a younger age The number of older people, who often have multiple long term health issues to manage, is growing Many people are treated in hospital when their needs could be better met elsewhere Care is not joined up between teams and not always of a consistent quality The configuration of our health services is designed to meet the health needs of the last century Many of the illnesses people suffer from are caused by poverty, stress, air quality, debt, loneliness, smoking, drinking, unhealthy eating and physical inactivity. At the same time as demand for care and services is rising, the available funding is set to fall in the future. If we do not act now, by 2021 more people will be suffering from poor health and there will be a 2 billion shortfall. The health and social care organisations across GM believe that these challenges can best be met by working together and taking charge of health and social care spending and decisions locally. In February 2015 all 37 organisations signed up to the landmark devolution agreement under which 6 billion of funding will be transferred from central government to Greater Manchester. The aim of devolution is to see the greatest and fastest improvement to the health, wealth and wellbeing of the 2.8 million people in the towns and cities of Greater Manchester. In order to achieve this, there needs to be a radical change in how health and social care is provided, as well as a new deal with people in Greater Manchester. This change is set out in the Greater Manchester Strategic Plan Taking Charge of Our Health and Social Care in Manchester which is available at The Strategic Plan has been built from the plans created by the local authorities, clinical commissioning groups (CCGs) and hospitals in each part of Greater Manchester. The plan describes five changes that need to take place to transform the health and social care system. 17

18 What this means for CMFT: The development of a Manchester local care organisation where our hospital doctors, nurses and community staff work with GPs and other professionals from social care and the voluntary sector as part of a single team to look after the physical and mental health needs of a defined area. This means that when people do need support from public services it s largely in their community, with hospitals only needed for specialist care. This is known as One Team. Working with the University Hospital of South Manchester (UHSM) - as part of the Healthier Together initiative - to deliver a single service for acute care. Under this arrangement clinical staff within A&E, acute medicine and general surgery from both hospitals will come together as a single service to deliver acute care across CMFT and UHSM. CMFT will be the specialist hospital with 24/7 A&E with full surgical back up and UHSM with be a local hospital which will not have a full A&E department 24/7, but will still care for the majority of acutely ill patients. Aligning our secondary services with those provided at UHSM and North Manchester General through the Independent Review of Hospital Services in the City of Manchester. The purpose of the review is to develop a high level vision of how future clinical services could be provided under the banner of a single hospital service. It will set out the benefits that could be derived from a more effective alignment of hospital services across the city and the most effective way to ensure these benefits are delivered. 18

19 Developing our specialist services such as children s surgery and ophthalmology as specialist service chains. This will mean taking responsibility for the provision of specialist services across the whole of GM. Services will continue to be provided locally, but the clinicians will all be part of the same single team working to the same procedures and protocols. Exploring the sharing of some clinical and non-clinical support functions across Greater Manchester. This could include back office functions, pharmacy, estates management, procurement, radiology and pathology. Important events after the financial year end There have been no significant events after 31 st March 2016 that have affected the Trust. Going concern declaration After making enquiries, the Directors have a reasonable expectation that Central Manchester University Hospitals NHS Foundation Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. Sir Michael Deegan Chief Executive 26 th May

20 1.2 Performance Analysis Measuring our operational performance The Trust has a number of specific local measures against which we check our performance. These cover clinical quality and safety, patient experience, service development, research and innovation, staff development and finance. We also assess how we are performing against a range of national standards and targets. We develop an operational plan each year which summarises all our aims, key priorities and how we will measure success. Our staff, partner organisations, Governors and members all contribute to developing this plan. Table 1 shows how we performed against these aims and priorities. Table 1 Strategic aims Improving the safety and clinical quality of our services Key priorities for 2015/16 Delivering safe, harmfree care focusing on evidence based pathways, supervision and clinical leadership Measures of success HSMR/SHMI of less than 100 before rebasing achieved Compliance with NICE guidance achieved How we performed HSMR SHMI 98 Crude Mortality Rate 1.4% NICE compliance achieved for most guidelines. (246 since 2002) Plans are in place to meet partial compliance where required. NICE guidance informs the annual clinical audit plan. No significant compliance risk has been identified. 10% reduction in rate of serious harm (L4&5) per 1000 bed days on 2014/15 levels 10% reduction in the new cases of AKI stage 2&3 occurring during hospital stay on 2014/15 Average Length of Stay (LOS) across MRI reduced from 6.8 days to 5.5 days through the Transformation Programme Serious harm per 1000 bed days not reduced. 50% of serious harm is falls focus for 16/17. A reduction of 8.75% was achieved in real terms, but if average reductions are taken into account, the improvement over the same period was 11.1%. 6.6 days Average LOS was on a downward trend for Q1 and Q2 but in Q3 and Q4 there was an increase. This was seen predominantly in 2 specialties. A focus 20

21 Strategic aims Key priorities for 2015/16 Deploying nursing and midwifery establishments, informed by evidence based acuity and dependency tools and professional guidance Measures of success Board review of ward establishments completed twice in year How we performed on the very complex and long lengths of stays over the summer saw a number of long stay patients discharged, 4 of which were over 200+ days and a further 5 over 100+ day, increasing the overall LOS. Board Reports submitted 6 monthly detailing nursing and midwifery workforce position, ward establishment reviews, and compliance with National Quality Board and NICE/professional staffing guidance. Allocate Safer Care tool implemented on all wards by March 2016 Regular updates provided on the nursing and midwifery workforce position to Trust Management Board, Nursing and Midwifery Professional Forum and HR Scrutiny Committee. Allocate e-rostering and safer care tool implemented in all nursing and midwifery areas. Turnover of no more than 15% achieved for band 5 staff nurses by March 2016 Established key performance dashboard to ensure use of system is embedded in all areas Band 5 turnover at the end of March 2016 was reduced to 18.3% from 22.2%. Our Nursing and Midwifery retention strategy and work programme was implemented in August

22 Strategic aims Key priorities for 2015/16 Exceeding all key NHS commissioned standards and deliverables, including access and quality outcomes Measures of success 4hr emergency access target delivered National quality outcome measures delivered How we performed Achieved the standard in two out of four quarters, and with an overall year performance level of 93.6%. The local and national performance dipped significantly during Q3 and Q4 and CMFT was no exception. However, it did perform strongly in comparison with local Trusts and peers. Trauma: 7 out of 13 indicators scoring over 90% Stroke: overall compliance with Sentinel Stroke National Audit Programme (SSNAP) rating as planned. There has been a deterioration in audit data quality. Time spent on designated stroke ward continued to prove a challenge. All other access targets including referral to treatment time and cancer wait times delivered Baseline measured and target set for being seen within 30 minutes of outpatient appointment time The referral to treatment targets were achieved consistently throughout each month of the year, as were the majority of the cancer wait targets. The 62 day referral from GP cancer target was not delivered in Q1 and Q2 due to a marked increase in demand which the Trust responded to and delivered from Q3 onwards. The 30 minute target is one of the 12 CMFT Outpatient Standards. Each Division has undertaken a selfassessment to understand the 22

23 Strategic aims Improving the experience for patients, carers and their families Key priorities for 2015/16 Delivering personalised, responsive and compassionate care in partnership with patients and families in appropriate environments safeguarding the most vulnerable Measures of success Friends & Family response rate of more than 15% achieved How we performed baseline and all have improved during 15/16. 2 divisions are achieving the required thresholds with all other divisions having plans to further improve. FFT response rate for ward areas = 15.4% FFT response rate for A&E areas = 9.4% More than 85% 2015/16 position is patients reported that 87.1% (a 2.3% they were involved improvement from in decisions about 2014/15) their care and treatment More than 85% 2015/16 position is patients reported that 93.6% (a 1.4% staff provide help improvement from when asked 2014/15) More than 85% 2015/16 position is patients reported that 94.3% (a 1% they feel the staff improvement from are always friendly, 2014/15) caring and pleasant Compliance with Level 3 safeguarding children training achieved 96% compliance achieved (CMFT compliance target is >90%) Developing our specialist services and, in collaboration with our partners in health and social care, leading on the development and implementation of integrated care Development and implementation of Place Based Care models of delivery Development of specialist services in particular Domestic abuse risk assessment and referral completed for all patients attending A&E with a history of domestic abuse Increase in the % of diabetic patients seen in community setting on 2014/15 levels Number of (total of 108) adult social care staff working in integrated community teams Commissioner agreement to being a centre for vascular Undertaken for patients who consent to a risk assessment and referral Agreement around model of care and decision to pilot intermediate care in a locality as part of integrated neighbourhood team to enable shift to begin in early 2016/17 Delay in externally developed target operating model for integrated teams, slippage to 2016/17. Interim designation as a centre for complex endo-vascular 23

24 Strategic aims Increasing the quality and quantity of research & innovation, contributing to improving health & well-being Key priorities for 2015/16 cardiovascular, cancer and genomics services. Integrating research into patient choice and the treatment pathway Measures of success and for complex endovascular services achieved Commissioner agreement to being a specialist cancer surgical centre for urology achieved Single gynaecology cancer service for Greater Manchester and Cheshire implemented Designation as a congenital cardiac surgical centre (adults and children) achieved Designation as a central genomics lab achieved Annual patient recruitment 7765 patients recruited to clinical trials Percentage of Trust patients entered into trials 5% total patients Patient research survey returns - 25% increase in response rate on 2014/15 How we performed services achieved Commissioners have not yet designated vascular centres in GM Commissioners have not yet designated urological cancer centres in GM Designation as lead provider achieved. Discussions on operating model continuing. Continuing to engage with the NHSE programme. Tender process delayed The recruitment to March 2016 for NIHR reportable studies is 7,915, which is slightly above target. 1.83% of total patients entered into trial in the period April 2015 to March There were 490,860 individual patients seen by the Trust in that period, including A&Es, and we recruited 7,915 Portfolio participants. Rounding that up to 9,000 to account for non-portfolio recruitment gives 1.83% of patients recruited into research. 149 patients have completed the survey, a significant increase on the 25%. The survey has been completed across 9 teams: Renal Rheumatology Gynaecology Midwifery 24

25 Strategic aims Key priorities for 2015/16 Measures of success How we performed Manchester Heart Centre Adult Oncology Paediatric Oncology Cardiovascular Trials Unit Manchester Centre for Sexual Health Providing the best quality assured education and training Delivering excellent education and learning with the aim of further developing reputation, innovation and attracting and retaining a highly skilled workforce Website analytics 5% increase in hits on website on 2014/15 Increase in % of staff reporting they have received training/learning and development on 2014/15 Website page views (hits) have increased by 10.61% when comparing the period 1 st April st March 2015 (158,204) with 1 st April st March 2016 (174,985). 76% of staff stated that they had received training. This is 3% better than the average for our benchmark group. No direct comparison can be made with the previous year as the focus of the question is different. 84% of staff felt that the training had helped them do their job more effectively Increase in % staff reporting that the training/learning and development helped them in their job, (66% in 2014), 84% stay up to date said that it helped professionally and them to deliver a deliver better patient better patient experience on experience (65% in 2014/ ) and 90% stated that it had helped them keep up to date professionally (76% in 2014) Increase in % staff reporting that their manager identified their training needs as part of their appraisal and supported them in receiving training/learning and development on 2014/15 67% of staff reported that their training needs were identified in the appraisal process (71% in 2014) 25

26 Strategic aims Developing our organisation, supporting the well-being of our workforce and enabling each member of our staff to reach their full potential Key priorities for 2015/16 Implementing the OD Strategy, focusing on: developing leadership capability; talent management; values and behaviours and education and training. Measures of How we performed success staff and All targets met. SFFT survey targets Response rate above met the national average at 42%. A significant increase in the staff engagement score to within the top 20%. 17 key findings in top 20%. Divisional medical All divisions have engagement plans in Medical Engagement place Plans in place 90% of staff received At the end of March an appraisal 2016 the appraisal compliance rate was 85% 90% of staff At the end of March compliant with mandatory training % staff who have completed Living the Values training 2016 the Corporate Mandatory training compliance rate was 91% and the Clinical Mandatory training compliance rate was 89% 10% of staff have been through the Living the Values facilitator training. Implementing the HR Strategy focusing on: Workforce Planning and redesign; recruitment and retention and employee health and wellbeing Revising and implementing the Equalities, Diversity & Inclusion (ED&I) Strategy Vacancies reduced to 5% Time taken to fill vacancies reduced to 65 days 90% completion of exit questionnaires for staff who leave Sickness absence rate reduced to 3.6% 90% completion of return to work interviews following sickness absence ED&I strategy in place, measurements agreed and feedback on the development provided. Vacancies reduced to 4.4% 64 days achieved 8.5% compliance. 4.71% achieved This is a significant reduction in sickness absence from 5.21% in 2014/15 89% compliance overall, with some parts of the Trust meeting the target The strategy was agreed by CMFT board in November The action plan is under development with input from key staff groups and will be launched on 1 st April. 26

27 Strategic aims Remaining financially stable Key priorities for 2015/16 Maintaining financial stability in an environment of increasing financial challenge and a demanding trading gap requirement Measures of success Monitor Continuity of Service Risk rating of 3 maintained throughout the year Year-end deficit no worse than 19m 15/16 capital plan achieved within 31 million budget How we performed A set of measurements has been proposed and the team are working with Informatics to develop a dashboard for ED&I. Revised Financial Sustainability Risk Rating introduced mid-year. The revised Risk Assessment Framework rates the Trust s financial sustainability measure as a 2. This financial sustainability measure will continue at a 2 while any level of deficit remains in the Trust. The operating deficit for the 2015/16 year was 18.5m against the opening plan of 19m. After allowing for technical, nonoperating items, this deficit increased to a bottom line deficit for the year of 29.2m. Capital expenditure for 15/16 was 24.7m against a final capital programme value of 29.1m. CMFT s performance is also measured against an extensive range of indicators and targets, which are set by the NHS nationally and also by our local commissioners. These indicators cover a wide range of areas, including quality, clinical performance, patient safety and experience, finance, human resources and key performance standards subject to the regulatory framework. More detailed information about these measures, and our performance against them during 2015/16, can be found in part two of the Quality Report on pages Managing performance across a very large Trust like CMFT is a challenge, and we have developed an online intelligence system which enables us to do this effectively and in real time. All staff, as well as our Governors, can view this system on a daily basis, to access up to date performance information. 27

28 Our clinical and operational staff use the information to produce bespoke reports which analyse patient activity and assist with planning and administration as well as performance management tracking. Using this information tool reinforces that performance management is part of everyone s job. The Chief Operating Officer s team also monitors the intelligence system and produces regular performance reports to share with the Board of Directors, our Governors, commissioners and regulators. Information on performance is available to Board members and Governors through the online Board Assurance Framework system. In a clear Red, Amber, Green (RAG) rated graphical format, this shows any current areas of concern, possible factors behind them and actions being taken to bring performance back to the required level. Each Executive Director has responsibility for a range of indicators related to their areas of operation, and monitors progress on resolving any issues identified. Our commissioners also play a key role in helping us to achieve excellent performance. They set local indicators, some of which carry financial penalties if we do not achieve the required outcomes. Formal contract review meetings with commissioners enable our teams to ensure everything is on track to provide excellent care to our patients, and to manage financial and other resources wisely. Identifying and responding to trends Using our central intelligence system, we are continually tracking both performance and demand and adjusting our services to deliver the patient care that is needed. For example, in the first half of 2015/16, demand for surgical treatment for a range of cancers rose by 17%. Responding to this unexpected increase in demand was difficult, but by identifying the issue and putting additional resources in place we were able to meet treatment targets for the remainder of the year. In recent years, our use of high quality reporting has been essential in relation to managing CPE. This has allowed us to provide the right amount of isolation capacity and track the impact of large scale testing for CPE as part of our core commitment to patient safety. Looking beyond our own hospitals and community services, CMFT works closely with the System Resilience Group covering Manchester and Trafford. This group assesses demand for health services across our entire local health economy, and collaborates on forward planning. Having robust CMFT performance information enables us not only to assess past performance delivery, but also to anticipate and plan for likely future demand alongside other Trusts, primary care and social services across Greater Manchester. 28

29 Our financial performance The Trust s financial out turn for 2015/16 was a deficit of 18.5m compared to an original plan of 19m deficit. The Trust had been forecasting a 30m deficit throughout the second half of the year but has been able to reduce this to an operational deficit through a number of one-off measures including a contractual settlement. The underlying variance to plan of 30m largely reflects the current national picture: combining significant pressures on urgent care services and a reduction in planned activity plus overspends on medical and nursing staffing. During the year, CMFT has reviewed the valuation basis of the property and estate used to provide services, to ensure that it remains the most appropriate basis. This has resulted in a change in the valuation basis of the land owned by the Trust, so that it is now valued by reference to alternate sites that may be available to provide the services from. This has resulted in a reduction in land value of 15.5m. We have commissioned work on the valuation of the buildings on the same basis but this has yet to report, and so building values have been uplifted to reflect market conditions. The net movement in property values has resulted in an impact on the Statement of Comprehensive Income of 10.7m, meaning the Trust retained deficit for the year is 29.2m The Trust s financial plan for 2015/16 was to achieve a Continuity of Service Risk Rating (CoSRR) level 3. (The measure became known as the Financial Sustainability Risk Rating or FSRR during 2015/16). In fact, we achieved a level 2, which was caused by the move to a deficit position. CMFT has an overall financial challenge for 2016/17 of 90m which is made up of two elements: The level of year on year efficiency challenge faced by all hospitals. Underlying challenges arising from our current trading position. Given the scale of the challenge, CMFT has entered a process of internal turnaround, and has engaged external consultants, through NHS Improvement, to support this process of delivering a return to financial balance. Solutions to the overall scale of these challenges will be delivered largely through reducing costs and increasing efficiency. Growth is forecast in a limited number of specialties, and where specific commissioner intentions are known these have been accounted for in the financial plan. Significant themes of this work are as follows: Cross-cutting work streams to improve efficiency and productivity and thus support the recovery of activity underperformance and the delivery of contracted growth. Recovery of run rate issues from 2015/16, including managing CPE and reducing excess nursing and medical staffing costs. 29

30 Management controls on expenditure to aid short term delivery of savings, while more complex plans move through the planning stage to delivery. Accelerated corporate savings included a review of administrative and support functions where IT could be an enabler of additional efficiency. A review of loss-making services, with a view to longer term changes to these services following involvement of commissioners and other providers. After assessing the scale of the overall 90m challenge (which is around 11.5% of relevant operating income), and realistic timescales for delivery of the full set of savings programmes to meet this challenge across all of our hospitals, the Board has approved a provisional Financial Plan for 2016/17 which contains a forecast surplus of 4.7m for this financial year. On the two main metrics of financial sustainability used by Monitor to assess regulatory risk across the Foundation Trust sector, the 4.7m surplus forecast results in a Capital Service Cover rating of 1 (the lowest rating), whereas the Trust s Liquidity rating is forecast to remain at level 3 (the second-strongest rating) throughout the year. As a result, Monitor s Continuity of Service Risk Rating for CMFT will remain at level 2 in 2016/17, in line with the position delivered in 2015/16. The CMFT Charity We are also the Corporate Trustee to the CMFT Charity (registration no ) and have sole power to govern the financial and operating policies of the Charity so as to benefit from the Charity s activities for the Trust, its patients and its staff. The Charity is therefore considered to be a subsidiary of CMFT and has been consolidated into the accounts in accordance with International Financial Reporting Standards. The accounts disclose the Trust s financial position alongside that of the Group which is the Trust and the Charity combined. A separate set of accounts and annual report have been prepared for the Charity for submission to the Charities Commission. 30

31 Launching the 3.9 million helipad appeal in September 2015 Our impact on the environment We are committed to being a leading sustainable healthcare organisation, and to carrying out our business with the minimum impact on the environment. Our Sustainable Development Management Plan (SDMP) priorities are: To reduce our carbon footprint by a minimum of 2% year on year, through a combination of technical measures and staff behaviour change. To embed sustainability considerations into our core business strategy. To work collaboratively with our key contractors and stakeholders to deliver a shared vision of sustainability. To comply with all statutory sustainability requirements and implement national strategy. During 2015/16, across the Trust we: Decreased total waste volumes by 4% Reduced water consumption by 6% Reduced energy costs by over 3% Launched a new Sustainable Travel Plan for our staff Involved staff in a Green Impact campaign, which saved 130,000 and generated 2,000 environmental improvement actions Introduced initiatives to make our procurement more sustainable. You can find more details about all these activities in our Sustainability Report on pages

32 Case study: Green Awards for staff initiatives CMFT s annual staff recognition awards had two very worthy finalists in the Green Award category. Gillian Hobson and the Managed Print Project (MPP) Team were nominated for their hard work in managing the roll-out of new multifunctional devices (which include a printer, copier and scanner) to replace individual devices across the central site. The team also had the idea of gathering together all the toners and ink cartridges which are not compatible with the new devices, creating a library of stock which can be used across the Trust while the MPP rolls out. So far the Toner Library has saved the Trust over 7,000 and prevented cartridges and printers going to landfill. The replaced printers are also being re-purposed across the Trust, to fill in for broken devices or meet other business needs. Jane Jones and the Trafford Pharmacy Team recognised that they would often send out items for patients which were returned unused, particularly asthma inhalers. Unfortunately as they weren t able to differentiate clearly which had been used by patients and which had not, these returns meant throwing away perfectly good equipment. Their response was to purchase heat sealing equipment and they now heat seal every inhaler sent out into its own small individual bag. When the inhalers are returned still sealed, they can be reused rather than being thrown away. On top of this, inhaler propellant is a powerful greenhouse gas, so the team s initiative has had an impact on the Trust s carbon footprint too. This idea, which won the Green Award, will save CMFT more than 3,000 each year, and could easily be adopted by other pharmacy teams as well as the wider NHS. Jane Jones (centre) and the Trafford Pharmacy team 32

33 Responding to social, community and human rights issues Our Trust hospitals and community services provide care to diverse and complex communities in Manchester and Trafford. Manchester wards such as Ardwick, Moss Side, Rusholme, Hulme and Longsight are some of the most deprived in the UK. They have higher than average emergency hospital admissions, cases of lung cancer, childhood obesity and teenage pregnancy. Areas such as Hulme face major challenges linked to deprivation with 49.5% of children living in poverty, compared to England s average of 27%. 1 The life expectancy of Trafford residents is higher than the national average, with 79.4 years for men and 83.5 years for women, compared to a national average of 78.3 for men and 82.3 for women. 14.5% of the residents are from a black or minority ethnic (BME) population, compared to a BME population of 9.8% for the North West region, and 14.6% for England. In Trafford, it is estimated that there will be a 23% increase in the number of people aged 65 and above, from 2008 to It is expected that there will be 25% more people aged 65 to 69 years and a 56% increase in the number of people aged 85 years and above in the same timeframe. Over 33,000 people in Manchester (almost 1 in 10 working age residents) are inactive in the labour market due to a health condition, accounting for over half of all key working age benefit claimants in the city. Manchester has a vibrant and diverse population with 33.4% of residents from ethnic minority groups, an estimated 35,750 lesbian, gay and bisexual people living in the city and 153 languages spoken. During 2015/16 we have developed new three-year Equality, Diversity & Inclusion (ED&I) strategy. This sets out our vision and aims for the Trust and the communities we serve, and builds on the effective ED&I policies already in place. We consulted with over 450 people and organisations, and by listening to what they had to say we have built a strategy that focuses on what is important to the Trust and its people. The new strategy was approved by the Board of Directors in November 2015, and is being rolled out from This year we also launched the Equality Advocate scheme, implemented the NHS s Work Force Race Equality Standard, and played an active part in the NHS Employers Equality & Diversity partners. Our widening participation programme has continued to deliver outstanding access to employment and opportunities for our local communities. Every year we run events, conferences, training and activities across the Trust to help provide inclusive care for our patients and staff. 1 Statistics from the State of the City Report ty_report 33

34 More details about our policies and performance can be found in our ED&I Report on pages Case study: Midwives recognised for tackling human trafficking Specialist midwives Marie Zsigmond, Amanda Lewis and Siobhan O'Neill won the Royal College of Midwives Team of the Year Award in March 2016, for their project to identify and support potential victims of trafficking (PVoT). They have led on a piece of work raising awareness of human trafficking, which has been instrumental in increasing referrals of potential victims to a multi-agency human trafficking group. The team developed a system that involves other agencies such as the police, Home Office and social services. Other initiatives include mandatory training for staff to recognise the signs of human trafficking, and the formation of the Manchester Safeguarding Children's Board Multi-Agency Human Trafficking Sub-Group. This was formed to promote networking, to share information, and develop response strategies and training. As a result of the team's work, a major initiative was launched in collaboration with the police. Thanks to this project, the hope is that midwives will be more vigilant in spotting the signs of potential victims of trafficking, and have the confidence to escalate any concerns. CMFT midwives receive the Royal College of Midwives Team of the Year Award in March 2015, Case study: Meeting the needs of our community Manchester is home to many refugees and asylum seekers. The specialist midwifery service for asylum seekers and refugees, set up in 2005 at Saint Mary s Hospital, is one of the few services in the UK solely dedicated to providing maternity care for this group of women. Sandra Cahill, our specialist midwife for refugees, is establishing a Northwest Midwifery Refugee network to develop a responsive maternity refugee service. It will share collective experience, build health evidence (the largest dispersal area in the UK) and help to overcome obstacles and share experiences of negotiating systems of support in the political arena. 34

35 Case study: involving BME communities in research Dr Iain McLean from CMFT s Research and Innovation Division was named as the 2015 Equality and Diversity Champion at our annual We re Proud of You staff awards. Iain was nominated by a colleague for his role in organising a workshop to understand how best to approach recruiting participants from black and minority ethnic (BME) communities in research. The workshop featured presentations from CMFT researchers who had specific experience of recruiting to studies for conditions that disproportionately affect minority groups. The outputs of the workshop fed into the Division s plans for International Clinical Trials Day and, ultimately, shaped the research recruitment strategy to provide more patients with research as a choice alongside their other treatment options. Recognising exceptional performance by our staff The outstanding performance, skills and innovation of a wide range of CMFT staff have been recognised with regional, national and international awards during 2015/16. The individuals and teams who won these accolades included: Janet Concannon, WellChild Special Recognition Award Marie Zsigmond, Siobhan O'Neill & Amanda Lewis, Royal College of Midwives (RCM) Team of the Year Kirsti Redfern, RCM JOHNSON'S Mentor of the Year Doctors Phil Riley, Alice Chieng, Janet McDonagh, Rachel Gorodkin & Ben Parker, Pharmaceutical Marketing Excellence Award MREH teams, Best Ophthalmology Care Innovation, Best Ophthalmology Team (highly commended) Professor Dame Tina Lavender, one of the BBC's 100 inspirational women for 2015 MRI interventional radiography team, North West Radiography Team of the Year Dan Moroney, Electrical Apprentice of the Year (highly commended) Green Team, NHS Sustainability Day Awards (winner & highly commended), HSJ Awards (two highly commended awards) RMCH Ward 84, North West Pride Award Farooq Ahmed, Royal College of Surgeons Gold Medal Saint Mary's teams, Journal of Midwifery 2015 Team of the Year and Contribution to Eradication of FGM awards Dr Alex Heazell, Star Legacy Foundation s Research Star Saint Mary s Sexual Assault Referral Centre (SARC), Patient Experience National Network (PENN) 2016 Award. 35

36 Jo Fee (centre) received the CMFT Oustanding Achievement Award from Chairman Steve Mycio (right) and Chief Executive Sir Michael Deegan (left) at the annual staff recognition We re Proud of You Awards. Until her retirement in 2016, Jo was a member of the Safeguarding Children Team which supports, trains and supervises staff working in the difficult area of protecting children. Key priorities and performance for 2016/17 Each year, through our annual planning process we agree, in discussion with our Council of Governors, a set of key priorities these are the must-dos for the coming year and are developed in the context of our vision and strategic aims. The summary plan below links our key priorities for 2016/17 to our vision and strategic aims. The Trust s Operational Plan sets out in detail how we plan to achieve our key priorities and meet all our quality, operational and financial requirements for 2016/17, and this is available on our website at OUR VISION - To be recognised internationally as leading healthcare; excelling in quality, safety, patient experience, research, innovation and teaching; dedicated to improving health and well-being for our diverse population Strategic Aims - Our aims over the next 5 years Improving the safety and clinical quality of our services Key Priorities - What we need to do in 2016/17 1. Delivering safe, harm-free care focusing on evidence based pathways, supervision and clinical leadership and embedding CMFT Clinical Standards in day to day practice Metrics - How we will know we have delivered Improvement on 2015/16 position for Never Events achieved Improvement on 2015/16 position for mortality - HSMR, SHMI, crude mortality achieved Improvement on 2015/16 position for 7 day services achieved 36

37 OUR VISION - To be recognised internationally as leading healthcare; excelling in quality, safety, patient experience, research, innovation and teaching; dedicated to improving health and well-being for our diverse population Strategic Aims - Our aims over the next 5 years Improving the experience for patients, carers and their families Key Priorities - What we need to do in 2016/17 2. Ensure professionally informed, evidence based nursing and midwifery establishments supported by recruiting and retaining an engaged workforce able to respond to future care delivery needs. 3. Achieve all key NHS commissioned standards and deliverables, including access and quality outcomes 4. Delivery against the Trusts Transformation strategy with the aim to reach the top decile for quality - clinical outcomes, safety, patient and staff engagement & experience and operational efficiency measures. 5. Deliver well-led compassionate, individualised care in partnership with patients and families in appropriate environments, safeguarding vulnerable people Metrics - How we will know we have delivered Band 5 staff nurse vacancies reduced Improvement on 2015/16 staff survey results for nurses & midwives achieved Spend on locum & agency staff reduced 4hr emergency access target delivered Waiting time targets delivered National quality outcome measures achieved Average length of stay reduced Theatre utilisation improved Improvement on the 2015/16 position for National Patient Survey achieved Improve on 15/16 FFT score for % patients likely / extremely likely to recommend CMFT Full compliance with requirements for access to care for people with a learning disability Individualised care plans utilised for all patients at end of life. Developing our specialist services and, with our partners in health and social care, leading on the development and implementation of integrated care 6. Playing our part in transforming the health and social care system through supporting Greater Manchester Devolution, and the delivery of Locality Plans (particularly in Manchester and Trafford) Integrated health and social care teams established across Central Manchester Proposals for the development of our specialised services agreed Plans for working more closely with UHSM and PAHT developed 37

38 OUR VISION - To be recognised internationally as leading healthcare; excelling in quality, safety, patient experience, research, innovation and teaching; dedicated to improving health and well-being for our diverse population Strategic Aims - Our aims over the next 5 years Providing our patients with cutting edge care through applied research and innovation to deliver improved safety, clinical quality and a patient centred approach to our services Key Priorities - What we need to do in 2016/17 7 Strengthen and drive the translation of cutting-edge science into new tests and treatments that benefit patients Metrics - How we will know we have delivered Application for NIHR Biomedical Research Centre and Clinical Research Facility submitted Precision Medicine Hub established on campus by Autumn 2016 Clusterlabs project (onsite accommodation for biomedical companies) launched Providing the best quality assured education and training Developing our organisation, supporting the well-being of our workforce and enabling each member of our staff to reach their full potential 8 Drive engagement with research through participant recruitment, public and patient involvement (PPI) and communications 9 Delivering excellent education and learning with the aim of further developing reputation, innovation and attracting and retaining a highly skilled workforce 10 Implement the OD Strategy, focusing on: developing a high performing, inclusive and values based culture that increases organisational resilience and agility and City of Manchester system leadership and integration (LCO) 11 Implement the people strategy focusing on: workforce information and policies, workforce design and succession planning, attraction and resourcing; staff engagement; talent and performance management 12 Develop a clear action plan and measurement framework to implement three year ED&I strategy Number of patients taking part in research studies increased Mandatory Training compliance at 90% 10% increase in the number of apprentice starts achieved Above average score in staff survey for providing staff with personal development Maintain the 2015/16 response rate to the NHS Staff Survey Staff engagement score achieved within the top 20% of acute trusts Number of key findings scoring in the top 20% increased Retention of staff ( over 12 months service) rate >80% achieved Vacancies reduced to 5% (all staff groups) Time taken to fill vacancies reduced to 65 days 3 year plan in place and balanced scorecard developed to measure progress 38

39 OUR VISION - To be recognised internationally as leading healthcare; excelling in quality, safety, patient experience, research, innovation and teaching; dedicated to improving health and well-being for our diverse population Strategic Aims - Our aims over the next 5 years Remaining financially stable Key Priorities - What we need to do in 2016/17 13 Ensure short & medium term financial stabilisation, the on-going management of cash and ensuring the delivery of CIPs 14 To refresh the Going Digital Informatics strategy for , following engagement and consultation on this with stakeholders Metrics - How we will know we have delivered Monthly deficit progressively reduced throughout the year Trust liquidity position maintained Cost improvement programmes delivered IM&T strategy updated Delivery programme for 2016/17 clearly identified Benefits realisation reviews undertaken for all significant implementations during 2015/16 39

40 2. Accountability Report 2.1 Directors Report The CMFT Board of Directors is responsible for preparing the Trust s annual report and accounts. We believe that, taken as a whole, the report and accounts is fair, balanced and understandable and provides the information necessary for patients, regulators and stakeholders to assess CMFT s performance, business model and strategy. In preparing this report, the Directors have ensured that so far as we are each aware, there is no relevant audit information of which the auditors are unaware. The Directors have taken all steps that we ought to have taken in order to make ourselves aware of any relevant audit information and to establish that the auditors are aware of that information. Each Director has also: made such enquiries of his/her fellow directors and of the Trust s auditors for that purpose; and taken such other steps (if any) for that purpose, as are required by his/her duty as a director of the Trust to exercise reasonable care, skill and diligence. The Board of Directors is responsible for determining the Trust s: strategy, business plans and budget policies, accountability, audit and monitoring arrangements regulation and control arrangements senior appointment and dismissal arrangements. The Board is also responsible for approving the Trust s annual report and accounts and ensuring that CMFT acts in accordance with the requirements of its Foundation Trust license.. Sir Michael Deegan Chief Executive Officer 26 th May

41 Board of Directors Profiles Mr Steve Mycio OBE, Chairman (Appointed January 2015) Qualified as a Fellow of the Chartered Institute of Housing. Interim Chief Executive, Office of the Police Commissioner, Greater Manchester (March September 2014) Deputy Chief Executive, Manchester City Council ( retired September 2011) Background in Housing Management and Regeneration culminating in the role of Director of Housing ( ) Board member of Manchester United Foundation Charity Deputy Chair of Governors at Manchester Health Academy Sir Michael Deegan CBE, Chief Executive (Appointed September 2001) Holds a first degree in Law and a Masters degree in Industrial Relations from the University of Warwick. Previously Chief Executive at Warrington Hospital and then North Cheshire Hospitals NHS Trust Involved in the preparation of the Government s NHS Plan in 2000 Held post of Director of Human Resources for the NHS Has worked widely across the public sector including roles in local government and education Chair of the Shelford Group of Foundation Trusts (2016/17). Mrs Gill Heaton OBE, Deputy Chief Executive (Appointed December 2001) Undertook nurse training at the Manchester Royal Infirmary in the late 1970s. Trained as a Health Visitor within community services. In the early 1990s completed the General Management Training Scheme. April 2007 designated as the Deputy Chief Executive Worked as a senior nurse in various clinical areas, such as intensive care and medical wards Has held senior management posts in large acute Trusts, including Mental Health, as well as leading the General Management Training Scheme for the North West Region Chair, Manchester Provider Board Professor Robert Pearson, Executive Medical Director (Appointed April 2006) BSc, MB ChB (Hons) MD FRCS Trained in Manchester, London and Nottingham. Responsible Officer for CMFT Appointed Consultant Surgeon MRI 1990 Spent 12 years on the Northwest Surgical training committee, the last four as Chair and Programme Director for General Surgery and associated subspecialties Previously Clinical Head of the Division of Surgery 41

42 Previously Chair of the NHS National Technology Adoption Hub Stakeholder Board Member of Executive Management Team, Manchester Academic Health Science Centre (MAHSC) MAHSC representative on Greater Manchester AHSN (Academic Health Science Network) Strategic Board Mr Adrian Roberts, Executive Director of Finance (Appointed May 2007) Qualified as a Chartered Certified Accountant in 1988 and designated a Fellow of ACCA in Honours degree in Modern History, University of Oxford, Executive Director of Finance since May 2007 Prior to joining the Trust, 16 years experience as an NHS Director of Finance, predominantly in Stockport, including securing Stockport s authorisation as one of the first 10 Foundation Trusts in April 2004 Mrs Margot Johnson, Executive Director of Human and Corporate Resources (Appointed May 2013) Worked in the NHS for over 30 years, mostly within Human Resources. Is a fellow of the CIPD. Holds a Masters in Strategic HRM and is a qualified coach. First started work in Finance but after 3 years took the opportunity to transfer into Human Resources. Has worked across all sectors of the NHS but mostly in the Acute hospital environment. During career she worked in generalist HR roles and has also specialised in Workforce Planning, Organisational Development and Medical Staffing and as part of a team responsible for developing a privately financed NHS hospital, from business case through to opening. Has also spent a short period working in general management and took a secondment to work as part of a multiagency inquiry team, working alongside the police, Social Services and Education. A HR Director in teaching hospitals for 13 years. Mrs Julia Bridgewater, Chief Operating Officer (Appointed September 2013) Julia has over 30 years experience in the NHS, holding a range of operational management roles across the acute sector. Joined NHS Graduate Training Scheme in 1984 after completing a degree in Theology at the University of Manchester. She has spent the majority of her career in the acute sector in the West Midlands, in various roles, including managing Surgery, Orthopaedics, Business Planning and Service Development. Appointed Chief Executive of the University Hospital of North Staffordshire NHS Trust (UHNS) in 2007 where she guided the hospital through a period of turnaround. UHNS was successful in having approved a 400 million PFI Scheme in May and services were transferred to the single site development in

43 Lead Shropshire Community Trust for a period of six months before joining CMFT. Mr Darren Banks, Executive Director of Strategy (appointed April 2015) Darren is a qualified accountant and has held senior financial and operational management positions within the NHS. Director of Strategy for CMFT since April 2006 and has led a number of major organisation-wide initiatives including the successful Foundation Trust application in January 2009, the acquisition of Trafford Healthcare Trust in April 2012 and played a pivotal role in the establishment of the Greater Manchester Major Trauma Centre Collaborative - a delivery mechanism for genuine cross-institutional working. Member of the Greater Manchester Devolution Transition Team, which is helping to shape the future governance arrangements linked to this historic agreement. Responsible for all aspects of strategic planning and for providing a robust framework for the development of corporate and service strategy. Manages many of the Trusts major stakeholder relationships and works closely with our hospital leadership teams to ensure appropriate strategic positioning to deliver our vision. Mrs Cheryl Lenney, Chief Nurse (appointed July 2015) Cheryl has over 35 years' experience as a nurse and a midwife. She is the Director of Infection Prevention and Control and is accountable for nursing and midwifery on the Board of Directors Trained as a nurse in Blackpool and as a midwife in Cornwall. Gained the Advanced Diploma in Midwifery at Saint Mary's Hospital Completed a Masters in Health Service Management at Manchester University. Has held a number of senior nursing and leadership roles across the NHS including Head of Midwifery and Director of Nursing. Mr Anthony Leon, Non-Executive Director & Deputy Chairman (Appointed April 2001) A Chartered Accountant who was Managing Partner of the Manchester practice of Binder Hamlyn for 15 years Director of Bright Futures Educational Trust Previously Chairman of the Mancunian Community Health NHS Trust, from 1995 to 2001 Treasurer of The University of Manchester Institute of Science and Technology to 2003 Chair of the Audit Committee Deputy Lieutenant in the County of Greater Manchester 43

44 Professor Rod Coombs, Non-Executive Director (Appointed 2007, term of office ended 14 th March 2016) Deputy President and Deputy Vice Chancellor University of Manchester. BSc in Physics, and MSc and PhD degrees in the economics of innovation and technical change. After a short period at the beginning of his career working in laboratory research, he switched to social science. Worked for over 25 years on analysing the role of technical change in the economy; the management of R&D and innovation processes in large companies; and the role of government policy in promoting innovation in the economy. In 1993 became the first Professor of Technology Management at UMIST. During that period he initiated and ran several large collaborative research programmes, and also worked as a consultant to a number of large researchintensive companies, as well as advising national and European government agencies. In 2002 he became a Pro-Vice-Chancellor of UMIST, and was heavily involved in the project to merge UMIST with the former Victoria University of Manchester to create a new University of Manchester (which legally came into existence in October 2004). In 2004 he was appointed as one of the Vice-Presidents of Manchester University and had responsibility for various aspects of Knowledge Transfer, Research and External Relationships. In August 2010 he became Deputy President and Deputy Vice Chancellor of Manchester University. Mrs Brenda Smith, Non-Executive Director (Appointed November 2008, term of office ended 4 th December 2015) BA, MBA, ACA, FRSA (Fellow Royal Society of Arts); Doctor of Letters (Salford University for services to broadcasting and the region). Member of the Board of Governors at The University of Manchester and a member of the Investment Advisory Panel of North West Business Finance A media business executive, with a professional commercial background and experience in a FTSE100 company at executive level. Continues to work as an advisor Previously Deputy Chairman and Managing Director of Granada Television Ltd and more recently President EMEA for Accent Media Group (global media company). Also served as a Non-executive Director for Manchester Airport Group and the North West Development Agency Lady Rhona Bradley, Non-Executive Director (Appointed November 2008, term of office ended 4 th December 2015) Qualified Social Worker, MA, BA (Hons). Chief Executive of a leading North West third sector organisation and charity 44

45 Previously worked for what is now the Care Quality Commission (CQC) as a Service Inspector, conducting statutory inspections of Youth Offending Teams and Local Authority Children s Services. Background in public sector criminal justice and social care Previously an elected member of Manchester City Council, and Non- Executive director of Manchester Airport Group and Manchester Ship Canal Company Previously Chair of Local Children s Safeguarding Board and the Children and Young People s Strategic Partnership Board Appointed Deputy Lieutenant for Greater Manchester Mrs Kathy Cowell OBE, Non-Executive Director & Senior Independent Director (appointed March 2013) A banker by profession, having worked for Cheshire Building Society for 24 years until taking early retirement in Chair of Your Housing Group (a social housing provider) Deputy Chair of Cheshire Young Carers Founder member of Cheshire Community Foundation Deputy Lieutenant of Cheshire Member of the Strategic growth Community East Cheshire Hospice Keen interest in local communities with past roles including: chair of the Queen s Award for Voluntary Service, chair of Cheshire Building Society Foundation, Chairman of the Cheshire & Merseyside Courts Board since its inception in April 2004, a member of the Lord Chancellors Advisory Committee on the appointment of Justices of the Peace, and a member of the Manchester United Foundation. Held several Non-Executive roles in health, in both the provider and commissioner roles. Mr John Amaechi OBE, Non-Executive Director (appointed March 2015) Psychologist and former professional basketball player. Works extensively with both public and private sector companies throughout the UK, Europe and USA as an executive coach. His specialist field is organisational change, particularly in the areas of motivation, engagement and leadership. Global ambassador for Amnesty International Member of the Greater Manchester Police and Crime Commissioner Ethics Committee Held a number of high profile positions including Non-Executive Director of the Inclusion Board of the 2012 Olympic Games in London. Involved with NHS leadership North and South West and the NHS Inclusive Leadership masterclass programme. Mr Anil Ruia OBE, Non-Executive Director (appointed March 2015) Anil is a director of a Manchester textile firm and Chairman of a tea company in India. 45

46 Chair of the Governing Body of The University of Manchester Board member of the Higher Education Funding Council Previously was High Sheriff of Greater Manchester He has many external interests which involve supporting local community, business, educational and charitable organisations. Previously Chair of the Arts Council North West and a Board member of the Arts Council England. Board member of the North West Development Agency and the North West Cultural Consortium, a Trustee of National Museums Liverpool. Also a Governor of Manchester Grammar School and a Non-Executive Director at Granada Television. Mrs Chris McLoughlin Non-Executive Director (appointed October 2015) Chris s professional background is in nursing and social work, and she is Director for Safeguarding and Prevention at Stockport Metropolitan Borough Council. Worked as a nurse in Manchester Royal Infirmary in the 1980s and subsequently became a social worker based in a community team in central Manchester. Held a number of key leadership roles in Manchester City Council in Children and Family Services ( ). Joined Stockport Metropolitan Borough Council in 2009 as Director for Social Care and Health Since October 2012 has been responsible for the multiagency Safeguarding Children's Unit and all Integrated Children's Services including Social Care, Health, Youth Offending, Drug and Alcohol services for young people, parent support and Early Intervention teams Chair of Greater Manchester (GM) Teaching Partnership Represents the GM Directors of Children's Services on the GM Mental Health Executive and also the GM Justice & Rehabilitation Executive Dr Ivan Benett, Non-Executive Director (appointed January 2016) Ivan has worked as a GP in Central Manchester for 30 years, and is Clinical Director of NHS Central Manchester Clinical Commissioning Group (he retires from this post and clinical practice in August 2016). Primary Care Champion for Greater Manchester Healthier Together Programme Member of NICE Quality Standard Advisory Committees Previously Professional Executive committee (PEC) Chair with NHS Central Manchester Primary Care Trust. Has worked in general practice since 1985, and was the first honorary consultant in primary care at the Manchester Royal Infirmary. Trained at CMFT, and was a junior doctor at Saint Mary's Hospital and the MRI. 46

47 Professor Colin Bailey, Non-Executive Director (appointed March 2016) Colin has been the Deputy President and Deputy Vice-Chancellor at The University of Manchester since January Chair and Trustee of The Northern Consortium Board Co-Chair and Trustee of 'Find a Better Way' Chair of the Governing Board of the Knowledge Centre for Materials Chemistry Chair Panel 1 of the Membership Committee at The Royal Academy of Engineering Member of the Manchester Museum of Science and Industry Advisory Board. Joined the University in 2002, where his roles have included Vice- President and Dean of the Faculty of Engineering & Physical Sciences ( ) and Head of School of Mechanical, Aerospace and Civil Engineering ( ). Previously a Principal Engineer at The Building Research Establishment Contributed to Manchester's strategy and vision for the Northern Powerhouse Was a member of the Steering Group for the NW Business Leadership Team. Mr Nicholas Gower, Non-Executive Director (appointed March 2016) The majority of Nic s executive career, twenty-three years, was spent as a partner in PricewaterhouseCooper LLP (PWC). Currently an Independent Member of the Audit Committee at Progress Housing Association (since 2016) Non-Executive Director of both the Furness Building Society (since 2014) and the Seashell Trust (since 2007) - he also chairs the Audit Committee of both organisations Board nominated Governor of the Royal School Manchester for Seashell. Leadership roles at PWC included Partner Lead on Assurance Quality and Risk Management for the Northern business (2012) and Leader of the Regions Valuation Team (2010). Joined Coopers & Lybrand (now PWC) in 1985 as a manager, having begun his career at Spicer & Pegler (now merged with Deloitte). Attendance at Board Meetings May 15 Jul 15 Sept 15 Nov 15 Jan 16 Mar 16 Steve Mycio Chairman Sir Michael Deegan Chief Executive Professor Robert Pearson Medical Director x Gill Heaton Deputy Chief Executive x 47

48 Margot Johnson Executive Director of Human & Corporate Resources Adrian Roberts Executive Director of Finance Julia Bridgewater Chief Operating Officer Darren Banks Executive Director of Strategy Cheryl Lenney Chief Nurse (appointed July 2015) Anthony Leon Non-Executive Director and Deputy Chairman Brenda Smith Non-Executive Director and Senior Independent Director (term of office ended December 2015) Professor Rod Coombs Non-Executive Director Lady Rhona Bradley Non-Executive Director (term of office ended December 2015) Kathy Cowell Non-Executive Director John Amaechi Non-executive Director Anil Ruia Non-Executive Director Chris McLoughlin Non-Executive Director (appointed October 2015) Dr Ivan Benett Non-Executive Director (appointed January 2016) Professor Colin Bailey Non-Executive Director (appointed March 2016) Nicholas Gower Non-Executive Director (appointed March 2016) May 15 Jul 15 Sept 15 Nov 15 Jan 16 Mar 16 x x x x x x x x = attended the meeting, X = did not attend the meeting, = not applicable The Trust maintains a Register of Interests for directors, which is open to the public. This can be accessed on the Board of Directors page of our website ( The Trust maintains a Register of Interests for governors, which is open to the public. This can be accessed on the Meet the Governors page of our website ( 48

49 To communicate with the Board of Directors, please contact the Director of Corporate Services/Trust Secretary by or telephone Financial compliance The Trust has complied with the cost allocation and charging guidance issued by HM Treasury. The Trust has made no political donations during the financial year (2014/15: nil) The Better Payment Practice Code requires the Trust and the Group to aim to pay all undisputed invoices by the due date, or within 30 days of receipt of goods or a valid invoice, whichever is later. The Trust continues to process all ordering and receipting of goods and services via an electronic purchase to pay system and this is reflected in the overall performance. The results in 2015/16 were, overall, 96% (95% in 2014/15) by volume and 93% (92% in 2014/15) by value of invoices paid within the target of 30 days. No payments were made under the Late Payment of Commercial Debts (Interest) Act in either 2015/16 or 2014/15. Section 43(2A) of the NHS Act 2006 (as amended by the Health and Social Care Act 2012) requires that the income from the provision of goods and services for the purposes of the health service in England must be greater than its income from the provision of goods and services for any other purposes. Central Manchester University Hospitals NHS Foundation Trust has complied with this requirement and is satisfied that the income received from provision of non-nhs goods and services does not have any significant impact on the provision of NHS goods and services for the purposes of the health service in England. Enhanced quality governance reporting We have a number of arrangements in place to govern service quality, including our Board Assurance Framework, internal Quality Reviews, Quality Committee, Clinical Governance Committee and Ward Accreditation Programme. These are explained in more detail in the Annual Governance Statement on page 116 onwards, and within the Quality Report on page 49 onwards. We use Monitor's quality governance framework to help us reach our overall evaluation of the Trust s performance, internal control and board assurance framework and a summary of action plans to improve the governance of quality. 49

50 Patient care Providing high quality, safe and compassionate care to patients and their families is at the heart of what we do each and every day. In our Quality Report, you can read more about: how we performed in meeting key health care targets, the way we monitor improvements in the quality of the healthcare services we provide and our progress towards meeting national and local targets (page 193 onwards) the outcome of our Care Quality Commission inspection (page 183 onwards). We will receive the final report in May 2016, and have plans in place to implement the CQC s recommendations during We have listened to the views and experiences of our staff and patients, the wider public and our commissioners throughout our drive for consistent quality across all our services. Here are just some of the highlights of the quality improvement and service transformation programmes we have carried out over the past year. 1. New services introduced in 2015/16. April 2015 The new 17m Altrincham Hospital opened its doors to patients on 27th April. The purpose-built hospital provides a modern and spacious healthcare environment which has replaced previous outdated facilities in an old Victorian hospital. All services from the previous hospital transferred to the new development, including the nurse-led minor injuries unit for the assessment of minor conditions including fractures, burns and wounds where emergency nurse practitioners see patients a day. Altrincham Hospital provides a wide range of general and specialist outpatient clinics, diagnostic services (X-ray and ultrasound), physiotherapy and phlebotomy (blood testing) for more than 24,000 patients every year. These are complemented by a number of new and extended services including: a new renal dialysis unit, the first time that maintenance dialysis has been provided in Trafford a major expansion of adult ophthalmology services provided by experts from Manchester Royal Eye Hospital expanded adult and paediatric audiology clinics where more than 5,000 patients are currently treated. His Royal Highness The Duke of Gloucester KG GCVO visited the hospital on 3 rd September to perform the official opening ceremony and meet staff and patients. 50

51 Chairman Steve Mycio OBE (left) with His Royal Highness The Duke of Gloucester KG GCVO at the official opening ceremony in September. April 2015 Manchester Royal Eye Hospital (MREH) introduced vitreoretinal surgical services for patients at Rochdale Infirmary. This expansion of our services will improve the patient experience, with reduced waiting times and ease of access for many patients to a more local district hospital. Patients with eye conditions that require vitreoretinal surgery, such as retinal detachment, macular holes, and severe diabetic eye disease, can now be treated by a MREH surgeon in Rochdale if this is more convenient for them. Vitreoretinal conditions are amongst the most urgent of eye conditions, with quick treatment being paramount due to potential for vision loss. This is a good example of NHS organisations working together for the benefit of patients, providing a local service using multi-disciplinary teams from CMFT and the Pennine Acute Hospitals NHS Trust. October 2015 CMFT has introduced a new kind of informal support for head and neck cancer patients, jointly with colleagues from The Christie NHS Foundation Trust and assisted by Macmillan and Manchester Cancer. We held our first Health and Wellbeing Clinic in October 2015, in response to patient feedback. People living with cancer have sometimes said that they feel abandoned once their treatment is over. The new clinics provide patients and carers with information, support and the opportunity to speak with their peers and their medical team in an informal environment. The aim is to help patients move on after treatment and assist with the emotional impact of this transition from patient to survivor. 51

52 The event was attended by over 50 patients and carers, and following a series of short presentations from the Head and Neck Team, patients had the opportunity to browse an information market place for advice on nutrition, exercise, mouth care, lymphedema, support for getting back into work and financial support. Four Health and Wellbeing clinics will take place over the 12 months to October The launch of the Health and Wellbeing Clinic for head and neck cancer patients 2. Transforming Care for the Future programme One of our key priorities is to continue to transform the way we care for our patients so that we consistently meet their expectations of high quality, safe and compassionate care. Given the increasing demand on healthcare resources, we also need to deliver our services as efficiently and productively as possible. In February 2015, we launched the Transforming Care for the Future (TCF) programme. This programme aims to help our Trust reach the top ten per cent over the next three years, measured against our peers. Here are the key measures for success: 52

53 To achieve these targets, TCF is: creating the right culture to deliver change through embedding our Trust s values and behaviours giving staff a clear improvement methodology and building their skills Implementing a governance process which ensures change occurs and is managed in a logical and controlled way Contribute efficiency savings through transformation The following case studies showcase some of the activities and achievements of the TCF programme. SAFER Standards Week 12 th October 2015 saw the start of Embedding the SAFER Standards Week across Manchester Royal Infirmary and Trafford Hospital. SAFER standards are a set of principles which aim to standardise behaviours in order to provide safer care for our patients. They are designed to improve patient experience, quality and flow. The week aimed to allow patients to get to the next stage in their journey more quickly, with patients being admitted to the right place at the right time. Headlines from the week included: Improved A&E performance and reduced waiting times Increase in discharges Fewer patients staying in hospital for 14 days or more where this wasn t necessary. Improved communication and escalating issues to senior colleagues more quickly contributed to this Discharges from wards earlier in the day Project PAtTH The TCF team worked with the Surgical Division in November and December 2015 on a rapid improvement initiative called Project PAtTH (Perfect Admission to Theatres). An assessment of our Trust s elective (nonemergency) surgery standards had shown that a number of patients are cancelled on the day of their operation for a variety of reasons and there are areas for improvement. The initiative was designed to provide a focus on streamlining the patient s admission to surgery. The key objective was to improve performance, ensure patients are kept safe and they get their surgery on time, without unnecessary delays or cancellations. Over the course of the three-week project, the following areas were improved: Increase in number of patients having their surgery confirmed in a timely manner through the scheduling process reduction in cancellations on the day percentage of patients ready on time for theatre the go-ahead approach being given for time-critical care 53

54 Experience based design (EBD) in Outpatients Work began in December 2015 on a major project with Manchester Royal Eye Hospital Outpatients and MRI Cardiology Outpatients to pilot an approach called Experience Based Design (EBD). In this approach, staff and patients worked in partnership to identify areas for improvement before coming up with solutions together; creating a better environment for everyone. The project started with a series of staff and patient interviews, which were filmed, face-to-face and over the telephone. This feedback was combined with information collected from observations, previous patient listening events, complaints, compliments and friends and family results to identify key themes for improvement. Over 70 Eye Hospital patients and staff got together on 10 th February 2016 to hear the overall feedback and then embarked on sharing ideas for initial improvements. Feedback and ideas gathered at the event will be incorporated into the Eye Hospital s transformation plans. Participants will also be invited to a follow-up event, to hear what impact their involvement has had on service improvements. Patients and staff at Manchester Royal Eye Hospital share ideas on improving the experience in Outpatients Transform Together Fund In July 2015, we set up a small fund with support for our hospital charity to encourage staff to implement their ideas for transforming patient care. So far 22 bids for funding have been received, and six projects have been given awards. These include: Providing pedometers for patients undergoing pulmonary (lung) rehabilitation Patient diaries and speaking valves for critical care patients Developing an out of hours play service for patients at the Royal Manchester Children s Hospital using Manchester University medical student volunteers The project to transform outpatient services across Manchester Royal Eye Hospital 54

55 Our Critical Care team introducing patient diaries and speaking valves 3. Service improvements following staff/patient surveys and comments We want all our patients and their families to have the best possible experience when they use our hospital inpatient services. They are encouraged to give us feedback or share their concerns by: Filling in questionnaires Completing the Friends and Family Test Using our Patient Experience Tracker electronic tool Speaking to senior staff during monthly Quality of Care Rounds Contacting our Patient Advice and Liaison Service (PALS). We welcome the opportunity to feed all this information into our Improving Quality Programme. Here are some examples of action taken over the past year in response to patient/staff feedback and Care Quality Commission (CQC) reports. Focus on food standards Patient satisfaction with meals is an area that has been highlighted by the national Inpatient Survey, local patient feedback and the CQC as needing improvement. We have set the target of reaching and maintaining a score of 85% satisfaction or above. We have a Patient Dining Group which looks at ways to improve food quality, choice and the dining experience for patients. One idea being piloted is to create a more home like environment, for example by offering open visiting on frail elderly wards so that relatives can support patients at meal times, and holding weekly celebratory events such as Jelly Friday to encourage patients to socialise together at mealtimes. Informal feedback so far has been extremely positive. The Trust also welcomed Health Watch Trafford and Health Watch Manchester on a joint Enter and View visit to the Division of Surgery. One of the recommendations from that visit was a review of the protected mealtime process and how this is explained to patients and visitors and then managed. 55

56 Managing clinic waiting times Manchester Royal Eye Hospital introduced patient pagers as a result of comments and complaints about waiting times in clinics. The hospital looked at ways to improve communication through putting waiting times on TV screens and the pager initiative. Patients can now leave the department, for example to get refreshments, if there is a significant wait for the doctor. A follow-up survey showed that the patient response was overwhelmingly positive. Redesigning an appointment booking system A complaint was made by a dental patient about the failure to book a postsurgery follow-up appointment. As a result, the follow-up appointment booking process was redesigned, becoming an based referral system sent to a specific address. The new system s effectiveness is monitored by the Dental Hospital matron every month. 4. Communicating with patients and carers Clear and timely communication is a very important aspect of caring for our patients and their families. In addition to effective face communication, our staff make a key contribution to the wide range of leaflets and online information we provide to patients and their relatives. Recent developments include: An easy read version of the Information about your stay booklet, for children, people with learning disabilities or communication difficulties, and those who may not have English as a first language. A new step-by-step guide to making a complaint, written and illustrated in an accessible way. 5. Complaints handling Sometimes things do go wrong, and we have a clear process for handling, responding to and learning from complaints and from positive feedback. Patients can find details on our website ( and the Trust s updated complaints, concerns and compliments policy was circulated to all our staff in January We have also rolled out a rapid-response system for hospital inpatients called 'Tell us Today'. Patients or their relatives can call a dedicated telephone service operated by a senior nurse or manager, who will listen to their concerns and put them in contact with a senior member of staff in the area of concern within one hour. Our Director of Nursing regularly reports to senior colleagues on how complaints are being managed, highlighting any trends and concerns. This information is also reported quarterly to our Board of Directors, to ensure they are aware of the issues and that appropriate action is taken. All opportunities for learning and improvement are shared across the Trust. 56

57 You can find details about the number of complaints we received and how they were addressed on pages of the Quality Report. During autumn 2015, a new survey was developed to find out how satisfied people who made a complaint were with how we responded. The survey is based upon the My Expectations vision, developed jointly by the Parliamentary and Health Service Ombudsman, Local Government Ombudsman and Healthwatch. We started using it on 1st January 2016 and the results will inform improvements to the Trust s complaints handling and Patient Advice and Liaison Service (PALS) during Stakeholder relations CMFT is a leading player in the GM health and care system which serves almost three million people. During 2015/16, our leadership team and colleagues across the organisation have built on strong existing partnerships and also established new relationships with key stakeholders. CMFT is committed to working collaboratively to deliver the best for our patients, their families and the wider community. 1. Working in partnership to deliver improved healthcare CMFT is proud to work with a large number of partner organisations to share skills, innovation and resources, with the aim of delivering even better care to patients. Here are just a few examples: Salford Royal partnership Throughout the year, we have continued to develop our partnership working arrangements with Salford Royal NHS Foundation Trust (SRFT) under the terms of our Strategic Partnership Agreement, and the governance of the CMFT/SFRT Joint Management Board. Our two Trusts now undertake the vast majority of elective orthopaedic activity through shared use of the Manchester Orthopaedic Centre on the Trafford General Hospital site. During 2015/16 there has been a concentration on team building, streamlining activities, and improving productivity. Surgeons at work in the Manchester Orthopaedic Centre 57

58 The shared work on radiology services has identified some interesting opportunities to gain additional benefits by working together across the two Trusts. In particular, CMFT and SRFT have initiated a collaborative programme of activity to re-procure the Picture Archiving and Communication System (PACS) which allows X-rays and other diagnostic images to be stored and viewed electronically. This procurement is expected to be completed in 2016/17, and the enhanced ability to transfer images between hospitals will make it easier to provide consistent care for patients who have to transfer access specialist care). In November 2015, CMFT and SRFT successfully combined our separate immunology laboratories to form the Greater Manchester Immunology Service, which is based on the CMFT site. In the second half of the year, plans were developed to bring together the associated clinical services (e.g. immunology and allergy outpatient clinics), and we expect to implement these plans in 2016/17. Partnering with Nuffield Health We have also continued our partnering activities with Nuffield Health, and in January 2016 the Nuffield Diagnostic Suite was opened in the City Labs development, next to Manchester Royal Infirmary (MRI). CMFT has an agreement with Nuffield Health to use some of the capacity in the Diagnostic Suite (e.g. for MR scans), to ensure that NHS patients can get timely diagnosis and also access to more specialist functions such as heart scans. 2015/16 also saw Nuffield Health getting planning approval for the development of a new private hospital on the Elizabeth Gaskell site, opposite Royal Manchester Children s Hospital on Hathersage Road. This development will provide potential for greater synergy between CMFT and Nuffield Health in a wide range of areas including clinical services, research and education, and possibly staff benefits. Manchester Provider Partnership The Manchester Provider Partnership is a collaborative working arrangement between all of the key organisations providing health and social care in Manchester. The work of the Manchester Provider Partnership is particularly focused on out of hospital care, and further progress was made on this agenda in 2015/16. This included more detailed planning around the implementation of the One Team Model, which is the Manchester approach to integrating out of hospital services around defined neighbourhoods. This work is now led by the Manchester Provider Group, which includes representatives of a wide range of health and social care organisations (e.g. primary care, community services, social care, mental health services, hospital care and the ambulance service), and is led by the CMFT Deputy Chief Executive, Gill Heaton. 58

59 Joint working with Bolton FT Bolton Foundation Trust has a small vascular service and was finding it difficult to sustain its existing level of service. We have been working with Bolton FT to support their vascular service in the short term and to provide, in the longer term, an out-reach model of care so that Bolton patients can continue to attend outpatient appointments and have daycase surgery at Bolton, but will attend the specialist centre at MRI if they require inpatient arterial surgery. 100,000 Genome Project CMFT is working with a number of partners in Greater Manchester including The Christie, University Hospital of South Manchester (UHSM) and Salford Royal as part of the ground-breaking 100,000 Genome Project. This three year project, led by NHS England and Genomics England, has been set up to study sets of genes in patients with cancer and rare diseases and use the results to develop new treatments and transform the way the NHS delivers care. The Manchester Centre for Genomics Medicine, part of the Saint Mary s Division within CMFT, is taking a leading role across Greater Manchester in recruiting patients, taking DNA samples and when results are obtained, feeding back to patients. 2. Service development and other local initiatives City of Manchester Single Hospital Service Review Towards the end of 2015 CMFT, in collaboration with UHSM and Pennine Acute Hospitals Trust (PAHT), established a process to undertake a review of hospital care in Manchester. The City of Manchester Single Hospital Service Review is a response to the requirements for hospital services described in the Manchester Locality Plan (see pages for more information). Its aim is to assess the potential benefits to patients of a closer alignment of hospital services in the city, and to look at the most effective leadership and governance arrangements to achieve these benefits. The role of Independent Review Director was undertaken by Sir Jonathan Michael, who has a background as a Renal Physician, a Medical Director, and as Chief Executive at a number of large teaching hospitals. The Review will be completed in early in 2016/17, with its findings and recommendations being reported to the Manchester Health and Wellbeing Board in June Case study collaborating on CHAMP CHAMP (Children's Health and Monitoring Programme) was developed by our Trust in 2013, initially as an online system to support parental feedback following the National Child Measurement Programme (NCMP). During 2015/16, it has been extended to offer on-line annual growth updates to parents of primary aged children. 59

60 CHAMP is part of the Reducing Childhood Obesity in Manchester (RCOM) Programme, a collaboration led by Gill Heaton, our Deputy Chief Executive, working in close partnership with City in the Community (Manchester City Football Club), Manchester City Council, Health Education North West, The University of Manchester and ASDA. CHAMP Statistics; 48,000 children measured by the School Health Service in Manchester 12,000 Parent registrations onto CHAMP s received per month 84% Parental satisfaction with CHAMP The programme has been warmly received by school teams and local parents who have been keen to take part in individual discussions and group sessions. By exploring how the broad range of partners can work together to engage with and empower the community, we aim to prevent overweight children in Manchester and help keep children healthy. 3. Consultation with local groups and organisations Over the last year CMFT has worked with local groups and organisations through a range of mechanisms. In Manchester we have engaged with the local council and elected members through two statutory boards: The Manchester Health and Wellbeing Board, which oversees delivery of the Manchester Health and Wellbeing Strategy, with the Chairs of commissioner and provider organisations, including the Chair of CMFT. The Manchester Health Scrutiny Committee, which reviews and investigates health and care service delivery in Manchester through regular update reports and discussion with commissioners and providers, including CMFT. During the year, the Trust (in close collaboration with commissioners) has actively worked with the consultative bodies in Manchester on issues such as the Manchester Single Hospital Service Review. In a similar way, we have continued to engage with the equivalent consultative structures within the Trafford health and social care system: 60

61 The Trafford Health and Wellbeing Board, which oversees delivery of the Trafford Health and Wellbeing Strategy, where CMFT is represented by the Deputy Chief Executive. The Trafford Health Scrutiny Committee, which reviews and investigates health and care service delivery in Trafford through regular update reports and discussion with commissioners and providers, including CMFT. During the year, the Trust (in close collaboration with commissioners) has actively worked with the consultative bodies in Trafford on issues such as discontinuing service provision on the Stretford Memorial Hospital site, and the optimal future arrangements for the Trafford Urgent Care Centre. Manchester City Council and Trafford Council have also established a Joint Health Scrutiny Committee to consider issues which could have implications for the health services available to residents of both areas. A major consultation exercise is underway in the city, the Healthier Manchester review, which is gathering views and feedback from people and organisations on how health and care services delivered outside of hospital, by all providers, need to radically change by CMFT has developed further strategic partnership relationships this year through the establishment of the Manchester Provider Board, which includes both statutory and voluntary sector partners from primary, community, social and acute care sectors. The board has been created to oversee and be accountable for the effective delivery of an integrated place based approach to out of hospital care services, which will underpin the Healthier Manchester strategy and plan. 4. Other patient and public involvement activities Drawing on patient experience By involving patients, their carers and our staff, we can help reduce inequalities and promote service improvement. We pro-actively seek the views and experiences of patients (children, young people and adults), relatives and carers to influence the way we design and deliver services. This can range from asking individual patients to get involved, through to engaging with larger groups of service users and the wider public. There are many different ways we can reach and engage with patients, including: patient information leaflets, questionnaires, roadshows and other events, social media campaigns, drop-in sessions, experience-based design projects, newsletters and our website. Our Patient Experience and Quality team has created a best practice guidance booklet which any member of staff can use. 61

62 It outlines our approach to engagement and consultation and the benefits of using patient experience to shape our services and improve quality. It also offers practical ways to inform, consult, involve and engage with the people who use our services. The team is currently working on a new framework for patient experience, which will include the development of a CMFT Patient Panel. Working closely with the communities we serve CMFT believes that working in partnership with the communities we serve should be part of everyday life at our Trust. We continue to engage with patients and the public through a range of events and activities. Examples include a series of discussion meetings to gain insight for the new Self Care Strategy in the city, and some outreach work to gain views and feedback on how integrated health and social care teams should operate. New approaches that CMFT is actively supporting include a local community action group to support people to live well with dementia. Our community services colleagues actively engage directly with local groups such as Chorlton Good Neighbours, while our central site hospitals work with partners such as the Whitworth Art Gallery on key areas including dementia. Our hospital in Trafford has also worked in partnership with carer and dementia groups to implement John s Campaign for open visiting times on its wards. We are continuing to develop our approach to community engagement and partnership working across the wider health and well-being agenda. For example, our Chairman has recently visited all the local housing groups to talk about how we can work more closely together. We are actively promote employment and volunteering opportunities with CMFT, with over 764 opportunities taken up by people from the five local wards in Manchester to engage with us. CMFT s Equality, Diversity and Inclusion External Review Group continued to develop in 2015/16 and it played a strategic role in helping the team at CMFT consult widely on its new Equality, Diversity & Inclusion strategy. The External Review Group s membership is from local partner organisations across Manchester and Trafford. Over the next 12 months, we will be building a partnership programme to help bring together the work that we do with our communities to improve the health and well-being of the people we serve. Council of Governors role Our Council of Governors also plays an important part in connecting the Trust with our staff and public members and the wider public. Governors are here to listen to members views and suggestions and to share information about the performance of the Trust and developments across the wider NHS with them. 62

63 We have two key events each year which are open to members and the wider public and are supported by our Governors: the Annual Members Meeting and our Young People s Event. The 2015 Annual Members' Meeting was held on 22nd September and was open to both our members and the public - over 250 people attended. The theme was 'Proud to Care for You' and our staff showcased the outstanding services that they provide across our hospitals and in the community. The Trust's Board of Directors and Lead Governor also provided information about our performance and achievements in 2014/15 in addition to our future plans. You can find further information on our website: Each summer, the CMFT Membership Team hosts a Young People's Open Day. Since the event began in 2010, around 2,200 young people, teachers, friends and parents have attended. They have not only gained an insight into CMFT, but also discovered more about career opportunities in the NHS, volunteering and work experience in our hospitals, as well as receiving health and well-being advice from our health experts. The 2015 event was held on 26th June and we had some exciting new career and information stands, including medical engineering, our A&E team and eye care (orthoptics). Also new for 2015 was our 'Looking After You' health advice area. Our staff talked to the delegates about their roles in the NHS, in addition to providing health information. There were also plenty of fun interactive sessions, and our employment team were available to tell delegates about work experience opportunities, and how to become a hospital volunteer. You can find further information on our website: You can read more about how our Governors engage with members and the wider public on page 145 onwards. Governors in action at our Annual Members Meeting in September

64 2.2 Remuneration Report This Remuneration Report describes how the Trust applies the principles of good corporate governance in relation to Directors remuneration, as required by the Companies Act 2006, Regulation 11 and Schedule 8 of the Large and Medium-Sized Companies and Groups (Accounts and Reports) Regulations 2008 and elements of the NHS Foundation Trust Code of Governance. Annual statement on remuneration During 2015/16, new appointments were made to the roles of Executive Director of Strategy and Chief Nurse. Decisions on their remuneration were based on available benchmarking information against the national peer group for this organisation the Shelford Group of ten leading NHS multi-specialty academic healthcare organisations ( CMFT s Executive Directors are employed on contracts of employment whose provisions are consistent with those relating to other employees within the Trust. There are no components within the remuneration relating to performance measures, bonuses or benefits in kind. Contracts for directors do not contain any obligations which could give rise to or impact on remuneration payments or payments for loss of office. Senior managers remuneration policy On 2nd June 2015, the Secretary of State for Health wrote formally to the Chairs of all NHS Provider Trusts, NHS Foundation Trusts and Clinical Commissioning Groups in relation to the pay for very senior managers (defined as Chief Executives and Executive Directors) and the need to ensure that executive pay remains proportionate and justifiable. The Trust subsequently conducted a review of its policies on executive remuneration. The CMFT executive pay structure is very simple. There is basic pay, which includes a small non-pensionable car allowance. All pay is taxed at source. There are no bonus payments. Salaries are benchmarked each year against the comparator group of Shelford Trusts or, where necessary, other professional groups. All new appointments are sourced at the benchmark level and adjustments are made only if the market rate or existing salary indicates this is necessary. The pay of Executive Directors is set using the Trust s preferred benchmark for a range of indicators the Shelford Group of hospitals. Any variations to Executive salaries outside the benchmark are driven purely by market factors. The remuneration policy for other senior managers (those reporting directly to Executives) provides a progression ladder between the pay of other employees and that of Executive Directors. It therefore commences at Agenda for Change (AfC) Band 9 and progresses to 10k below that of the lowest paid Executive Director. CMFT did not consult with employees when preparing the senior managers remuneration policy. 64

65 The Trust s underlying principle in respect of Directors remuneration is to ensure that individuals are appropriately rewarded relative to their responsibility, breadth of portfolio and performance. This principle must be applied consistently and fairly in line with best practice and equality requirements. Only in this way will CMFT be able to attract, retain and motivate high calibre senior managers who can perform to the highest levels of expectations in order to ensure we maintain our excellent standards of clinical outcomes and patient care, functions efficiently and are well positioned to deliver the business strategy. The recruitment market is competitive for high quality candidates and therefore CMFT must ensure that compensation packages, and any associated benefits, are attractive. But, at the same time, we must also be flexible enough to accommodate the differing experience levels of candidates, and take into account other variables which may impact on our the ability to attract and retain suitable staff. Directors of the Trust are employed on a permanent contract basis. During 2015/16, an appointment to the Board was made to cover the role of Chief Nurse which was subsequently confirmed as a substantive appointment at the Remuneration Committee held on 13 th April Required notice periods are 12 weeks, except for the Chief Executive whose notice period stands at six months. Where salaries of very senior managers exceed 142,500 per annum, these have been reviewed and found to be appropriate to match market rate, maintain relativities with other very senior manager posts and to match pay in the jobs from which individuals were recruited. Performance of the Executive Directors is assessed and managed through regular appraisal against predetermined objectives along with monthly one to one reviews with the Chief Executive. Similarly, the Chairman holds monthly one to one s with the Chief Executive. Any deficit in performance is identified during these regular meetings. Serious performance issues are managed via our organisational performance capability management policy. Performance of the Non-Executive Directors is assessed and managed through regular appraisal by the Chairman against predetermined objectives along with regular one to one reviews with each NED. Any deficit in performance is identified during these regular meetings along with opportunities for regular professional development. Appraisals led by the Chairman - for the Chief Executive and Non-Executive Directors are also used as an opportunity to identify continuing professional development needs. No performance payment element has been paid to any of the Trust s Executive Directors during 2015/16. Equally, there have been no payments to both Executive and Non-Executive Directors for loss of office. 65

66 There are no special contractual compensation provisions for early termination of Executive Directors contracts. Early termination by reason of redundancy is subject to the normal provisions of the Agenda for Change (AfC): NHS Terms and Conditions of Service Handbook (Section 16). For those above the minimum retirement age, early termination by reason of redundancy is in accordance with the NHS Pension Scheme. Employees above the minimum retirement age who themselves request termination by reason of early retirement are subject to the normal provisions of the NHS Pension Scheme. The principles for determining how payments for loss of office will be approached, including: how each component will be calculated whether, and if so how, the circumstances of the loss of office and the senior manager s performance are relevant to any exercise of discretion would all be considered on a case by case basis by the Remuneration Committee and would be approved by Monitor in advance. Remuneration Committee (of the Board of Directors) The Remuneration Committee is a subcommittee of the Trust Board of Directors chaired by Steve Mycio with membership comprising Anthony Leon (Deputy Chairman), Brenda Smith (Independent Non-Executive Director up to 04/11/15), Kathy Cowell (Independent Non-Executive Director) and Non- Executive Directors Lady Rhona Bradley (up to 04/11/15), Professor Rod Coombs (up to 14/03/16), John Amaechi, Anil Ruia, Chris McLoughlin (from 26/10/16), Dr Ivan Benett (from 04/01/16), Professor Colin Bailey (from 14/03/16), and Nicholas Gower (from 14/03/16). The Committee s main purpose is to set rates of remuneration, terms and conditions of service for the Chief Executive, Executive Directors and Directors, i.e. those people in senior positions having authority or responsibility for directing or controlling the major activities of the Trust. The Chief Executive, Sir Michael Deegan, and the Executive Director of Human & Corporate Resources, Margot Johnson, are also in attendance to provide information on Directors performance and a review of general pay and reward intelligence including comparative data on Directors salaries and NHS guidance on pay and terms and conditions, as requested. Individuals do not participate in any discussion relating to their own remuneration. The Committee met twice during 2015/16. Attendance at the meeting held on 11 th May 2015 included: Steve Mycio John Amaechi Lady Rhona Bradley Professor Rod Coombs Kathy Cowell Anthony Leon Chairman Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director 66

67 Brenda Smith Anil Ruia Sir Michael Deegan Margot Johnson Alwyn Hughes Non-Executive Director Non-Executive Director Chief Executive Executive Director of Human & Corporate Resources Trust Board Secretary It was agreed that for staff on national terms and conditions (Agenda for Change and Doctors and Dentists pay and conditions) the Trust applies the terms of the pay settlement agreed by the Department of Health and NHS Employers. It has been a long standing arrangement within CMFT that all those who are not on Agenda for Change terms and conditions are applied the lowest national pay award for all staff. This group includes Executive Directors of the Trust. Decisions relating to salary levels in the rest of the organisation are factored into the Remuneration Committee s discussion of executive salaries. The committee does not consult with employees when considering its policy on senior managers remuneration. The Committee noted that Executive Directors last received pay uplift of 1% in 2013/14, in line with all other NHS staff. This was the first pay increase for this group since 2009 when the Trust became a Foundation Trust. However, in reviewing salary levels during the year, and taking into consideration the prevailing financial challenges facing the NHS and using the evidence gained from the updated comparator information, the Committee took the view that there would be no adjustments (uplifts) made to the Executive Directors in 2015/16 in line with senior managers paid on Agenda for Change rates. Additionally, the Committee considered those staff reporting to Executive Directors who were placed into local pay in September It was noted that most of these staff were placed onto a spot point between the maximum of the Band 9 pay scale and 120k. A small number remained on AfC Band 9 and continued to receive increments. It was also agreed that this group did not receive a pay award in 2014/15. For those who remain on a Band 9, it was further agreed that the same incremental pay freeze be applied as for other staff on senior AfC pay rates. The Remuneration Committee also received a report in relation to changes to the Executive Director team to ensure organisational resilience along with recommendations on the appropriate level of remuneration for the posts of the Executive Director of Strategy and Chief Nurse. Attendance at the meeting held on 14 th March 2016 included: Steve Mycio John Amaechi Professor Colin Bailey Chairman Non-Executive Director Non-Executive Director 67

68 Dr Ivan Benett Professor Rod Coombs Kathy Cowell Nicholas Gower Anthony Leon Chris McLoughlin Anil Ruia Sir Michael Deegan Margot Johnson Alwyn Hughes Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Chief Executive Executive Director of Human & Corporate Resources Trust Board Secretary The Committee considered the steps taken since July 2014 to put in place arrangements to ensure future organisational resilience for those functions discharged through the office of the Medical Director, and agreed to the reduction in working days for the Medical Director, from 5 days a week to 4, effective from 1 st April Remuneration & Nominations Committee (of the Council of Governors) The Remuneration & Nominations Committee of the Council of Governors met three times during 2015/16 to consider the remuneration of the Non- Executives and the Chairman, and the appointment of four new Non- Executive Directors. The Non-Executive Directors are not employees of the Trust. They receive no benefits or entitlements other than fees and are not entitled to any termination payments. The Trust does not make any contribution to the pension arrangements of Non-Executive Directors. The terms of office for Non-Executive Directors at the Trust are managed in accordance with Monitor s Code of Governance, i.e. any term beyond six years (two three-year terms) will be subject to rigorous review and subject to annual reappointment. Furthermore, the Trust s Constitution mandates the removal of the Chairman or another Non-Executive Director through the approval of three-quarters of the members of the Council of Governors. The Remuneration & Nominations Committee has a responsibility to consider the structure, size and composition of board and make recommendations for any changes. It is also, with external advice as appropriate, responsible for the identification and nomination of new Executive and Non- Executive Directors. When appointing new Non-Executive Directors to the Board during 2015/16, the Trust engaged an external recruitment agency to act as its recruitment advisors to identify, and encourage applications from potential candidates who met the constitutional requirements for membership of the Trust. 68

69 Individuals were targeted who had skills and experience in line with the person specification for the Non-Executive Director positions and backgrounds that were complementary to the existing Board. Candidates were assessed on the basis of the qualities and expertise criteria set out in the advertisement and applicant information pack, the competences they demonstrated at interview and the eligibility noted in the applicant information pack. The views of the stakeholder panels from morning sessions were also shared with the Trust s Nominations (Appointments) Committee at the end of the formal interviews. The external recruitment agency provided assurance that the process undertaken had been open, fair and transparent and candidates had been assessed on the basis of merit and in line with best practice for public appointments The Trust appointed a search and selection supplier following two competitive tender exercises, the latter of which created a local framework of suppliers in September Gatenby Sanderson was selected on both occasions to support the appointment of Non-Executive Directors in October 2015 and March An assurance report is prepared for the Council of Governors once a decision is made to appoint, outlining the process followed and the assessment methods used to secure the candidates. A fixed fee of 12,000 per candidate or 16,000 for two appointments made together was agreed. Attendance at the Remuneration & Nominations Committee of the Council of Governors meeting held on 15 th June 2015 included: Cllr Rabnawaz Akbar David Edwards Sharon Green Keith Paver Brenda Smith Margot Johnson Alwyn Hughes Nominated Governor (Manchester City Council) Public Governor (Greater Manchester). Staff Governor (Nursing & Midwifery) Lead & Public Governor (Chair) Senior Independent Director (part of meeting) Executive Director of Human & Corporate Resources Director of Corporate Services/Trust Board Secretary An external appraisal specialist was used to undertake a 360 appraisal of the Chairman. In addition, a Governor questionnaire fed in views on Non- Executive Directors and the Chairman to the Lead Governor and Senior Independent Director respectively. 69

70 The following recommendations were made by Committee Members to the Council of Governors at their meeting held on 1 st July 2015, at which the Committee s recommendations were approved: The Council of Governors approved and acknowledged that the performance review process for the Chairman had been successfully undertaken. The Council of Governors approved and acknowledged that the performance review process for the Non-Executive Directors had been successfully undertaken. The Council of Governors approved the recommendation made by the Remuneration Committee of the Council of Governors that an uplift should not be applied for 2015/16 to the remuneration of the Chairman, Chair of the Audit Committee and the Non-Executive Directors. Attendance at the Nominations (Appointments) Committee held on 30 th September 2015 included: Steve Mycio Cllr Rabnawaz Akbar Beverly Hopcutt Richard Jenkins Gillian Easson In Attendance Sir Michael Deegan Emma Pickup Chairman Nominated Governor (Manchester City Council) Staff Governor (Other Clinical) Public Governor (England & Wales) External Assessor (Chair, Stockport FT) Chief Executive External Recruitment Agency The following recommendations were made by the Nominations (Appointments) Committee to the Council of Governors at their meeting held on 14 th October 2015, at which the Committee s recommendations were approved: The Council of Governors approved the Nominations (Appointments) Committee s recommendation that Christine McLoughlin and Dr Ivan Benett be appointed as Non-Executive Directors for Central Manchester University Hospitals NHS Foundation Trust for an initial period of three years from the earliest possible start date. Attendance at the Nominations (Appointments) Committee held on 24 th February 2016 included: Steve Mycio Julie Cheetham Geraldine Thompson Carol Shacklady Chairman Nominated Governor (CM CCG) Staff Governor (Other) Public Governor (Greater Manchester) 70

71 Christine Outram External Assessor (Chair, The Christie FT) In Attendance: Sir Michael Deegan Emma Pickup Chief Executive External Recruitment Agency The following recommendations were made by the Nominations (Appointments) Committee to the Council of Governors at their meeting held on 2 nd March 2016, at which the Committee s recommendations were approved: The Council of Governors approved the Nominations (Appointments) Committee s recommendation that Professor Colin Bailey and Nicholas Gower be appointed as Non-Executive Directors for Central Manchester University Hospitals NHS Foundation Trust for an initial period of three years from the earliest possible start date (in order to enable a period of shadowing of the incumbent Non-Executive Directors). The Council of Governors also approved the Nominations (Appointments) Committee s recommendation that Kathy Cowell was reappointed as CMFT Non-Executive Director with effect from 1 st March 2016 to 28 th February Sir Michael Deegan Chief Executive 26 th May

72 Details of Executive remuneration 2015/16 A B C D E F Salary Taxable Annual Long term All pension Total benefits in performance performance related kind related related benefits bonuses bonuses Steve Mycio Chairman (from 1 st January 2015) Lady Rhona Bradley Non-Executive Director (to 4 th December 2015) Professor Rod Coombs Non-Executive Director (to 14 th March 2016) Kathy Cowell Non-Executive Director Anthony Leon Non-Executive Director Brenda Smith Non-Executive Director (to 4 th December 2015) John Amaechi Non-Executive Director (from 16 th March 2015) Anil Ruia Non-Executive Director (from 16 th March 2015) Chris McLoughlin Non- Executive Director (from 26 th October 2015) Dr Ivan Benett Non-Executive Director (from 4 th January 2016) Professor Colin Bailey Non-Executive Director (from 14 th March 2016) (Bands of (Rounded to (Bands of (Bands of (Bands of (Bands of 5,000) nearest 5,000) 5,000 2,500) 5,000) 100)

73 2015/16 A B C D E F Salary Taxable Annual Long term All pension Total benefits in performance performance related kind related related benefits bonuses bonuses Nic Gower Non-Executive Director (from 14 th March 2016) Sir Michael Deegan Chief Executive Professor Robert Pearson Medical Director Gill Heaton Executive Director of Patient Services/Chief Nurse (to May 2015) Gill Heaton Deputy Chief Executive (from 2 nd June 2015) Julia Bridgewater Chief Operating Officer Adrian Roberts Executive Director of Finance Margot Johnson Executive Director of Human & Corporate Resources Cheryl Lenney Chief Nurse (from 1 st July 2015) Darren Banks Director of Strategic Development (from 1 st April 2015) (Bands of (Rounded to (Bands of (Bands of (Bands of (Bands of 5,000) nearest 5,000) 5,000 2,500) 5,000) 100) Highest paid director s salary 222, 500 Median total remuneration 28,180 Remuneration ratio

74 Explanatory notes 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 salaried remuneration of the highest paid director in Central Manchester University Hospitals NHS Foundation Trust in the financial year 2015/16 was 222,500 (2014/15 227,500). This was 7.9 times (2014/ times) the median remuneration of the workforce, which was 28,180 (2014/15 28,181). In 2015/16 no employees received remuneration in excess of the highest paid Director (2014/15 nil). Total remuneration includes salary, non-consolidated performance-related pay, benefits-in-kind, and any severance payments. It does not include employer pension contributions and the cash equivalent transfer value of pensions. During 2014/15 Peter Mount, Chairman, retired and was replaced by Steve Mycio, previously a Non-Executive Director, effective from the 1st January The remuneration stated for Steve Mycio only reflects the first 3 months of his appointment as Chairman. Annual remuneration for this position would be within the banding 60k to 65k. During 2015/16 Gill Heaton left the post of Director of Patient Services/Chief Nurse. Effective from 2nd June 2015 she was appointed Deputy Chief Executive; the 2015/16 remuneration stated for this post only reflects 10 months of appointment. Annual remuneration for the position would be within the banding 100k to 105k (with no pension benefits). From 1st July 2015 Cheryl Lenney was appointed Chief Nurse; the 2015/16 remuneration stated for this post only reflects 9 months of appointment. Annual remuneration for the position would be in the banding 135k to 140k. Four new Non-Executive Directors (Christine McLoughlin, Ivan Benett, Colin Bailey and Nic Gower) were appointed during the year to 31st March 2016; remuneration reported only reflects their term of office to this date. A full year s remuneration would show all these officers within the 15k to 20k banding. 2014/15 A B C D E F Peter Mount Chairman (to 31 st December 2014 Steve Mycio Chairman (from 1 st January 2015) Salary Taxable Annual Long term All pension Total benefits in performance performance related kind related related benefits bonuses bonuses (Bands of (Rounded to (Bands of (Bands of (Bands of (Bands of 5,000) nearest 5,000) 5,000 2,500) 5,000) 100)

75 2014/15 A B C D E F Lady Rhona Bradley Non-Executive Director (to 4 th December 2015) Professor Rod Coombs Non-Executive Director (to 14 th March 2016) Kathy Cowell Non-Executive Director Anthony Leon Non-Executive Director Steve Mycio Non-Executive Director (to 31 st December 2014) Brenda Smith Non-Executive Director (to 4 th December 2015) John Amaechi Non-Executive Director (from 16 th March 2015) Anil Ruia Non-Executive Director (from 16 th March 2015) Sir Michael Deegan Chief Executive Professor Robert Pearson Medical Director Gill Heaton Executive Director of Patient Services/Chief Nurse (to May 2015) Julia Bridgewater Chief Operating Officer Salary Taxable Annual Long term All pension Total benefits in performance performance related kind related related benefits bonuses bonuses (Bands of (Rounded to (Bands of (Bands of (Bands of (Bands of 5,000) nearest 5,000) 5,000 2,500) 5,000) 100)

76 2014/15 A B C D E F Adrian Roberts Executive Director of Finance Margot Johnson Executive Director of Human & Corporate Resources Salary Taxable Annual Long term All pension Total benefits in performance performance related kind related related benefits bonuses bonuses (Bands of (Rounded to (Bands of (Bands of (Bands of (Bands of 5,000) nearest 5,000) 5,000 2,500) 5,000) 100) Highest paid director s salary 227,500 Median total remuneration 28,181 Remuneration ratio 8.1 Pension benefits 2015/16 Name and (a) (b) (c) (d) (e) (f) (g) (h) title Real Real Total Lump sum Cash Real Cash Employer s increase in increase in accrued at pension Equivalent increase in Equivalent contribution pension at pension pension at age related Transfer Cash Transfer to pension lump sum pension to accrued Value at 1 Equivalent Value at 31 stakeholder age at pension age at 31 pension at April 2016 Transfer March pension age March 31 March Value (bands of (bands of (bands of (bands of 2,500) 2,500) 5,000) 5,000) Sir Michael Deegan Chief Executive Julia Bridgewater Chief Operating Officer Adrian Roberts Executive Director of Finance to to to 55 0 to to to 70 0 to to to to to to Nil 1, ,206 Nil 1, ,014 Nil 76

77 Margot Johnson Executive Director of Human & Corporate Resources Cheryl Lenney Chief Nurse (from 1 st July 2015) Darren Banks Director of Strategic Development (from 1 st April 2015) 0 to to to to to to to to 155 1, Nil 1, Nil 5.0 to to to Nil The above table gives pension benefits accruing from the NHS Pension Scheme up to 31st March Note that as Non-Executive Directors do not receive pensionable remuneration, there are no entries in respect of pensions for these Directors. A Cash Equivalent Transfer Value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a scheme member at a particular point in time. The benefits valued are the member's accrued benefits, and any contingent spouse's pension payable from the scheme. A CETV is a payment made by a pension scheme, or arrangement to secure pension benefits in another pension scheme, or arrangement when the member leaves a scheme, and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits which the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity within this Trust and this Group, to which the disclosure applies. The CETV figures and other pension details include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS Pension Scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the Scheme at their own cost. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries. Real Increase in CETV - this reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another pension scheme or arrangement), and uses common market valuation factors for the start and end of the period. Directors' Remuneration and Benefits The aggregate amount of Directors' remuneration for 2015/16 was 1,537k ( 1,321k in 2014/15). The Trust and the Group made a contribution to the NHS Pension Scheme, a defined benefit scheme, of 130k in respect of eight Directors in 2015/16 (2014/15: 112k in respect of six Directors. 77

78 Expenses Directors The total number of Directors in office during 2015/16 was 20 (2014/15-17 Directors) The number of Directors receiving expenses in 2015/16 was 7 (2014/15-7) The total amount of expenses paid to Directors in 2015/16 was 4,507 (2014/15-6,981) Governors The total number of Governors in office during 2015/16 was 40 (2014/15 43 Governors) The number of Governors receiving expenses in 2015/16 was 6 (2014/15-4) The total amount of expenses paid to Governors in 2015/16 was 1,426 (2014/15-678) 78

79 2.3 Staff Report Staff numbers and roles At CMFT we had a workforce of 13,368 people (at 31 st March 2016). The table below gives a breakdown of our staff numbers by role and type of contract. Staff Group Permanent Fixed Term Sodexo* Total Administration and estates staff 2, ,515 Health care assistants and other support staff 1, ,380 Medical and dental staff ,155 Nursing, midwifery, health visiting staff & learners 4, ,680 Healthcare Science and Other Scientific, therapeutic and technical 2, ,638 staff All employees 11,719 1, ,368 *Some of our administration and estates staff are managed by our facilities management partner Sodexo. In 2015/16 the split between female and male employees was: Female: 10,544 Male: 2,824 The gender split for senior managers (defined as anyone who reports to an Executive Director) and Directors was: Female: 22 Male: 13 Our Board of Directors, including Non-Executive Directors, had a gender split of: Female: 8 Male: 12. The staff sickness absence rate for 2015/16 across the Trust was 4.71%. Staff policies and actions during the year Offering opportunities to disabled people The Trust is positive about employing disabled people and our recruitment and selection procedure includes provision to ensure that all discriminatory practices are avoided. We require Trust employees to comply with all appropriate policies and procedures, including the equality and diversity policies, when recruiting staff. The Trust is a user of the Disability Symbol and is committed to providing an interview to any disabled application who meets the minimum criteria for a job opportunity and will conisder them on their abilities. 79

80 Candidates will also be asked whether they require any adjustment to enable them to attend and participate fully in the interview process. Supporting all colleagues CMFT has a range of employment policies, procedures and guidance documents which support our staff and managers during their employment with us. The policies and procedures framework provides advice, guidance and practical support on the effective management of a range of areas including sickness absence, learning, development & training, organisational change and overall terms and conditions of employment. This advice and support is underpinned by the provision of toolkits and training courses for a range of key employment policies and procedures. The policy framework is underpinned by the Equality & Diversity in Employment policy, which applies to all aspects of the Trust s relationship with our staff and the relationships between staff at all levels. It also supports the delivery of our Equality, Diversity & Inclusion strategy. Consulting with and informing our staff The Trust is committed to working in partnership with staff side colleagues through forums such as the Trust Joint Negotiation and Consultative Committee and the Joint Local Negotiating and Consultation Committee. We also have a range of internal communication channels including a staff- only intranet, weekly e-newsletter (Wednesday Weekly News) and monthly Team Brief. We are also committed to a culture of safety and learning in which everyone feels able, empowered and safe to raise a concern and for these conversations to take place as part of everyday practice, without fear of blame or reprisal. CMFT has a zero tolerance approach to bullying and in October 2015 we launched an updated Raising Concerns Policy. Involving our staff in our performance. We encourage staff to participate in CMFT s performance through involving them in delivering key objectives and engaging them in sharing their views. This is achieved through two main channels the annual staff survey, which asks all staff members a number of questions about their working environment, and quarterly staff opinion pulse checks which are a good indicator of staff engagement. In 2015, our staff survey scores show real progress and improvement, despite the intense challenges we have been facing, and this is a reflection of the energy and effectiveness of all of our staff. Looking after staff health and safety. The Trust's Safe, Effective, Quality Occupational Health Service (SEQOHS) accredited Occupational Health Service provides confidential and impartial health advice to staff and to line managers to protect and promote their health, safety and well-being at work. This is done in a number of ways including: 80

81 o management referrals assessments to support attendance and fitness for work; o providing advice on rehabilitation and adjustments at work; o Immunisations and vaccination screening programmes; o clinical management of staff who sustain accidental inoculation injuries; o workplace risk assessments and health surveillance programmes; o Therapeutic interventions including counselling, physiotherapy and osteopathy. Our annual influenza vaccine campaign has taken place successfully, working jointly with vaccinators in each Division, to protect patients and staff. 72% of health care workers providing direct patient care came forward to be vaccinated. This compares against a national average of 47% Chief Executive Sir Michael Deegan (seated) and Board colleagues (l to r) Julia Bridgewater, Bob Pearson, Adrian Roberts and Gill Heaton launched the flu vaccination campaign. The Health & Safety service have supported the introduction of safer sharps. In summer 2015 safer sharps were introduced for blood collection, insulin pens and arterial blood gas syringes. The new one-day Managing Health & Safety course was launched in June To date, 180 managers have attended the training. The moving and handling training provided for staff has also been further developed to provide targeted support. The Staff Support Service provides support to individuals and teams on managing under pressure and maintaining healthy and effective team working. 81

82 The service continues to develop new ways to support staff including a Computerised Cognitive Behaviour Therapy (CCBT) programme, and also provides training to promote psychological health and wellbeing, whether personal or work-related. These include Stress and Wellbeing Workshops; Mindfulness Drop in Sessions; Performing Under Pressure; Resilience Training for Managers & Senior Clinicians; and Managing Mental Health at Work. Countering fraud and corruption. The Trust is committed to reducing the level of fraud, bribery and corruption within both the Trust and the wider NHS and aims to eliminate all such activity as far as possible. The Trust has an Anti-Fraud, Bribery and Corruption Policy which encourages anyone having reasonable suspicions of fraud, bribery or corruption to report them. It is also CMFT s policy that no employee will suffer in any way as a result of reporting reasonably held suspicions. All members of staff can therefore be confident about reporting their suspicions. This protection is given under the Public Interest Disclosure Act, which the Trust is obliged to comply with NHS Staff Survey results In 2015, a random sample population of 850 CMFT staff were asked to complete the annual NHS staff survey. Nationally the response rate decreased from 42% to 41%. The CMFT response rate decreased from 44% to 42%, but remained above the national average. Response rate Trust National National Trust average average 44% 42% 42% 41% Trust improvement or deterioration CMFT achieved a response rate of 42% which is 2% lower than 2014.This was 1% above the national average of 41%. Summary of performance Since 2014 there has been a statistically significant increase in staff recommending CMFT as a place to work or receive treatment; from 3.63 to This is ranked above the average for all Acute and Community Trusts which is When considering all 33 key findings, the Trust is now better than average for 17 out of the 32 indicators and below the average for 4 indicators. Since the 2014 staff survey there has been a statistically significant positive change to 4 key findings and there are no statistically significant negative changes in key findings. The tables below detail our best and worst scores when compared to other Acute and Community Trusts in England. 82

83 Top 4 Ranking Scores 2015 KF29. Percentage of staff reporting errors, near misses or incidents witnessed in the last month KF8. Staff satisfaction with level of responsibility and involvement KF6. Percentage of staff reporting good communication between senior management and staff KF11. Percentage of staff appraised in last 12 months Trust Acute and Community Trusts Trust Acute and Community Trusts 93 N/A* 94% 90% 3.91 N/A N/A 39% 30% 84 N/A 93% 86% *The Acute and Community Trust group was created in 2015 and so there are no computed figures for 2014 to compare 2015 performance against. Bottom 4 Ranking Scores 2015 Trust Acute and Community Trusts Trust Acute and Community Trusts KF28. Percentage of staff witnessing potentially harmful errors, near misses or incidents in last month 32% N/A* 34% 29% KF23. Percentage of staff experiencing physical violence 4% N/A 3% 2% from staff in last 12 months KF24. Percentage of staff/colleagues reporting most 66% N/A 50% 52% recent experience of violence KF20. Percentage of staff experiencing discrimination at 10% N/A 11% 10% work in last 12 months *The Acute and Community Trust group was created in 2015 and so there are no figures for 2014 to compare 2015 performance against. Trust improvement or deterioration Improvement by 1% Improvement by 0.10 Improvement by 7% Improvement by 9% Trust improvement or deterioration Deterioration by 2% Improvement by 1% Improvement by 16% Deterioration by 1% Staff Engagement Score Over the last 12 months several initiatives have been rolled out in an attempt to address key staff concerns, such as survey confidentiality, as well as providing additional ways throughout the year for staff to feedback their opinions through a number of mechanisms including the staff survey, staff family and friends test and corporate and local staff engagement sessions. 83

84 We also introduced quarterly staff pulse checks that enabled staff to give their views on how likely they would be to recommend our Trust as a place to work and receive treatment, whether safety and quality was a priority and how well our values were being lived by us all. Receiving feedback throughout the year enabled us to act more quickly to address any concerns or ensure good practice is shared. We launched our you said we did campaign to raise awareness and further enable staff to get involved in making improvements based on issues they have raised. Many actions have been taken as a direct result of staff suggestions and this has led to the increase in our overall staff engagement score from 3.76 to 3.89 which is better than average for Acute and Community Trusts and in the top 20% for all Acute Trusts. Listening to all our staff is a key part of the engagement process Improvement plans We have identified a number of key goals that we aims to achieve by the next annual staff survey, through the delivery of divisional and Trust-wide action plans. These are to: Continue to improve the staff response rate to ensure it is either equal to or above the national average Improve the staff engagement score, but as a minimum keep within the threshold for the highest 20% of acute trusts, and to do the same for those key findings where this was achieved this year Continue to increase the number of key findings scoring in the 20% of all acute trusts by a minimum of 10% Have no key findings in the bottom 20% of acute trusts. Achieve improvements in the areas where staff experience has deteriorated. 84

85 During 2015/16, several initiatives have been rolled out in an attempt to address key staff concerns and provide additional ways to engage with staff, and these will continue in 2016/17: the introduction of quarterly staff opinion pulse checks to assess and understand progress involving over 300 staff in Transformation/Organisational Development workshops introducing Divisional walk rounds to increase the visibility of senior staff the creation of Divisional newsletters increasing the availability of health and wellbeing initiatives. Expenditure on consultancy During the year the Trust spent 1,640k on consultancy ( 2,442k in 2014/15). Off-payroll engagements The Trust seeks assurance in respect of tax arrangements of individuals engaged off-payroll and the information is recoded centrally. No individuals with significant financial responsibility will be engaged off-payroll. For all off-payroll engagements as of 31 March 2016, 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. 1 No. that have existed for between one and two years at time of reporting. 0 No. that have existed for between two and three years at time of reporting. 1 No. that have existed for between three and four years at time of reporting. 1 No. that have existed for four or more years at time of reporting 3 For all new off-payroll engagements, or those that reached six months in duration, between 1 April 2015 and 31 March 2016, 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 2015 and 31 March No. of the above which include contractual clauses giving the trust the right to request assurance in relation to income tax and National Insurance obligations 1 No. for whom assurance has been requested 1 Of which: No. for whom assurance has been received 0 No. for whom assurance has not been received 1 No. that have been terminated as a result of assurance not being received. 0 85

86 For any off-payroll engagements of board members, and/or, senior officials with significant financial responsibility, between 1 April 2015 and 31 March 2016 Number of off-payroll engagements of board members, and/or, senior officials with significant financial responsibility, during the financial year. Number 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 off-payroll and on-payroll engagements

87 87

88 2.4 Activity Reports Sustainability, Equality and Research Sustainability Report We are committed to being a leading sustainable healthcare organisation. Our Sustainable Development Management Plan (SDMP) priorities are: To reduce our carbon footprint by a minimum of 2% year on year, through a combination of technical measures and staff behaviour change. To embed sustainability considerations into our core business strategy. To work collaboratively with our key contractors and stakeholders to deliver a shared vision of sustainability. To comply with all statutory sustainability requirements and implement national strategy. Each year we spend over 10 million heating and lighting our Estate, providing water and disposing of our waste. In 2015/16 our annual carbon emissions from energy totalled 60,025 tonnes. We remain committed to delivering an ambitious programme of improvements across our key sustainability work areas to minimise our environmental impact, and work towards the 2050 target of an 80% reduction in carbon emissions. This section highlights some of the work we have delivered this year towards our SDMP (which you can download at Celebrating our success We have continued to be recognised for our innovative and engaging approach to sustainability with success in the following national awards: Highly commended in Healthcare Services Journal (HSJ) Value in Healthcare Awards, Energy Efficiency category, 2015 Finalists in the NHS Sustainability Day Awards 2015, in the Waste, Behaviour Change and Travel categories Highly commended in the HSJ Awards, Improving Environmental and Social Sustainability category, Energy efficiency Overall energy usage has remained similar to the previous year, although we have seen an increase in the intensity of activity on site and addition of new equipment and facilities. We have benefited from a relatively mild year and low energy prices which has meant that energy costs have reduced by 3%. We continue to deliver our ambitious programme of investment in energy efficiency schemes, focusing on energy efficient lighting, building management system optimisation and improvements to plant room and pipework insulation. We are currently investigating measures to reduce energy use at peak times, with plans to implement this strategy for winter 2016/17. A series of energy audits has taken place both during the daytime and at night, with an ongoing action plan of improvements being implemented. 88

89 Carbon (tco2e) Bright ideas We are investing in a rolling programme of lighting replacement, with more efficient LED fittings saving up to 75% of the energy consumption of standard fittings. Water consumption has decreased by around 6% since 2014/15, as a result of a focused effort to promptly locate and repair leaks. Resource 2013/ / /16 Use Gas (kwh) 122,293, ,819, ,558,234 tco 2e 25,943 23,880 24,035 Oil Use (kwh) 566, , ,382 tco 2e Coal Use (kwh) Electricity Green Electricity tco 2e Use (kwh) 63,388,584 62,552,551 62,374,160 tco 2e 35,492 38,741 35,860 Use (kwh) tco 2e Total Energy CO 2 e 61,616 62,774 60,025 Total Energy Spend 9,127,425 8,467,257 8,154,532 Water 2013/ / /16 Mains m tco 2e Water & Sewage Spend 937, , ,327 Carbon Emissions - Energy Use 80,000 60,000 40,000 20, / / /16 Gas Oil Coal Electricity 89

90 Weight (tonnes) Waste Our total waste volumes have decreased by 4%. Due to changes with our waste management contractors, and contamination of the general domestic waste stream with food, our recycling rate has reduced from 40% in 2014/15 to 17% in 2015/16, and waste to landfill has increased. Significant activities this year have included: In January 2016, launching Warp It, an innovative new way for staff to offer surplus or unwanted items to other departments, and find items they need for their own departments. All food waste now going to an off-site anaerobic digestion facility and being converted to renewable energy. We have increased segregation of this stream by over 214%. We are also identifying ways to reduce overall volumes of food waste. Improving waste segregation through further roll out of a tiger bag offensive waste stream, for non-infectious healthcare waste. This waste stream costs around a third less to treat than infectious waste and has a much lower environmental impact. We now produce 1 bag of tiger (offensive) waste for every 2 bags of orange (infectious waste), down from 1:5 in 2014/15. Launching a bespoke waste e-learning package, primarily focused at clinical staff. Waste 2013/ / /16 Recycling (tonnes) tco 2e Re-use (tonnes) tco 2e Compost WEEE High Temp recovery High Temp disposal Nonburn disposal Landfill (tonnes) tco 2e (tonnes) tco 2e (tonnes) tco 2e (tonnes) tco 2e (tonnes) tco 2e (tonnes) tco 2e Total Waste (tonnes) % Recycled or Reused 45% 40% 17% Waste Breakdown Recycling Re-use Compost WEEE High Temp recovery High Temp disposal Non-burn disposal Landfill Total Waste tco 2 e

91 Sustainable Travel In February 2016 we approved a new Sustainable Travel Plan, setting out ways to achieve 10% of our staff changing to more sustainable and active travel modes by This year we have invested significant resources into improving cycling facilities for staff, with the opening of our second cycle hub facility at Grafton Street Multi Storey car park, providing cycle and clothes lockers, shower facilities, changing area and drying facilities. Specific activities delivered this year have included: Installation of two public bike pumps, and two new secure cycle storage facilities at our Central and Dental Hospital sites, with grant support from Transport for Greater Manchester (TfGM). Cycle maintenance sessions are now held monthly and we ve continued to host the monthly cyclists breakfasts with our Corridor Manchester partners. In late 2015, we started to offer a free personalised travel planning (PTP) service to all new starters as part of our induction programme. Launching a new electric shuttle bus service, moving patients and visitors from the two multi storey car parks on the Central site. Continuing to deliver the subsidised 147 hybrid bus service, linking Piccadilly Station and the Central site. Demand for our electric vehicle charging points has increased, and we are planning to increase the number of charging points at our sites in Work is now underway on the Oxford Road Bus Priority Scheme, and in the near future the road will be closed to general traffic between 6am and 9pm. We have been working closely with TfGM and the Corridor Manchester partners to communicate and minimise disruptions as a result of the associated roadworks. 91

92 Staff engagement and communications We remain committed to raising awareness across the organisation to reduce energy, water and waste and engage staff in sustainable behaviours. Thirty teams took part in our nationally recognised NUS (National Union of Students) Green Impact programme in 2015/16. Over 2,000 environmental improvement actions and 130,000 of cost savings were delivered. The Little things, big difference campaign has continued to gain momentum across the Trust, with a new set of posters being produced along with a short film to raise awareness of the benefits to staff being involved in the Green Impact programme. Bright ideas Ian Wilde from the Renal Team identified savings of over 13,400 by optimising settings on the automated sterilisation process for renal dialysis equipment, generating annual savings of over 400,000 litres of water and 25,000 kwh of electricity. Sustainable procurement The managed print project is now fully operational with the number of printers across the site reduced by around 75%. With default double-sided printing, energy saving mode devices and a reduced number of machines, this significantly reduces the carbon footprint of the Trust s printing requirements. Full inventory tracking of medical products is now in place across the Children s Hospital theatres, with further rollout planned. This means that accountability across the supply chain is improved and stock loss has significantly reduced. Work is also underway to procure better value waste contract arrangements, with the process expected to complete in mid Bright ideas Staff Nurse Anant Gurav, from our Withington Cataract Centre, identified improvements to theatre packs by suggesting amalgamating commonly required items into a single pack. This initiative reduced carbon footprint, minimised packaging waste and saves around 10,000 per year. The idea has now been replicated across our hospitals, with others now requesting the Withington Pack. 92

93 NHS Good Corporate Citizenship Assessment We use the NHS Good Corporate Citizenship Assessment to measure and benchmark our sustainability performance. In February 2016, we achieved a score of 64% which is an improvement of 3% against the 2015 score of 61%. Key areas of improvement include travel, facilities management and models of care. 93

94 Equality, Diversity & Inclusion Report (ED&I) 2015/16 in numbers 2533 opportunities for young people to get involved visit or work with CMFT 170 Equality Advocates recruited 450 people and organisations consulted as part of setting the Equality, Diversity & Inclusion Strategy 76.3% our patients live in Greater Manchester 11% of Trust workforce comes from the five wards in Central Manchester 32% of our workforce comes from the Manchester local authority area 87% of our workforce comes from Greater Manchester, covering the 10 local authorities 227 people have accessed our clinical pre-employment scheme and been guaranteed an interview, 76% of whom gained employment in the Trust 125 apprenticeships ran during this year 775 work experience placements run every year 382 young people attended the Young People s Open Day 400 Equality Impact Assessments were undertaken We carried out around 41,000 face to face translation appointments for our patients, covering 100 languages. Governors Our Governors continue to play a vital role in representing the interest of the communities we serve. They support a wide range of activities and events such as the Youth Forum and Children s Learning Disability Network. To help Governors in their roles we have also provided in house equality and diversity training. Case study: Governor involvement in widening participation Corporate citizenship is a crucial part of the Trust s values and how we operate through socially responsible policies from employment and procurement to energy and waste management. Sue Webster, a Governor since 2009, has chaired the Governor Corporate Citizenship Working Group and championed this work. Sue said: As a public governor for Manchester I have been proud to chair the Governors Corporate Citizenship Group. The Group champions and monitors the performance of initiatives it believes can make a real difference to the Trust and the diverse communities it serves. High on our agenda is widening participation rates, improving the Trust s recruitment of local young people and those with disabilities in particular. Improving access to meaningful paid work for these groups has been achieved through the dedicated efforts of the Trust and the support of other partners in the city. The figures speak for themselves. This programme has led not only to a doubling of employment rates for those with disabilities, but also the number of young people in employment between rising, and improved recruitment processes at the Trust. The Trust has been recently recognised for this initiative by NHS Employers. 94

95 To ensure that the Trust s Governors and members are representative of the communities we serve, we monitor our membership to highlight areas of underrepresentation and actively recruit members from these groups. Recruiters go to a wide range of local community venues (such as health centres and mosques) and network with faith groups and key community groups to ensure we are being inclusive in our member recruitment process. The CMFT Membership Team have used the Patient Experience Team s Seldom Heard Groups database when mailing out Annual Members Meeting, Young People s Event and Membership promotional materials, to ensure that these groups get to hear about CMFT activities and have the opportunity to come along. ED&I External Review Group We have established a CMFT Equality, Diversity & Inclusion External Review Group. This group works in partnership with us to ensure that we understand the needs of all our stakeholders. The group provides external scrutiny to our work and draws on advice from equality experts. Its includes representatives from the Black Health Agency, Trafford Diverse Partnerships, LGBT Forum, Faith Network 4 Manchester, Manchester s Carers Forum, Breakthrough UK, our Clinical Commissioning Group, Manchester City Council and Manchester University. Equalities Implementation Group This group brings together staff from across CMFT and plays a key role in delivering key objectives, implementing the Trust s ED&I Strategy and sharing good practice. This year, it has focused on the development of a new three-year ED&I strategy for CMFT. In May 2015, we proposed a vision and key priorities that we felt were important to CMFT, our staff, patients, carers, visitors, Governors, volunteers and the communities we serve. We talked to 450 people and organisations either at big events, staff meetings, face to face or online. From this consultation, we made changes to the proposed strategy and in November 2015 the Board approved it. Our vision is: Valuing the voices of our diverse people to be the best we can. To make it a reality, we will aim to Be accessible to all Listen and respond to all our people Benefit from the diverse skills and knowledge of our people Work in partnership to provide opportunities for our communities to live healthy lives. To download the strategy, please go to: We will be launching our action plan and measurement framework in May 2016 as part of ED&I Week. The Accessibility Board In 2015 we established a new board to ensure that CMFT is accessible and user friendly for all the people who visit our sites. The purpose of the group is to: To oversee the development of plans to improve accessibility for all users of CMFT sites To provide strategic direction to the Trust and the work streams 95

96 Once plans are in place, to monitor progress against the plans To escalate all major risks to the Risk Committee Work with patients, staff and the community to audit CMFT s accessibility for all user groups Ensure compliance with the Accessible Information Standard The working group is accountable to the internal Operational Management Group and is chaired by the Director of Property & Facilities. Equality & Diversity Co-ordinators The Trust has a team of Equality & Diversity Coordinators who work across all divisions and corporate services to act as a link on ED&I issues. Their main role is to provide leadership within a division or service by: Ensuring key equality and diversity messages are shared Supporting managers and staff within the division/service on improving equality and diversity Supporting the production and implementation of equality and diversity action plans Collating and submitting evidence for the NHS Equality Delivery System Making equality and diversity part of our day-to-day business All co-ordinators receive training through a foundation programme delivered by our Service Equality Team. Equality Advocates CMFT s equality advocate programme is a new and exciting initiative that has helped to promote and raise the profile of ED&I. The programme was initiated in July 2015 and has been extremely successful so far, recruiting over 170 members of staff from a wide range of backgrounds and job roles. An equality advocate is a member of staff who is committed to the principles of ED&I and is willing to play a vital role in promoting the agenda in their own workplace. The programme has been supported by the Board, with particular input from Chairman Steve Mycio and Non-Executive Director John Amaechi, who is the ED&I lead on the Board. The equality advocates receive a range of support to help them carry out their role including support from their Divisional Equality and Diversity co-ordinators and deputies. They also receive an extensive training programme from the ED&I team. The advocates have introduced different ways of promoting equality and diversity in their workplace such as celebrating Chinese New Year and Black History Month as well as raising awareness of issues related to disability. 96

97 Some of our CMFT Equality Advocates Staff Networks We have a thriving network of staff groups including the Black and Minority Ethnic (BME) Staff Network, the Disability Staff Network and the Lesbian, Gay, Bisexual and Transgender (LGBT) Staff Network. This year a new BAME Nurses Professional Forum was established. The networks have been involved in wider equality initiatives within the Trust and have worked hard to increase their membership and create a better understanding of their role in the Trust. The BME network was nominated for the Excellence in Diversity Awards Case study: LGBT Network leads CMFT presence at Manchester Pride Our LGBT network, working alongside our NHS colleagues across Manchester, has been involved in Manchester Pride over the last few years. It s a great opportunity to show our solidarity with the LGBT community of Greater Manchester and have some fun. CMFT s LGBT network organised an army of volunteers to walk in the parade, support the LGBT Forum in caring for people throughout the Pride events and promote healthy messages to the community. Once again in 2015 Manchester Pride was a great success and the NHS were proudly represented in the march and as volunteers throughout the weekend in August

98 Youth Forum at Royal Manchester Children s Hospital (RMCH) Children and young people who use health services have very specific needs and CMFT believes that no-one is better placed to tell us what it feels like to be a child or young person in hospital than young people themselves. Established in 2002, the Youth Forum is now in its 13 th year. Over those 13 years members have provided invaluable input to the development and delivery of hospital services for children and young people. Achievements include contributions to the design of the new Children s Hospital as well as active involvement in seeking feedback from patients so that we can keep improving the care we provide to young people. Reporting & Assurance The Trust uses the NHS Equality Delivery System (EDS 2) to report and assure our work on Equality, Diversity & Inclusion. EDS focuses on our service to patients and aims to improve access to services; the experiences of those using our services and outcomes for patients. It also helps us to improve equality and diversity for staff working in the Trust. There are four levels of performance: 1. Excelling 2. Achieving 3. Developing 4. Underdeveloped In 2014/15 through our rigorous internal verification process, three out of our nine clinical divisions were assessed as Achieving. The remainder our divisions and corporate services were assessed as Developing. All of our divisions that were assessed as Developing were making process towards Achieving. The internal verification exercise for 2015/16 is underway, and progress has been made in all our divisions and corporate services. The indication is that at least as many if not more of our clinical divisions will be assessed as Achieving, compared with the previous year. What this means in practice is that our services are improving their accessibility to a wider range of people. We continue to improve the experience that people have of using our services and outcomes for our patients and other service users. CMFT as a public body has a legal duty to advance equality under the Equality Act As part of this duty the Trust assesses the effect or possible effect all new and updated polices might have on equality, as well as any changes to services. We assess these effects by using an Equality Impact Assessment (EqIA) process. During 2015/16, 400 EqIAs were completed across a range of new polices, revised policies and service changes. We continually review the EqIA process to ensure that it takes any recent legal development into account and is easy to use for all Trust staff who need to undertake an EqIA. Equality, Diversity & Inclusion for our patients The Trust analyses key diversity data for its patients across our inpatients, outpatients and emergency services. The diversity of our patients reflects the communities that we serve. 98

99 For information on the diversity of the outpatients and emergency attendances please go to our website The data is published each year at the Trust Annual General Meeting. Interpretation and Translation Service CMFT continues to place a high importance on ensuring our services are accessible to people speaking no or limited English. The Trust s Interpretation and Translation Service provides 24 hour, face to face and telephone interpreters. We also provide document translation services using qualified translators who are members of relevant professional bodies. In 2015/16, the service carried out around nearly 41,000 face to face interpreting appointments covering 100 languages (an increase of 5.7% in activity on the previous year) and over 8,200 telephone interpretation appointments covering 59 languages. The service also carried out 221 document translation requests covering 34 languages. Patient support case studies: Across the Trust our teams are working hard to deliver and develop services that meet the needs of all our patients. Here are some examples of good practice in action. Case study: Working with BME patients in Orthotics Sharon Chambers, Orthotics Co-ordinator, identified that the wigs and hosiery didn t meet the needs of our BME patients. Working with patients she contacted the suppliers and discussed the needs of BME patients with them. She visited the supplier outlet and worked with the team to develop samples. The first set of samples she felt didn t meet the standards she expected for her patients. Once a set of samples had been identified that were of high enough quality, she worked with a patient to make sure they looked right and found something that looked realistic. Sharon said: When working with patients who have had cancer or faced hair loss I wanted to be able to provide them with a wig that made them feel confident. As well as dealing with all the other challenges their illness brought, I wanted them to feel good about how they looked and cared for by CMFT. This solution is now part of the standard support offered to all patients through the Orthotics Team. Sharon has also worked with the suppliers of the hosiery provided through CMFT to ensure that it is supplied in a wide range of skins tones so that it meets the needs of our diverse patients. 99

100 Case Study: Community Learning Disability Team and Radiology working together to support patients with learning disabilities. Attending scans at hospital sites can be very challenging for patients with learning disabilities. Our community teams and Radiology department have been working with patients, their families and carers to help them feel safe and supported during their scans. Members of the community Learning Disability team were able to support patients understanding through the use of pictures and the drama therapist spends time with patients to help them understand what is happening. The Radiology team allocate extra time for patients, so supportive reasonable adjustments can be before and during the scan. The teams have had positive feedback from families and carers about the support they give to the patients. The Community Learning Disability team provide support for their patients during their hospital treatments from surgery to dialysis. This is a key part of their role in reducing the health inequalities that people with learning disabilities face. CMFT also provides a wide range of opportunities for patients to help them be proactive about their own health. The major reception areas are used to promote health awareness campaigns, and we encourage patients/visitors to access wider support, for example through promoting local Carers Support Groups. Equality, Diversity & Inclusion for our colleagues CMFT is working hard to ensure all its staff feel included, supported and empowered. The Trust continues to roll out a wide range of programmes that offer support, provide opportunities and monitor impact. We want our workforce to represents the population it serves and we continuously collect and review staff data to help to understand our workforce. This information is used to make sure that the Trust s employment practices and recruitment processes are fair to everyone. The data is published each year at the Trust s Annual Members Meeting. Workforce statistics 2015/16 There continues to be no significant change to the age profile of our workforce with 99% of the Trust workforce aged 22+. The percentage split between male and female staff has stayed the same over the last three years. Approximately 74% of our workforce is White. 17% are from a Black and Minority Ethnic (BME) background. 9% of the staff have not stated their ethnicity. 2% of staff have recorded a disability. However, this data does not truly reflect the number of disabled staff within the organisation as staff do not have to disclose this information. 100

101 Staff 2014/15 % Staff 2015/16 % Age % 0 0% % 145 1% % % Ethnicity White % % Mixed 268 2% 284 2% Asian or Asian British % % Black or Black British 622 5% 668 5% Other 189 1% 206 2% Not Stated % % Gender Male % % Female % % Not Stated Recorded Disability 260 2% 269 2% (Information extracted from staff database on 31 st March 2016) After extensive consultation, the NHS Equality and Diversity Council agreed an NHS Workforce Race Equality Standard (WRES) which came into effect in April The standard requires the Trust to demonstrate progress against a number of indicators of workforce race equality. In line with the key WRES milestones agreed by NHS England, the Trust published baseline information in June 2015 ( We have an implementation group looking at how to support BME staff across the Trust. On 19 th May 2015, we ran our third CMFT Diversity Conference, attended by over 180 delegates from both CMFT and our external partners. This year s conference led with the theme Diversity Delivers - Our Story. This built on the feedback from previous conferences that hearing other people s stories made the biggest impact to delegates. The speakers invited were selected for the interesting and diverse stories they had to tell and how they could help the audience consider their own diversity as well as the people they support or care for. Training and development The Trust provides a wide range of training and development for staff. There is both mandatory training as part of staff development and also regular opportunities for staff to develop their understanding of diversity. In addition, an Equality and Diversity Workshop to increase the knowledge and skills of line managers around Equality in Employment is delivered bi-monthly. Equality, diversity and human rights training are part of CMFT s mandatory training programme, which all staff must complete on an annual basis. CMFT s mandatory induction programme also includes Equality, Diversity & Inclusion training. We run induction training for new staff twice a month throughout the year, in addition to local induction for staff, and provide bespoke programmes for key staff. 101

102 Every year we hold an Equality, Diversity and Human Rights Week, which coincides with NHS Equality, Diversity and Human Rights Week in May. The 2015 Week consisted of 40 activities organised by divisions and corporate services. Activities were designed to raise understanding of equality, diversity and human rights issues for both patients and staff. The activities also helped to develop the skills of staff in this area. CMFT also hosts an annual Equality and Diversity Autumn Roadshow. The 2015 Roadshow consisted of six half-day events, offering between three and nine 45 minute micro training sessions. Both the Week and Roadshow support our staff to learn about how they can positively contribute to the support and services we provide to our diverse patients. Inclusion for our colleagues and the community The Trust delivers a range of well-established and successful educational, employment and positive action programmes for people of Manchester and Trafford. These programmes help us to employ a diverse and representative workforce that in turn delivers better patient care. We also work to inspire and support the aspirations and career goals of local young people. The economic prosperity and regeneration of the neighbourhoods in which we operate has been a longstanding priority and the programmes we deliver illustrate the commitment to the health, wealth and wellbeing of the communities we serve and operate within. CMFT is committed as a local employer, as well as a public body, to help provide solutions to these social and economic challenges faced by the communities we serve. Our widening participation work will also nurture and inspire CMFT s future workforce. We have also developed a wide programme of education and employment programmes to support local young people, develop skills as well as gain employment. In recognition of the progress we have made in supporting young local people into employment, CMFT was invited in 2015 by NHS Employers to create a best practice case study and short film to support the national NHS Think Future Workforce Development Initiative. Pre-Employment Programmes (PEPs) These programmes are the main recruitment initiative that supports our longstanding and on-going commitment to employ local people of all ages. The PEPs cover both clinical and non-clinical roles, and begin with a quarterly open day open to all members of the local community who wish to find about more about roles in the NHS and at the Trust. 102

103 The main features of the programmes are: an enhanced work placement opportunity, accredited learning, bespoke sector-specific training, employability skills and a guaranteed interview on successful completion of the role. Employment gained through the PEPs is mainly permanent, part or full time at bands 2-4. All clinical posts involve an intensive apprenticeship on commencement. Clinical PEP 2015/16 Number of people taking part: 193 Number under 25: 105 Number of people who completed the programme: 140 Number of people obtaining employment: 120 (85%) This PEP is aimed at local people who wish to explore a career in healthcare in one of the most challenging, yet rewarding roles as NHS (Trainee) Nursing Assistant. The 8-week programme is delivered in conjunction with The Manchester College, Skills for Health and supported by Job Centre Plus. It gives participants an overview of the Nursing Assistant role and of what life is like working in a hospital environment. The PEP also offers participants the opportunity to undertake a short work placement in a ward or other hospital setting. Participants who complete all aspects of the programme successfully are then offered a guaranteed interview for the role of trainee nursing assistant. Non-Clinical PEP 2015/16 Number of people taking part: 34 Number under 25: 30 Number of people who completed: 24 Number of people obtaining employment 19 (79%) This programme is aimed at local young people who wish to explore a career in non clinical roles such e.g. Administration, IT, Health Care Sciences. A work placement of up to 8 weeks is offered to participants, supported currently by Job Centre Plus and the Prince s Trust. Participants learn and participate in all aspects of the role, including undertaking relevant specialist training and a guaranteed interview offered. Support to apply for vacancies at CMFT is then offered to all successful participants. Apprenticeships 2015/16 Number of people taking part: 125 Number under 25: 35 We have been delivering apprenticeships since 2011 across the nursing and midwifery profession for those working as trainee nursing assistants. We have enrolled over 460 apprentices on the programme, with approximately 180 learners involved at any one time. All those commencing an apprenticeship are given a minimum of 12 months to complete a Level 2 Apprenticeship and 18 months for a Level 3. We have a very successful track record of completions with achievement of over 90% success rates. Over the next 12 months we are aiming to double the numbers of apprenticeships, providing further capacity to offer more opportunities for our large numbers of administration and clerical staff. 103

104 Training is tailored to meet the demands of the role, and the manager, and the learner is supported throughout the life of the programme both on and off the job. The programmes are offered to existing employees and there are no age restrictions, although we are proactive in our engagement with the local school leavers who perhaps leave school with few or no qualifications and are seeking alternative employment options. The scheme links in closely with the PEP team and offers those candidates who have completed the clinical programme a guaranteed interview for a trainee nursing assistant post. Supported Internship Programme We believe every young person should have the opportunity and support to obtain their dream job. CMFT therefore delivers Supported Internship Programmes for Manchester and Trafford residents who have a learning disability and are aged Both sites enable young people with moderate to severe learning disabilities to gain experience and develop employability skills in a real work place, surrounded by other working people. The key aim is to help the young people gain paid employment after the programme. Supported Internship Programme Number of people taking part 70 Number of extended work placements offered: 210 Number of people who completed 68 Number of people obtaining employment 44 (65%) Retention of employment at one year 93% The trust s commitment to supporting disabled young people is demonstrated by the high employment outcomes achieved, the number of bespoke placements offered and by our proactive contribution every year to hosting or attending an employer event. For 2015/16 these have included the regional Disability Confident employer event, where a Trafford intern presented to the employers present. Two previous interns also spoke at the NHS Learning Disability Employment Engagement event, presenting their advice on best practice for becoming an accessible employer for people with disabilities to NHS employers. CMFT has also developed positive action interventions such as working interviews, accessible induction and bespoke training for staff and managers to continue to support the inclusion of disabled talent within our workforce. Work experience and links with local schools and colleges Our work experience programmes are aimed at providing opportunities for people to spend time with us to develop their understanding of the roles in the NHS, develop their confidence and add to their CV s. They also enable us to help inspire ad develop the future NHS workforce. We offer one-week clinically based work experience to students from our local schools/ colleges who are interested in careers in nursing or other healthcare professions. 104

105 Work experience placements 2015/16 Number of people taking part: 775 Number under 25: 758 Students apply to us via their school/college and are accepted for placements so long as they can demonstrate a genuine interest in the area they have chosen for placement. Case study: Greater Manchester NHS Careers Hub A key development in the provision of careers and engagement opportunities is the establishment of a Greater Manchester NHS Careers Hub, led by CMFT. The Hub will exist to assist all stakeholders including schools, colleges, jobcentres and individuals to find about out the range of careers and opportunities available at NHS Trusts throughout Greater Manchester. The Hub will also signpost enquires, provide 1:1 advice and coordinate NHS staff involvement and presence at local careers and engagement opportunities. It will endeavour to ensure that access to opportunities is equitable and accessible to all Greater Manchester residents. For more information please contact careers.hub@cmft.nhs.uk Margot Johnson, Executive Director of Human and Corporate Resources at CMFT, said: This is a great opportunity for the NHS to reach people who want to find out more about all that the health service does. We are proud to be leading on this innovative partnership and look forward to offering opportunities to inspire and engage our future NHS workforce. Taste of Medicine Programme Number of people involved: 88 (68 in 2014/15) This is a week-long programme for A-Level students who are interested in a career as a doctor. Students apply via their college and rotate in half day sessions observing the role and work of various health care professionals. At the end of the week the students spend time talking to junior doctors about their role and their studies at the Manchester Medical School. CMFT has also taken part for the last two years in the regional Teen Tech Event. This event is designed to inspire local young people about working in science and technology Each year our Foundation Trust membership team organises a Young People's Open Day. To date, around 2,200 young people with their teachers, friends and parents have attended and not only gained an insight into our organisation, but also discovered more about career opportunities in the NHS, volunteering and work experience in our hospitals in addition to receiving health and well-being advice from our health experts. 105

106 The Social Mobility Foundation placement programme Number of people involved: 7 This is a work placement scheme specifically for A Level students aiming to have a career in medicine or a related profession who have been pre-selected by the criteria set by the Social Mobility Foundation (SMF). This is an organisation which aims to support disadvantaged gifted and talented young people in accessing higher education. The young people are then referred to the Trust to access addition work experience and exposure to work in a health care setting. Case Study: Placements and Summer Internships for Social Mobility students In addition to the valuable work experience placements offered to social mobility students, the concept of a summer internship was piloted in Supported by the Medical Secretarial Team in the Division of Clinical Sciences (CSS) a 6-8 week paid internship was advertised (after internal recruitment processes were followed), to local students who meet the strict criteria of the Social Mobility Foundation. After an extensive application and interview process Mandy Kenyon, Medical Education Lead and Assistant Directorate Manager (Anaesthesia) appointed two successful candidates, Abeni Adeyemi and Ahmed Abubakar. The students completed their internship successfully and have since gone on respectively to undertake a gap year and degree in medicine at The University of Manchester. Isobel Plant, Social Mobility Co-ordinator, North West and West Yorkshire, said: The SMF are very grateful to CMFT for hosting our students. The placements and internships provided were incredibly valuable and gave our students an opportunity that they would have otherwise have found difficult to secure. The opportunities were carefully tailored to the students interests and career aspirations, which will really enhance their university applications and help in financing university studies. Inspiring Minds Programme 2015 Number of people taking part: 12 Number under 25: 11 1:1 Bespoke guidance session 12 Bespoke mentoring sessions offered with specialist staff 5 Work placements 4 Paid work 1 CMFT recognises the barriers faced by young people in or leaving care to access vocational opportunities. The new Inspiring Minds pilot programme aims to support young people leaving care to access bespoke vocational opportunities with the Community Resourcing team. 106

107 Bespoke opportunities are offered, such as careers guidance, mentoring, work experience placements information on job opportunities, access to existing preemployment programmes, CV and application support and mock interviews, leading to interview opportunities where possible. A referral process is in place from local social work teams and individuals can also self-refer. Manchester Health Academy (MHA) engagement programmes Number of people taking part: (secondary school and sixth form) 563 As the main sponsor for the Manchester Health Academy School, the Trust delivers strategic support including active membership of the MHA governing body. Our operational support ranges from health careers related events, specific project support and interactive cross school curriculum enhancing activities to careers advice and enhanced work placement/employment opportunities. In addition to opportunities for students, the Trust supports the Academy by providing four senior leaders of the Trust as governors. These four Governors provide support for the financial scrutiny of the Academy, leadership and HR expertise, community engagement and links to key stakeholders across Manchester. Community engagement with the Army Reserve CMFT recognises the importance of supporting the armed forces, Army Reserve and their families. In 2016, we were proud to receive a Bronze Award from the Armed Forces Covenant Employer Recognition Scheme (ERS). In addition to supporting staff reservists to attend training and promoting Army Reserve opportunities to all staff, we are pleased to support an Army Reserve Apprentice Training Programme in partnership with Army Reserve Field Hospital 207 and Trafford College. After a successful pilot year, the programme supports Army Reserve Apprentices to gain practical clinical care skills on the Emergency Surgery and Trauma Unit at MRI. Volunteers programme Our Trust has 687volunteers on the Central Manchester site and 70 volunteers at Trafford Hospital. The volunteers reflect the communities we serve, with representation across ages, across all ethnic groups and within those acknowledging a disability. To ensure that our volunteer programme is reaching out to all our communities, the team have developed a system to ask and record volunteers details of their protected characteristics in a sensitive and confidential manner. The process has increased our knowledge of those who are volunteering, informed volunteer recruitment policy and highlights the need to offer volunteering to all those in our community. The volunteers provide vital support to our patients, whilst in turn many of our volunteers gain valuable experience of a hospital environment. This helps with college, university and job applications. 107

108 Research and Innovation Report We work with patients, universities, industry and others to take the best new ideas from cutting-edge science and use them to create real-life tests and treatments that benefit patients more quickly. Our research revolutionising treatment and changing lives Without the involvement of patients in our research, we wouldn t be able to deliver improved patient care. During 2015/16 8,759 patients and healthy volunteers participated in clinical research studies across our hospitals. Aged three years old Rumbi took part in a study to test a new treatment regimen for a rare kidney cancer. The findings from this study went on to change clinical practice and Rumbi, now 11 years old, is fit and well and hopes to become a paediatrician. I m looking forward to starting secondary school and working towards one day becoming a paediatrician myself. Rumbi Alan was diagnosed with diabetes aged 22, and initially didn t understand the importance of managing his condition which has led to problems with his eyes, feet and stomach. If every person who participates in research can save one person in the future from going through what they went through, then it s a positive experience. Alan Alan is now involved in a lot of diabetes support groups across Manchester including the Health Beat Diabetes, which aims to encourage people in Greater Manchester with diabetes to get involved with research. When George was diagnosed with immune thrombocytopenia (ITP) a rare blood disorder, his parents decided to take part in a research study trialling a new treatment. The Haematology team worked with us to really consider the treatment options available for George. Joanne (George s mum). As a result of the study, researchers have demonstrated for the first time the effectiveness of the treatment in children with persistent or chronic ITP. 108

109 Our patients are regularly the first-in-the-world to have the opportunity to trial new treatments, and even more are first in the UK. We aim to provide as many patients as possible with the opportunity to take part in research, which led to the development of a nationally recognised workshop to look at methods of how we can involve more patients from Black, Asian and Minority Ethnic (BAME) and hard to reach communities in our research. Research impact Dr Alexander Heazell co-authored the Lancet Ending Preventable Stillbirth Series. His research suggested that grief and symptoms of depression after stillbirth often endure for many years and the vital need to provide sensitive and respectful bereavement care. Results from the world s biggest ovarian cancer screening trial (UKCTOCS), involving Saint Mary s Hospital, suggests that screening based on an annual blood test may help reduce the number of women dying from the disease by around 20%. Manchester Royal Eye Hospital performed the first global implant of the Argus II bionic eye device in a patient with dry aged related macular degeneration. Collaboration delivering key infrastructure and networks In the last 12 months we have strengthened our networks and collaborations to help us develop the very best research infrastructure: Neil Hanley, Professor of Medicine at The University of Manchester and Honorary Consultant Endocrinologist at CMFT, was appointed as Clinical Head of the Research and Innovation Division. Part of Neil s role is to strengthen scientific links with the university, where he is one of only three Wellcome Trust Senior Clinical Fellows. In partnership with the Northern Health Science Alliance, CMFT and partners including the Manchester Academic Health Science Centre and The University of Manchester were announced as a regional centre of excellence in the UK Precision Medicine Network. The centre will work on locally driven programmes to develop innovative technologies and solutions for broader use in healthcare. Partners across Manchester, including Manchester Academic Health Science Centre, NIHR Clinical Research Network: Greater Manchester (hosted by CMFT) and Manchester Science Partnerships, came together to launch Health Innovation Manchester (HInM). As part of the region s devolution of health and social care HInM builds on existing expertise and assets in the area to speed up the discovery, development and delivery of innovative solutions to help improve the health of Greater Manchester, and beyond. R-Peak, the CMFT developed research database, has successfully been launched across 15 NHS partners that make up the NIHR Clinical Research Network: Greater Manchester. 109

110 The Local Portfolio Management System enables the efficient delivery and management of clinical studies, including finance, study progress and performance. The R-Peak team (l-r): Akinbode Ayanniran, Information and Data Manager; Craig Johnson, Head of Information Management & Technology, NIHR CRN: GM; Elizabeth Mainwaring, Research Support Manager; Emma Columbine, Clinical Trial Co-ordinator Department of Eye Research; Daniel Zamora, R-PEAK Project Manager; Mark Delderfield, Software Development Manager; Andy Fairclough, Research Support Officer. CMFT was a part of the Oxford Road Corridor Partnership of NHS, academic and other organisations which was successful in its bid to Innovate UK to secure the only award of UK City for the Internet of Things (Project name is Cityverve) with industry partners Cisco and BT. Dr Louise Hunter was awarded one of the first ever Peter Mount Awards, named after our previous Chairman, which provide support for doctors wanting to break into research. Louise has now gone on to receive a national Medical Research Council Clinical Research Training Fellowship to complete a PhD and launch her career as a researcher. Dr Charlotte Mahoney, Clinical Research Fellow in Urogynaecology at Saint Mary s Hospital was awarded a NIHR Doctoral Research Fellowship to explore the effects of childbirth on sensation and the link with pelvic floor dysfunction. Kylie Watson, Senior Midwife, Saint Mary s Hospital and Tope Adeniyi, Senior Clinical Embryologist, Department of Reproductive Medicine both secured NIHR Clinical Doctoral Fellowships, which will support them to conduct research whilst continuing clinical practice. 110

111 2.5 Statement of Compliance with NHS Foundation Trust Code of Governance Central Manchester University Hospitals NHS Foundation Trust has applied the principles of the NHS Foundation Trust Code of Governance on a comply or explain basis. The NHS Foundation Trust Code of Governance, most recently revised in July 2014, is based on the principles of the UK Corporate Governance Code issued in The Board of Directors and the Council of Governors are committed to continuing to operate according to the highest corporate governance standards. In order to do this, the Board of Directors: meets formally on a bi-monthly basis in order to discharge its duties effectively. Systems and processes are maintained to measure and monitor the Trust s effectiveness, efficiency and economy as well as the quality of its healthcare delivery. regularly reviews the performance of the Trust against regulatory and contractual obligations and approved plans and objectives. Relevant metrics, measures and accountabilities have been developed in order to assess progress and delivery of performance. has a balance of skills, independence and completeness that is appropriate to the requirements of the Trust. All Directors have a responsibility to constructively challenge the decisions of the Board. Non-executive Directors scrutinise the performance of the Executive management in meeting agreed goals and objectives and monitor the reporting of performance. Where board member does not agree to a course of action it is minuted. Non-executive Directors are appointed for a term of three years by the Council of Governors. The Council of Governors can appoint or remove the Chairman or the Non-executive Directors at a general meeting. Removal of the Chairman or another Non-executive Director requires the approval of three-quarters of the members of the Council of Governors. The Chairman ensures that the Board of Directors and the Council of Governors work together effectively and that Directors and Governors receive accurate, timely and clear information that is appropriate for their respective duties. The Council of Governors: represents the interests of the Trust s members and partner organisations in the local health economy in the governance of the Trust. acts in the best interests of the Trust and adheres to its values and code of conduct. holds the Board of Directors to account for the performance of the Trust and receives appropriate assurance and risk reports on a regular basis. The 111

112 Governors are consulted on the development of forward plans for the Trust and any significant changes to the delivery of the Trust s business plan. meets on a regular basis so that it can discharge its duties, and the Governors have elected a lead Governor. The lead Governor s main function is to act as a point of contact with Monitor, our independent regulator. The Directors and Governors continually update their skills, knowledge and familiarity with the Trust and its obligations, to fulfil their role on various Boards and Committees. A performance review process involving the Governors, of the Chairman and Nonexecutive Directors has been developed. The Senior Independent Director supports the Governors through the evaluation of the Chairman. Each Executive Director s performance is reviewed by the Chief Executive who in turn is reviewed by the Chairman. The Chairman also holds regular meetings with Non-Executive Directors without the Executives present. Independent professional advice is accessible to Non-Executive Directors & Trust Board Secretary via the appointed Independent External Auditors, and Senior Associate of a local firm of solicitors. All Board meetings and Board Sub-Committee meetings receive sufficient resources and support to undertake their duties and this was independently reviewed in 2014/15 with recommendations for further refinement and strengthening successfully introduced during Q1 and Q2 of 2015/16. The Chief Executive ensures that the Board of Directors and the Council of Governors of CMFT act in accordance with the requirements of propriety or regularity. If the Board of Directors, Council of Governors or the Chairman contemplate a course of action involving a transaction which the Chief Executive considers infringes these requirements, he will follow the procedures set by Monitor for advising the Board and Council for recording and submitting objections to decisions. During 2015/16 there have been no occasions on which it has been necessary to apply the Monitor procedure. CMFT staff are also required to act in accordance with NHS standards and accepted standards f behaviour in public life. In 2014/15, we reported on our programme of work to develop our values and behaviours framework with over 4,000 staff. In 2015/16, we introduced our Living the Values training and have trained over 900 trainers across the Trust to deliver this programme to as many people as possible. We have also been measuring through our quarterly pulse checks how well our values are known by staff. The Trust ensures compliance with the Fit and Proper Person (FPP) requirement for the Board of Directors. All existing Directors completed a self-declaration and this exercise will be repeated out on an annual basis. All new appointments are also required to complete the self-declaration and the full requirements of the FPP test has been integrated into the pre-employment checking process. The Trust holds appropriate insurance to cover the risk of legal action against its directors in the roles as directors and as trustees of the CMFT Charity. 112

113 Relationship with stakeholders and duty to co-operate CMFT has well developed mechanisms for engagement with third party bodies at all levels across the organisation. These include regular arrangements such as standing meetings, as well as time-limited arrangements set up for a specific purpose. GM Devolution has changed the landscape significantly and a set of governance arrangements have been established that are designed to ensure co-operation and close working across the whole of the GM health and social care system. Some of our pre-existing partnership arrangements will therefore be replaced by the GM Devolution governance structure. The Board ensures that effective mechanisms are in place and that collaborative and productive relationships are maintained with stakeholders through: Direct involvement e.g. attendance at Board to Board meetings, attendance at Partnership Board meetings Chair involvement e.g. attendance at Manchester Health & Wellbeing Board Feedback e.g. from the Council of Governors and in particular nominated Governors Board updates on Strategic Development Board Assurance report - delivery of our key priorities (many of which rely on good working relationships with partners) The following describes some of the arrangements in place with our key stakeholders. Commissioners Effective mechanisms to agree and manage fair and balanced contractual relationships include: A range of executive team to executive team and board to board meetings with key commissioners: o Central Manchester CCG o Specialised Commissioners Dedicated Contracts and Income Team that liaise between the Trust, the clinical divisions and commissioners Other Providers Partnership boards have been established with partners in service delivery which have representation from executive and non-executive directors, for example: Alder Hey the other provider of specialised children s services in the population of the North West Salford Royal NHS FT another provider of specialised services to the population of GM. The existing GM Acute Provider CEOs Group has now developed into the GM Provider Federation Board which is part of the GM Devolution arrangements and will facilitate joint and joined up working across all GM providers. 113

114 City of Manchester (NHS and Manchester City Council) Collaborative working arrangements exist across the City Council, the providers and the CCGs. These include: Health & Wellbeing Board - Manchester Health & Wellbeing Board has included the NHS providers from it establishment. It brings together representatives from Manchester City Council, acute trusts, CCGs, mental health trust, public health and Healthwatch Health & Wellbeing Executive as above Manchester Provider Board - brings together acute trusts, GP federations, pharmacy, mental health trust, Manchester City Council and the voluntary sector working together on the development of out-of-hospital services. City of Manchester Single Hospital Service Review there has been close joint working in 2015/16 and 2016/17 across the Manchester hospitals on a project to review service provision across the city with a view to identifying how the three hospitals can work together more closely in future. Academic institutions The Trust has a strong and well documented relationship with its key academic partner, The University of Manchester, and there are joint committees that support the main activities e.g. clinical appraisals, research and education. CMFT has function links with Manchester Metropolitan University and Salford University to support training of nurses, allied health professionals (AHPs) and scientists, and some specific research collaborations. The Trust is a founder member of the Manchester Academic Health Science Centre that provides for a relationship between CMFT and the other main academic hospitals and UoM to deliver improvements in healthcare, driven from a platform of research excellence. The Greater Manchester Academic Health Sciences Network, whose remit is to drive forward the adoption of innovations to improve healthcare, is located in Citylabs on our central Manchester site. Health Innovation Manchester was established in 2015/16 to create a compelling shop window for external stakeholders and potential customers to access the Greater Manchester NHS ecosystem and CMFT has representation on the governance board. Industry The Trust has a number of industry interfaces that encompass both large corporates and SMEs. Our approach to selecting and securing our industry partners is to choose the best partner to address specific problems. For example we recently determined a need to acquire a strategic property partner and this opportunity was tendered. The Trust now has a 10 year relationship with Bruntwood to provide a range of property and estates related services. Roche (diagnostics) and Congenica (genomics) are other examples. 114

115 In addition the Trust, in a joint venture with Manchester Science Partnerships (MSP), operates a medtech centre that provides early stage incubation space for CMFT and other NHS spinouts and SMEs that wish to co-develop novel solutions with the Trust. The Trust and MSP also work together to operate the new Citylabs development that houses a number of SMEs and corporate which are developing new products and services relevant to our core services, including laboratory diagnostics, genomics, information management and technology (IM&T) and clinical trials. 115

116 Audit Committee Annual Report 2015/16 Purpose of the report This annual report has been prepared for the attention of the Trust s Board of Directors and reviews the work and performance of the Audit Committee during 2015/16 in satisfying its terms of reference. Producing an Audit Committee Annual Report represents good governance practice and ensures compliance with the Department of Health s Audit Committee Handbook, the principles of integrated governance and Monitor s Risk Assessment Framework. Through the Audit Committee, the Board of Directors ensures that robust and effective internal control arrangements are in place and regularly monitored. The Audit Committee receives regular updates on the Board Assurance Framework and is therefore able to focus on risk, control and related assurances that underpin the delivery of our Trust s key priorities. Committee membership The Audit Committee membership during 2015/16 comprised: Anthony Leon Deputy Chairman of the Board & Chair of the Audit Committee John Amaechi Non-Executive Director Professor Colin Bailey Non-Executive Director (from 14/03/16) Dr Ivan Benett Non-Executive Director (from 04/01/16) Lady Rhona Bradley Non-Executive Director (up to 04/11/15) Professor Rod Coombs Non-Executive Director (up to 14/03/16) Kathy Cowell Non-Executive Director & SID Nicholas Gower Non-Executive Director (from 14/03/16) Chris McLoughlin Non-Executive Director (from 26/10/15) Brenda Smith Non-Executive Director (up to 04/11/15) Anil Ruia Non-Executive Director Compliance with the Committee s terms of reference The Audit Committee met five times during 2015/16, and the meeting minutes are submitted to the next available Board of Directors meeting. Audit Committee members met in private with the auditors prior to the Audit Committee meeting in February The Director of Operational Finance, Chief Accountant, Director of Corporate Services, Head of Internal Audit and Internal Audit Manager, representatives of External Audit and the Anti-Fraud Specialist have attended Audit Committee meetings. Executive Directors, Corporate Directors and other members of staff have been requested to attend the Audit Committee as required. The Audit Committee reviewed its terms of reference in November

117 Anthony Leon Rod Coombs Rhona Bradley Brenda Smith Kathy Cowell John Amaechi Anil Ruia Ivan Benett Chris McLoughlin Colin Bailey Nic Gower Meeting attendance Date 01/04/15 X 26/05/15 x 02/09/15 X X 04/11/15 X 03/02/16 X X X X X = attended the meeting, x = did not attend the meeting Audit services provision Internal Audit has been provided by Mersey Internal Audit Agency (MIAA). External Audit has been provided by Deloitte LLP for the past three years. The Council of Governors at its meeting in October 2015 approved the Audit Committee s recommendation for the re-appointment of Deloitte LLP for a further three years, following a competitive tendering process. The Audit Plan for 2015/16 was based on detailed planning work, discussion between the External Auditors and Trust management team(s), consideration of recent sector developments and prior year knowledge. Consideration was also given to the level of staffing capacity required to satisfy the delivery of the comprehensive audit programme. Assurance The Audit Committee agenda is constructed in order to provide assurance to the Board of Directors across a range of activities including corporate, clinical, financial and risk governance and management. The Audit Committee agenda covered the following: Monitoring of the Audit Committee s work programme 2015/16 Receiving minutes and considering reports (as required) from the following Board Committees: 117

118 o o o Trust Risk Management Committee Finance Scrutiny Committee Clinical Effectiveness Scrutiny Committee (replaced by the Quality & Performance Scrutiny Committee from September 2015) HR Scrutiny Committee o External Audit progress reports Internal Audit progress reports Anti-fraud reports Losses and special payments reports Tenders waived reports. Work and performance of the Committee during 2015/16 The Audit Committee has adhered to the work programme agreed in April All reports scheduled for each Committee meeting have been received on time. Reports from Board Committees The Audit Committee has continued to focus its attention throughout the year on the Trust Risk Management Committee and Board Scrutiny Committee reports. Non- Executive Directors are invited to attend the Risk Management, Scrutiny Committees, Clinical Effectiveness and Human Resources Committees. A number of risks reported through the Risk Management Committee and scrutinised by the Audit Committee were further highlighted at the Board of Directors meetings or Finance Scrutiny meetings, in particular the Run Rate and Trading Gap challenges facing Divisions within the Trust. The Board Assurance process was reviewed at the Audit Committee with two key strategic aims from the Board Assurance Framework (BAF) scrutinised on a rolling basis at each meeting. The key strategic aims reviewed at the Audit Committee during 2015/16 were: o Improving the safety and clinical quality of our services o Improving the experience for patients, carers and their families o Developing our specialised services and, in collaboration with our partners in health and social care, leading on the development and implementation of integrated care o Increasing the quality and quantity of research & innovation, contributing to improving health and well-being o Developing our organisation, supporting the well-being of our workforce and enabling each member of our staff to reach their full potential o Remaining financially stable. The Committee s focus was on seeking assurance that the process outlined had been adhered to, along with any gaps in control/assurances. It also considered whether actions were clearly identified to mitigate and/or reduce the risk(s). The focus on outstanding actions in the Board Assurance Framework is ongoing to ensure that risks are managed throughout the year. The key risks aligned to the key strategic aims reviewed by the Committee, on behalf of the Board, included: 118

119 1. A&E performance and Emergency Department 15/16 capacity 2. Infection control - CPE 15/16 3. Regulatory framework 15/16 4. Patient records 15/16 5. Never events 15/16 6. Major Trauma 15/16 Downgraded 7. Communication of diagnostic test and screening test 15/16 results 8. ICE Order Communications Implementation 15/16 Downgraded 9. Compliance with Building Regulations - Fire Stopping New 15/ Financial control and failure to deliver trading gap 15/16 savings / financial challenge for future years 11. Equality and Diversity Programme 15/16 Downgraded 12. Stretford Memorial Hospital New 15/16 Downgraded 13. Corporate and clinical mandatory training compliance New 15/ Nurse staffing New 15/ Management of the Mental Health Act New 15/ Diagnostics Adult Endoscopy New 15/ End of Life Care New 15/ Community Services: Building Fabric New 15/ Nutrition RMCH 15/16 Downgraded 20. Nutrition Patient Dining Experience New 15/ Transition of care New 15/1 Downgraded 22. Obstetric capacity New 15/16 The Audit Committee reviewed the external audit plan for 2015/16 and agreed the following significant risks as being the key areas of focus for the 2015/16 external audit: recognition of NHS Revenue; property valuations; and management override of controls. External Audit The 2014/15 accounts were audited by Deloitte LLP and the findings presented to the Audit Committee in May Based on the results of the External Auditor's procedures, except for the effects of the matters described in the Basis for qualified conclusion (regarding errors in the calculation of the maximum time of 18 weeks from point of referral to treatment in aggregate patients on an incomplete pathway indicator for the year ended 31st March 2015), the Audit Committee noted that nothing had come to the External Auditor's attention that caused them to believe that, for the year ended 31st March 2015: the quality report was not prepared in all material respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual ; 119

120 the quality report was not consistent in all material respects with the sources specified in Monitor s detailed requirements for quality reports 2014/15; and the indicators in the quality report subject to limited assurance had not been reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual. The Chairman of the Audit Committee and Non-Executive Directors had met earlier with the Executive Director of Finance and the Director of Operational Finance to discuss and interrogate the 2014/15 accounts. External Audit commented on the additional assurance this had given to the process. The Audit Committee considered the External Audit Annual Governance report, the report from the Executive Director of Finance and changes to accounting policies. The Audit Committee approved the accounts for the period 1st April 2014 to 31st March The Council of Governors subsequently received the report on the accounts from the Independent Auditor in July Deloitte LLP provided regular progress reports to the Audit Committee throughout the year. In addition regular updates were provided on: 2014/15 Foundation Trust Performance year to 31st March 2015 The 2015/16 Compliance Framework Monitor s Enforcement Guidance Monitor consultation on the 2015/16 Annual Reporting Manual (ARM) 2015/16 Annual Reporting Manual changes. Internal Audit The Audit Committee received the draft Internal Audit plan for 2016/17 and draft Anti-Fraud Work Plan for 2016/17 in April The plans provide evidence to support the Head of Internal Audit Opinion, which in turn contributes to the assurances available to the Board in completing its Annual Governance Statement. The Head of Internal Audit Opinion 2015/16 was presented to the Audit Committee in April 2016 and significant assurance was given on the adequacy of the system of internal control. The following Internal Audit Reports have been received by the Audit Committee throughout the year. Report Issued Assurance Rating Healthcare Associated May 2015 Significant Infections Critical Application Review, May 2015 Limited Chameleon Electronic Patient Record (EPR) System Local Clinical Research Network September 2015 Significant 120

121 Report Issued Assurance Rating Divisional Review: Pay September 2015 Significant Protection Off Payroll Arrangements September 2015 Limited Reference costs September 2015 N/A Information Governance September 2015 Significant Toolkit Review: Phase 1 Scheme of Delegation November 2015 N/A Referral to Treatment : Data Quality February 2016 N/A Risk Maturity: Divisional Level February 2016 Significant Combined Financial Systems April 2016 Significant Assurance Framework Opinion April 2016 Significant Nurse Staffing levels April 2016 Significant Divisional Review: Referral to Treatment Data Quality April 2016 Significant Information Governance April 2016 Significant Nursery Business Model April 2016 Significant Car Parking April 2016 Limited The Audit Committee received updates on the status of implementing Internal Audit recommendations at each meeting. This year the Committee focused again on the timescales for the implementation of action plans and monitored the breaches. Performance against key indicators in the Internal Audit Plan was reviewed at each meeting by the Committee. Limited assurances and significant issues considered The Committee focused on audit reports which had received a limited assurance and where the risk profile represented significant issues for the Trust. When appropriate, the Committee requested the presence of key individuals to present their action plans to fulfil the recommendations. In particular presentations and reports were received on: Mortality Review Policy Clinical Audit Assurance IT Critical Application: Chameleon Electronic Patient Record (EPR) System Car Parking The Committee also received the following policies for review and update following the independent review of the Trust s governance arrangements in 2014/15 and implementation of key recommendations in Quarter 1 and Quarter 2 of 2015/16: Updated Standing Orders for the Practice and Procedure of the Board of Directors (November 2015) Updated Scheme of Decision and Scheme of Delegation (January 2016) Updated Trust Governance Policy (November 2015) this was previously known as Governance Strategy. 121

122 During the course of the year, Internal Audit have undertaken follow-up reviews and reported the outcome to Audit Committee in relation to: Divisional Governance Review Surgery Treasury Management Stocks Management IT Asset Management Combined Financial Systems Patient Records Infection Control Monitor & Reporting Referral to Treatment Data Quality Review Appraisals E-Rostering Business Continuity Mortality Framework Divisional Pay protection IT Project Governance Critical Application, Review Chameleon EPR System Off- Payroll Arrangements Local Clinical Research Network Risk Management Divisions A total of 60 recommendations have been actioned out of 70. The Trust is actively progressing the one action rated as high and this is close to completion. Internal Audit will continue to track and follow up outstanding actions. Anti-fraud measures The anti-fraud service to the Trust was provided by Mersey Internal Audit Agency who were appointed from April 2013, and a nominated anti- fraud specialist works with the Trust. The Audit Committee received regular progress reports. Details of investigations carried out during the year were provided to the Committee. A programme of work was presented to the Committee in April Areas which continued to be covered during 2015/16 included: Inform & involve Fraud Awareness Programme Prevent & deter NHS Protect Bulletins/Guidance Prevent & deter Follow Up Reviews Car Parking Hold to account Pre-Employment Detection Review Hold to account - Investigations An anti-fraud annual report was presented to the Audit Committee in April 2016 and this provided a summary of the anti-fraud work undertaken based upon the annual work plan. Losses and compensation At each meeting, the Committee received information about the levels and values of losses and compensation payments within the Trust. Additional analysis was included on payments for the loss of dentures, glasses and hearing aids, recognising the particular impact these losses have on patient experience. Throughout the year bad debts and claims abandoned accounted for the biggest proportion of losses reported to the Committee. 122

123 Tenders waived A summary of all tenders waived was presented at each Audit Committee meeting. In addition, the number of quotation waivers was reported. All waivers were in accordance with the Trust s Standing Financial Instructions. Other reports The Audit Committee also received the following reports and information: The Annual Report and the Quality Report for the Trust, in May The Committee also received and approved the Annual Accounts following the delegation of approval power from the Board of Directors. The Annual Governance Statement for 1 st April 2014 to March 2015, in May This described the system of internal control that supports the achievement of the Trust s policies, aims and key priorities. The Annual Governance Statement was supported by independent assurances and reflected that there were no control issues that required disclosure. An update on the 2015/16 annual accounts process; the Committee approved a change to the accounting policies in respect of group assets. Priorities for 2016/17 The Audit Committee will review the arrangements to be put in place/developed in relation to: Compliance with Foundation Trust authorisation/licence Care Quality Commission and compliance Approval of internal regulatory documents Board Assurance Framework Clinical Audit Strategy and Plan Monitoring audit recommendations and reviewing all audits with a limited assurance. Developing the role and skills of the Audit Committee Audit Committee members are encouraged to attend workshops arranged by the Trust s Internal and External Auditors. Conclusion The Audit Committee has continued to consider a much wider spectrum of risk during the year, and this will carry on during 2016/17. Also, in co-operation with the Finance Scrutiny Committee, particular emphasis will continue to be given to the finances of the Trust, taking into account the wider economic situation. The Committee has been proactive in requesting reports in areas of concern, particularly in non-financial areas. The Committee will maintain its increased focus during 2016/17 on following up Internal and External Audit reports where limited assurances have been given and will continue to monitor the clinical audit process. The Audit Committee has met its terms of reference as detailed throughout this report. Anthony Leon Chairman, CMFT Audit Committee 24th May

124 2.6 Regulatory ratings The Trust submits quarterly reports to Monitor, the independent regulator of Foundation Trusts. Performance is assessed by Monitor to identify where actual or potential problems may arise. In doing this, Monitor publishes quarterly and annual risk ratings. The ratings are designed to indicate where compliance is being maintained in accordance with the Trust s terms of authorisation. Risk ratings are published for the following areas under Monitor s risk assessment framework: The Financial Sustainability Risk Rating (FSRR). (Ratings are 1-4, where 1 represents the highest risk and 4 the lowest). Governance (Rated Green, Amber/Green, Amber/Red, Red) The Trust s financial sustainability for 2015/16 was rated as 2, and the planned FSRR level was achieved. Our governance rating was green. CMFT s quarterly ratings for 2015/16 are shown in the table below and further information on the FSRR can be found on page 29. Analysis of actual Governance Rating compared with the Annual Plan The Trust achieved a Green rating for governance consistently throughout the year. The main points in relation to governance risk discussions with Monitor during 2015/16 related to 62 day cancer performance during the first half of the year when demand rose significantly and the Trust s failure to meet the 95% A&E access standard in Q3 and Q4. With respect to cancer the Trust was able to demonstrate an insight into the growth and the measures it had taken to increase surgical capacity which saw a return to delivery from Q3 onwards. With regards to A&E the Trust was able to demonstrate a comparatively strong position against a backdrop of increased demand, both local and national performance decline, and robust economy wide planning for 2016/ /15 Domain Annual Plan 2014/15 Actual performance 2014/15 Q1 Q2 Q3 Q4 Continuity of Service Rating Governance rating 2015/16 Domain Financial Sustainability Risk Rating Governance rating Annual Plan 2015/16 Actual performance 2015/16 Q1 Q2 Q3 Q

125 2.7 Statement of accounting officer s responsibilities Statement of the Chief Executive's responsibilities as the accounting officer of Central Manchester University Hospitals NHS Foundation Trust The NHS Act 2006 states that the chief executive is the accounting officer of the NHS foundation trust. The relevant responsibilities of the accounting officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by Monitor. Under the NHS Act 2006, Monitor has directed Central Manchester University Hospitals NHS foundation trust to prepare for each financial year a statement of accounts in the form and on the basis set out in the Accounts Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of Central Manchester University Hospitals NHS foundation trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year. In preparing the accounts, the Accounting Officer is required to comply with the requirements of the NHS Foundation Trust Annual Reporting Manual and in particular to: observe the Accounts Direction issued by Monitor, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis make judgements and estimates on a reasonable basis state whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual have been followed, and disclose and explain any material departures in the financial statements ensure that the use of public funds complies with the relevant legislation, delegated authorities and guidance and prepare the financial statements on a going concern basis. The accounting officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS foundation trust and to enable him/her to ensure that the accounts comply with requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the NHS foundation trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities. To the best of my knowledge and belief, I have properly discharged the responsibilities set out in Monitor's NHS Foundation Trust Accounting Officer Memorandum Sir Michael Deegan Chief Executive Officer 26th May

126 2.8 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 Central Manchester University Hospitals 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 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 Central Manchester University Hospitals NHS Foundation Trust; evaluate the likelihood of those risks being realised and the impact should they be realised; to manage them efficiently, effectively and economically. The system of internal control has been in place in Central Manchester University Hospitals NHS Foundation Trust for the year ended 31 March 2016 and up to the date of approval of the annual report and accounts. Capacity to handle risk The Trust leadership plays a key role in implementing and monitoring the risk management process (see further details below). The Chief Executive chairs the Trust Risk Management Committee and actual risks scoring 15 or above are reported to the committee. Risk reports are received from each responsible Director and each Executive Director, with details of the controls in place and actions planned against which assessment is made by the committee. The Audit Committee monitors assurance processes and seeks assurance across all risks in order to provide independent assurance to the Board of Directors that risks have been properly identified and appropriate controls are in place. The risk appetite is determined by the Board and monitored by the Audit Committee to ensure that the risks faced are consistent. The Board has designated the Medical Director as the lead Executive and Chairman of the Clinical Effectiveness Committee. This committee has a focus on patient safety and clinical effectiveness. A significant amount of work has been undertaken to develop clinical effectiveness indicators across all clinical divisions. The Medical Director is supported by a Clinical Effectiveness Team. A Trust risk management training programme has been designed and delivered which undergoes an annual evaluation process. 126

127 The risk management team includes a training post dedicated to risk management training. The Trust has operational risk and safety meetings at all levels which review high level incidents and trends so that lessons can be learnt for the future. We have developed robust mechanisms for recording untoward events and learning from them. As part of our Clinical Effectiveness Performance Framework, each division records its activity and performance against the key clinical effectiveness indicators and produces a summary for discussion at their divisional review. Areas of good practice are collected on a corporate basis and shared throughout the organisation. CMFT is also represented on a number of national and regional working groups. The Trust has established a Quality and Performance Scrutiny Committee a forum where Board members can scrutinise specific subjects, examples of which have been mortality, infection control and serious incidents, ensuring a level of detailed review and challenge. The risk and control framework A risk management process covering all risks has been developed throughout the organisation at all levels with key indicators being used to demonstrate performance. The whole system of risk management is continuously monitored and reviewed by management and the Board in order to learn and make improvements to the system. The Trust s management structure has established accountability arrangements through a scheme of delegation covering both corporate and clinical divisional arrangements. This is reflected in the corporate and divisional work programmes/key priorities and the governance arrangements within the Trust. The responsibilities of each Executive Director are detailed below: Deputy Chief Executive Assumes responsibilities for the Chief Executive in his absence Responsible for developing integrated care across acute, community and local authority boundaries with the City of Manchester. Chief Nurse Responsible and accountable for leading professional nursing, patient experience and engagement The Trust s Director of Infection Prevention and Control Chairs the Quality Committee and the Infection Control Committee. Executive Director of Finance Responsible for the wide range of interrelated work programmes around finance, contracting, information and strategic planning,. Responsible for developing and overseeing delivery of financial plans across the Trust for current and future financial years, ensuring these are integrated with operational and service delivery requirements. 127

128 Produces the Annual Plan submission to Monitor and maintains the on-going compliance relationship with Monitor, through monitoring submissions and exception reporting as required. Holds regular meetings with local commissioners and with the North West Specialised Commissioning Team, maintaining dialogue across service delivery and planning issues including forward projections, significant developments within individual services and strategic service changes. Responsible for developing and delivering on any transactions which may be contemplated by the Board, which may extend the scope of the Trust s activities and responsibilities. The Senior Information Risk Officer for the Trust Medical Director Responsible for leading on patient safety and clinical effectiveness, research and innovation and medical education. Chairs the Clinical Effectiveness Committee, the Safeguarding Effectiveness Committee and the Research Governance Board. Responsible for ensuring compliance with statutory requirements regarding Safeguarding children and vulnerable adults as well as ensuring the Trust is compliant with the Human Tissue Act. The Responsible Officer for the Trust, for the purposes of the revalidation of doctors with the General Medical Council, and the Caldicott Guardian for the Trust. Executive Director of Human and Corporate Resources Provides strategic direction and leadership on a range of corporate functions to enable the delivery of the highest quality of services to patients. Provides strategic advice to the Chief Executive and Board of Directors on all employment matters. Responsible for developing, implementing and monitoring a comprehensive HR Strategy ensuring that employee recruitment, retention, leadership, motivation and effectiveness are maximised. Responsible at Board level for effective internal and external communications ensuring at all times the appropriate positive projection of the Trust through the media. Responsible to the Board for its secretariat function, Governors and membership, to include support for its various meetings and internal processes. Chief Operating Officer Responsible for the successful delivery of clinical operations in the Trust, playing an active role in the determination and implementation of corporate strategies and plans. Has responsibility for four key elements: o Operational leadership of all clinical Divisions and Directorates. o Performance management and delivery of all national and local targets. o Modernisation and process redesign of Trust clinical and business processes. o Business continuity management (including emergency planning). 128

129 Provides effective management of the Trust on a day-to-day basis, ensuring the provision of appropriate, effective high quality patient-centred care, which meets the needs of patients and can be achieved within the revenues provided. Contributes to the development and delivery of the wider Trust agenda, including implementation of the Trust s strategic vision. Executive Director of Strategy Responsible for all aspects of strategic planning and for providing a robust framework for the development of corporate and service strategy. Manages many of the Trust s major stakeholder relationships and works closely with our hospital leadership teams to ensure appropriate strategic positioning to deliver our vision. Plays a pivotal role as a member of the Greater Manchester Devolution Transition Team and helps to shape the future governance arrangements linked to this historic agreement. Our Risk Management Strategy provides us with a framework that identifies risk and analyses its impact for all individual management units e.g. directorates, departments, functions or sites for significant projects and for the organisation as a whole. The completion of Equality Impact Assessments is part of this process. Any hazard identified is analysed against its severity and the likelihood of it occurring. This determines the overall risk ranking and ensures there is a common methodology being used to rank risks across the organisation. The strategy clearly sets out the individual and corporate responsibilities for the management of risk within the organisation. Implementation of the strategy ensures the Board is informed about significant risks and is then able to communicate those effectively to external stakeholders. The Risk Management Strategy is distributed throughout the organisation and to all local stakeholders and is reviewed every two years. There is increasing involvement of key stakeholders through mechanisms such as the Quality Reviews, the annual Clinical Audit and Risk Management Fair and Governors learning events. Each division and corporate service systematically identifies, evaluates, treats and monitors action on risk on a continuous basis. This work is then reported back through the local and corporate risk management and governance frameworks. This also connects the significant risks (those appraised at level 15 or above on the risk framework) to the organisation objectives and assesses the impact of the risks. The outcome of the local and corporate review of significant risk is communicated to the Risk Management Committee so that plans can be monitored. All divisions report on all categories of risk to both the Trust Risk Management and Clinical Effectiveness Committees. The Risk Management Committee undertakes further evaluation of the risks presented and their action plans and updates the Assurance Framework so that at any given time the significant risks to the organisation are identified. 129

130 Risk Management and Assurance Framework processes are closely aligned and the Assurance Framework is dynamic and embedded in the organisation. Controls and assurances provide evidence to support the Annual Governance Statement. A significant level of assurance has been given by Internal Audit during 2015/16 in its Head of Internal Audit Opinion. All identified risks within the organisation are captured in the Risk Register. This document also contains the detailed risk assessments and resulting action plans associated with the external assurance sources detailed under review of effectiveness. The Board is therefore able to monitor progress against such action plans. Risk assessment is a fundamental management tool and forms part of the governance and decision making process at all levels of the organisation. The Medical Director and Chief Nurse work closely on the alignment of patient safety and the patient experience. Clinical risk assessment is a key component of clinical governance and forms part of the Risk Register. The Trust also has established arrangements to advise and engage with both the Manchester and Trafford Health & Wellbeing Overview and Scrutiny Committees when there are proposed service changes which may impact on the people who use our services. We endeavour to work closely with patients and the public to ensure that any changes minimise the impacts on patients and public stakeholders. As a Foundation Trust, we also inform our Council of Governors of proposed changes including how any potential risks to patients will be minimised. Overview of the organisation s major risks The Trust has identified a number of significant internal control issues, also known as significant risks, during 2015/16. These have been or are being addressed through robust monitoring at the bi-monthly Risk Management Committee, chaired by the Chief Executive. A full list of risks and whether they are current year, future year or new identified risks is given on page 119. A&E Performance & Emergency Department Capacity - Clinical Non-elective workload and pressures facing the Trust - and in particular Manchester Royal Infirmary (MRI) and Royal Manchester Children s Hospital (RMCH) - during 2015/16 were significant, and above those being experienced by other Trusts locally in terms of attendances, acuity and admissions. The Board of Directors received routine information on operational performance, transformation improvements and system wide resilience to gain assurance that the patients of Central Manchester received timely care that was effective and safe. We implemented a command and control structure to ensure the most prompt resolution of issues in real time. This was based upon clear escalation routes and responsibilities. To build sustainable improvements on the back of operational delivery, our Transformation team have completed or are working on a number of work streams e.g. rapid improvement events and Perfect Weeks. 130

131 Infection Control - Carbapenemase Producing Enterobacteriaceae (CPE) Clinical The Trust has continued to monitor and manage performance during 2015/16 on all aspects of infection prevention and control. We continue to adopt a zero tolerance approach to Health Care Acquired infections, and the effectiveness of this has been particularly evident in the challenge which was presented by the increased prevalence of Carbapenemase Producing Enterobacteriaceae (CPE). A full range of key actions have been identified and implemented throughout 2015/16 and included the establishment of: o dedicated cohort/isolation wards o a more advanced screening test which is more sensitive; extended screening to include high risk admissions as well as contact tracing amongst inpatients to help us to identify patients with CPE and manage them appropriately o a data capture process for real time access to the register of CPE-positive patients o area appropriate environmental screening leading to investment and changes to the clinical environment. The detailed Annual Infection Prevention and Control Report for 2015/16 can be found at Regulatory Framework Clinical Our Trust was inspected by the Care Quality Commission in November 2015 and has received an overall rating of Good putting CMFT in the top 10% of large acute Trusts at the time of writing. In response, it is expected that this risk score will be reduced during early 2016/17. Patient Records Organisational We have identified through a series of audits and external review that the current patient record within the Trust needs to be improved in terms of quality of content and the management of the record i.e. tracking, storage and filing. Improvements have been made through a campaign to improve records management and work continues on the development of a single patient view electronic record. Never Events Clinical The Trust has reported seven Never Events in 2015/16. Whilst patients have not come to significant harm, we have a zero tolerance approach to these events and a programme of work continues to be in place to mitigate this risk and reduce occurrence to zero. Communication of Diagnostic Test and Screening Results - Clinical We have identified a number of risks in relation to the communication of diagnostic and screening test results and have since implemented a programme of work to mitigate these. One of the high impact interventions to address this risk was the introduction of a new electronic system to order diagnostic tests and communicate test results which was completed in June This has improved the communication of test results. Work is now focused on other areas of risk and it is anticipated this risk will be reduced further in 2016/

132 Financial control and failure to deliver trading gap savings / financial challenge for future years Financial If the Trust fails to maintain adequate control over financial performance then the organisation is at risk of not being clinically and financially sustainable over a five year period. The Trust has put in place an internal turnaround approach and progress is monitored on a weekly basis by the Executive Team and reported to Trust Management Board, the Board of Directors and in detail at Finance Scrutiny Committee. Commissioning Risk - Financial There remains a potential for disparity between the Trust and our commissioners when agreeing the contract each year. The normal process of engagement and meetings with commissioners is ongoing and continues to seek to mitigate these and arrive at outcomes that are mutually positive. Corporate & Clinical Mandatory Training Compliance - Clinical New fundamental standard regulations came into force for all providers from 1 st April 2015 with 11 regulations that set out the standards of quality and safety required. At Corporate Induction, all staff are made aware of the Corporate and Clinical Mandatory training requirements. The CMFT target for both these requirements is a completion rate of 90%. There has been a significant increase in compliance rates since the risk was identified. Trust wide completion rates at the end of March 2016 were: Corporate Mandatory training 91% Clinical Mandatory training 89% Nurse staffing Clinical The NHS is facing a deficit in the number of qualified nurses over the next three years to meet the requirements to provide safe and effective nurse staffing within healthcare providers. CMFT introduced a range of workstreams and strategies to address this challenge during 2015/16, including comprehensive domestic and international recruitment campaigns, retention strategies and focused education and development programmes. Management of the Mental Health Act - Clinical We identified a risk in respect of patients requiring physical health care whilst detained under the Mental Health Act The risk relates to management of the Act and ensuring that patients get the appropriate psychiatric support whilst in the care of the Trust. We are working to mitigate this risk over the next twelve months and a draft strategy has now been completed and will shortly start a process of consultation. Draft policies for the management of patients detained under the Act are also now completed and will be consulted upon. End of Life Care - Clinical The Trust recognised that there was variation in the levels of assurance about the different ways in which End of Life Care (EoLC) is being delivered across CMFT. This presents a risk of poor experience for patients approaching the end of life. 132

133 In response, we have introduced an Executive Oversight Task and Finish Group to oversee delivery of the EoLC Strategy and a range of associated work programmes. The comprehensive work programmes and enhanced reporting structure within the Trust have enabled significant progress to be made on delivery of the work programmes to date against national and local standards. Community Services: Building Fabric - Organisational The Trust recognised that the current condition of the environment in a number of clinical locations across the City managed by NHS Property Services (including Longsight) was not of a standard that was felt to be adequate or suitable for the range of services provided. In response, we have introduced a range of short, medium and long term programmes to address the shortfalls. Compliance with Building Regulation - Fire-stopping - Organisational Following a Department of Health Estates & Facilities Alert, the Trust has undertaken surveys across the estate and identified a large number of relatively minor defects in the fire compartmentation across the whole estate (including Trafford). The Trust has been assured that there is no risk to patients staff or visitors and a programme of works has been underway across the estate along with the implementation of additional measures, such as evacuation drills, review of ward evacuation procedures and restrictions on works that carry an increased fire risk, as an additional safeguard during this period. Nutrition Patient Dining Experience - Organisational A thematic review of the Trust s National Inpatient Survey results over a four year period identified food as an area where sustained improvement in patient experience has not been achieved, despite a continued focus on food and nutrition. Data provided by monitoring tools offers limited assurance that individual patient needs are being met consistently in all areas in relation to choice, food service and quality of the food provided. Ongoing focus and attention at Divisional level includes regular compliance audit and contract monitoring. Obstetric capacity - Clinical Saint Mary s maternity unit has seen an increase in the numbers of women booking to give birth within the new Saint Mary s Hospital (including the Salford Midwifery led Unit), which has risen from over 5,000 to 9,000 in the last six years. This has been achieved through adequate resourcing of staff and effective use of space. However, there has been a further increase in the number of births, to 9,267 in 2015/16. This, combined with a delay in the ability to recruit midwives, has caused an increased risk at times of peak activity. Saint Mary s has introduced a range of mitigating actions to improve the experience for women and babies. Major trauma Organisational Downgraded in 2015/16 Following a review of major trauma services across Greater Manchester in 2014, going forward CMFT will no longer be a principal receiving site for major trauma for adults. The Trust identified that this presented a risk for patients who required specialist services provided by CMFT such as obstetric, hepatobiliary, vascular, vascular interventional radiology and cardiothoracic services. 133

134 This risk has since been mitigated by the agreement of exceptional pathways of care for patients, whereby CMFT will continue to provide these services. This will ensure that patients continue to receive the appropriate care that they require, in the appropriate setting. These services are also vital for the children s major trauma centre which will continue to be provided from RMCH. ICE Order Communications Implementation Clinical Downgraded in 2015/16 The ICE system went live in June 2015 and was implemented successfully. Prior to go live, staff training targets were achieved in all Divisions and SOPs were in place, and, signed off. Feedback since implementation has been extremely positive with recognition of the continued potential to develop and adapt the system even further to support and facilitate optimum operational use. Equality, Diversity & Inclusion Programme Organisational Downgraded in 2015/16 This risk was originally established in April 2012, and during the intervening period the Trust had been developing robust governance arrangements to ensure that the ED&I agenda is integrated into our overall governance structure for the organisation. There is growing evidence of good progress towards integrating equality priorities into CMFT s overall culture. Following a meeting with the Equality & Human Rights Commission in August 2015, the Trust was informed that close monitoring would cease as a significant amount of commitment and momentum in driving this agenda was evident throughout the organisation over the last three years. Stretford Memorial Hospital Organisational Downgraded in 2015/16 There had been three main areas of concern with the Stretford Memorial Hospital: the quality of the clinical environment was very poor and offered a substandard experience for patients; the management of any sort of medical emergency was of concern; and security of the site was substandard and staff had very limited resources to call upon, in terms of colleagues, if they had to manage any sort of security challenge. The Trust took the necessary steps to temporarily close Stretford Hospital whilst a review of its future service provision was being assessed in discussion with Commissioners. All services had been relocated to either the Trafford or Altrincham sites. Nutrition (Children s) Clinical Downgraded in 2015/16 Extensive evidence of the action taken and the improvements that had been made in relation to Nutrition was submitted to the CQC in March In response, confirmation was received from the CQC that the compliance issue relating to nutrition had been satisfactorily addressed and that the compliance requirements would therefore be removed from the CQC website. In view of the considerable action taken and the achievement of over 75% patient satisfaction in the Patient Experience Tracker metric for providing good nutrition, the risk score relating to children s food and nutrition was reduced. 134

135 Transition of Care Clinical Downgraded in 2015/16 Whilst there had been examples of good practice within CMFT, it was considered that there was not a consistently high standard for transfer of care for children and young people. In response, a range of actions were implemented to mitigate the risk. These included setting up an executive oversight task and finish group in December 2015, chaired by the Medical Director, to oversee design and delivery of a transitional strategy and associated work programmes. This risk was subsequently downgraded to a Level 12. Quality governance arrangements Our Quality Report 2015/16 describes all the key elements of CMFT s quality governance arrangements, from measuring the patient experience through the improving quality programme to the initiatives for measuring clinical effectiveness, compliments, complaints and patient safety. Compliance with CQC registration is monitored through a number of Trust Committees but the main Committees are the Clinical Effectiveness Committee, the Quality Committee and the Risk Management Committee. The Trust undertakes an annual programme of internal quality reviews (see below); the review is structured using both the core standards and key lines of enquiry. This review along with the internal and clinical audit programmes, the ward accreditation programme and the Divisional Review process all provide assurance on compliance with the CQC Fundamental Standards All divisions report risks via an electronic system and risks are escalated up to the Risk Management Committee above a score of 15. These risks are mapped against the key priorities on the Board Assurance Framework. This can be mapped to the Fundamental Standards. The Board has not undertaken an annual self-assessment against the CQC Fundamental Standards in 2015/16 as a comprehensive inspection was undertaken and the draft report received in year. The Information Governance section below contains more information about data security risks. The quality of performance information is subject to an annual audit which evaluates the key processes and controls for managing and reporting the indicators. Each year two indicators are chosen along with an indicator put forward by the governors of the Trust. For 2015/16 the indicators chosen are the referral to treatment standard, the A&E 4 hour standard and Friends and Family testing. Quality Reviews CMFT established internal peer Quality Reviews to provide further assurance on the quality of care being delivered and in order to quickly identify and respond effectively where improvement is required. The aim of the Reviews is to strengthen clinical quality assurance information and they have been led by the Medical Director and Chief Nurse. The process for the Quality Reviews was aligned with those questions helpfully set out by the CQC in their intended review of clinical care going forward: Is care safe? Is care effective? Are staff caring? Is the organisation responsive? Is the organisation well led? 135

136 The Quality Review was also designed using our Trust values and behaviours framework and this very much formed part of the training and the ethos for the review. Most importantly, the findings and resulting action are intended to provide confidence for patients and service users that they will receive the best experience and the best care at the right time. The outcome of the reviews is captured in detail within the Quality Report (page 187 onwards). The findings from the reviews and follow-up visits have been used to inform our work plans for 2016/17 and they will be repeated this year. Central Manchester University Hospitals NHS Foundation Trust is required to register with the Care Quality Commission (CQC) and our current registration status is fully registered with no conditions. The Care Quality Commission has not taken enforcement action against the Trust during 2015/16. The Trust has not participated in any special reviews or investigations by the CQC in 2015/16. The Trust is fully compliant with the CQC s registration requirements. Divisional Review Process The Divisional Review Process informs the Board of Directors, the Risk Management Committee and the Divisional Clinical Effectiveness Groups on aspects of all risks identified through the analysis of incidents, complaints, clinical audit, concerns and claims reported throughout the Trust. Assurance Framework The Assurance Framework structures the evidence on which the Board of Directors depends to assure it is managing risks which could impact on the organisation s key priorities. Review of economy, efficiency and effectiveness of the use of resources We invest significant time in improving systems and controls to deliver a more embedded range of monitoring and control processes. The in-year use of resources is closely monitored by the Board of Directors and the following sub committees: Audit Committee Remuneration Committee Finance Scrutiny Committee Quality & Performance Scrutiny Committee Trust Risk Management Committee Human Resources Scrutiny Committee The Trust employs a number of approaches to ensure best value for money (VFM) in delivering its wide range of services. Benchmarking is used to provide assurance and to inform and guide service redesign. This leads to improvements in the quality of services and patient experience as well as financial performance. A range of key performance metrics are highlighted in the Performance Analysis (Measuring our operational performance) section on pages

137 CMFT maintains a record of attendance at the Board and details of this for 2015/16 can be found on pages The Audit Committee produces an annual report of its effectiveness (pages ) which is included together with an overview of the work of the Remuneration and Nomination Committees. The Trust is compliant with the principles and provisions of the NHS Foundation Trust Code of Governance following an annual review with Board members. The Board s statement on compliance is contained in detail on page 64 onwards. Information governance Information Governance (IG) is a framework of legal principles and best practice guidelines to be followed by CMFT and individuals to ensure compliance with legal, regulatory and Trust requirements and the provision of a secure and confidential information environment. This includes: Ensuring Data Protection registration and compliance Implementation of policies, processes and templates to govern, document, promote and support the IG framework Development and implementation of an IG review programme to strengthen evidence of IG with Trust divisions and departments through reviews and audits and provision of specific IG training as required Promoting and supporting the roles within Trust divisions and departments of the Divisional IG lead, Information Asset Owners (IAO) and Information Asset Administrators (IAA) Liaising with other NHS organisations to ensure that there are robust information sharing agreements to enable appropriate sharing of data required to support the delivery of the best possible care and service Completion of the annual NHS Information Governance (IGT) toolkit which is a self-assessment of performance against key IG standards including Information Governance Management, Confidentiality and Data Protection, Information Security, Clinical information, Secondary Use and Corporate Information. The Trust s 2015/16 Information Governance Toolkit (IGT) assessment scored 74% and an associated audit undertaken by the Trust s auditors gave significant assurance. We are reviewing the IG improvement plan to ensure we continue to build and improve on our Information Governance practices. Incidents are logged for Information Governance breaches and these incidents are managed in line with the Trust s incident management policy. Serious Information Governance incidents are also managed in line with the Health and Social Care Information Centre (HSCIC) Checklist Guidance for Reporting, Managing and Investigating Information Governance and Cyber Security Serious Incidents Requiring Investigation (IG SIRI). The table below includes all IG incidents assessed against the national SIRI classification system. There were no incidents in 2015/16 at a level which required to be reported to the Information Commissioners Office (ICO), Department of Health and other central bodies /regulators. There has been an increase in incidents against numbers logged in 2014/15, due in part to an increased awareness of IG and associated breaches. 137

138 Category Breach Type Total A Corruption or inability to recover electronic data 19 B Disclosed in Error 82 C Lost in Transit 0 D Lost or stolen hardware 0 E Lost or stolen paperwork 36 F Non-secure Disposal - Hardware 1 G Non-secure Disposal - Paperwork 13 H Uploaded to Website in Error 1 I Technical Security failing (including hacking) 6 J Unauthorised access / disclosure 29 K Other (excluding the Wellcome Trust Clinical Research Facility - 37 incidents) 69 The principal risks to compliance with the NHS foundation trust condition 4 (FT Governance) The principal risks to compliance with the NHS FT Condition 4 are outlined below although the action taken by the Trust to mitigate these risks in the future is outlined elsewhere in the Annual Governance Statement. Compliance with Care Quality Commission registration requirements The Foundation Trust is fully compliant with the registration requirements of the Care Quality Commission. Compliance with equality, diversity and human rights legislation Control measures are in place to ensure that all the organisation s obligations under equality, diversity and human rights legislation are complied with. Compliance with the NHS Pension Scheme As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer s contributions and payments into the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations. Control measures are in place to ensure that all the Trust s obligations under equality, diversity and human rights legislation are complied with. Compliance with Carbon Reduction Delivery Plans We have undertaken risk assessments and Carbon Reduction Delivery Plans and these are in place in accordance with emergency preparedness and civil contingency requirements, as based on UKCIP 2009 weather projects. This ensures that the 138

139 organisation s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with. 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 Medical Director, as a member of the Board, is appointed to lead and advise on all matters relating to the preparation of the Trust s Quality Report. The Trust continues to have robust data quality procedures in place that ensure that the data used in the Quality Report reflects the position accurately. These data quality procedures span from ensuring data is input into transactional systems correctly, information is extracted and interpreted accurately and that it is reported in a way that is meaningful and precise. All staff who have a responsibility for inputting data are trained fully in both the use of the systems and in how the information will be used. Furthermore, there are corporate data quality links with each of the clinical Divisions that work with operational staff to ensure the highest levels of integrity. Before the Quality Indicators are made available in the Quality Report or any Trust monitoring report, they go through a series of sign off steps resulting with Executive Director sign-off. The content of the Quality Report and the indicators that make up the metrics section are added to and amended as priorities change or whenever a shift in focus is required. There is a formal annual review whereby the metrics are decided on for the coming year however this does not prevent changes in year. All changes to the Quality Report and any of the metrics reports are signed off by the Executive Medical Director and Director of Clinical Governance. Within the Trust, a significant validation exercise is undertaken each month to ensure the accuracy of our reported elective waiting time position. This validation effort is supported by a suite of reporting that allows all of our operational teams to view their elective waiting list positions at patient level detail. To provide assurance to the organisation that this validation process is completed, a monthly meeting is held where every element of our waiting list is reviewed and signed-off by the senior Corporate Performance Team. The Trust also regularly updates, and provides training on, its Patient Access Policy to ensure that all staff are working to the correct standards in terms of managing an elective waiting list. Compliance with these standards is regularly audited by both our internal and external auditors. The key risk to ensuring the quality and accuracy of our waiting list position is to ensure that our administrative and managerial staff have the correct knowledge and skills to fully understand the standards that we work to. 139

140 It is on this basis that significant resource is put into ensuring that our training processes for staff (especially of newly recruited staff) are robust. Recognising the concerns raised in the previous year s quality accounts regarding RTT data quality, the Trust has implemented additional training solutions, improved performance reporting and formal sign off processes at period ends. The steps taken have been subject to internal audit reporting, which has provided the audit committee with the overall outcome of significant assurance. This programme of improvement and follow-through has been recognised by the external auditors despite the overall modified opinion for 2015/16. The recommendation is that ongoing assurance is provided by the internal audit programme set for 2016/17. In terms of the A&E indicator, the Trust recognises the limitation of scope barriers which has proved challenging for a complete audit a position highly prevalent across the NHS. But there are also qualitative improvements in administrative practice that can be made which will to stand up to future scrutiny. The internal audit programme will similarly be used as the vehicle to provide the assurance moving forward. 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 our Trust who have responsibility for the development and maintenance of the internal control framework. I have drawn on the content of the Quality Report included in 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 of Directors, the Trust Risk Management Committee, the Audit Committee, the Quality & Performance Scrutiny Committee, and the HR Scrutiny Committee and a plan to address weaknesses and ensure continuous improvement of the system is in place. My review is also informed by other major sources of assurance such as: Internal Audit Reports External Audit Reports Clinical Audit Reports Patient Surveys Staff Survey Royal College accreditation Health and Safety Executive Inspection Reports Care Quality Commission Intelligent Monitoring Standards PLACE assessments Senior Leadership Walk-rounds Clinical Pathology Accreditation 140

141 Care Quality Commission - registration without conditions Equality and Diversity Reports General Medical Council Reports. The Trust applies a robust process for maintaining and reviewing the effectiveness of the system of internal control. A number of key groups, committees and teams make a significant contribution to this process, including: Board of Directors The statutory body of the Trust is responsible for the strategic and operational management of the organisation and has overall accountability for the risk management frameworks, systems and activities, including the effectiveness of internal controls. The Terms of Reference and responsibilities of all Board Committees are reviewed regularly in order to strengthen their roles in governance and focus their work on providing assurances to the Board on all risks to the organisation s ability to meet its key priorities. Audit Committee The Audit Committee provides an independent contribution to the Board s overall process for ensuring that an effective internal control system is maintained and provides a cornerstone of good governance. The Audit Committee monitors the assurance processes of all other Board Committees (see also the Audit Committee Annual Report 2015/16 on pages ). Quality & Performance Scrutiny Committee This committee provides assurance on the Trust s work on quality (Patient Safety & Patient Experience) and performance (all key performance measures excluding Workforce & Finance). The committee is led by a Non-Executive Director who identifies areas that require more detailed scrutiny arising from: national reports, Board Reports, the Board Assurance Report, patient feedback and public interest issues. The committee does not replicate the work of other committees with related interests e.g. e Trust Risk Management Committee, the Clinical Effectiveness Committee and the Quality Committee. Examples of key areas of focus during 2015/16 include: Ongoing Review of Never Events; RCP Audit/National Hip Fracture Database; Nursing & Midwifery Workforce (Safer Staffing to match Patient Acuity & Dependency); FALLS Work Programme; Urgent Care Activity in Q3 & Q4; Outcome of the Emergency Bleep Meetings Annual Report; Mortality Annual Report; AQuA Quarterly Mortality Report; CPE Action Plan; Management of Sepsis in A&E; RTT, Diagnostics & Cancer Performance; Family Friendly Test (FFT) Compliance; Management of Complaints in Divisions. Human Resources Scrutiny Committee This committee reviews CMFT s Human Resources Strategy and monitors the development and implementation of the key workforce deliverables: 141

142 o Organisational Development and Equality, Diversity and Inclusion Strategies which enable us to build on our strengths and improve quality and effectiveness where necessary o Workforce Planning Strategy and Plan which supports patient safety and other core priorities including strategic service developments and the requirement for economic sustainability o Reward, Recognition and Accountability Strategy and Plan o Staff Health and Wellbeing Strategy and implementation plan Examples of key areas of focus during 2015/16 include: Update on progress with the Workforce Recovery Programme; Progress report from the Employee Wellbeing Enabler Group; Update on Sickness Absence Management from three Divisions; Progress report from the Performance Management & Capability Enabler Group; Progress report from the Employee Resourcing Enabler Group; Update on Staff Engagement in Turnaround Internal Audit Internal Audit provides an independent and objective opinion to the Accounting Officer, the Board and the Audit Committee, on the degree to which the Trust s systems for risk management, control and governance support the achievement of the Trust s agreed key priorities. Internal Audit work to a risk based audit plan, agreed by the Audit Committee, and covering risk management, governance and internal control processes, both financial and non-financial, across the Trust. The work includes identifying and evaluating controls and testing their effectiveness, in accordance with Public Sector Internal Audit Standards. A report is produced at the conclusion of each audit and, where scope for improvement is found, recommendations are made and appropriate action plans agreed with management. Reports are issued to and followed up with the responsible Executive Directors. The results of audit work are reported to the Audit Committee which plays a central role in performance managing the action plans to address the recommendations from audits. Internal audit reports are also made available to the external auditors, who may make use of them when planning their own work. In addition to the planned programme of work, internal audit provide advice and assistance to senior management on control issues and other matters of concern. The Internal Audit team also provides an anti-fraud service to the Trust. Internal Audit work also covers service delivery and performance, financial management and control, human resources, operational and other reviews. Based on the work undertaken, including a review of the Board s risk and assurance arrangements, the Head of Internal Audit Opinion concluded in April 2016 that significant assurance could be given that there is a generally sound system of internal control, designed to meet the organisation s objectives, and that controls are generally being applied consistently. 142

143 Trust Risk Management Committee The Risk Management Committee provides the Board of Directors with an assurance that risks are well managed with the appropriate plans in place. Reports demonstrate that the Risk Management reporting process includes all aspects of risk arising out of clinical and non-clinical practice. The key areas of focus during 2015/16 are highlighted under Overview of the organisation s major risks section on page 130. Clinical Audit The Clinical Audit Department oversees the development and delivery of an annual Clinical Audit Calendar. This plan includes mandatory national audits, locally agreed priority audits and monitoring audits in respect of external regulation and accreditation. The calendar is presented to the Trust Audit Committee and provides assurance on both clinical outcomes and compliance with guidance such as that provided by the National Institute for Health & Care Excellence (NICE) and the National Confidential Enquiry into Patient Outcome and Death (NCEPOD). The Trust registered 409 clinical audits in 2015/16, which took place across all our Divisions with their results disseminated and action taken in response. Independent Board Effectiveness Review During the second half of 2014, the Board of Directors commissioned an independent review of the Trust s governance arrangements and Board effectiveness via the External Auditors (with reference to Monitor s Well-led framework for governance reviews: guidance for NHS foundation trusts ). The Well-led framework prescribes four domains and ten high level questions against which Board governance and effectiveness should be assessed. The External Auditors used this structure to undertake the review and then benchmarked our Trust s governance using a body of good practice outcomes and evidence. Throughout the independent review a number of areas of good practice were highlighted: The Board of Directors has a clear focus on strategic direction. There is effective engagement of key stakeholders in strategic planning. There is a high degree of Board cohesion. There is effective Board level reporting of organisational performance. Opportunities for enhancing organisational governance were also identified along with an action plan focusing on the main headlines and 36 key recommendations contained in a final report against which a response and/or a planned action are recorded. In April 2015, the Board of Directors held an Away Day to enable full consideration and debate of the recommendations identified for Board resolution. During Q1 and Q2 of 2015/16, progress was reviewed on a monthly basis with all key actions completed by late autumn

144 Conclusion All significant internal control issues have been identified in this statement as part of the Risk and Control Framework section. The Board confirms that it is satisfied that, to the best of its knowledge and using its own processes and having regard to Monitor s Quality Governance Framework (supported by Care Quality Commission information, our own information on serious incidents, patterns of complaints) CMFT has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to our patients.... Sir Michael Deegan CBE Chief Executive Officer 26th May

145 Our Council of Governors The Council of Governors was established following the Trust s authorisation in January 2009 to become Central Manchester University Hospitals NHS Foundation Trust. The Board of Directors is committed to understanding the views of Governors and Members via its Council of Governors and holding and attending regular Governor and Members Meetings. The Council of Governors discharges its statutory duties at meetings of the Council of Governors, which met three times during 2015/16 in addition to attending a fourth event at our Annual Members Meeting. The Board of Directors and Council of Governors operate by the Board being responsible for the direction, all aspects of operation and performance and effective governance of the Trust with the Council of Governors being responsible primarily for assuring the performance of the Board. The Board of Directors and Council of Governors are provided with high quality information appropriate to their respective functions and relevant to the decisions that they have to make. The Chairperson is responsible for leadership of both the Board and the Council of Governors, with Governors also having a responsibility to ensure arrangements work and taking the lead in inviting the Chief Executive to their meetings and inviting attendance by other Executives and Non-Executives as appropriate. The Chair ensures that the views of Governors and members are communicated to the Board as a whole. The interaction between the Board of Directors and the Council of Governors is primarily a constructive partnership seeking to work effectively together in their respective roles. Governors are encouraged to act in the best interests of the Trust and are bound to adhere to our values and code of conduct. The Council of Governors adopts a policy to proactively engage with the Board of Directors in those circumstances when they have concerns. The Council of Governors is encouraged to ensure its interaction and relationship with the Board of Directors is appropriate and effective, with the Trust s Constitution outlining the process to resolve any disagreements between the Council of Governors and Board of Directors. Governors also have the right to refer a question to the Independent Panel for Advising Governors if more than 50% of Governors who vote approve the referral. In a recent Governor Survey (March 2016), our Governors cited that they felt proud to be an NHS Foundation Trust Governor (90% response rate). Governor role and statutory requirements The Trust has developed a Governor Framework which outlines the role and responsibilities of Governors and incorporates the statutory mandatory duties defined in the Health and Social Care Act (2012): To hold the Non-Executive Directors individually and collectively to account for the performance of the Board of Directors 145

146 To represent the interests of the members of the Foundation Trust as a whole and the interests of the public. Further details in relation to the role, responsibilities and powers of Governors are given on page 154 onwards. Governors hold our Non-Executive Directors (individually and collectively) to account for the performance of our Board of Directors by ensuring that they act so that we do not breach the terms of our authorisation. In addition, Governors receive agendas and approved minutes and are encouraged to attend each Board of Directors Meeting, which enables them to have a real-time review of the performance of our Board of Directors. Governors also actively monitor the performance of our Trust by attending quarterly Performance Review Meetings, ensuring that high performance standards are maintained. Governors are responsible for feeding back information about the Trust - its vision, forward plan (including its objectives, priorities and strategy) and its performance - to members and the public. In the case of Nominated Governors, this information is fed back to the stakeholder organisations that nominated them. Governors are, in return, also responsible for communicating back to the Board of Directors the opinions canvassed, ensuring that the interests of our members and the public are represented. In order to support Governors to canvass the opinions of members, the public and stakeholder organisations and effectively represent their interests, we hold a Governors Annual Forward Planning Workshop. At this event, our Governors, members and the public s views are considered during the development of the Trust s forward plans. An overview of our forward plans, plus the full public versions, are available on our website ( and via the Our Forward Plans Tell Us Your Views webpage and provides members and the public an opportunity to contact Governors and forward their views. In addition, future planning priorities are communicated to our members and the public through our membership newsletter (Foundation Focus Newsflash), inviting views to be forwarded to Governors and the Trust (via the Foundation Trust Membership Office). We also seek the views of members by directly ing them, inviting their review of our plans and encouraging their views in relation to our future planning priorities, in addition to inviting suggestions about ways to further improve our services. A Forward Plan Questionnaire and on-line survey is made available, which enables both members and the public to rank proposed priorities in addition to forwarding their views and suggestions. The views received are captured as part of the Trust s Membership Forward Plan Report which is shared with Governors and considered by the Board of Directors as part of our Annual Forward Planning Process. 146

147 Governors are also encouraged to identify and prioritise quality indicators/priorities as part of the Annual Forward Planning Workshop and from the suggestions made, Governors agree a local quality indicator for the forthcoming year. In a recent Governor Survey (March 2016), Governors cited that they are able to influence the direction of the Trust s future strategy and identify a local quality indicator as a result of being involved in the Trust s Annual Forward Planning process (90% response rate). Each year, at a Council of Governors Meeting, CMFT provides the Council of Governors with the following documents: Trust Annual Accounts Any report of the auditors on them and Trust Annual Report. An Annual Report overview is presented by our Directors to members at the Trust Annual Members Meeting, which is open to the public and was held on 22 nd September As part of this reporting process, the Board sets out clearly its financial, quality and operating objectives for the Trust and discloses sufficient information, both quantitative and qualitative, about the Trust s business and operation including clinical outcome data to allow members and Governors to evaluate its performance. At each Annual Members Meeting, the Board of Directors invites questions from Governors, members and the public with formal minutes being taken in order to capture questions raised/ corresponding responses and actions to be taken forward. Copies of previous minutes are published on our website Foundation Trust Events webpage Governor elections Our Council of Governors has both Elected and Nominated Governors (35 in total), with Public Governors being elected directly from and by our public members, Staff Governors directly elected from and by our staff members and Nominated Governors being nominated from partner organisations. The table below outlines the composition of our Council of Governors: Governor Constituency/Class/Partner Organisation Number of Governor Posts Public Manchester 9 Trafford 3 Greater Manchester 4 Rest of England & Wales 2 Total:

148 Staff Nursing & Midwifery 2 Other Clinical 2 Non-Clinical & Support 2 Medical & Dental 1 Total: 7 Nominated Manchester University 2 Central Manchester Clinical Commissioning Group 1 Trafford Clinical Commissioning Group 1 Specialised Commissioning 1 Manchester City Council 2 Trafford Borough Council 1 Youth Forum 1 Volunteer Services 1 Total: 10 Governors serve a term of office of three years, at the end of which they are able to offer themselves for re-election/re-nomination. A Governor may not hold office for more than nine consecutive years, and is not be eligible for re-election if he/she has already held office for more than six consecutive years. Governors also cease to hold office if they no longer live in the area of their constituency (Public Governors), no longer work for our Trust or hold a position in the staff class that they represent (Staff Governors) or are no longer supported in office by the organisation that they represent (Nominated Governors). Governor elections were held during the summer 2015 in order to fill the seats of those Governors whose term of office ended during 2015 and to fill vacant seats. As part of the Governor election process, the names and biographies of Governor candidates (contested seats) were forwarded to relevant member constituencies to enable members to make informed election decisions and, where applicable, included the prior performance of those Governors standing for re-election. A Governor Election webpage has been developed which outlines to members and the public the process for standing for election as a Governor and includes all candidate statements (names and biographies) and Governor election documents produced during the election process. In addition, each year a bespoke Potential Candidate Governor Election Information Pack is developed which includes a list of Frequently Asked Questions, the role and duties of Governors and key election information. The pack is published on the Governor Election webpage during the election process and mailed to those members who have expressed a specific interest in the role of Governor/standing for election. All successfully elected/nominated Governors biographies (pen portraits) are available on our Meet the Governors webpage 148

149 Our Board of Directors can confirm that elections for both Public and Staff Governors were held in accordance with the election rules as stated in our Constitution (approved by Monitor now part of NHS Improvement Independent Regulator of Foundation Trusts). Date of Election September 2015 CMFT Governor Election Turnout Data Number of Number Number of Election Constituencies Involved Members in of Seats Contestants Turnout Constituencies Contested Public Manchester % Public Trafford % Public Greater Manchester % Staff Medical & Dental N/A (election unopposed) 1 1 N/A Staff Nursing & Midwifery Staff Non-Clinical & Support % N/A (election unopposed) 1 1 N/A Successful candidates (both new and re-elected) were announced at our Annual Members Meeting held on 22 nd September 2015 and formally started their role from the end of the meeting. Members of the Council of Governors Constituency/Organisation, Election/Nomination and Term of Office Information Lead Governor & Public Governor The Lead Governor role facilitates direct communication between Monitor now part of NHS Improvement (Independent Regulator of Foundation Trusts) and our Council of Governors in the circumstance that it is not appropriate to communicate through normal channels. David Edwards Greater Manchester Constituency Elected 2013 Term of office 3 years ending 2016 Lead Governor elections were held during September 2015 with Dave Edwards being elected (unopposed) for a one year term of office. Public Governors Jayne Bessant - Manchester Constituency Elected 2008 (shadow Council of Governors) and re-elected 2011 & 2014 Term of office - 3 years ending

150 Peter Dodd Manchester Constituency Elected 2008 (shadow Council of Governors) and re-elected 2010 & 2013 Term of Office - 3 years ending 2016 Thomas Marsh Manchester Constituency Elected 2015 Term of office 3 years ending 2018 Patrick McGuinness Manchester Constituency Elected 2014 Term of office 3 years ending 2017 Mike Molete Manchester Constituency Elected 2015 Term of office 3 years ending 2018 Susan Rowlands Manchester Constituency Elected 2010 & re-elected 2013 Term of office - 3 years ending 2016 Sue Webster Manchester Constituency Elected 2008 (shadow Council of Governors) and re-elected 2011 & 2014 Term of office - 3 years ending 2017 Abebaw Yohannes Manchester Constituency Elected 2014 Term of office 3 years ending 2017 Nik Barstow Trafford Constituency Elected 2015 Term of office 3 years ending 2018 Cheryl Rivkin Trafford Constituency Elected 2015 Term of office 3 years ending 2018 Christine Turner Trafford Constituency Elected 2015 Term of office 3 years ending 2018 Ivy Ashworth-Crees - Greater Manchester Constituency Elected 2008 (shadow Council of Governors), re-elected 2009, 2012 & 2015 Term of office - 3 years ending 2018 Carol Shacklady Greater Manchester Constituency Elected 2014 Term of office 3 years ending

151 Barrie Warren Greater Manchester Constituency Elected 2013 Term of office 3 years ending 2016 Alan Jackson Rest of England & Wales Constituency Elected 2013 Term of office 3 years ending 2016 Richard Jenkins Rest of England & Wales Constituency Elected 2010 and re-elected 2013 Term of office - 3 years ending 2016 Public Governor term of office ended during 2015/16: Malcolm Chiswick Trafford Constituency term of office ended September 2015 George Devlin Trafford Constituency term of office ended September 2015 Matthew Finnegan Trafford Constituency term of office ended September 2015 Keith Paver Manchester Constituency term of office ended September 2015 Andrew Peel Manchester Constituency resigned March Staff Governors Isobel Bridges Non-Clinical & Support Constituency Elected 2012 and re-elected 2015 Term of office - 3 years ending 2018 Theresa Clegg Nursing & Midwifery Constituency Elected 2015 Term of office 3 years ending 2018 Peter Gomm Non-Clinical & Support Constituency Elected 2013 Term of office 3 years ending 2016 Sharon Green Nursing & Midwifery Constituency Elected 2012 and re-elected 2015 Term of office - 3 years ending 2018 Beverley Hopcutt Other Clinical Constituency Elected 2008 (shadow Council of Governors) and re-elected 2010 & 2013 Term of office - 3 years ending 2016 John Vincent Smyth Medical & Dental Constituency Elected 2012 and re-elected 2015 Term of office - 3 years ending

152 Geraldine Thompson Other Clinical Constituency Elected 2014 Term of office 3 years ending 2017 Staff Governor Term of Office Ended during 2015/16: Mary Marsden Nursing & Midwifery Constituency term of office ended September 2015 Nominated Governors Rabnawaz Akbar Manchester City Council Nominated 2011 and re-nominated 2014 Term of office - 3 years ending 2017 Julie Cheetham Central Manchester Clinical Commissioning Group Nominated 2012 and re-nominated 2015 Term of office - 3 years ending 2018 Angela Harrington Manchester City Council Nominated 2008 (shadow Council of Governors) and re- nominated 2011& 2014 Term of office - 3 years ending 2017 Alexander Heazell University of Manchester Nominated 2015 Term of office 3 years ending 2018 Mariam Naseem Youth Forum Nominated 2015 Term of office 3 years ending 2018 Paul Lally Trafford Borough Council Nominated 2014 Term of office 3 years ending 2017 Graham Watkins Volunteer Services Nominated 2014 Term of office 3 years ending 2017 Nominated Governor Term of Office Ended during 2015/16: Michael Gregory Trafford Clinical Commissioning Group resigned February 2016 Ariful Islam Youth Forum resigned September 2015 Henry Kitchener University of Manchester retired March Governor contact details Governors welcome the views and suggestions of members and the public, and you can find their contact details and biographies on the Meet the Governors webpage Alternatively members and the public can contact Governors via the Foundation Trust Membership Office ( or ft.enquiries@cmft.nhs.uk ). 152

153 Governors particularly welcome the opinion of our members and the public in relation to our forward plans. Governors are encouraged to canvass membership and public views during attendance at key membership and Trust events, including our Annual Members Meeting and Young People s Event. These events have dedicated Governor Engagement sessions and this year included an interactive questionnaire for attendees to complete. Participants were invited to forward their key priorities around 5 key areas: Quality, Services, Our People, Research and Finance. This information was shared with the Governors Membership Group and was included in the Membership Forward Plan Report and shared with Governors as part of the Governors Annual Forward Planning Workshop. Membership event information is available on our membership events webpage and promoted via our membership newsletter (Foundation Focus), which this year included a calendar of events/meetings and involvement opportunities open to members and the public. Communicating with the Board of Directors Directors can be contacted via the Director of Corporate Services/Trust Secretary by Trust.Secretary@cmft.nhs.uk or telephone Governor governance arrangements As part of our governance arrangements, in order to become (or continue as) a Governor, individuals must meet our Governor criteria. The criteria outline the mandatory requirements that all Governors upon election/nomination are required to comply with and include: Statutory Restrictions as outlined by our Constitution Declaration of Interests Code of Conduct (includes Nolan Principles) Disclosure and Barring Service Check (formerly CRB) Trust Internet and Use Policy Trust Media Policy Social Media A Guide for Governors. Fit and Proper Persons Test (as described in our provider licence). All Governor positions (Public, Staff and Nominated) are subject to the fulfilment of the above eligibility criteria, with Governors ceasing to hold office should these criteria be/become unfulfilled. A copy of the Governor criteria is available on our Council of Governors webpage or by contacting the Foundation Trust Membership Office (contact details on page 170). Declaration of interests Details of the Council of Governors declarations of interests are held by the Foundation Trust Membership Office with a copy of the register being available to members and the public via the CMFT website s Meet the Governors webpage Alternatively members and the public can contact the Foundation Trust Membership Office to obtain a copy (contact details on page 170). 153

154 The Governors Declaration of Interest Register is updated annually, following which it is formally recorded at a Council of Governors Meeting. The register discloses the details of any company directorships or other material interests held by Governors. None of our Council of Governors holds at the same time positions of Director and Governor of any other NHS Foundation Trust. Our Constitution, which was agreed and adopted by the Council of Governors, outlines the clear policy and fair process for removing from our Council of Governors any Governor who has an actual or potential conflict of interest which prevents the proper exercise of their duties. Governors roles and responsibilities under the legislation The Council of Governors receives and considers appropriate information which enables it to discharge its duties. In a recent Governor Survey (March 2016), all our Governors cited that they felt they had a clear understanding of the role of Governor (90% response rate). Statutory roles and responsibilities of the Council of Governors 2006 Act Appoint and, if appropriate, remove the Chair Appoint and, if appropriate, remover other Non-Executive Directors Decide the remuneration and allowances and other terms and conditions of office of the Chair and the other Non-Executive Directors Approve (or not) any new appointment of a Chief Executive Appoint and, if appropriate, remove the NHS Foundation Trust s Auditor Additional powers In preparing the NHS Foundation Trust s forward plan, the Board of Directors must have regard to the views of the Council of Governors Amendments to the 2006 Act made by the 2012 Act Hold the Non-Executive Directors, individually and collectively, to account for the performance of the Board of Directors Represent the interests of the members of the Trust as a whole and the interests of the public Approve significant transactions Approve an application by the Trust to enter into a merger, acquisition, separation or dissolution Decide whether the Trust s non-nhs work would significantly interfere with its principal purpose, which is to provide goods and services for the health service in England, or performing its other functions Approve amendments to the Trust s Constitution. The Council of Governors may require one or more of the Directors to attend a Governors Meeting to obtain information about performance of the Trust s functions or the Directors performance of their duties, and to help the Council of Governors to decide whether to propose a vote on the Trust s or Directors performance Source: Your Statutory Duties; A Reference Guide for NHS Foundation Trust Governors (Monitor August 2013) 154

155 Governor aim & objectives In keeping with these duties, we have developed the following Governor aim and objectives: Our Governor aim: Governors proactively representing the interests of members as a whole and the interests of the public via active engagement and effectively holding the Non-Executive Directors, individually and collectively, to account for the performance of the Board of Directors. Our Governor objectives: Governor engagement Governors to be proactive in developing and implementing best practice membership and public engagement methods. Governor assurance Governors to act as the conduit between the Foundation Trust Board of Directors and members/public by conveying membership/public interests and providing Board performance assurance. Governor development CMFT to support the developing and evolving role of Governor by equipping Governors with the skills and knowledge in order to fulfil their role. Governor engagement, assurance and development We provide many opportunities for Governors to be actively involved, which we feel helps us to make a real difference to our patients and the wider community. Over the past year, Governors have attended a wide variety of meetings/events from which Governor-driven actions have been agreed and taken forward. These have included actions to improve the experiences of both our patients and staff, in addition to raising issues on behalf of our members and the public. Members and the public receive information about how Governors have discharged their responsibilities via our membership newsletter, and our Lead Governor also provides an overview at our Annual Members Meeting. The main Governor involvement areas include: Holding the Non-Executive Directors individually and collectively to account for the performance of the Board of Directors, by attending regular Performance Meetings to review the Trust s performance across patient quality, clinical effectiveness, patient experience, finance and productivity and formally receive Board Assurance Reports. Representing the interests of our members and the public, and canvassing and forwarding member and public views to the Board of Directors at meetings. Regularly attending Governor Meetings and Development Sessions to discuss and agree with our Board of Directors how Governors will pursue opportunities and undertake additional roles, in order to represent members and the public and/or to meet the needs of our local community. 155

156 At a Council of Governors Meeting, Governors are formally presented with the final Annual Report/Accounts and Annual Plan and are consulted on the development of forward plans for CMFT and any significant changes to the delivery of our Business Plan. Governors are presented with CMFT s progress in achieving our Forward Plan priorities at Governor Development Sessions. Working closely with the Board of Directors, Governors are involved in the Trust s Annual Forward Plan priority decision-making process. Governors are encouraged to identify and prioritise quality indicators/priorities as part of the Annual Forward Planning Workshop and from the suggestions made, Governors agree a local quality indicator for the forthcoming year. As part of this process, Governors are formally presented with the final Quality Report, which helps them to fulfil their duty of holding the Non-Executive Directors to account for the performance of the Board of Directors. Governors are involved in recruiting new members and monitoring our membership profile; helping to develop membership engagement initiatives; ensuring that our membership communication is effective and reviewing the progress of our Membership Strategy. Casting a critical eye over the experience that our patients have, in areas such as accessibility, cleanliness and the environment, and overall 'customer care' and attending carers groups to directly engage with service users. Ensuring that CMFT meets its responsibilities to the wider community and plays a key role in monitoring employment, education, procurement and environmental initiatives. The Council of Governors Remuneration and Nominations Committee (a panel of Governors rotated each year and chaired by the Lead Governor) reviews and makes recommendations to the Council of Governors as a result of actively participating in an annual appraisal programme. This facilitates the 360 o appraisal process for the Chairman (led by the Senior Independent Director) and receives feedback on the appraisals of the Non-Executive Directors, including any re-appointment/terms of office (led by the Chair) and the remuneration of the Chair and Non-Executive Directors. The panel of Governors then reports directly to the Council of Governors seeking approval of their recommendations. Governors are actively involved in the selection of and approving the appointment of the Chair and Non-Executive Directors and agree with the Nominations Committee a clear process for new nominations. Governors are actively involved in the selection of and approving our External Auditors and take the lead in agreeing with the Audit Committee the criteria for appointing, re-appointing and removing External Auditors. Governors cast a critical eye over the health and wellbeing of our staff through channels such as staff survey findings, training programmes, workforce data and appraisals. They also assist in the development/progression of staff engagement initiatives. Governors actively participated in a Governor Focus Group as part of the recent Care Quality Commission inspection of the Trust which provided an opportunity for Governors to share their views and experiences directly with inspectors. 156

157 Governors actively participate in Quality Mark Assessments for Elder-Friendly Hospital Wards and Patient Led Assessments of the Care Environment (PLACE). Governors were invited to participate in stakeholder sessions established as part of the Senior Director and Non-Executive Director interview process. Feedback from each stakeholder session helps to shape the formal interview questioning process (undertaken by the Remuneration & Nominations Committee for Non-Executive Director appointments). Governors have actively participated in our Children with Medical Complexities Group, Complaints Scrutiny Group and attended our Annual Equality & Diversity Conference. Governors have been involved in several staff initiatives including the selection panel for our Staff Recognition Programme - the We re Proud of You Awards and Going the Extra Mile Awards. Governors have continued to be actively involved in our Internal Quality Reviews, which was an evolutionary process developed in order to give us a better understanding of our delivery of care. Governors have continue to be actively involved in driving improvements in relation to our Out-Patient Services including participating in our Out-Patient Standards Progress Panel and providing feedback regarding patient letters. Governors have participated in our Smoking Policy Working Group to explore ways to improve the environment around our sites and the patient/visitor experience. Governors have been involved in several Patient Experience Workshops in order to support the Trust to develop a new approach to patient experience. Governor engagement with a regional Dental Trauma Network has been established to develop educational resources for the wider public, schools and sports clubs. Governors have participated in a Social Value Workshop in addition to providing feedback in relation to our Travel Plan. Governors have been proactive in raising awareness and issues in relation to accessibility for disabled people including a Governor-led review of accessibility for disabled attendees at membership events. Governor involvement in the development of a new Forward Plan questionnaire/online survey and were encouraged to canvass views of members and the public (and for Nominated Governors the partner organisations that they represent) in relation to our future priorities. Governors have been instrumental in forwarding ideas/suggestions in relation to the current Governor Meeting Framework in order to identify both areas of strength and areas requiring further development in order to enhance the effectiveness and impact of Governors. The Health and Social Care Act (2012) states that Foundation Trust must take steps to secure that the Governors are equipped with the skills and knowledge in order to fulfil their role with the Trust being committed to providing high quality information including regular updates, presentations, and training to Governors in order to facilitate this in addition to aiding the Governor decision-making process. 157

158 In a recent Governor Survey (March 2016), the majority of Governors cited that the Trust provides the necessary resources to develop and update Governor skills and capabilities (90% response rate). Our Governor development programme is informed via Governor Questionnaire findings, Governor Skill Mix Matrix findings and Governor Framework Review Workshop feedback. CMFT encourages Governor development across a number of key areas: Equality and Diversity Training a bespoke annual workshop is held for Governors with Governors also actively participating in the consultation for the new Equality, Diversity & Inclusion Strategy and are regularly provided with key Equality and Diversity updates. Induction training for all new Governors including the provision of a Governors Resource Pack and additional support arrangements for Governors. Governor mentor/buddy assigned to our Nominated Youth Governor, to provide support in preparation for Council of Governors meetings. Chairman-led Governor development sessions (in summer and winter), covering topical health matters and the impact on the Trust/Governor role; CMFT s progress in achieving our Annual Forward Plan objectives; and an indepth review of the Trust s Annual Report, Accounts, External Auditor Reports and Quality Report. Governor attendance at external training events for example, the (Mersey Internal Audit Agency (MIAA) Understanding Mortality event provided an opportunity for Governors to learn more about mortality data and helped to inform discussions about mortality as one indicator of care quality. Annual Lead Governor elections - the Lead Governor role facilitates direct communication between Monitor now part of NHS Improvement (Independent Regulator of Foundation Trusts) and our Council of Governors in the circumstance that it is not appropriate to communicate through normal channels. Dedicated Lead Governor/Governor meetings promotes free discussion/debate. Membership and public engagement a Governor Briefing Pack and bespoke Governor Engagement Packs are also produced in preparation for key membership events, in addition to the start of the Annual Forward Planning Process. Encouraging Governor attendance at Board of Directors Meetings (open to the public) to directly observe Non-Executive Directors scrutiny, challenge and support of Executive Directors. In addition, patient story film clips are presented to Governors to enable them to listen to the real-life experiences of patients of our Trust. Following the public meeting, a dedicated private session has been established for Governors to raise any questions and/or observations on the items discussed at the Board of Directors. Chairman s briefings, produced on a monthly basis, which provide key CMFT and wider NHS information. From information received at meetings and via these briefings, Governors are encouraged to share the Board of Directors assurance with members/the public in relation to CMFT s performance, services/plans and the effectiveness of Governors in representing members/public views. 158

159 Governors regularly receive briefings and updates regarding internal programmes of work such as Transforming Care for the Future and external programmes such as Greater Manchester Health & Social Care Devolution and the Single Hospital Services Review. Dedicated Governor visits including viewing some of the new LIME Arts projects in Radiology and the Burns Unit on the central site, and a tour of Trafford Hospital to visit some key departments/areas. Future priorities to support Governor development during 2016/17 include: The establishment of a new Governor Development & Training Plan informed via Monitor s Guidance Documents, Governor Framework Workshop findings, Governor Questionnaire Findings, and Governor Skill Mix Assessment. The establishment of specialised Governor training sessions linked to the new Governor Development & Training Plan key priorities. A new Governor Framework to be developed which will outline in more detail the Governor role and responsibilities in addition to the Governor aim, objectives and key priorities. To continue to hold key performance review meetings focusing on patient safety, patient experience and productivity & efficiency review and scrutiny of Board Assurance Reports enabling Governors to effectively hold the Board of Directors to account. A Governor Skill Mix Matrix which enables Governor competencies/expertise to be captured and used effectively when assigning/progressing Governor-led involvement projects. Continuing to hold dedicated Governor and Non-Executive Director Networking Meetings, enabling assurances to be sought directly from Non- Executive Directors alongside identifying and capturing Governor development needs. Meetings also help Non-Executive Directors to gain a deeper understanding of Governor/member views about CMFT. Continuing to provide Governors with updated information as part of their bespoke Governor Engagement Packs, Chairman s Briefings and Membership and Public Engagement: Governor Briefing Pack. This will further support Governors as they engage with members and the public. Monitoring arrangements Governor development is monitored in a number of ways: An annual questionnaire is completed by Governors which identifies development needs. Governors meet with the Chairman on a regular basis outside of the Council of Governors meetings, to highlight any development needs. The Governor Skill Mix Matrix enables any competency gaps (individually or across the Council of Governors as a whole) to be highlighted and corresponding training needs to be identified. Led by the Chairman, Governors are invited to self-evaluate their collective performance/effectiveness as part of the annual Governor Questionnaire process. Ideas/suggestions for further improvements are then considered/progressed as part of the Governor development programme. The Chairman meets regularly with the Lead Governor in order to address any Governor issues and identify areas for further development. 159

160 Additional support for Governors As an NHS Foundation Trust, CMFT is committed to establishing a truly representative membership and welcome members and Governors from all backgrounds and protected characteristics. We do not tolerate any form of discrimination, harassment or victimisation. We are committed to supporting Governors so that they are able to undertake their role to the best of their ability and we recognise that they may need additional support to do this. We appreciate that additional support may be required for a variety of reasons including: Physical accessibility (e.g. disability, older or frail people) Language Culture and traditions Social expectations (young people) Lifestyles. In relation to disabilities, we appreciate that these are of a diverse nature and if a Governor considers him/herself to have a disability and/or require additional support in relation to this or for any other reason, support is provided via the Director of Corporate Services/Trust Secretary or Foundation Trust Membership Manager. As an NHS Foundation Trust we ensure that we support Governors to undertake their role through any reasonable adjustment. In a recent Governor Survey (March 2016), Governors cited that they felt that the Trust provides the appropriate level of support to carry out the role and responsibilities of Governor (90% response rate). Governor Groups Governors play a vital role in helping us to plan and develop future services by responding to feedback from their constituents and the wider community. We have four Governor Groups which look at practical ways to make a difference to patient care within our hospitals and aspire to help reduce health inequalities in our surrounding communities. Staff wellbeing is also a key priority, and the groups usually each meet four times per year. Each Governor Group is assigned a Non-Executive Director and supporting Director so that the views of Governors can be considered/understood and conveyed to the Board. Non-Executive Directors and the supporting Directors support the progress of initiatives in relation to each Group s work streams. Trust Officers also attend each Governor Group in order to provide Governors with high quality information relevant to their respective functions. At each Governor Group meeting, the assigned Non-Executive Director also provides a Board update. This supports Governors in forwarding the Board of Directors assurance to members and the public about CMFT s performance, services and plans. 160

161 Staff Experience Group supports the development and implementation of CMFT s Staff Health and Wellbeing Strategy and staff engagement initiatives, in addition to reviewing the Trust s staff survey findings and workforce data including equality and diversity data. Recent work projects include Governor monitoring of Workforce Data/Recovery Plans and associated Key Performance Indicators, in addition to their continuing involvement in the Trust s Staff Recognition Programme. Corporate Citizenship Group advises and engages with the Trust s Corporate Citizenship programme with work projects being generated around five main themes: Employment; Carbon Reduction (Energy and Sustainability); Sustainable Travel & Transport; Sustainable Procurement and Cultural Partnerships. Recent work projects include Governor involvement in supporting the Trust s employment, apprenticeships and work placement programmes (Supported Traineeships, Clinical Pre-Employment and Manchester Health Academy) and attending celebration events for programme graduates, with Governors continuing to monitor the Trust s Employment Key Performance Indicator to measure progress made to recruit young, local employees. Support is also given to the development of carbon reduction and sustainable procurement initiatives. Patient Experience Group- supports the implementation of the Trust s Quality Strategy by advising on issues such as accessibility, customer focus, front of house/reception areas, patient information, and developing meaningful involvement with patient partnership groups. Recent work projects include Governor attendance and feedback at Carer events; involvement in the nursing and midwifery Going the Extra Mile Awards Review Panel; monitoring patient experience/survey findings and the Trust s position in relation to harm free care (pressure ulcers, falls and catheter acquired urinary tract infections). Membership Group helps to recruit, retain, communicate and engage with members, ensuring a representative base is established which accurately portrays the diverse communities that we serve. Membership engagement best practice methodologies continue to be developed and supported by Governors. Recent work projects include Governors support of CMFT s public member recruitment campaign; this was held to enlist young members and address short falls in the membership profile. Governors are actively involved in the planning of membership engagement events (Young People s Event and Annual Members Meeting) which included a dedicated Governor Question and Answer session and interactive questionnaires, in addition to improving accessibility for disabled people. 161

162 Governors continue to support the Trust s Annual Membership Engagement Communication Plan, including initiatives targeted at reaching Seldom Heard Groups. Monitoring arrangements for Governor Groups As part of the Governor Meeting Framework Review process, the Chairman met with the Lead Governor and Governor Group Chairs to discuss current meeting arrangements and determine achievements made during the year, in order to establish a focus of work for the coming year and identify any areas requiring improvement. Periodic review of the Terms of Reference and membership of each Group is undertaken. The meeting papers for all Governor Groups are circulated to all Governors and Non-Executive Directors, providing them with a deeper understanding of the work projects being progressed by each Group and the corresponding views of Governors and Members. The minutes of each Group are also incorporated into each Council of Governors Meeting Pack with the Governor Chair of each Group providing responses to any queries raised and/or requests for further information at each meeting. Governor and Director attendance at Council of Governor Meetings 2015/16 Our Constitution, which was agreed and adopted by the Council of Governors, outlines the clear policy and fair process for the removal from the Council of Governors of any Governor who consistently and unjustifiably fails to attend the meetings of the Council of Governors or has an actual or potential conflict of interest which prevents the proper exercise of their duties. Governor Attendance at Council of Governor Meetings 2015/16 Governor Name 1 st July th October nd March 2016 Rabnawaz Akbar Ivy Ashworth-Crees X Nik Barstow Jayne Bessant X X X Isobel Bridges Julie Cheetham X X Malcolm Chiswick X Theresa Clegg George Devlin X Peter Dodd X David Edwards Matthew Finnegan X Peter Gomm X Sharon Green Michael Gregory X X 162

163 Governor Attendance at Council of Governor Meetings 2015/16 Governor Name 1 st July th October nd March 2016 Angela Harrington X Alexander Heazell X Beverley Hopcutt X Ariful Islam X Alan Jackson X X X Richard Jenkins X Henry Kitchener X Paul Lally X X Mary Marsden Thomas Marsh X Patrick McGuinness X X Mike Molete Mariam Naseem X William Keith Paver Andrew Peel Cheryl Rivkin X Sue Rowlands Carol Shacklady John Vincent Smyth X Geraldine Thompson Christine Turner Barrie Warren X X Graham Watkins Sue Webster Abebaw Yohannes X = attended the meeting, X = did not attend the meeting, = not applicable Director Attendance at Council of Governor Meetings 2015/16 Director Name 1 st July th October nd March 2016 John Amaechi Non-Executive Director Professor Colin Bailey Non-Executive Director (appointed 14 th March 2016) X 163

164 Darren Banks X Executive Director of Strategy Dr Ivan Benett Non-Executive Director (appointed 4 th January 2016) Lady Rhona Bradley X Non-Executive Director (term of office ended 4 th December 2015) Julia Bridgewater Chief Operating Officer Professor Rod Coombs X X Non-Executive Director (term of office ended 14 th March 2016) Kathy Cowell Senior Independent Director/ Non- Executive Director Sir Michael Deegan Chief Executive Gill Heaton X Deputy Chief Executive Nic Gower Non-Executive Director (appointed) Margot Johnson X Executive Director of Human & Corporate Resources Cheryl Lenney X Chief Nurse Anthony Leon X Deputy Chairman/ Non-Executive Director Chris McLoughlin Non-Executive Director (appointed 26 th October 2015) Steve Mycio Chairman Professor Robert Pearson Medical Director Adrian Roberts X Executive Director of Finance Anil Ruia X Non-Executive Director Brenda Smith Senior Independent Director/ Non- Executive Director (term of office ended 4 th December 2015) = attended the meeting, X = did not attend the meeting, = not applicable 164

165 Membership Membership aim and key priorities Our aim is for CMFT to have a representative membership which truly reflects the communities that we serve, with Governors actively representing the interests of members as a whole and the interests of the public. Our key priorities are: Membership community to uphold our membership community by addressing natural attrition and membership profile short-falls. Membership engagement to develop and implement best practice engagement methods. Governor development - to support the developing and evolving role of Governor by equipping Governors with the skills and knowledge in order to fulfil their role. (see page 158 above for further details). Our membership community Our membership community comprises both public and staff constituencies with the public constituency being made up of Public Members (vote for and elect Public Governors) and the staff constituency being made up of Staff Members (vote for and elect Staff Governors). Public members Public membership is voluntary and free of charge and is open to anyone who is aged 11 years or over and resides in England and Wales. Our Public Member constituency is subdivided into 4 areas: Public Constituencies Number of members City of Manchester 6184 Rest of Greater Manchester 5485 Trafford 1420 Rest of England & Wales 1661 Total 14,753* *This includes three members who subsequently moved outside the Trust area The maps below illustrate the Manchester, Trafford and Greater Manchester constituency (areas which fall outside of these wards are captured in the Rest of England & Wales constituency). 165

166 GreaterManchester Manchester Trafford 166

167 Staff members Staff membership is open to individuals who are employed by the Trust under a contract of employment including temporary or fixed-term (minimum of 12 months) or exercising functions for the Trust with no contract of employment (functions must be exercised for a minimum of 12 months). All qualifying members of staff are automatically invited to become members as we are confident that our staff want to play an active role in developing better quality services for our patients. Staff are however able to opt out if they wish to do so. The Staff Member constituency is subdivided into 4 classes: Staff classes Number of members Medical & Dental 1,323 Nursing & Midwifery 4,033 Other clinical staff 4,524 Non-clinical & support 3,959 Total 13,839 Membership Engagement & Membership Strategy A Membership Engagement & Membership Strategy has been produced to outline how patients, carers, members of the public and the local communities that we serve can become more involved by becoming members of our Trust. The Strategy defines our membership community, outlines how we recruit, retain, engage, support, and involve our membership and communicate effectively with members. In addition, the Strategy outlines the Governor role and duties and key areas to support and develop the evolving role of Governors. the composition of the Council of Governors which is reviewed as and when any changes occur in relation to our public membership (to be representative of the communities of the Trust) and our staff membership (to be representative of the staff employed at the Trust), while ensuring that the Council of Governors is not so large as to be unwieldy. The review process for the composition of our Non-Executive Directors this is undertaken when a Non-Executive Director vacancy arises to ensure that appropriate skill sets are identified prior to commencing the recruitment process. The Board of Directors works with an external organisation (recognised as an expert at appointments), to identify the skills and experience required for Non-Executive Directors. The Membership Strategy is reviewed/updated by the Governors Membership Group to ensure that key health economy and profile information is aligned with our Annual Forward Plans and Equality and Diversity Reports. A copy of the strategy is available to members and the public on the Trust s Membership webpage Alternatively, a copy can be obtained from the Foundation Trust Membership Office (contact details on page 170). 167

168 Membership Community In 2015/16, CMFT held a public membership recruitment campaign to address shortfalls in our membership profile, as a result of natural attrition and, in keeping with our Membership Strategy, in order to sustain a majority of public members. A public membership profile was presented to the Governors Membership Group outlining the key membership profile groups to be targeted. The corresponding campaign was specifically focused on recruiting young people (aged years) in addition to recruiting members across a range of ethnic groups in order to sustain a truly representative public membership profile. The recruitment event was held across all our hospital sites in addition to key GP community venues and through contacts with local community groups (Arab, Chinese and Gypsy or Irish Traveller). The public membership recruitment campaign was completed in February 2016 and was successful in achieving positive outcomes in relation to each targeted profile group. Around 600 new public members were recruited resulting in a total public membership of around 14,700. Together with our staff membership of around 13,800, this gave an overall membership community of over 28,000 members at 31st March During 2016/17, we again aim to uphold our membership community by addressing natural attrition and membership profile short-falls. Membership was also promoted through the Trust s website homepage, Facebook and Twitter pages which included a statement from our Lead Governor outlining the benefits of becoming a member. A Trust/membership promotional video is also available on You Tube. In addition, we promote membership through a membership display stand which is rotated throughout the various entrances to the Trust s hospital sites. Membership welcome packs are sent to all new members and include an invitation to their family/friends to become a member. Regular membership newsletters (Foundation Focus Newsflash) and an Annual Members Meeting invitation are sent to members, circulated to key community groups (seldom heard groups) and displayed on the Trust s website. Membership promotional materials are also regularly circulated to patient/public areas throughout our hospitals. The dedicated Foundation Trust section of the Trust s website is regularly updated promoting membership, the role of Governor, elections and forthcoming membership events and includes the facility for people to apply for membership by completing an online application form. Members and the public s views are canvassed by Governors throughout the year in relation to our forward plans via the Our Forward Plans - Tell Us Your Views webpage and through our membership newsletter. A key priority area for 2016/17 is to again target membership recruitment in the young people s age group to sustain an 11 to 16 year-old membership population of around 5%. In addition, hard to reach groups will continue to remain a recruitment focus, particularly recruiting minority ethnic groups. 168

169 Membership will continue to be promoted by our display stand, website and social media channels, newsletters and posters throughout CMFT and on hospital public transport. Monitoring arrangements for membership The Board of Directors monitors how representative our membership is and the level and effectiveness of membership engagement as part of the Annual Reporting Process. Governors support the Board of Directors in monitoring our membership community/representation via the Governors Membership Group to ensure natural attrition and profile short-falls are identified and membership recruitment initiatives are developed to address any imbalances. The Group reports to the Council of Governors attended by the Board of Directors. Membership analysis data Age Membership 2014/15 % Membership 2015/16 % , , , , Not Stated Ethnicity White 10, , Mixed Asian or Asian British 1, , Black or Black British Other Not Stated Gender Male 6, , Female 7, , Not Stated Recorded Disability 1, , Although the 0 16 year old membership group figure may appear low, the Trust s membership base for this group is between the ages of years. Total Public Membership (31st March 2016) = 14,753 (832 members with no stated age, 598 members with no stated ethnicity and 122 members with no stated gender). Staff membership at 31 st March 2016 = 13,839 this includes facilities management contract staff and clinical academic (The University of Manchester staff). (See page 79 of the Staff Report for workforce analysis data.) 169

170 How to become a member We are committed to establishing a truly representative membership and we welcome members from all backgrounds and protected characteristics including age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation (this is not exclusive of other diverse backgrounds). Membership application forms are on the Trust s website ( or available from the Foundation Trust Membership Office, which you can contact at ft.enquiries@cmft.nhs.uk or on Changing your membership details or cancelling your membership As part of the membership application process, the Department of Health asks NHS Foundation Trusts to capture information about ethnicity, language and disability status so that we can be sure that we are representing all sections of our communities. We therefore ask membership applicants to disclose this information during the application process. All information collected is confidential, in keeping with Data Protection rules, and is not released to third parties. Changes to information or cancellation of membership are done via the Foundation Trust Membership Office. Help us to reduce our carbon footprint CMFT has a Sustainable Development Management Plan, which includes actions to reduce our carbon footprint and save valuable natural resources. One of our sustainability commitments is to reduce the number of documents that we print, and we encourage members to help us achieve this by providing their address. Membership engagement In addition to upholding our membership community, CMFT also strives to actively engage with our members so that their contribution and involvement is turned into tangible service benefits - thus improving the overall experiences of our patients. Membership engagement is facilitated via our strong working relationship with our Governors and by developing engagement best practice. In 2015/16, membership engagement initiatives included: An interactive Young People s Health Event which includes health information and interactive demonstrations from varying health professionals with stands promoting key health service areas within the Trust, in addition to advice on NHS careers/voluntary services. The latest event (June 2015) included attendance by a number of Governors and provided an opportunity for young people to forward their views and opinions: o A total of 382 young people, students, teachers, staff and staff children attended o Attendees also included groups of students from 9 various schools/colleges/universities from across Manchester and Greater 170

171 Manchester in addition to a group of attendees from the Young Disabled People s Forum o 31 stands were enlisted to promote various NHS careers (including nonclinical and clinical roles) and provide young people s health information in addition to a new Looking After You area o Governors Engagement Sessions were provided, with members being signposted to engage with Governors and participate in a new young people s interactive questionnaire which enabled views to be canvassed in relation to our forward plan priorities. An interactive Annual Members Meeting at which Directors presented the Trust s Annual Report and Accounts, including past performance and plans for the future. The Lead Governor also presented a Membership Strategy and Governor & Membership overview. The meeting was held on 22 nd September 2015 and focused on the theme 'Proud to Care for You'. Our staff showcased the outstanding services that we provide across our six hospitals and in the community and included attendance by a number of Governors and provided an opportunity for members and the public to forward their views and opinions: o A total of around 200 members and the public attended o 27 Stand holders were enlisted from the Trust and partner organisations to showcase the outstanding services we provide and centred upon the theme Proud to Care for You o Governors Engagement Sessions were provided, with members being signposted to engage with Governors and participate in a new interactive questionnaire which enabled views to be canvassed in relation to our forward plan priorities. Members were encouraged to share their experiences of care, and those of their families and friends, as part of the recent Care Quality Commission inspection of the Trust. Invitations were sent to members to attend our membership events, including personalised invitations, with event information also circulated to seldom heard groups. Invitations were sent to members to become involved in the Trust s Patient Led Assessment of the Care Environment (PLACE) Assessments. A number of Chairman/Staff Governor Engagement Sessions with Staff Members were held at varying hospital locations and at which staff members were encouraged to forward their views and suggestions. A Governor bulletin is circulated to all staff members highlighting membership and Governor information. Governor attendance at the Trust s Youth Forum meetings, with Youth Forum representatives contributing to the Governors Membership Group, facilitating more effective engagement between young members and Governors. 171

172 A Membership Engagement Communication Plan has been developed to enable meaningful engagement and communications with both Governors and members. The Patient Experience and Equality and Diversity Teams assist in promoting membership events to Seldom Heard Groups. The public and members are also encouraged to contact our Governors via our Meet the Governors webpage Contact information is also promoted in our membership newsletter, and Governors welcome views and opinions when they attend key membership and trust events. Foundation Focus newsletters are regularly produced and circulated to members and the public, covering topics including: o Members in Action and Governors in Action features providing an overview of how Governors have discharged their responsibilities and membership involvement/feedback plus a bespoke calendar of events. o A young people s newsletter promoting our Annual Young People s Event and feedback from attendees. o A Forward Plan newsletter encouraging membership and public involvement/completion of our Forward Plan Questionnaire/On-line survey and contacting Governors to forward views and opinions in relation to our proposed future priorities. The canvassing of member and public views by Governors is encouraged during attendance at both CMFT and local public/patient events and via our Membership and Governors web pages, newsletters and with people also encouraged to send us their views and suggestions via the Trust s freepost address. A new Forward Plan Questionnaire/on-line survey was made available to both public and staff members and the wider the public in 2015/16. This enabled participants to rank/forward their views about our proposed priorities, in addition to encouraging ideas about ways to improve our services. The views and opinions received are captured as part of the Trust s Membership Forward Plan Report and are considered by the Board of Directors and Governors as part of our Annual Forward Planning Process. Suggestions for ways to improve our services are forwarded to relevant CMFT work programmes, for example our Transformation and Quality teams. A dedicated FT enquiries account is available to members and the public, enabling direct contact with the Foundation Trust Membership Office and/or Governors. Membership and Public contacts over the past year have included: o Interest in becoming a member and/or the role of Governor o Interest in Governor elections/standing for election as a Governor o Compliments - positive experiences as patients o Information sharing between other NHS Foundation Trusts/Governors 172

173 o Information about job vacancies, work placements and volunteer opportunities o Removal from membership list or changes to membership details o Request for copy of our Forward Plan o Request for contact with Lead Governor/Governors and/or wish to share ideas/suggestions o Request for dates of meetings/events that are open to the public o Request for membership/public involvement opportunities. Public and Staff Welcome packs have been developed with all new public members being sent packs which are segmented into: o Public (Adult years) o Children & Young People s (11 17 years). Packs include a welcome letter from the Chairman, membership & governor information, involvement form and a freepost envelope. Completed membership involvement forms members interests are recorded with a thank you letter sent to the member. The members involvement interests are forwarded to relevant Trust Officers to help CMFT make contact when relevant member involvement opportunities occur. Membership involvement opportunities The table below outlines the involvement opportunities that members are encouraged to participate in: Involvement Opportunity Participating in Surveys Attending Member Events/Meetings Attending Open Days/Health Promotional Events Recruiting New Members Fundraising Activities Participate in Consultation about Trust Plans Find out more about the Work of the Trust Standing for Election as a Governor Membership Engagement Involvement Opportunities Children & Young Public Members (11 17 years) Adult Public Members (18+ years) Staff Members (If aged 16+ years) 173

174 Involvement Opportunity Join the Trust s Volunteer Services Become a Member of the Trust s Youth Forum Meetings Attending Chairman/Staff Governor Engagement Sessions Membership Engagement Involvement Opportunities Children & Young Public Members (11 17 years) (If aged 16+ years) Adult Public Members (18+ years) Staff Members N/A N/A N/A N/A N/A CMFT is very keen to involve members, patients and the local community in developing our services, and you can read more about our engagement and consultation activities on pages (Directors Report). Membership engagement will continue to be our key priority during 2016/17, with Governor-driven suggestions and actions being encouraged to further enhance and develop Governor/membership engagement initiatives. We are confident that by engaging with our members in a way that meets their needs and continuing to uphold a membership community that truly reflects the diverse communities that we serve, we can ensure that as many people as possible have the opportunity to contribute and be involved in the development of services that mirror our patients needs. Monitoring arrangements CMFT is committed to supporting Governors in canvassing the views and opinions of our members and the public. Membership and public engagement initiatives are developed and monitored via the Governors Membership Group in conjunction with the Council of Governors. The involvement interests indicated by members and attendance at key membership events are used to gauge levels of engagement. Board of Directors engagement with Governors The Chair ensures that the views of Governors and members are communicated to the Board as a whole. The interaction between the Board of Directors and the Council of Governors is seen primarily as being one of a constructive partnership, seeking to work effectively together in their respective roles. The Council of Governors adopts a policy to proactively engage with the Board of Directors in those circumstances when they have concerns. The Council of Governors is encouraged to ensure its interaction and relationship with the Board of Directors is appropriate and effective, with the Trust s Constitution outlining the process to resolve any disagreements between the Council of Governors and Board of Directors. 174

175 The Council of Governors would only exercise its power to remove the Chairperson or any other Non-Executive Director after exhausting all means of engagement with the Board. The Board of Directors engages with Governors on a regular basis in order to understand and obtain both Governors and members views and respond to any concerns. All Executive and Non-Executive Directors attend Council of Governors Meetings at which Governors have the opportunity to directly forward their views to Directors and seek assurances on any concerns or issues that may arise. At quarterly Governor Performance Review Meetings, attending Directors hold discussions with Governors in order to understand their views on the Trust s performance and provide details of actions in place to improve performance where required. Governors are actively encouraged to provide feedback on the Trust s Board Performance Report with a view to ensuring that the right level of detail/information is provided, appropriate assurances received and/or action is taken. This informs accurate decision-making, appropriate to their respective functions and relevant to the decisions that Governors have to make. A Non-Executive Director is a member of each Governor Group, which is a forum for the views of Governors and members to be considered/understood and, in turn, conveyed to the Board of Directors. At each Group, Non-Executive Directors provide Board/NED updates in order to further support Governors in forwarding Board of Directors assurance to members and the public in relation to CMFT s performance, service and plans. Non-Executive Directors and supporting Directors support the progress of initiatives in relation to each Group s programme of work. Trust Officers also attend in order to provide Governors with high quality information, appropriate to their respective functions and relevant to the decisions that they have to make. The Chair also hosts a number of Governor Development Sessions attended by both Executive (as appropriate) and Non-Executive Directors. A range of topics are discussed for example performance against CMFT s key priorities, annual report and patient experience information. At these sessions, Governors are encouraged to proactively engage, raising any concerns or issues, and to offer their views and suggestions for consideration. Governors play a key role in the Trust s Forward Planning process which is facilitated via an Annual Forward Planning Workshop, hosted by the Chair, and led by the Executive Director of Strategy. Key Trust Officers again provide high quality information with Non-Executive Directors also attending. During this workshop, Governor and member views are sought, with the Board of Directors taking account of their views (where appropriate). 175

176 In addition, Governors are also encouraged to identify and prioritise quality indicators/priorities as part of the Annual Forward Planning process and from the suggestions made, a local quality indicator is agreed for the forthcoming year. The Board of Directors, in consultation with the Council of Governors, appointed one of the independent Non-Executive Directors to become the Senior Independent Director. Governors are encouraged to attend Board of Directors Meetings (open to the public) to directly observe Non-Executive Directors scrutiny, challenge and support of Executive Directors. Agendas and minutes are circulated to Governors in advance of each meeting. Governors are also signposted to associated meeting papers in order to receive and consider appropriate information required to enable them to discharge their duties. In addition, patient story film clips are presented to Governors to enable them to listen to the real-life experiences of CMFT patients. Following the public meeting, a dedicated private session has been established for Governors to raise any questions and/or observations on the items discussed at the Board of Directors. The public interests of patients and the local community are shared with the Board of Directors through the work of our Governors, and also by engagement with local groups and organisations. You can read more about how we do this, including the partnership programme we are developing in 2016/17, on pages (Directors Report) 176

177 3. Quality Report Part One Welcome and Overview 3.1 Statement on Quality from Sir Mike Deegan, Chief Executive 3.2 Welcome from Professor R C Pearson, Medical Director 3.3 Care Quality Commission and External Regulations 3.4 CMFT Quality Reviews 3.5 Board to Ward Part Two Statements of Assurance from the Board and Priorities for Improvement 3.6 Overview of Priorities 3.7 The NHS Outcomes Framework 3.8 Patient Safety 3.9 Clinical Risks 3.10 Clinical Effectiveness Infection Control Harm Free Care Mortality Sepsis Clinical Audit National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Research Medical Education Medical Appraisal 3.11 Patient Experience Ward Accreditation Friends and Family Test Food and Hydration Compliments, Concerns and Complaints Dementia-John s Campaign 3.12 Other News Acute Kidney Injury (AKI) End of Life Care (EOLC) Transition Urgent and Emergency Care Transformation Informatics Update 3.13 Divisional Reports 3.14 Data Assurance Processes and Information Governance 3.15 Our People 3.16 Glossary of Definitions Part Three Other Information 3.17 Performance of the Trust against selected metrics 3.18 Performance of Trust against national priorities and core standards 3.19 Feedback from Governors 3.20 Commissioner s Statement 3.21 Feedback from the Health and Wellbeing Scrutiny Committee 3.22 Statement of Directors responsibilities in respect of the Quality Report 3.23 Independent Assurance Report to the Council of Governors of Central Manchester University Hospitals NHS Foundation Trust on the Annual Quality Report 177

178 Part 1: Welcome and Overview 3.1 Statement on Quality from Sir Michael Deegan, Chief Executive I am pleased to present our Quality Report for 2015/16. Here at Central Manchester University Hospitals NHS Foundation Trust we are absolutely committed to the delivery of the highest standards of care and the best patient experience. The 2015/16 Quality Report gives an overview of how we have set out to do that this year, some of our achievements to date and where we still need to improve. This year the challenges of continuing to improve quality, safety and the patient experience against a backdrop of the requirement for NHS efficiencies, an increase in demand for services have continued just as I reported last year. I am pleased to report that the Board of Directors has again unashamedly had patient safety, clinical quality and patient experience as our number one objective throughout the year. Every decision we have made has been assessed to understand the impact on the quality of the services we provide. Overall it has been a very good year for improving the quality of our services. I have seen first-hand some of the fantastic work which is taking place across all of our services and the challenges our staff experience to provide the best experience and clinical outcomes for all our patients, whether that is in the home, in the community or in one of our many hospitals. The following report sets out the detail and I would like to present here some personal highlights: In November 2015 the CQC undertook their planned comprehensive inspection of all of our services. I am delighted to report that their rating for the Trust overall was Good. This rating is one that the Board of Directors and all of our staff are rightfully proud and our aim to SHINE was achieved. I am particularly proud that our Child and Adolescent Mental Health Services were rated as Outstanding. Our Staff survey results have also shown an improvement this year. Since 2014 there has been a statistically significant increase in staff recommending CMFT as a place to work or receive treatment; from 3.63 to This is ranked above the average for all Acute and Community Trusts which is The Friends and Family test has shown that people believe that we are improving, with the vast majority of respondents saying they would recommend our services. Once again we undertook our programme of peer reviewed internal Quality Reviews across all of our services looking at the quality of care provided, sharing good practice and made recommendations for improvement. All our staff are encouraged to speak out safely and this year we appointed a Non-Executive Director of the Board as the Freedom to Speak Up Guardian. We will be working this year to develop a team of champions to support him in this role. 178

179 Because of the number, I cannot detail all of our outstanding projects in this report but we continue to be a leader in first class research. In 2015/2016, the Trust was the only site to start trials of the Bionic Eye in dry age-related macular degeneration (AMD), combining artificial and natural vision for the first time. Last year, new data published The Lancet also emphasised the instrumental role our patients and staff played in developing a new screening blood test that could reduce deaths from ovarian cancer by an estimated 20%. I reported last year that the next five years will be an exciting, interesting and challenging time for the NHS. Throughout the year we have focused on delivering care that is safe and clinically effective, because we recognise that this will provide the best patient experience and is also the most cost effective way of making the best use of our NHS resources. This report can only provide a snapshot of the very many excellent and innovative examples of care and services we provide across all of our Foundation Trust. I would like to say a huge thank you to all our staff, governors and partners for their personal contribution to improving the quality of care for people who use our services and for working together and making this another successful year for CMFT. I am pleased to confirm that the Board of Directors has reviewed the 2015/16 Quality Account and confirmed that it is a true and accurate reflection of our performance. Sir Michael Deegan, Chief Executive Officer May Statement from the Medical Director My aim as Medical Director is to ensure that Clinical Quality and Patient Safety remain absolutely central to what we do here in Central Manchester University Hospitals NHS Foundation Trust (CMFT). 2015/16 has been a year of continuing challenge for the NHS as a whole and Central Manchester University Hospitals NHS FT has not been an exception to that. As last year, challenging financial targets coupled with increased pressures on services such as our Accident and Emergency Departments have meant our staff have had to work even harder to deliver high quality care. We started the year as usual with a challenging work programme with ambitious targets. I am pleased to say we were able to achieve many of these and where we have not, we continue to work hard to improve. The Trust Quality Report sets out all of these achievements in detail but here are some of the headlines: The Care Quality Commission (CQC) rated the Trust as a whole as Good. This puts us in the top 10% of large Acute and Teaching Trusts in the NHS, and is a great tribute to all of our staff who provide such great and compassionate care to the patients who come to us for care. 179

180 There is more detail in the body of this report, but I want to thank all our staff who work day and night to deliver services they can be proud of. Mortality As one of a number of key measures on quality of care mortality measures are kept in continued focus. I am pleased again to report that the position to date is that the crude mortality rate for patients admitted to the Trust is the lowest in the North West and far better than the national average. For risk adjusted mortality indicators, the SHMI (Summary Hospital-level Mortality Indicator) at the Trust is below 100 and the HSMR (Hospital Standardised Mortality Ratio) is This, triangulated with other information, assures me that the mortality rate for the organisation is again slightly below expected. In the section on mortality you will be able to see some of the progress we have made on mortality review and the development of a new Trust Strategy. Sepsis How we treat patients of all ages who present with this serious condition has continued to be a major focus for 2015/16. After a number of interventions, this year we have seen a rapid achievement of the sepsis 6 (the current gold standard of treatment), and as a result, seen a reduction of 2 days in the length of stay of patients diagnosed with sepsis. We have decided after a review of progress and discussion with our Governors that this will continue to be a focus going forward to 2016/17. Dementia (John s Campaign) John s Campaign was founded in 2014 by the daughter of a patient based on the key principle of families/carers having the right to stay with patients with dementia when they are admitted to hospital. The principles of the campaign are based on the concept that parents are encouraged to stay with their children when they are admitted to hospital. Whilst patients with dementia are not children, their vulnerability and the distress they experience when admitted to the unfamiliar hospital environment impacts on their recovery, experience and the experience of their families. John s Campaign looks to address this by allowing families of patients with dementia to stay with them using a carer s passport, allowing them to be involved in their care resulting in better quality care and improved outcomes. This campaign is currently being trialled across all inpatient areas at Trafford Hospital. Patient Safety and Harm Free Care All our staff from the Board to individual clinical staff at the front line delivering care have access to a range of online safety metrics to enable them to assess quality and make improvements. 180

181 This year I am committed to working with clinical teams to reduce to zero the number of never events reported. I am disappointed to report that despite a comprehensive programme of work the Trust still reported seven of these events in 2015/16. Although none of these incidents resulted in major harm to patients, they should not have happened. This year my teams will be working again with individual clinicians on how to prevent never events. I have also been clear with all staff that individuals who fail to follow safety procedures will be held to account accordingly. Medical Education The first Developing Excellence in Medical Education conference was held last year in Manchester. I am delighted to say that the Trust's Medical Education team received four awards for their posters at the conference, demonstrating their ingenuity and commitment in the development and training of doctors. Our Trust library service was assessed and received a Library Quality Assurance Framework score of 90% compliance against national standards. This was a significant improvement on the previous year's results and is a reflection of the dedication and hard work of the team. I am also pleased to say that the pass rate of our year 5 medical students remains high. 99% was achieved which is a credit to the students and to the various staff who have been involved in supporting them during their training. Research and Innovation We are dedicated to driving continuous improvement in the care our patients receive through clinical research. We support some 300 investigators, who undertake research across a diverse range of clinical areas to deliver improved diagnostics, treatments and devices for patients in Manchester and beyond. In 2015/16 we dramatically improved our performance in initiating clinical studies. This means we are able to provide patients with quicker access to clinical studies as part of their clinical pathway. CMFT Standards We are committed to improving and transforming our services to provide the best experience and quality for our patients. We have invested time over the last twelve months working with staff and patients on the development of standards for outpatient care and elective and emergency pathways. This work sets the standard of care that can be expected for all patients across all of our hospitals and community services, the fundamental principle being this is the standard I would expect for myself or my family if we needed care. Setting these standards helps teams to assess the care they give, demonstrates best practice to share and highlights where improvement might be needed. Leadership and Safe Supervision You may remember that last year I reported the establishment of a number of leadership development programmes to ensure that the clinicians of today are our effective leaders of tomorrow. 181

182 Each of these programmes of work have demonstrated to me the enormous talent and contribution of the future leaders of our organisation and most importantly will continue to have direct impact on the quality of care received by all of our patients. I would like to take this opportunity to thank all of our staff and our partner s involved in the delivery of care for their hard work and very much look forward to another successful year ahead. Professor Robert C Pearson, Executive Medical Director May

183 3.3 Care Quality Commission Comprehensive Inspection The Care Quality Commission (CQC) carried out a scheduled comprehensive inspection of our hospitals and community services in November 2015.The inspection was welcomed by the organisation and has been a key external assurance mechanism for the assessment of quality of care. The Trust worked closely with the CQC in the run up to the onsite inspection, sharing many documents and data sets to give them a full understanding of the services provided. We are pleased to report that the CQC gave the Trust an overall rating of Good putting us in the top 10% of large acute Trusts in the country and one of only two combined acute and community Trusts at the time of writing. We are also really delighted to report that our Child and Adolescent Mental Health Services were rated as Outstanding for both in-patient and community services. This is a fantastic achievement of which we are immensely proud. A table containing detail on the ratings is on page 184. The CQC assess all relevant core services against five key lines of enquiry: Are services safe? Are services caring? Are services responsive? Are services effective? Are services well led? In order to engage all staff in the assessment process and to fully utilise this as a continuation of our programme of improvement, the preparation project was entitled Shine. The Shine project was made up of staff from right across the organisation representing their respective Divisions and specialty areas. Every single member of staff was invited to get involved and the assessors commented that during the inspection they were welcomed by pleasant, professional and knowledgeable teams. Around 115 inspectors visited the Trust over the two weeks of the inspection; most of these were allocated to the hospital inspections, a smaller team of 15 visiting our community services. The University Dental Hospital of Manchester was not included in the inspection and we expect this to be scheduled sometime in the future. CQC advised they would like to collaborate with the Dental Hospital to inform the inspection standards to be used for future Dental Hospital inspections. As a large acute and community services Trust, our services include almost all of the core services that the CQC inspect. The findings were made on the basis of observation through visits to the areas, discussions with staff and patients at interview and focus groups and review of documentary and statistical information. Each of our registered hospitals except the University Dental Hospital of Manchester was inspected and given a rating for all core services and an overall rating. 183

184 Manchester Royal Infirmary (This comprises the Manchester Royal Infirmary, Saint Mary s Hospital, the Manchester Royal Eye Hospital and the Royal Manchester Children s Hospital) Urgent and Emergency Services Medical Care including older people Surgery Critical Care Maternity and Gynaecology Neonatal Services Services for Children and Young People End of Life Care Outpatients and Diagnostic Imaging Safe Effective Caring Responsive Not Rated* Overall Rating Good Good Good Well Led Requires Improvement Good Good Good Good Good Good Requires Improvement Good Requires Improvement Good Good *CQC is currently not confident they are collecting sufficient evidence to rate effectiveness for Outpatients & Diagnostic Imaging Trafford Hospital Urgent and Emergency Services Medical Care including older people Surgery Services for Children and Young People End of Life Care Outpatients and Diagnostic Imaging Safe Effective Caring Responsive Not Rated* Overall Rating Good Good Good Well Led Good Good Good Good Requires Improvement Good Requires Improvement Good Good *CQC is currently not confident they are collecting sufficient evidence to rate effectiveness for Outpatients & Diagnostic Imaging Altrincham Hospital Minor Injuries Outpatients and Diagnostic Imaging Safe Effective Caring Responsive Not Rated* Well Led Good Good Overall Rating Good Good Good Good Good Good *CQC is currently not confident they are collecting sufficient evidence to rate effectiveness for Outpatients & Diagnostic Imaging 184

185 Community Services Community Services for Adults Safe Effective Caring Responsive Well Led Good Community In-Patient Services Good Community Services for Children and Young People Requires Improvement Community End of Life Care Requires Improvement Community Dental Services Good Child and Adolescent Mental Health Services Safe Effective Caring Responsive Well Led Child and Adolescent Mental Health Wards Outstanding Specialist Community Mental Health Services for Children and Young People Outstanding Of particular note, we are pleased to report that there are a number of really positive threads throughout the report - these are: Staff are caring and compassionate Staff are proud of their Services Staff are open when things go wrong and willing to learn The Trust values and behaviours of Pride, Respect, Empathy, Consideration, Compassion and Dignity are well embedded and demonstrated throughout The Trust has a strong track record in Quality Improvement, Research and Innovation The Trust has strong governance arrangements Evidenced based care As expected, the CQC have also highlighted a number of areas where we could improve and we are pleased to say that these are, in the main, in areas that the Trust had identified these areas for improvement and reported this to the CQC in advance of their visit, examples of these are: We were rated as requires improvement for urgent and emergency care reflecting pressures in our Emergency Department and patient flow. You can see what we are doing about this on page

186 Repair and maintenance in some of our Community premises. Much of what we needed to do was addressed within 48hrs of the CQC inspection and there are now more robust governance systems in place to ensure repairs are identified and made quickly and all premises meet the same high standards in respect of cleanliness. We were rated as requires improvement for End of Life Care. The CQC rated End of Life Services as Good for care, reporting that they observed caring staff and high quality care for patients at the end of their lives, this was further supported by the results of the National Care of the Dying Audit published in March However, it was felt by inspectors that we had not made enough progress on guidance and support for staff since the withdrawal of the Liverpool Care Pathway and that we needed to recruit some more staff to our Palliative Care Team. There is now a detailed plan in place to address these requirements, further detail can be seen on page 249 onwards. Nurse Staffing was highlighted as a concern by the CQC although the work the Trust is undertaking to improve the position was recognised by the inspectors. We continue to recruit to all of our nurse vacancies with local, national and international recruitment programmes in place. We are also working with all of our staff to make the Trust a great place to work and in doing so reduce turnover. This is monitored closely by the Board of Directors There were other recommendations made and the Trust has drawn up a detailed action plan to address the issues raised and will continue working with the CQC and our other partners to improve services and deliver the highest quality of care. The CQC report can be read in full at Central Manchester University Hospitals NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is fully registered with no conditions. Central Manchester University Hospitals NHS Foundation Trust has had no conditions on registration. The Care Quality Commission has not taken enforcement action against Central Manchester University Hospitals NHS Foundation Trust during 2015/16. Central Manchester University Hospitals NHS Foundation Trust has not participated in any special reviews or investigations by the Care Quality Commission during the reporting period. Assessing the Quality of Care Our Trust aims to continually improve the quality of the services we provide and seeks to provide the best care possible to the people who use our services. One of the ways in which we do this is to triangulate information generated by a number of different methods which provides us with a comprehensive view of the quality of our services and helps us to identify where improvements need to be made. 186

187 In support of our approach to continuous improvement, we track a number of clinical measures, undertakes a comprehensive programme of ward accreditation and regular senior leadership walk rounds. Other examples of how we collect information on the quality of our services are information and data review, drawing on clinical outcomes and patient feedback and by talking to staff and patients about their experiences. Finally, and probably most importantly, getting out and about and making sure we can see how all of this comes together across our hospitals and community services. Together all of this enables us to form a view on quality. We are also working closely with external partners and regulatory bodies such as the Commissioners and CQC in order that we gain an independent view of our services too. There are two key groups of people in the hospitals and services who can tell us about quality of care: patients (including their families and carers) and staff (of all disciplines and levels). The Trust works hard to seek and act upon the views of patients and we have made significant changes to practice and service delivery models on the basis of that information. 3.4 CMFT Quality Reviews The purpose of the Quality Review was to ensure that the organisation could be assured of the quality of care being delivered and that we could quickly identify and respond when we recognise that improvement is required. The aim of the reviews is to use the findings and resulting response to uphold public trust and confidence for patients and families in the services we provide and for them to be assured that they will receive the best possible experience and the best care at the right time. This year the Trust was notified in the summer that the CQC would be undertaking their comprehensive review of our services in November For this reason it was decided that whilst the internal Quality Review should still go ahead, the exercise would be scaled down in order that the organisation was not going through two full assessments in one year. The teams were smaller and the reviews undertaken over a shorter timescale. Staff and patient representatives were invited to take part in the annual Quality Reviews in Approximately 100 members of staff expressed an interest in taking part. The teams were selected from the applicants ensuring staff were allocated to areas other than their own and were representative of all staff groups and all levels of experience. Each team has been led by a Director in the organisation. No team member was involved in a review of their own Division. This provided a mix of expertise and experience as well as an independence from the Division being reviewed. 187

188 The visits were all completed by October The teams used a number of methodologies including interviews, meeting attendance, observation in clinical areas and patient conversations. All teams received training and preparation to undertake the reviews. We would like to thank all of the patients, staff, students and governors that contributed to the 2015 quality review. Review Outcomes The headline findings for the organisation were: Celebrating success Positive and professional attitude of staff throughout the organisation and pride in what they do Commitment to learning and making improvements High levels of incident reporting and being open Good awareness of Safeguarding requirements Improvements in some Community facilities and premises Patient safety seen as a priority in all areas Improvements in checks prior to surgery and interventional procedures Awareness of Equality Diversity & Inclusion requirements Good use of Audit and Clinical Effectiveness (ACE) Days to improve outcomes Evidence of good infection control practice Training of a good standard Excellence in Child and Adolescent Mental Health Services Good evidence of use of Clinical Audit Improvements required Information Technology infrastructure requires improvement in Community Services in particular Environmental improvements required Radiology, Adult Emergency Department in MRI and Community premises Timeliness of reporting on radiological tests Noise at night on wards Patient records storage and protection of confidential data Staffing numbers and the ability to release staff for training Medical devices checking, maintenance and training Communication and feedback Variability of cleanliness and tidiness Never events Timeliness of preparation and delivery of take home medications 3.5 Board to Ward Communication As a large NHS organisation, it is essential that the Board of Directors has a full understanding of all of the issues faced across all of our services across the Trust. In order to fully understand quality and performance across such a wide range of complex services, the Board of Directors use a number of different sources of information. 188

189 This enables them to see at a glance issues which might be emerging and ask questions of the right people when they need to. This means that the organisation can address problems quickly as they arise. Importantly, it also ensures that our staff can communicate with our Board of Directors when necessary. Listening to staff is one of the best ways to ensure that improvements are made where they are needed. There are a number of ways which the Board do this. They can use written reports and key performance indicators. These give Board members a view on performance against things such as how long patients stay with us, what complaints have been made and infection rates. They also regularly visit wards and departments to talk to staff and patients. Set out below is some more detail on how we ensure good communication between the frontline of patient care and the Board of Directors. Senior Leadership Walk Rounds The Senior Leadership Walk Rounds were developed as an integral part of the Quality Campaign. Each Walk Round is conducted by: A Senior Leader who is a member of the Board of Director, either an Executive or Non-Executive Director A Guide who is a senior nurse either a Director, Deputy Director, Head of Nursing or Midwifery The Senior Nurse-in-charge who is either a Matron, Ward Manager or Ward Sister. The Walk Rounds are used in conjunction with the Quality Care Round and Patient Experience Tracker to gather information from three perspectives thus providing additional levels of assurance. Members of the Board visit at least 6 areas every year based on an annual schedule that comprises all types of clinical areas including inpatient, outpatient, day-case, Theatre and Emergency Department areas. There are three main aims of the Senior Leadership Walk Rounds: Assurance: that there are continuous improvements to the quality and safety of service delivered across the Trust Appreciation: to demonstrate the interest of the Board of Directors as the Senior Leaders of the Trust in valuing the quality of staff and patient experience Action: to set the tone through role modelling and to engage and support front line staff in delivering an excellent patient experience demonstrating their engagement and the priority given to the quality and importance of continuous improvement in the services we provide The Senior Leadership Walk Rounds have been designed to demonstrate an active commitment to listening to the views of patients and staff. The current focus of the Senior Leadership Walk Round is based upon the aspects of care that we know, from the patient feedback in national surveys and local feedback, are areas that require improvement. 189

190 CMFT Standards The aim of our Transformation Programme is to support change and improvement across all of our services and to be in the top 10% of all similar Trusts for quality of care. To support this in year one we have focused on improving the quality of care and services we deliver by setting the CMFT standards for outpatients, elective and emergency services. These standards have been developed through extensive staff and patient engagement. During 2015/16 our hospitals have assessed their services against the standards, developed improvement plans and implemented changes. This has resulted in a reduction in the length of time some of our patients have had to spend in hospital, improved staff engagement and provided a better patient experience. 190

191 Part 2: Statements of Assurance from the Board and Priorities for Improvement from the Board of Directors 3.6 Overview of Priorities In we sought to improve performance across many areas of care. In the following section we present those areas of work with performance data. We have set these out in the following table and the detail is contained over the following pages. The Board of Directors of Central Manchester University Hospitals NHS Foundation Trust is assured that the priorities for quality improvement agreed by the Board are closely monitored through robust reporting mechanisms in place in each Division. A green tick indicates that we met our objectives for the year, a dash means we made good progress but did not quite reach our objective and a cross means we did not meet the objective and further work is required and will be undertaken. During 2015/16 the Central Manchester University Hospitals NHS Foundation Trust provided and/or sub-contracted all services as set out as Mandatory Services under the Terms of Authorisation relevant health services. The Central Manchester University Hospitals NHS Foundation Trust has reviewed all the data available to them on the quality of care in all of these relevant health services. The income generated by the health services reviewed in represents 100 per cent of the total income generated from the provision of relevant health services by the Central Manchester University Hospitals NHS Foundation Trust for CMFT uses indicators extensively to inform and monitor the quality agenda. We formally use this data to triangulate quality, workforce and financial indicators on a monthly basis at a number of different forums, including the Operational Managers Meeting chaired by the Chief Operating Officer and at every Board of Directors meeting. The Board of Directors intends to use this information to inform all decision making processes including priority setting throughout 2016/17. Our organisation will use the information to understand performance against the strategic aim of improving the safety and clinical quality of our services. This understanding will then inform prioritisation and quality improvement plans. Triangulation of this information and comprehensive understanding of cause and effect enables a focus on work streams that will improve both quality and productivity. 191

192 Whilst all Executive Directors have responsibility for the delivery of quality improvement, the named Executive leads for quality are the Medical Director and the Chief Nurse. They have set five clinical quality objectives for 2016/17 and these are: Mortality Sepsis End of Life Care Dementia Out-patient Care These priorities have been set in response to the following: Discussion with our Governors Internal assessment such as our Quality Reviews and Ward Accreditation which both involve discussion with patients, visitors and staff External review, such as our CQC Comprehensive Inspection Report National concerns and campaigns supported by the public The broad commitments set out in the Quality Strategy remain relevant and, along with the ambitions set out in the Trust Transformation Strategy will underpin Divisional and corporate work programmes for The following areas will be a focus for delivery in 2016/17: Leadership Evidence based care Research and innovation Communication Listening and responding Openness and transparency Accountability Celebrating success. Delivery of the Quality Strategy commitments will be underpinned by the development and delivery of a new Patient Experience Framework during 2016/17. The Trust Risk Management Committee oversees the management of all high level risks to the delivery of the organisational strategic aims and key priorities and these are mapped on the Board Assurance Framework. A thematic review of current risks on the Trust's risk register highlights the following three overarching risks to clinical quality: Demand - maintaining and improving the quality of clinical services with an increasing demand on services Staffing - maintaining and improving the quality of clinical services whilst reducing the nursing vacancy rate Finance maintaining and improving the quality of clinical services within the current financial constraints See more detail under Clinical Risks on page

193 All risks are monitored, and those presenting a more significant threat to the Trust objectives - scored at 15 and above - are monitored bi-monthly at the Trust Risk Management Committee. Detailed plans are in place to reduce all of these risks to an acceptable level. To deliver high quality services and continuous improvement we will maintain a continued focus on leadership. CMFT invested significantly in the development of all of our leaders in 2013/14 and 2015/16 and this is expected to continue to deliver quality improvements into 2016/17. The Board of Directors maintains a focus on performance against the Trust's quality metrics through the organisational governance processes, and through regular review of a comprehensive suite of quality metrics from which Board members drill down into the organisation to interrogate performance. 3.7 The NHS Outcomes Framework In this report, you will see performance figures and, where possible, comparative information so that you can see how well we are doing alongside our other NHS colleagues. There are some indicators which are measured as part of the NHS Outcomes Framework and we are presenting those here. This is so that all organisations are clear about performance in these areas and that comparisons can be made. The Outcomes Framework is a set of indicators designed to improve standards of care in five key areas: 1. Preventing people from dying prematurely 2. Enhancing quality of life for people with long-term conditions 3. Helping people to recover from episodes of ill-health or following injury 4. Ensuring that people have a positive experience of care 5. Treating and caring for people in a safe environment and protecting them from avoidable harm The indicators presented here all directly inform the five key areas of the NHS Outcomes framework above. Summary Hospital-Level Mortality Indicator (SHMI) The Central Manchester University Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: The Summary Hospital-level Mortality Indicator (SHMI), introduced during 2011, is a method to measure hospital mortality. It is based on all patient deaths including those which happen up to 30 days following discharge from hospital. It relies heavily on accurate record keeping and coding. The patient case note is examined by clinical coding staff who reflect what doctors have written in relation to any existing conditions the patient has, such as diabetes, as well as their diagnosis for their current hospitalisation episode and any procedures undertaken. 193

194 The patient s risk of dying is calculated using these measures. The baseline is 100, so a score below 100 means that mortality rates in an organisation are low (better) than expected. The table below shows our current SHMI figure. Indicator SHMI Outcome/s To be confident that our mortality rate accurately reflects clinical practice, coding and data quality CMFT 2014/15 CMFT 2015/16 National Average 2015/16 Highest Performing Trust 2015/16 Lowest Performing Trust 2015/ Patient Reported Outcome Measures The Central Manchester University Hospitals NHS Foundation Trust considers that this data is as described for the following reason: all patients undergoing these procedures have the opportunity to complete quality of life assessment questionnaires before and after surgery, the figures represent the percentage of patients reporting improvements in their health outcomes. The Trust has supported fully the process for gathering patient feedback prior to surgical procedures as part of the pre-operative process. This is collected by surveys which are then returned to our survey providers, the questionnaires which are sent to patients following their surgery are co-ordinated by an independent survey organisation. By sharing patient level detail with clinicians we will ensure learning and development. We need to continue promoting the completion of the surveys and continue to work with our survey providers to achieve high quality data which allows comprehensive review. Indicator Groin hernia surgery Varicose vein surgery Hip replacement surgery Knee replacement surgery Outcome/s To improve health outcomes following each of the 4 procedures CMFT 2014/ % 65.22% 90.68% 79.92% CMFT 2015/16 Not available at time of reporting. Too few responses to report Not available at time of reporting. Too few responses to report Not available at time of reporting. Too few responses to report Not available at time of reporting. Too few responses to report National Average 2015/16 Not available at time of reporting Not available at time of reporting Not available at time of reporting Not available at time of reporting Highest Performing Trust 2015/65 Not available at time of reporting Not available at time of reporting Not available at time of reporting Not available at time of reporting Lowest Performing Trust 2015/16 Not available at time of reporting Not available at time of reporting Not available at time of reporting Not available at time of reporting The percentage of patients readmitted to a hospital within 28 days The Central Manchester University Hospitals NHS Foundation Trust considers that this data is as described for the following reason: it is nationally standardised data which allows us to draw comparisons against the NHS as a whole. 194

195 Indicator Aged 0-15 Aged 16 or over Outcome/s To reduce readmissions and improve health outcomes Relative Risk 2014/15 Relative Risk 2015/16 Actual 2015/16 Expected 2015/16 Super Spells 2015/16 Rate 2015/ % % The percentage of staff employed who would recommend the Trust as a provider of care to their family or friends The Central Manchester University Hospitals NHS Foundation Trust considers that this data is as described for the following reason: the data below is taken from the 2015 NHS Staff Survey. Staff are asked whether or not they thought care of patients and service users was the organisation s top priority, whether or not they would recommend their organisation to others as a place to work, and whether they would be happy with the standard of care provided by the organisation if a friend or relative needed treatment. Questions 12a, Q12c and Q12d feed into Key Finding 24: Staff recommendation of the Trust as a place to work or receive treatment. Possible scores range from 1 to 5, with 1 representing that staff would be unlikely to recommend the organisation as a place to work or receive treatment, and 5 representing that staff would be likely to recommend the organisation as a place to work or receive treatment. NHS England introduced the Staff Friends and Family Test (SFFT) in all NHS trusts that provide acute, community, ambulance and mental health services in England from April Their vision is that all staff should have the opportunity to feedback their views on their organisation at least once a year. Our Trust surveyed all staff every quarter through the Staff Opinion Pulse Check, which asked additional questions about raising concerns, quality of care and values and behaviours. Regular surveys will allow us to identify any working areas or staff groups that might require a particular focus in order to ensure that staff view the Trust favourably as a place to work and receive care. Indicator Outcome/s CMFT 2014/15 CMFT 2015/16 National Average 2015/16 Highest Performing Trust (Acute and Community) 2015/16 Lowest Performing Trust (Acute and Community) 2015/16 Staff Survey Key Finding 1 staff recommending the Trust as a place to work or receive treatment an indicator of the Friends and Family test (Previously KF21) Staff report that they are treated with the appropriate values and behaviours by colleagues and by the organisation and that they would recommend the Trust

196 The percentage of patients who were risk assessed for venous thromboembolism (VTE) The Central Manchester University Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: patients are assessed, unless if part of the agreed group of exclusions. This is documented and then checked by the coding team. All patients who have a correctly completed VTE assessment are coded accordingly and this is the figure presented. The table below demonstrates that CMFT has continued to maintain its performance of assessing at least 95% of appropriate patients for VTE year on year. The aim is to maintain a minimum of 95% compliance throughout the year. Indicator VTE assessment Outcome/s To risk assess 95% of appropriate patients CMFT 2014/15 CMFT 2015/16 National Average 2015/16 Highest Performing Trust 2015/16 96% 96% 96% 100% 81% Lowest Performing Trust 2015/16 The rate, per 100,000 bed days of cases of clostridium difficile infection in patients aged 2 or over The Central Manchester University Hospitals NHS Foundation Trust considers that this data is as described for the following reason: it is nationally standardised data which allows us to draw comparisons against the NHS as a whole. Indicator Clostridium Difficile infection per 100,000 bed days Outcome/s To reduce C Difficile infection CMFT 2014/15 CMFT 2015/16 National Average 2015/16 Highest Performing Trust 2015/ Lowest Performing Trust 2015/16 The rate of patient safety incidents reported and the number and percentage of such incidents which led to severe harm or death (April to September 2015 published data) The Central Manchester University Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: increased reporting at low level of incidents, improved data quality checks. We report all our Patient Safety Incidents to NHS England (NHSE) and we are monitored alongside all other acute hospital Trusts. Data is made available from NHSE in six month groupings. The information table below provides details of the latest published data. Indicator CMFT Highest Performing Trust Lowest Performing Trust Average Number of incidents 12,080 12, N/A Rate of incidents reported per 1000 bed days Number resulting in severe harm or death N/A Percentage resulting in severe harm or death 0.2% 0.1% 2.9% 0.4% 196

197 Rate of serious harm reported per 1000 bed days Note: the methodology for calculating the rate per 1000 bed days has been changed this year to match NHS England. Therefore all years have been recalculated using this approach for comparison. The Trust reported a total of 12,080 incidents (61.3 incidents per 1000 bed days) during the period of April 2015 September This places us at the top nationally for acute trusts in terms of the numbers of incidents that are reported and in the top 5 acute trusts for the rate reported per 1000 bed days. Whilst we are amongst the highest reporters of incidents nationally, during this period our rate of serious harm per 1000 bed days was 0.13 which is better than the national average of 0.17 and we are also the highest reporter of no harm/near miss incidents. Below is a summary of our performance across a number of priority areas, with more about each area on the page indicated. Page Priority 2013/ / /16 Patient Safety Patient Safety Events 200 Learning from incidents 203 Medication Safety Harm Free Care Falls Pressure ulcers 211 Catheter acquired infection Clinical Effectiveness 206 Infection prevention 213 Hospital Mortality 217 Clinical Audit Commissioning for Quality Improvement Scheme (CQUINS) Local NA National NA Advancing Quality Acute myocardial infarction NA (heart attack) Coronary artery bypass graft NA (CABG) Heart failure NA Hip and knee replacement NA Pneumonia NA Stroke NA Patient Experience Real time patient feedback - Friend and 238 Family Test 249 End of life care 197

198 3.8 Patient Safety The information detailed below is the position as of April As in previous reports, this information may change and as such will be updated in future reports. Safety Improvement Strategy The Trust was one of the first to commit to the national Sign up to Safety campaign which aims to reduce avoidable harm by 50% over three years. Harm can be defined in many ways, but is usually referred to as any unintended physical or emotional injury resulting from, or contributed to by clinical care. Safety programmes are being implemented to reduce risk and improve patient experience. These include improvements in safety culture, safety in theatres, improving communication of test results and obstetric care. We are proud to have received funding for the programme to improve patient safety in obstetrics from the NHS Litigation Authority. This supports our work implementing safety strategies to reduce risk in obstetric care: Detection of fetal compromise: expansion of the intrapartum electronic documentation system and extended ultrasound services for women who are of high risk of fetal compromise or stillbirth. Antenatal screening: development of a pregnancy app. Reduction in maternal and neonatal morbidity associated with caesarean section: reduce operative complications performed in second stage of labour by introduction of fetal pillow device. Reduction of obstetric and anal sphincter injuries: introduction of Episcissors. Development of an electronic system for patients who either phone or attend Triage:an electronic system to respond and track triage phone calls Our full Safety Improvement Strategy can be found on our website: 198

199 Learning from incidents The Care Quality Commission undertook an inspection of our services in autumn The report from this inspection identified across the range of services inspected that there was a culture where staff felt able to report incidents and that they could demonstrate evidence of learning from these. Organisations that report more incidents usually have a better and more effective safety culture, demonstrated by high numbers of no harm or near miss incidents. It is vital that staff feel comfortable to report when errors occur so that learning can be shared, improvements made and reoccurrence prevented. This year the level of Patient Safety Incident reporting is 60.4 incidents per 1000 bed days. This is a slight decrease in volume from last year following improvements in services such as the implementation of the electronic diagnostic system ICE which has seen a decrease in reporting in relation to diagnostic test incidents. Of all incidents reported, 92% were no harm or near miss compared to a national average of 75.1%. As the numbers of near miss incidents that our staff report increases, the level of serious harm incidents has reduced. This is because we can learn from these near misses and put things in place to prevent a more serious error from occurring. In this way we can view our near misses as good catches! After every incident we review what happened and where possible make changes to prevent the same thing happening again. Examples of some of the actions following incidents include: Pilot of electronic VTE risk assessments Development of specific training packages Implementation of extended visiting within one Division to reduce falls. Serious harm incidents Whilst our aim is to increase incident reporting it is also to reduce the levels of serious harm. Incident grading ranges from 1 5 with serious harm incidents being classed as actual harm level 4 and 5. The table below demonstrates these. It can be seen that there has been a small increase in these from the previous year, although this includes a number of incidents that are still under investigation so this figure may change. There are key safety programmes in place to reduce these over the next year as detailed in our Safety Improvement Strategy. Year Level 4/5 Actual Harm Per 1000 bed days * * (*includes unconfirmed which are still under investigation) Note the methodology for calculating the rate per 1000 bed days has been changed this year to match NHS England. Therefore all years have been recalculated using this approach for comparison. 199

200 Types of incident that resulted in serious harm this year are: Falls account for around half of our serious harm incidents (28) Delay in access to services / diagnosis or test results (7) Unexpected clinical outcome / deterioration / death (7) Maternity / Neonatal care (6) Lessons Learned: communication and feedback To communicate learning and feedback from incidents we produce a twice yearly electronic publication accessible to all staff entitled Lessons Learned. This contains information around learning from various types of incidents, patient safety issues and initiatives, improvements and general risk and governance updates. This year we implemented a new monthly patient safety bulletin called Safety One Liners which shares information, initiatives and good practice. We have also used social media (Twitter) to facilitate wider learning - join During the year we have also implemented a system for learning from successes called Excellence Reporting. So far we have had 76 of these reported and we will be developing systems to support structured learning from these further next year. Training is available for staff to help improve and engage in a culture of safety, including Human Factors - Patient Safety and Root Cause Analysis. This training and feedback helps staff to understand how errors can occur and what we can do to help prevent this. Being Open & the Duty of Candour Our Trust is committed to promoting a culture of openness and transparency across all areas of our activities, including communicating honestly and sympathetically with patients and their families/carers when things have gone wrong. In line with the findings of the Francis report (2013) we believe that patients and their families/carers should receive a meaningful and sincere apology of regret for any harm that has occurred. This process involves being open, honest and transparent. In November 2014 The Statutory Duty of Candour came into force. This supports the requirement for clinicians to be open and candid with patients about avoidable harm and for safety concerns to be raised. Our policy is that following any incident resulting in harm information must be given to the patient and or their relatives as soon as possible after the event. This can range from informing the patient of the error as it occurs to sharing our investigation findings and actions planned to prevent reoccurrence. 200

201 We provide Being Open & Duty of Candour training for staff, which has been well attended since its development and have also updated electronic processes for staff to follow when completing the process. We also want our staff to be supported within these processes and we advocate the Speak out Safely campaign, which encourages staff to raise concerns freely. Feedback from CQC inspection The Care Quality Commission undertook an inspection of our services in autumn The report from this inspection identified across the range of services inspected that there were effective systems in place to meet the statutory Duty of Candour and staff were able to demonstrate an understanding of these. For our actual harm incidents level 3 to 5, we monitor that this is being undertaken within the Trust timeframe. Currently 95% have been completed within the timeframe. Never Events A Never Event is described by NHS England as a serious, largely preventable patient safety incident that should not occur if the available preventative measures have been implemented. There are 14 categories of Never Events, which include wrong site surgery, retained instrument and wrong route administration of chemotherapy. Practice for these is set nationally and we have risk assessments and measures in place to prevent them. We set out to have zero events at the start of the year. However, despite this, we had seven. All of these were related to completion of procedures and were in a range of settings including theatres, maternity and endoscopy. Following these events full investigations were undertaken and actions generated and completed. CMFT established a Never Events Working Group over 12 months ago. This group developed an action plan which is being implemented with a number of actions completed during the year including: Update of the Safer Surgery Checklist Policy and Procedure Update of counting procedures Identification of all invasive procedures undertaken in non-theatre environments, the completion of risk assessments on each of these and, where required, implementation of local procedures for safety checks Development of training materials videos. The new National Safety Standards for Invasive Procedures were published in September 2015, supported by a Patient Safety Alert with actions to be completed by all Trusts over the coming 12 months. These include a number of actions that we have already completed earlier this year, including the identification of procedures undertaken across all care settings with a risk assessment against each of these to identify whether local safety procedures are in place or required and the implementation of local Safety Standards in a number of non-theatre environments. 201

202 Type of patient safety incidents reported A breakdown of the top ten types of patient safety incidents reported is detailed in the table below, including a comparison with the previous year. It can be seen from this that there was a significant decrease in the number of clinical assessment (23%), pressure ulcer (25%) and patient fall incidents (12%) which demonstrates improvement work done in these areas. There was also a significant increase observed in infrastructure/facility incidents (47%); this is as a result of an increase in incidents related to lack of suitably trained/skilled staff. Incident Type Change Treatment/Clinical Care % Clinical Assessment/Screening % Communication/Documentation % Access, Admission, Transfer and Discharge % Medication Incidents % Personal Accident/Incident Falls % -12% Infrastructure/Facilities % Pressure Ulcers/Moisture lesions/kennedy Ulcers % Medical Device % Safeguarding Adult/Children % Medication Safety Taking a medicine is the most frequent action we take to improve health 2.5 million doses of medicines are administered every year in the average acute hospital. However, medicines can also cause harm and errors can potentially occur at any stage from admission to discharge. We aimed to have no serious harm medication incidents again this year. However, we have not achieved this aim as one serious harm medication incident occurred. This was an extravasation incident. Extravasation is the inadvertent leakage of a vesicant (something that causes skin or tissue irritation) solution from its intended vascular pathway (vein) into the surrounding tissue. We also wanted to maintain a strong culture of reporting medication safety incidents to make sure we learn lessons from when things go wrong. The number of incidents reported was slightly higher than last year which shows that we have maintained our strong reporting culture. Next year we will continue to work hard to reduce the level of harm caused by medication incidents. In : Most medication incidents reported caused no harm The number of incidents reported increased compared to last year No Never Events involving medication. 202

203 The serious harm incident has been fully investigated in order to identify what went wrong and lessons learned to prevent harm in the future. The lessons learned from the incident have been shared across the Trust. Improvements made last year Errors where a dose of medicine is missed or delayed might not seem serious, but can lead to harm particularly for certain types of medicine. This year, we have again reduced the percentage of patients who miss a dose of medicine. Transfer of patients into and out of hospital has been identified as a common source of medication errors. Pharmacists improve safety by checking a patient s medication on admission to hospital, and this year we have increased the percentage of patients who have their medication history checked by a pharmacist within 24 hours of admission. We want to do more planned improvements next year: This year, following the introduction of some high strength insulin products in the UK, we issued a Trust-wide Medication Safety Alert to highlight risks with these products. In 2016/17, we will introduce further measures to ensure we are using insulin safely. Learning lessons from medication incidents The Trust aims to learn lessons from medication incidents in a number of ways: We have a Medication Safety Group which includes doctors, pharmacists, nurses and patient representatives. The group reviews and shares learning from all medication high level incidents through analysing trends in low level incidents to identify common themes. There is Medicines Management training for all clinical staff highlighting high risk medicines and common errors. The Trust has a Medication Safety Officer who is part of the national medicines safety network that highlights medicines safety concerns and shares good practice regarding medication safety. 203

204 3.9 Clinical Risks Through the year the Trust records risks on the Trust Risk Register. The risk register is used to ensure that staff are aware of risks and that actions are being taken to mitigate those risks. A small number of those risks are deemed serious enough to require a regular report to the Trust Risk Management Committee. This committee is attended by Executive and Non-Executive Directors and progress reports are made on progress to reduce the risk. The risk register is by its nature a changing document and the Trust sets out to mitigate and reduce all risks to patient safety as quickly as possible. This year we have reviewed the process to further refine our reporting on the journey of risk, and our assurance that where possible all risks are being reduced. Examples of high level clinical risks this year include: Communication of Test Results Last year we reported that this was a risk and that whilst every year the vast majority of tests results are communicated to clinicians and acted upon in a timely way, in a small number of cases we had identified harm occurring as a result of the results not being communicated or acted upon quickly enough. This year we have focused on an upgrade to the current electronic communication system for test results. Clinical Work Station (the old system) was replaced in all departments on 24 June 2015 by a new system called Sunquest ICE. This was a huge logistical operation which was supported by a dedicated team of technical staff to ensure it was managed as safely as possible. We are delighted to report that this change took place safely and on the planned day. The benefits seen to date are: User friendly Easier to use so tests can be requested more quickly Mobile Wider access to results it doesn t matter if the tests were requested within primary (community) or secondary (in hospital) care Opportunities for sharing results between different hospitals and specialties Improved patient safety i.e. reduced sampling and labelling errors. Following a review of all reported incidents pre and post implementation of the new system we are pleased to report that we have improved safety and reduced harm for those tests managed on that system. The Trust is now concentrating on results that are communicated differently. We have seen evidence that harm still occurs, for example when a radiological result is not communicated in a timely way, and we are reviewing our processes to ensure this is improved. 204

205 Never Events As reported in the Patient Safety section, during 2015/16 the Trust had seven Never Events against an aim of 0. These events have not resulted in serious harm this year but because of their potential to do so we maintained the high risk score across the year. We are aiming for a period of six months without any events before we can be assured that the work undertaken has addressed the risk. We have a number of local teams now working on this to assess the level of risk in every single part of the Trust and make sure that everything possible that can be done to avoid never events in the future is done. (More detail can be seen on page 202). Care of Patients with both Physical and Mental Health Problems The Trust identified earlier in the year that patients presenting with both mental and physical health problems may not always get the right support for their mental health. In 2015/16 we appointed an independent consultant to advise us on what we needed to do differently to ensure every patient had all their healthcare needs met to the best of our ability. We are pleased to report that this work has now concluded and a detailed plan is in place for improvement. Once assurance can be gained that the plan has been implemented and that quality of care is satisfactory then this risk can be downgraded Clinical Effectiveness Infection Prevention and Control Infection prevention and control is a fundamental aspect of safe patient care. Protecting our patients against hospital acquired infections is a key priority for our organisation and one which we consider to be the responsibility of all staff. Our aim was to eliminate all avoidable hospital associated infections, caused by Meticillin Resistant Staphylococcus Aureus (MRSA) and Clostridium Difficile infection(cdi). This year we have continued to make good progress with reducing the number of patients who developed infections whilst in our care. It is a mandatory requirement for all Trusts to report all MRSA bacteraemia and CDI. Meticillin Resistant Staphylococcus Aureus (MRSA) Bacteraemia What To reduce the number of cases of MRSA bacteraemia (bloodstream infections) within the Trust How Much Zero avoidable infections By When March 2016 Outcome There was a total number of five incidents of MRSA bacteraemia Progress The total number of reportable MRSA bacteraemia attributable to the Trust is five. This compares to seven incidents for 2014/15, which represents a 29% reduction. All five of these cases were reviewed and deemed to be avoidable infections. 205

206 Of the five cases, two patients acquired MRSA during their hospital stay, two patients had a delay of treatments and one was a contaminant. (A contaminant is when the sample has become contaminated during the taking of the blood and is not a true infection). Clostridium Difficile Infection (CDI) Clostridium Difficile is a cause of healthcare associated diarrhoea which has the potential to cause serious illness. It is a common bacterium that exists harmlessly in the bowel of 3% of healthy adults and up to 30% of older people. Clostridium Difficile can multiply and produce toxins that cause diarrhoea and illness, usually as a consequence of treatment with antibiotics. A trajectory of no more than 66 hospital attributable cases was set by NHS England for 2015/16. What To reduce the number of cases of CDI within the Trust How much No more than 66 lapses in care By when 31 March 2016 Outcome The number of attributable incidents of CDI reported to Public Health England (PHE) for 2015/206 was 67. Of these 3 were deemed to demonstrate a lapse in care. (2 cases pending review) Progress We review all cases of CDI at a multi-disciplinary meeting to determine whether the case was linked with a lapse in the quality of care provided to the patient. A lapse in care is denoted as an avoidable infection. Furthermore each CDI case is also reviewed externally by our local Clinical Commissioning Group (CCG) and another local Trust who have upheld all our decisions. Although we have reported 67 cases of CDI, we have three lapses in care; compared to the 10 in the previous year. This is a reduction of 70%. Moreover,of these 62 cases were all agreed as unavoidable with two still pending review. In addition we have reviewed our antibiotic treatments for high risk patient groups, such as those who are immuncompromised or previously known to have had CDI. 206

207 Graph identifying cumulative CDI cases Carbapenemase-producing Enterobacteriaceae (CPE) Carbapenamase-producing Enterobacteriaceae (CPE) is the name given to gut bacteria which have developed resistance to a group of antibiotics called carbapenems. Infections caused by CPE bacteria can usually still be treated with antibiotics. However, treatment is more difficult and may require combinations of drugs to be effective. Though a number of Trusts have experienced problems with CPE, we have the greatest number of cases in any Trust to date. In recognition of this, we have invested considerable resource in the identification and control of CPE, coupled with a detailed research programme to inform current and future strategy. In particular, a considerable body of work is being undertaken with Public Health England to help generate the evidence base for national and international guidelines for controlling CPE and other antibiotic resistant organisms. What To reduce the number of cases of CPE within the Trust By when 31 March 2016 Outcome Successful reduction in new cases of CPE We investigate all our CPE bacteraemia with all staff involved in the patient care; root causes were identified and issues addressed. Five incidents of CPE bacteraemia were reported this year compared to 17 in the previous year. The Infection Prevention and Control Team have worked closely with the Divisions on a variety of control strategies, including an enhanced screening policy and continued review and management of cohort wards. This approach has been successful in reducing our acquisition rate. In Quarter One of 2015 (April June) there were 186 new cases, which reduced to 77 in Quarter Four (Jan-March 2016). 207

208 Key priorities/next steps for 2016/17 Continue to implement actions to further reduce the incidence of CPE and contribute to national strategy. Continue to progress in the development of service for the use of the hydrogen peroxide vapour to enhance decontamination of the environment. Development of surveillance on monitoring of the usage of intravenous devices, using PatientTrack (an electronic system for collecting physiological information). To build on the work already undertaken and extend our programme of surveillance for Surgical Site Infections (SSIs). Feedback from CQC Inspection The Care Quality Commission (CQC) report identified several examples of outstanding practice across a range of services, including the identification and control of CPE as well as the work with Public Health England to help generate the evidence base for national and international guidelines for controlling CPE and other antibiotic resistant organisms. Focus on Practice - Hand Hygiene International Hand Hygiene Day (May 2015) and International Infection Control week (October 2015) CMFT participated in national initiatives including the World Health Organisation (WHO) Save Lives: Clean your hands campaign and International Infection Control week. 208

209 The Infection Prevention and Control/Tissue Viability team (IPC/TV) had stands in each atrium for both the public and staff. This year we focused on hand hygiene and the events generated a good response with positive feedback. Replacement of Hand Gel Dispensers The latest initiative in our on-going hand hygiene campaign is the replacement and upgrade of alcohol hand gel dispensers across the Trust. All old dispensers have been replaced with new, including new signage, and additional dispensers have been placed where required. The aim is to improve immediate access to alcohol hand gel at the point of care, as this is considered the strongest predictor in the undertaking of hand hygiene. Alcohol hand gel in more accessible places will continue to improve compliance in the undertaking of this activity whilst managing patient care across CMFT. Hand hygiene monitoring project Hand hygiene is considered a key element of infection prevention and control and is monitored and audited regularly in all clinical areas through direct observation of practice. We have participated in an innovative project, in collaboration with a Lancashire based company Veraz Limited, who have developed a system to objectively measure hand hygiene compliance in clinical areas on an on-going basis. The VeraMedico system automatically tracks and records each episode of hand hygiene compliance via monitoring equipment, wireless networks and electronic badges. When staff are compliant with hand hygiene the badge lights up green. The project was piloted on four surgical wards. Preliminary results indicate improved hand hygiene compliance and a poster presentation summarising the first stage of the trial was showcased at the national Infection Prevention Society Conference held in September Internal Audit Review of Processes for Clostridium Difficile Infection The Monitor Risk Assessment Framework 2014/15 set out a range of performance indicators upon which the Trust is assessed on a quarterly basis. One of the indicators relate to CDI. The aim of the audit was to provide assurances that there were robust processes in place for reviewing cases of CDI which support the overall decision of whether a case was unavoidable or avoidable. The review confirmed we have appropriate processes in place to consider all CDI cases attributed to the Trust leading to the decision as to whether the infection was avoidable or unavoidable. Whilst the audit review agreed and reported all cases were suitably assessed, the panel recommended that the record keeping of the processes be strengthened and this has been addressed. 209

210 Harm Free Care Catheter Associated Urinary Tract Infection (CAUTI) This is defined as a urinary tract infection acquired whilst a patient has a urinary catheter in situ. What To establish robust surveillance of the incidence of catheter associated urinary tract infections. By when March 2016 Outcome Achieved Progress Catheter associated urinary tract infection is one of the most common types of hospital acquired infections. During their hospital stay, 10%-12% of patients will require a urinary catheter which will make them more susceptible to a urinary tract infection. This year: All positive urine specimens from patients with a urinary catheter have been investigated by the Continence Nurse Specialist and the outcome reported onto a database. The CAUTI Root Cause Analysis (RCA) tool has been reviewed to ensure a more complete investigation of CAUTI incidents. The investigation is undertaken by the clinical team and is reviewed through local divisional harm free care meetings. An integrated care pathway has been developed and implemented across the adult divisions of the Trust to ensure that patients received timely and appropriate catheter insertion and care. Catheter care competencies are now in place to provide a framework of practice. It is important to note that there was under-reporting of laboratory results from Trafford which may account for the low numbers for Trafford. This issue has now been resolved. 210

211 Reduction in harm from pressure ulceration What To reduce harms caused to patients from pressure ulceration How much To reduce the number of acquired pressure ulcers in 2015/2016 By when March 2016 Outcome A further reduction in avoidable pressure ulceration Progress Building on progress during 2014/2015, the Trust has again significantly reduced the number of incidents of pressure ulcers patients have developed whilst in our care. Grade 1 Grade 2 Grade 3 Grade /2015 (actual) st April 2015 to 31 st March 2016 % reduction of pressure ulcers on previous year % 3% 72% 50% Infection Control Education The Infection Prevention and Control/Tissue Viability Team have been supporting staff in the clinical areas with identification and reporting of tissue damage. By being highly visible in the clinical area, the team has been able to undertake one to one training sessions on pressure ulcer prevention and management. It has also provided the opportunity for clinical staff to stop and ask the specialist team about patient management. Bespoke training has also been undertaken with the Divisions regarding issues raised following investigation of avoidable pressure ulceration, for example prevention of pressure ulcers caused by the use of medical devices such as naso gastric tubes and oxygen masks. Training for new starters to the Trust on induction and for international nurses has been delivered to ensure staff are aware of how to prevent pressure damage and therefore reduce the risk of harm to our patients. Within the critical care areas, weekly ward rounds are undertaken with a focus on prevention of tissue damage by reviewing those very high risk patients to ensure that all appropriate care and prevention plans are in place. The Infection Prevention and Control/Tissue Viability Team took part in an International event, Stop the Pressure day, in November The team visited patient and visitor areas within the organisation to increase public awareness on how to reduce the risk of pressure ulceration and give skin care advice. 211

212 Patient information Patient information leaflets have been developed for all adult acute and community areas. The leaflet gives patients and carers advice on how they can help reduce their risk of tissue damage. It also gives them information on how to contact the team if they have a problem with their skin. Improvements in documentation Following a review of each grade 3 and 4 pressure ulcer incident, we identified a need to improve the documentation in the community setting to facilitate communication between carers and district nurses. The community integrated care pathway has been developed which has improved communication and ensured the same standard of care is provided for all patients. A new wound assessment chart has been developed within the hospitals which will improve the monitoring of healing wounds. Equipment The current contract for the provision of dynamic mattresses across acute and community service is due for renewal in August Currently the team are reviewing and developing a service contract to meet the needs of patients within our care. Next steps/ further improvements We are currently evaluating a portable camera to improve monitoring of patients wounds within the community. The device will allow district nurses to liaise with the Infection Prevention and Control/Tissue Viability Team. This technology has the potential to enable district nurses to consult with the team whilst with the patient, and receive immediate advice on management of the pressure ulcer/wound. Undertaking an evaluation of a new technology with the critical care area that can detect damage before it is visibly seen on the skin. This is intended to instigate earlier prevention strategies and therefore prevent deeper tissue damage. Mortality The process of a continual endeavour to understand the factors affecting mortality and to decrease avoidable in-hospital deaths is overseen within the organisation by the CMFT Mortality Surveillance Group, chaired by an Associate Medical Director. The group has supported the development and use of a single mortality review tool for adult use, and consistent use of neonatal and paediatric tools in the review of stillbirth. There are a number of key mortality measures which are reported publicly. Two of the main indicators are Summary Hospital level Mortality Indicator (SHMI) and Hospital Standardised Mortality Indicator Ratio (HSMR). Both of these indicators compare acute Trusts in England, and have an average of

213 The key differences between HSMR and SHMI are: SHMI includes all deaths, while HSMR includes only a compilation of 56 diagnoses (which account for around 80% of deaths) SHMI includes post-discharge deaths, while HSMR relates only to in-hospital deaths HSMR is adjusted for more factors than SMHI, such as palliative care and case mix. Information and data sources reviewed come from both external and internal sources and are as follows: External: National datasets such as the Standardised Hospital Mortality Indicator (SHMI) and the Hospital Standardised Mortality Ratio (HSMR). These methodologies are used and published by the NHS Information Centre and Dr Foster respectively. Disease of condition specific mortality alerts from Dr Foster Regional data published by the Advancing Quality Alliance (AQuA). AQuA is an NHS health and care quality improvement organisation with whom the Trust works to improve quality of care. AQuA publications compare hospitals across the North West, for overall mortality rates and HSMR and SHMI, as well as other indicators of coding indices and quality. Internal: Mortality Dashboard/Indicators which includes internal information about the number of deaths in the organisation A six monthly narrative report from each Division based on mortality review Information from the Emergency Bleep meeting where we review emergency calls made. Performance SHMI 98 HSMR For the organisation overall, crude death rates (actual number of deaths presented as a percentage of hospital discharges) are decreasing, in line with those in England and the North West as shown below (AQuA analytics quarterly report September 2015). Across the North West, the Central Manchester University Hospitals NHS Foundation Trust crude mortality rate is the lowest by some margin; (AQuA analytics September 2015). 213

214 Part of this we believe is due to the low mortality rates, but some of it is also due to the fact that we have a large number of admissions and discharges in our children s and maternity services which decrease the percentage rate. Local processes In 2015/16 the Trust set out its mortality review processes in a comprehensive Strategy document. This strategy details CMFT s approach to mortality and learning from mortality review over the coming years, and is designed to support the objective of providing safe high quality patient care. The aim of the strategy is to ensure that our Trust is a leader in quality of care, that this is evidenced to all and, most importantly, reflected in outcome measures such as crude mortality, HSMR and SHMI. The Trust has defined clinical effectiveness as: The provision of the highest standards of care based on sound evidence based practice, given in an environment which is safe, free from unacceptable risk and operating a constant dynamic of improvement This can only be delivered where outcomes are transparent, accountability is clear and the commitment to clinical effectiveness is shared by all. Our mortality strategy integrates with a number of other key strategies and work streams, including the quality strategy, to ensure a cohesive and embedded approach to mortality reduction at all levels. All deaths reviewed are graded to enable us to identify where specific improvements are required. The grades are as follows: Grade 0 no suboptimal care Grade 1 suboptimal care but different management would not have prevented the death Grade 2 suboptimal care, different care might have made a difference (possibly avoidable death) Grade 3 suboptimal care, different care would reasonably have been expected to make a different (probably avoidable death) 214

215 The organisation has defined a number of types of deaths that must be reviewed formally - these are: 10% random sample to a maximum of 50 deaths in each Division All deaths where the patient is aged under 18 All maternal deaths All neonatal deaths Any unexpected death Any death as a result of Venous Thromboembolism All deaths following elective surgery All deaths where the patient has MRSA Any death where the circumstances are subject to patient safety incident investigation Any death of a patient resulting from a never event Any death graded at a 3 (see classification score above) following an Emergency Bleep Meeting Any death where a serious complaint has been received Any death of a patient who has a recognised learning disability Themes A review of themes from the divisional mortality reports shows slight variability across different clinical areas. Themes include issues around specific aspects of care; poor documentation; failure to respond to early warning scores; documentation of fluid balance; pre-operative assessment; delay in weekend assessment and treatment; delayed recognition of Acute Kidney Injury and non-communicating children. These areas all have on-going work programmes to improve performance, with demonstrable improvement in several areas. Internal analysis of weekend death rates has demonstrated small increases in over the last three years. However, within CMFT, patients admitted at the weekends, compared with weekdays, do not have an increased risk of death. Divisional mortality groups include consideration of this in their discussions. Summary The overall mortality figures for CMFT are stable, although our aspiration is for these to decrease and reflect an ever improving high standard of care. There remain issues of coding to address. A systematic approach to themes analysis, with sharing of this across the organisation, has led to interventions that will improve patient safety. This is facilitated by a standard reporting format and framework. The CQC, in their most recent inspection of our hospitals, recognised the good work that was being undertaken on mortality. 215

216 Sepsis Sepsis accounts for approximately 37,000 deaths in the UK each year. The mainstay of effective treatment is early recognition and rapid initiation of treatment. This can be difficult when the presentation is atypical and because sepsis can imitate many other conditions. Within CMFT, early recognition of sepsis is supported by a Sepsis Policy, the Early Warning Score and Patientrack systems and the Acute Care Education programmes. In 2014/5, CMFT obtained funding from the Health Foundation to improve the early recognition and diagnosis of sepsis in the Accident and Emergency Department. A baseline analysis demonstrated low achievement of the Sepsis 6 (the current gold standard of treatment) within one hour, and a very large number of patients with potential sepsis. Formal analysis of the patient pathway using the Safer Clinical Systems methodology identified barriers to care. These included barriers to communication. A number of interventions were designed and implemented: pre-briefs at the start of each shift, name boards for staff, a sepsis trolley and stickers along with a programme of education and staff engagement. Over the twelve month period of the project, there was a decrease in length of stay for this group of patients of two days and an improvement in rapid achievement of the sepsis 6, e.g. a 75% decrease in time to antibiotics. On-going monitoring of the care of septic patients in A and E is in place. For ward patients, a monthly audit is being instituted, supported by a daily ward round by a Consultant Microbiologist. In January 2016, CMFT was found to be almost completely compliant with the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) on sepsis. A sepsis strategy is being developed to ensure continuation of the improvements achieved in the care of this group of patients, and to deliver on-going compliance with NCEPOD recommendations and international best practice. Learning from Clinical Audit to Improve Care National Audit National clinical audit is designed to improve patient outcomes across a wide range of conditions. Its purpose is to engage all healthcare professionals across England and Wales in systematic evaluation of their clinical practice against standard, to support and encourage improvement and deliver better outcomes in the quality of treatment and care. National audit is divided into two main categories: snapshot audits (patient data collected over a short, pre-determined period) and those audits where data on every patient with a particular condition or undergoing specific treatment is included, for example patients who have had a stroke and patients who have treatment for certain types of cancer. 216

217 During 2015/16, 49 national clinical audits and 2 national confidential enquiries covered relevant health services that Central Manchester University Hospitals NHS Foundation Trust provides. During that period Central Manchester University Hospitals NHS Foundation Trust participated in 100% national clinical audits and 100% national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries that Central Manchester University Hospitals NHS Foundation Trust was eligible to participate in during 2015/16 are as detailed in Tables 1 and 2 below. The national clinical audits and national confidential enquiries that Central Manchester University Hospitals NHS Foundation Trust participated in during 2015/16 are as detailed in Tables 1 and 2 below. Table 1 Details of National Audit Participation Title Site No Cases % Cases Submitted Adult Critical Care Case Mix Programme ICNARC CMP CMFT % British Thoracic Society Emergency Use of Oxygen MRI % Trafford 9 National Emergency Laparotomy Audit CMFT % National Joint Registry (NRJ) CMFT Knees: 396 Hips: 374 % unknown Elbows: 1 Shoulders: 22 College of Emergency Medicine VTE Risk in Lower Limb CMFT % Immobilisation College of Emergency Medicine Procedural Sedation in CMFT % Adults Trauma Audit & Research Network (TARN) MRI % RMCH Audit of Patient Blood Management in Scheduled CMFT % Surgery 2015 Audit of the Use of Blood in Lower GI Bleeding CMFT 19 % Unknown 2016 Audit of the Use of Blood in Haematology % Bowel Cancer (National Bowel Cancer Audit Programme) CMFT % Lung Cancer (National Lung Cancer Audit) MRI % Trafford 68 Oesophago-gastric Cancer (National) CMFT % National Prostate Cancer Audit CMFT % Acute Myocardial Infarction (MINAP) CMFT % Adult Cardiac Surgery Audit (ACS) CMFT % Cardiac Arrhythmia (Cardiac Rhythm Management Audit) MRI % Trafford 43 Congenital Heart Disease (Paediatric Cardiac Surgery) CMFT 2 100% Aged Coronary Angioplasty (NICOR Adult Cardiac Interventions CMFT % Audit) National Heart Failure(HF) MRI % Trafford 50 National Cardiac Arrest Audit (NCCA) MRI % Trafford RMCH 5 20 National Vascular Registry CMFT Ongoing 217

218 Title Site No Cases % Cases Submitted Lower limb angioplasty/stenting Lower limb bypass Lower limb amputation National Vascular Registry the repair of Abdominal aortic CMFT 78/82 95% aneurysm (AAA). National Vascular Registry Carotid endarterectomy. CMFT 63/64 98% National Adult Diabetes Audit CMFT % (2013/14) 3967 (2014/15) National Diabetes Footcare Audit CMFT 31 % National Pregnancy in Diabetes Audit CMFT 83/83 4 patients refused National Diabetes Inpatient Audit MRI 171 Trafford 28 National Paediatric Diabetes Audit RMCH 286 Trafford 79 The National Chronic Obstructive Pulmonary 36 Disease Unknown 100% 100% 100% CMFT % (COPD) Rehabilitation Audit Renal Replacement Therapy (Registry) CMFT % Rheumatoid and Early Inflammatory Arthritis MRI 49 % Trafford 28 unknown Inflammatory Bowel Disease (IBD) Programme Biologics MRI 21 % Audit Trafford 69 Unknown RMCH 50 Sentinel Stroke National Audit Programme MRI 203/206 99% Trafford % Fall and Fragility Fractures Audit Programme (FFFAP). Hip CMFT % Fracture Fall and Fragility Fractures Audit Programme (FFFAP). CMFT % Inpatient Falls UK Parkinson s Audit MRI % Trafford 21 College of Emergency Medicine Vital Signs in Children RMCH % Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE UK) Maternal deaths eligible for notification are: All deaths of pregnant women and women up to one year following the end of the pregnancy (regardless of the place and circumstances of the death). Saint Marys 3 100% Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE UK) Perinatal and Infant Death Neonatal Intensive and Special Care (NNAP) Saint Mary s % Saint % Mary s Paediatric Intensive Care Audit Network (PICANet) RMCH % British Thoracic Society Paediatric Asthma RMCH 46/53 87% UK Cystic Fibrosis Registry RMCH 178/ % Elective Surgery (National PROMS Programme) CMFT 522/ % National Audit of Intermediate Care CMFT 120/200 60% National Ophthalmology Audit MREH Submission 31/08/2016 The reports of 15 national clinical audits were reviewed by the provider in 2015/16 and Central Manchester University Hospitals NHS Foundation Trust intends to take/has taken the following actions to improve the quality of healthcare provided (Note: this is a summary of actions from a sample of the audits reviewed) National Audit Actions completed/planned National Hip Fracture Undertake a service improvement workshop 218

219 Database National Neonatal Audit Programme National Neonatal Audit Programme Acute Coronary Syndrome Sentinel Stroke National Audit Programme National Chronic Obstructive Pulmonary Disease Paediatric Intensive Care Audit Network Royal College Emergency Medicine - Paracetamol Overdose Review current input to hip fracture service by Orthogeriatric Clinicians Implement Falls accountability meetings Reflect new temperature range standards on neonatal clinical effective dashboard to enable adequate monitoring Reflect new temperature range standards on neonatal clinical effective dashboard to enable adequate monitoring Appoint a new infant feeding coordinator Visit one of the units with high rates of breastfeeding to share best practice Review the use of secondary prevention in light of new medications available Implement a weekly therapy meeting to review all the stroke patients to determine if they are applicable for therapy Review of Non Invasive Ventilation service Improve education programme for medical and nursing staff Rationalise paracetamol level testing to make testing before 4 hours after ingestion impossible Local Clinical Audit Local clinical audits are carried out by doctors, nurses and other hospital staff. Audits can be done as part of training, for example by junior doctors, but they also take place to look at areas where patient safety is important. Clinical audit is a way of ensuring what should be done is being done. Where the results of an audit are not satisfactory, the Trust requires that an action plan is put in place to make changes to services to improve patient care. When these changes have been made, the audit may be repeated to make sure that there has been an improvement. Each year we carefully plan which audits we want to carry out. Important topics for audit are those areas in which we can improve patient safety and the quality of patient care. The plan also makes sure that we repeat audits where we did not meet our expected standard of care to see what improvements have been made. The Trust registered 409 clinical audits in 2015/16, which took place across all our Divisions. Most audits are carried out by collecting information from a patient s health record or by observing hospital staff perform their duties. For example, an audit of the Procedure Safety Checklist was undertaken by members of staff, observing their colleagues taking part in the safety processes. Learning and Improving from clinical audit The reports of over 400 local clinical audits were reviewed by the provider in 2015/16 and Central Manchester University Hospitals NHS Foundation Trust intends to take a range of actions to improve the quality of healthcare provided. 219

220 This year we have implemented a new electronic Clinical Audit Module, which enables us to track and monitor the completion of actions following clinical audit more effectively. Review of actions to date demonstrates the following levels of completion Division Total Actions due 2015/16 Completed Ongoing Breached Clinical Scientific Services % Corporate Services % Dental Hospital % Manchester Royal Eye Hospital % Medicine And Community Service % Research And Innovation 4 4 0% Royal Manchester Children s Hospital % Specialist Medical Services % Saint Mary s Hospital % Surgery (MRI) % Trafford Hospitals % Trust Total % Examples of audits that took place in 2015/16 are detailed below: % Ongoing Breached The Dental Hospital recognised a problem with who was responding to the emergency pager. They undertook an audit to find out what exactly was wrong and as a result of their findings they changed the way they organised their response. They repeated the audit later and their results were much better, showing that the changes implemented had been successful. This was a good example of identifying a potential problem by using a clinical audit and demonstrating change. The staff involved will share the lessons they learned through an article in a Trust newsletter and as a poster at an exhibition of audits. The Emergency Department repeated an audit on sepsis. This was important because sepsis is a potentially life-threatening condition and it is important to take the right steps to tackle the infection quickly. After the last audit the department made changes to improve the way they recognised and responded to patients with severe sepsis by introducing a training programme and a new method of communication. They undertook a repeat audit collecting information on all the patients who had been treated for sepsis in September From the results of the audit they could show that the changes were having an impact, with a third more patients being treated in the time necessary and this meant that the department had reduced the mortality (death) rate of patients with sepsis and the length of time they stayed in hospital. A team of both nurses and doctors who work in the Acute Oncology Service carried out an audit looking at how they dealt with patients who were diagnosed with cancers of unknown primary origin. The results of the first audit they carried out in 2014 showed that improvements could be made in many areas. 220

221 After the changes had been made to the service, the team carried out the same audit a second time. The results showed there had been a marked improvement in following the correct pathways, from 69% to 95%. This meant that decisions were made faster and the time patients had to remain in hospital was shorter. Overall, it meant better results for patients and the team said that carrying out the audit had allowed them to see areas where they could still improve the service for patients. Feedback from CQC Inspection The Care Quality Commission undertook an inspection of our hospitals in November 2015, the report from this inspection identified across the range of services inspected that Clinical Audit was embedded and used to drive improvements in quality and safety. National Confidential Enquiries (NCE) During 2015/16 national confidential enquiries covered relevant health services that Central Manchester University Hospitals Foundation Trust (CMFT) provides. During that period CMFT participated in 100% national confidential enquiries which it was eligible to participate in. The national confidential enquiries that CMFT was eligible to participate in during 2015/16 were: Mental health study Non-invasive ventilation Young Persons Mental Health Chronic neurodisability study. The national confidential enquiries that the Trust participated in, and for which data collection was completed during 2015/16, are listed below alongside the number of cases submitted to the enquiry as a percentage of the number of registered cases required by the terms of the enquiry. Table 2- National Confidential Enquiries (NCE) NCE Study Eligible Participated % Submission Status Mental health study Yes Yes 30% Ongoing Non invasive ventilation Yes Yes Awaiting clinician questionnaire from NCEPOD Ongoing Young Persons Mental Health Chronic Neurodisability study Yes Yes Awaiting clinician questionnaire from NCEPOD Yes Yes Awaiting clinician questionnaire from NCEPOD Ongoing Ongoing 221

222 Outcomes The reports of two studies were received and have both been reviewed by the Trust. These were the reports of Gastrointestinal (GI) Bleed and the Sepsis Study, published July 2015 and November 2015 respectively. The Trust has undertaken a gap analysis on the recommendations from both reports and where applicable, actions are being taken to address any gaps identified. Some examples of these are: a business case is being put forward for a clinical lead in sepsis to champion best practice and take responsibility for the clinical governance of patients with sepsis. A protocol is being developed to ensure all patients with a GI bleed have a clearly documented re-bleed plan. It is worth mentioning that both gap analysis showed the Trust was compliant with most of the recommendations from both reports. Research We are dedicated to continuously improving the way we conduct our research whilst providing all patients with better access to clinical studies. We undertake research in a diverse range of clinical areas across our eight hospitals, regularly recruiting the first global patient into a study. In 2015/16, we carried out a programme of work to ensure that research is accessible to all patients. We developed a research recruitment strategy for all staff, which provides the tools to develop robust and successful strategies for recruiting patients to studies. This was complimented by a workshop delivered to research staff which focused on improving recruitment and retention of Black, Asian and Minority Ethnic patients to clinical studies, ensuring research is accessible to all. We have also worked to streamline our research processes to enable improved set up of clinical studies, whilst maintaining robust governance procedures. This means we can provide patients with better access to clinical studies as part of their clinical pathway. We re proud to share the positive impact research has for our patients. In 2015 we launched our patient stories campaign, which saw patients from across different ages and backgrounds share their stories of how being involved in research has helped transform their care. Manchester is leading the way for research and innovation An analysis published by the National Institute for You can learn more about the Health Research (NIHR) placed CMFT in the top impact of our research, 10 research active hospitals in the UK, which confirms our position as a national leader in including inspirational stories research and innovation. from our patients on page 108; This is in tandem with Manchester s growing presence in national healthcare agenda through Devolution Manchester and increased partnership or follow us on Twitter (@CMFT_Research). working across NHS Trusts through networks such as the Manchester Academic Health Science Centre (MAHSC). 222

223 As host of the NIHR Clinical Research Network:Greater Manchester, and through our representation on the strategic and management boards of the Greater Manchester Academic Health Science Network (GM AHSN), we are also helping bridge the gap between regional NHS organisations, industry and academia to support the UK s health and wealth agenda. Improving our research figures The number of patients receiving relevant health services provided or 8759 sub-contracted by Central Manchester University Hospitals NHS Foundation Trust in April 2015 March 2016 that were recruited during that period to participate in research approved by a research ethics committee. Number of external researchers enabled to conduct research in our 112 organisation via research passports New studies approved this year 292 Research studies open to recruitment or in the follow up phase 661 Feedback from CQC Inspection Following the recent Care Quality Commission (CQC) report, we were commended for embedding research throughout the organisation and creating a culture in which staff promote research opportunities to patients and the public. Medical Education and Library Services Undergraduate Medical Education The Trust, in partnership with Manchester Medical School, train over 400 undergraduate degree students each year on site. The medical degree is a 5 year course at the University of Manchester. During the past academic year, the Undergraduate Medical Education Team organised clinical placements and a range of other teaching sessions. We recently received recognition of our clinical skills teaching and resources by the General Medical Council (GMC). During a regional visit to the Trust they noted the commitment to developing students clinical skills and published a case study through their main sharing good practice webpage Formal teaching sessions supplement the direct patient contact time for our medical students, and provide depth and breadth to learning. During the last academic year, over 3,500 separate teaching sessions were delivered by a range of staff across the Trust. 94% of all planned sessions were successfully delivered. 223

224 This academic year, 99.21% (125) of our 5 th year medical students passed their final year exams to successfully complete their degree course. 94% of planned undergraduate teaching sessions were delivered as planned. Postgraduate Medical Education After completing a medical degree, our doctors undertake a two-year Foundation Doctor training placement. This is followed by a number of years working as a Specialty Trainee either in our hospitals or in linked General Practices. The annual General Medical Council National Training Survey told us that we were in the top 10 nationally for trainee satisfaction in the following specialties: Genitourinary Medicine Child and Adolescent Mental Health Respiratory Medicine We also had some areas to improve on, such as: Diabetes and Endocrinology GP training in Obstetrics & Gynaecology Acute Internal Medicine We have been working closely with our external stakeholders (Health Education North West) and our staff in those departments to improve the experience of our junior doctors. The Postgraduate Medical Education Team will continue to work collaboratively with its trainees and trainers to promote and improve its practice and deliver a high quality training programme for doctors at all levels. The team remains committed to delivering educational outcomes that will enhance the future of its trainee doctors and, through them, improve the quality of patient care. The Trust s Medical Education Team walked away from the first Developing Excellence in Medical Education Conference (DEMEC) in Manchester with four awards for their posters, voted for by more than 700 conference delegates. Allison Booth of the Undergraduate Medical Education Team and Karen Stuart, of the Postgraduate Medical Team, shared top honours in the e-learning category with their respective posters: A pilot study of the use of video-conferencing technology in medical student welfare and Smart solutions using web-based induction for trainees. In the continuing professional development category, Dr Margaret Kingston took the prize with, Developing effective role modelling skills in doctors and Professor Simon Carley won the global perspectives category with colleagues from the UK, Australia and Sweden with Are there too few women presenting at emergency medicine conferences? 224

225 Professor Robert Pearson, CMFT Medical Director, commented: There were 268 poster entries and for our Medical Education Team to be awarded People s Choice in 3 out of 7 categories is hugely impressive. This showcases the knowledge, expertise, skill, ingenuity and hard work of our Medical Education Team in the development and training of doctors. Library Service The CMFT Library Service provides a service to all staff and students on clinical placement. In 2015/16 the library service achieved an accreditation score of 90% against national standards. This was an increase of 16% from 2014/15. The library service underpins education and training by providing access to the latest knowledge, information, and evidence published in the disciplines of medicine, nursing and allied health. In 2015/16, the library team successfully bid to Health Education North West to improve the quality of the textbooks to support examination revision for undergraduate finals and professional examinations for medical trainees. This year the library also developed a Clinical Outreach service, sourcing the latest evidence and guidelines for our CMFT clinicians. This has resulted in over 400 searches of the medical literature. The library team also supported a number of research studies including the Stillbirth Priority Setting Partnership working with Saint Mary s Hospital and the Maternal and Fetal Health Research Centre at The University of Manchester. This work resulted in a presentation at the 2015 International Clinical Librarians Conference in Edinburgh. Medical Appraisal What 90% of doctors to have completed annual appraisal When March 2016 Outcome 85% of doctors were appraised Medical revalidation was introduced by the General Medical Council (GMC) to provide assurance to patients, the public, and employers that doctors are up-to-date and fit to practice and to contribute to the on-going improvement in the quality of medical care delivered to patients. Medical appraisal is at the heart of revalidation; it is where a doctor s performance is reviewed against four areas that are set out by the GMC. These are: knowledge, skills and performance safety and quality communication, partnership and teamwork maintaining trust. All licensed doctors at CMFT, along with all other doctors in the UK, are required to have an annual appraisal with supporting information collected about their work, including feedback from patients, doctors, nurses and other colleagues. In 2015/16, we have worked hard to ensure all doctors have their appraisal and have developed a robust system of appraisal and clinical governance that supports our doctors in preparation for revalidation. 225

226 The Trust doctors use an electronic appraisal system to store their appraisal documents. This system tracks every appraisal, making it easier for them to store information that will help to demonstrate they meet the required standards. To further support the monitoring and management of appraisals, CMFT also sends quarterly and annual appraisal and revalidation reports to NHS England, using the Framework for Quality Assurance (FQA) and Annual Organisational Audit (AOA) respectively. A paper is also presented annually to the Trust Board, highlighting the results of the AOA and any actions that are required to improve the appraisal and revalidation process Patient Experience Patient experience feedback provides a rich source of data to support continuous improvement of the Trust s services. Patient feedback is sought and received through a range of formats that lead to initiatives and projects that enhance and improve our patients experience of care, to ultimately deliver excellent patient experience. Examples of patient involvement and improvement initiatives in 2015/16 include: Trafford Division: Open Visiting Trafford s strategic aim is to become an Age Friendly Hospital and centre of excellence for rehabilitation and care of frail older patients. As part of this vision, we have looked at how we can support our patients and families to have the very best experience. We recognised that as a hospital we operate a 24 hour service, but for the family and visitors of our patients we had visiting times and restrictions in place. To change this we have supported John s Campaign, which promotes and enables carers to stay with their loved ones who have dementia during an admission to hospital. A three month pilot was undertaken on the Stroke Ward to look at how Therapeutic Open Visiting could help patients, families and carers. Prior to the pilot, questionnaires were given to patients, relatives and staff asking for their opinions of the current visiting hours and the potential for Therapeutic Open Visiting. These results influenced guidelines to support relatives and staff in ensuring delivery of patient care and therapy while maintaining patient privacy and dignity during the pilot. Outcomes of the pilot included improved communication between staff, patient and families and a reduction in the number of falls and complaints. Feedback showed 100% of patients and their families reported positively about the Therapeutic Open Visiting pilot. As a direct result, Open Visiting will be rolled out across other inpatient wards at Trafford Hospital during 2016/17. We will also be conducting a study to explore the benefits of rolling Open Visiting out across other areas of the Trust. 226

227 MREH: We re Listening We re Manchester Royal Eye Hospital: Manchester Royal Eye Hospital has always been at the forefront of patient engagement. This year we have taken another step forward and taken a more collaborative, blended approach to both patient engagement and service transformation. It has always been important to us to ensure that patient feedback directly drives improvements to our service. Patient and staff experience has been completely blended into a single, coherent and ambitious vision. New and dedicated roles in the hospital; including a Business Manager and an Experience and Quality Lead, are combining forces and developing relationships with the Trust s corporate teams Transformation and Patient Experience to spur innovation and public participation. The evidence for our work comes from our numerous patient listening events, assessments against outpatient and elective standards, filmed interviews with patients and an experience-based codesign event. We have actively engaged with hundreds of patients this year. The ethos of the Manchester Royal Eye Hospital s We re Listening We re Improving campaign extends to patients, their carers and our staff. The significant weight of blended evidence is now driving a long-term programme to overhaul the processes by which our outpatient department functions. Pushing Manchester Royal Eye Hospital right to the top of the Ladder of Participation, we are inviting patients to join forces becoming co-producers of our services. In this way patients make a regular commitment to working groups implementing positive change. Saint Mary s Hospital: Maternity Visiting Policy The Midwifery Team has used the Improving Quality Programme; the Trust s model for improvement and the Experience Based Design approach to improve the patient experience of visiting. The Maternity Visiting Policy was highlighted in a number of complaints both formal and informal where women told us that they wanted their partners to stay longer and for the visiting period to be extended. There were also examples when partners missed the birth of their babies because they had gone home and could not get back in time. It was also apparent that the midwives themselves were not being consistent when applying the existing policy so families did not know what to expect. We knew that other maternity units that had extended the visiting times had very positive feedback. A Midwifery Visiting Policy Task and Finish Group was set up with Midwifery representation from across all areas of the Directorate, a member of the Corporate Patient Experience Team, the Divisional Patient Experience and Quality Lead, the Inpatient Administration Manager and a Ward Clerk. An initial patient consultation was undertaken and a pilot scheme introduced to test the water, however some changes to visiting in the Induction of Labour Bay (IOL) were immediately introduced. 227

228 A staff and patient/user questionnaire was devised in order to fully understand the issues around our current visiting policy. 200 questionnaires were distributed of which 105 questionnaires were completed across all areas of the maternity service. To better understand the patient s perspective, questions were asked about patient understanding of our current visiting policy, what policy they would be happy to have on the ward and whether the current visiting policy restrictions impacted on the women and their ability to care for their baby. Based on the feedback from the questionnaires, a 30 day trial of new visiting times was introduced with the visiting times clearly displayed on the doors of the ward areas and on the website. Due to the very different nature of each of the areas within Maternity Services, we envisaged each area would have different expectations and needs and this was indeed the outcome of the 30 day trial. Open visiting for birth partners worked well on the Midwifery Led Unit and in the Induction of Labour Bay and extended time for partners up to 10pm was also well received. However, women on the postnatal wards welcomed protected meal times and rest periods. This showed a need to balance the needs of the individual women with the privacy and dignity needs of all others. An option for birth partners to remain with the newly delivered women was offered following the initial consultation and ground rules for birth partners who stay overnight were drawn up to ensure the safety and wellbeing of all women. A second consultation has been undertaken to test patient and visitor satisfaction with the revised visiting time and revisions will now be made to the Maternity Visiting Policy. Division of Clinical and Scientific Services (CSS): Patient & Carer Forum The Adult Critical Care Service at CMFT has established a Patient and Carer Forum which is chaired by a former patient. As part of this initiative a Critical Care Network helpline based at the Trust has been set up. As well as improving patient/carer information through filmed patient stories and the development of information leaflets, afternoon tea events have also taken place at a café in Didsbury to enable patients to share their experiences. Development of a Surgery School: This is a patient-focused education forum aimed at preparing patients for surgery and teaching them techniques to reduce postoperative pulmonary complications including use of incentive spirometry (a device to help keep the lungs healthy after surgery), coughing and deep breathing exercises, oral hygiene and patient information. Patients scheduled for major elective surgery are invited to attend a one hour educational session which is delivered by a multidisciplinary team. The session also includes a visit to the critical care units, which provides an excellent opportunity to see the environment in which they will be cared for, meet staff and ask questions and share their worries and concerns. 228

229 Since the start of the project the incidence of post-operative pneumonia has reduced by around 48%, which is a significant reduction in this type of post-operative complication. Division of Research and Innovation: Children s Clinical Research Facility The involvement of children and their families has been an integral part of this exciting project to upgrade our research unit at the NIHR/ Wellcome Trust Clinical Research Facility (CRF) at Royal Manchester Children s Hospital. Supported by CMFT Charity, the newly named Stoller Charitable Trust Unit aims to provide a more comfortable, enjoyable and fun space which children and their families can relax in whilst taking part in cutting edge clinical trials. Play Specialist, Emma Harrison and representatives from Lime Arts have worked together with children and families visiting the Unit, and local schools to bring early ideas to life. The Stoller Charitable Trust Unit focuses on the five senses with soothing colours chosen to decorate areas including the treatment room, a new chill-out space and parent s lounge. The playroom has had a complete overhaul including installation of an interactive projector screen. The children love that their spirograph designs and animal drawings have been incorporated into the window, ceiling and wall art of the facility. One young patient s idea to create a visual arts piece on the ceiling of the treatment room was the inspiration for an interactive, illuminated ceiling panel that represents different weather conditions. This is used by children to keep them calm and entertained during their invasive treatment regimes. Teenage visitors helped design the chill-out room, making sure seating and furniture was accessible to patients with disabilities. Division of Medicine and Community Services: Improving the healthcare experience for patients who have a learning disability and/or autism: In September 2015, the Division of Medicine and Community Services established a Learning Disability Nurse Liaison Role, in order to support patients with learning disabilities and/or autism through acute clinical care pathways. This role has proved to be a valuable resource to patients and staff throughout the Trust, and has become a link between Community and the Acute Directorates to enable care to be proactively planned for patients prior to admission and assist seamless transfer of care on discharge. 229

230 Assisted by our electronic flagging system, patients, or their carers, now receive either a face to face visit or telephone call to highlight the support service that is available to them, and to produce an individualised plan of care to support the individual. Verbal feedback has been received confirming that patients with a learning disability and their parents and carers really appreciate having a contact in the hospital who understands their specific needs and can support them to access the services they need. Patients and carers are also invited to the Trust Learning Disability Parent and Carer Forum. These meetings are held every three months, and encourage attendees to share their views and experiences and give us feedback on what s working well and how we can improve. At a recent learning disability and autism champions training event for acute staff, a parent attended and shared her experiences. This extremely rewarding event was an example of how we are creating opportunities for patients and carers to help us to improve services. We feel privileged to be able to offer a role that can have a major positive impact on the healthcare experience of people who may be vulnerable and help to reduce the health inequalities that people with learning disabilities often face. Division of Surgery: Specialing Project Emergency Surgical Trauma Unit (ESTU) A task and finish group was set up to review the role and responsibility of the practitioners who provide one to one observation and care known as specials for in-patients who have been assessed as high risk. This may be because the patient is at risk of falling or may be prone to wandering due to delirium. Considerable work is being undertaken to develop training for these practitioners, as well as developing supporting action cards, new documentation, risk assessments and care planning. The next step will be to roll the new approach out across other wards in the Division of Surgery, followed by Acute Medical wards, as well as implementing a formal training programme for staff. Division of Specialist Medical Services: Cardiac Rehabilitation: The MRI Cardiac Rehabilitation service has created a Facebook group as a modern method of communication to provide support, guidance and information to cardiac patients. The aim of this group is to provide current evidence-based health promotion advice, and to engage patients with their recovery and the cardiac rehabilitation programme, in order to provide better patient outcomes. This social media platform acts as an additional form of communication between the cardiac rehabilitation team, current patients and those who have been discharged from the service. For those currently involved in the service, the Facebook group provides updates about upcoming events, education sessions, and information for those who cannot attend the education sessions if they are on holiday, at home or in hospital. For patients discharged from the service, the Facebook group will provide on-going support and updates with regard to secondary preventative advice. 230

231 The development of this social media platform will enable education and support to a greater number of cardiac patients, particularly those who are unable to, or choose not to attend the Cardiac Rehabilitation Programme. The drive for the development of the Facebook group was based on patient feedback which demonstrated a gap in on-going support and continuing health promotion advice following discharge from the service. Although this is currently in the early roll out phase, patients have expressed a keen interest in this social media group. We plan to continue to utilise patient feedback to mould the service to ensure it meets the needs of patients and provide on-going advice and support which is valuable and relevant to service users. The ultimate goal is to improve patient engagement and experience. Royal Manchester Children s Hospital (RMCH): Humphrey Bear Story Book Using patient feedback to drive change is a well embedded culture at RMCH. Real time surveys were commenced across all wards and departments in 2010 as part of the Improving Quality Programme. Although the information was well used, staff were acutely aware that most feedback came from parents. Work began by reviewing and understanding what matters most when surveying children aged 3-6 years. Consideration was given to: Cognitive development - keeping questions and answers simple and relevant Social development focusing on aspects of care that matter most to this age group Using play for motivation including elements of play without adding in bias to the survey Education Level need for logical sequencing, a story with a beginning, middle and end. Using a story book concept Humphrey Bear Goes to Hospital, testing began on paper to capture feedback directly from children and parents. Based on feedback from the testing phase, an electronic story book was designed and developed that allowed young children to engage with Humphrey Bear s hospital experience in relation to: Food Opportunity to play Effectiveness of pain medication Friendliness of doctors and nurses National Friends and Family Test Interactive elements are included as a reward once the child answers each question. Audio was recorded using a child s voice as Humphrey Bear to improve accessibility for non-readers. 231

232 Once the prototype had been developed, testing with children, parents and staff took place across RMCH. Product evaluation forms were completed and improvements were made to software, graphics, audio or questions as suggested. Final stage testing included a lock down phase where the survey was added as a choice alongside the already established survey. Data was reviewed to check the validity of the responses; it was clear that the number of children completing the survey increased with 34 responses from the target age group within the first three days. The range of variation in the answers that were provided suggested that true feedback was being given. Already we have seen that where a child said they would not recommend the hospital there was also a negative response in relation to pain management. We will use this feedback to do more work on managing pain. The Humphrey Bear Storybook survey was officially launched at RMCH on National Book Day, 3 rd March Results after one month showed 92 children aged 3-6 years completed the new interactive storybook survey. Responses from children and young people aged six years and over are lower and it has been agreed that a specially designed survey will now be developed for this age group. University Dental Hospital of Manchester (UDHM): Outpatient Information Letters At the Dental Hospital we are currently focusing on the outpatient letters that we send to patients. This is a topic that a lot of staff and patients are interested in and about which views are mixed. We are trying to streamline the number of letters we send and improve the content. We also send costly information in the form of a patient booklet to all our patients and we wanted to know if patients found these useful. The project was initiated by two focus groups with a multidisciplinary team including administration, clinical and nursing staff. We also gathered the views of 50 patients who attended the hospital, to understand from the patient s perspective what information is important to them. The results were interesting and were not necessarily what we expected. The most important factors for the patients were being informed about what was going to happen at their appointment and how long their appointment would last. As a direct result of this feedback, we have included the information about appointments in a revised letter. We introduced the revised letter to patients and carers at our Patient Listening Event held on 2 nd March 2016 and will collate the feedback and include the comments from this event to ensure the information we send to our patients is what they want to know and will help them when they visit our hospital. Cancer Patient Experience: Supporting people living with or affected by cancer During 2015/16, the teams have continued to work with patients and carers to listen and consult with those who are living with or affected by cancer. The qualitative information received back from both national and local cancer in-patient surveys, combined with the establishment of cancer patient user forums within each tumour group, has influenced both education and service improvements across the Divisions. This has enabled us to deliver improvement in patient experience in the following areas: 232

233 Support given to patients by clinical nurse specialist Choice of treatment offered Information provided prior to surgery and diagnostic procedures Opportunities offered to participate in research. Listening and working with patients and carers affected by cancer assisted the teams with the co-design of services to support people affected by cancer. For example Check it Out Prostate Cancer Support Group for Black, Asian and Minority Ethnic community. Patient Support Group Oesophageal and Gastric Cancer patients Design of Health & Wellbeing clinics to support patients and carers following treatment, and assist with the transition from patient to survivor. The Head & Neck Cancer Team successfully hosted the first of four CMFT health & wellbeing clinics for patients and carers affected by head & neck cancer. These clinics provide patients and carers with information, support and the opportunity to speak with their peers and medical team in an informal environment about living and recovering from a diagnosis of cancer. Evaluations from the events were very positive from both professionals and patients: For my wife, having the chance to talk to other carers was fantastic; we found the session really useful would recommend to other patients In line with the National Cancer Strategy - Manchester Cancer, this programme of work will continue in to 2016 building upon the progress made. Building on improvements - next steps To build on the success of the already established improvements that have been made and to provide a structure to engage with all staff to continue to develop excellent patient experience, we are developing a new and innovative, value-based Patient Experience Framework. The new Patient Experience Framework will align key strategies and will recognise the interconnection of patient and staff experience. Effective leadership and good communication structures will be fundamental to successful delivery, and frontline leaders will be placed at the heart of driving patient experience, supported and coached by senior leaders. The Trust s 2015 Staff Survey has shown that staff motivation is above average when compared to other organisations. The Trust is therefore well placed to harness this high level of staff motivation to support improvements in Patient Experience. The Patient Experience Framework will be underpinned by the following key principles: Patient and staff experience are intrinsically linked Frontline leaders are champions for Patient Experience Patient Experience is the responsibility of every member of staff Multi-professional engagement in development and delivery of the Framework is essential 233

234 Individual needs, values and preferences must be respected Patients are active partners in care Environments of care must be conducive to supporting delivery of dignified, healing, compassionate and age appropriate care Effective information, communication and education underpins patient and staff experience Emotional and spiritual support and involvement of friends and family enhance patient experience Patient and staff experience feedback must be sought through a variety of mechanisms most suited to individual preferences. Through extensive engagement and consultation with patients and with all staff groups, the new Patient Experience Framework will define the elements that make a patient s experience excellent and the factors that motivate staff to drive improvement. Leadership, at every level, will form a thread through the Patient Experience Framework, from strategic alignment and support by the Board of Directors to front line leaders championing patient experience in their area. Skills training will be developed and delivered to all staff to ensure that everyone in the organisation is equipped and empowered to drive improvements in patient experience and measures will be established to monitor our success. Personal accountability will be core to the delivery of the Patient Experience Framework, and will be reflected within the appraisal process and in personal development plans. The findings from patient experience feedback, such as National Patient Surveys, the Friends and Family Test and Patient Experience Tracker surveys will be drawn together along with the introduction of additional methods to monitor progress. Feedback will be communicated through the Trust to ensure that frontline staff know what patients say about their experience of the Trust s services, have clear routes to share their ideas for improvement and have authority to drive change locally. Ward Accreditation The annual Ward Accreditation process was launched in 2011, as part of the CMFT s assurance mechanisms for ensuring high quality care and the best patient experience. The process, which is underpinned by the Trust s values and behaviours framework and the Nursing and Midwifery Strategy, includes inpatient wards, day case areas, critical care areas, dialysis units and for the first time in 2015/16 Emergency Departments. Annual unannounced accreditation visits are conducted by teams comprising a Director or Deputy Director of Nursing, a Head of Nursing and a member of the Quality Improvement Team. The accreditation team undertake a half-day observation visit to the clinical area, informed by analysis of a range of data relating to the area, including audit data, the quality dashboard, complaints, incidents, compliments and student feedback. Discussions with patients and staff are also key element of the process. 234

235 The Ward Accreditation process aims to provide a level of assurance for the Board of Directors, that areas are consistently delivering high quality care across four main categories. The categories have remained constant since 2011, but the standards required within each category are reviewed annually to ensure that they remain current and relevant. An example of a recent change in 2015 is the inclusion of a section on safer staffing. The categories are: Culture of Continuous Improvement: including leadership, team culture and use of evidence based practice and safer staffing. Environment of Care: including infection control, accessibility and safety standards. Communication About and With Patients: including team communication, documentation and patient perceptions. Nursing Processes: including medication management and the meals service. Each category is scored using standard criteria as White, Bronze, Silver or Gold, with the collated scores providing the overall Ward Accreditation result for the area. This result is validated by the Directors and Deputy Directors of Nursing to ensure consistency in approach. The criteria for each of the scores are: Gold: Excellent, achieving highest standards with evidence in data that success sustained for at least six months. Silver: Very good, achieving minimum standards or above with evidence of improvement in relevant data. Bronze: Good, achieving minimum standards or below but with evidence of active improvement work. White: Not achieving minimum standards and no evidence of active improvement work. All areas are supported to continuously improve and when wards/departments achieve gold, this success is formally recognised by the Chief Executive, Chief Nurse and senior divisional staff who attend the area to present their certificate. In addition, a small team of staff is invited to the annual We re Proud of You Awards gala dinner where a wall plaque is presented to the team by the Trust Chairman. Ward Accreditation Results 2015/ Number % Gold 17 26% Silver 37 57% Bronze 11 17% White 0 0% 235

236 Patient Experience Improvement Initiative At the beginning of 2015/2016, in order to support and spur innovation, prizes of 10,000 and 5,000 were introduced to fund patient experience improvements in recognition of areas that demonstrated the most improvement in the quality of patient experience. The aim of the initiative was to engage clinical teams to demonstrate and sustain success. The winning teams for 2015/2016 were: Ward 62 (St Mary s Hospital) The team from Ward 62 have used the money awarded to them to improve the environment for patients by creating a comfortable home from home environment examples being soft furnishings, distraction and relaxation equipment, information boards and a designated area to enjoy a cup of tea with family. Central Manchester District Nursing Service and Intermediate Care Nurses Both the community and intermediate care teams have bought pressure relieving equipment that will continue to support their work to continue to reduce harm to patients from pressure ulcers. Infant Feeding Team This team have invested the money awarded to them on equipment that will enable more Mums to be offered support with breast feeding when needed and educational and promotional information to further advertise the role and function of the team for parents, carers and professionals. Developments for 2016/2017 The accreditation process is a well embedded assurance mechanism in inpatient areas that has been demonstrated to drive continuous improvement across the Trust s services as well as recognising and valuing excellence. This year accreditation processes were introduced into the Trust s Emergency Departments and processes have now been developed for Outpatient areas, Clinical Research Units and Theatres and will be undertaken in 2016/17. The Trust provides a wide range of services in both acute and community settings. In 2016/17 our Improving Quality Team will engage with community-based staff to develop plans for the creation of an appropriate accreditation process for community services. In order to further embed sustained and continuous improvement, and to enable teams to collate their achievements, we have developed an Accreditation Portfolio, which will be introduced in 2016/17. Teams will collect and display evidence in the Accreditation Portfolio throughout the year, in line with each of the Accreditation Categories, demonstrating their improvement journey. The electronic database of evidence will be reviewed by the accreditation team at a number of points over the course of the year in addition to an annual Ward Accreditation observation visit. This approach will add a further tier of assurance into the process and provide a database of best practice, which can be shared and spread across the organisation. 236

237 Friends & Family Test (FFT) The Friends and Family Test (FFT) is a single survey question which asks patients: How likely are you to recommend our service to friends and family if they needed similar care or treatment? The FFT survey question was launched in 2013 and initially asked of adult patients who attended Accident and Emergency Departments, received in-patient care and all women using Maternity Services. In 2015, the inclusion criteria were expanded to include patients using the community, outpatients, and mental health services. Separate processes to capture feedback from children and young people and their parents were also included and the requirement to capture narrative comments. The Friends and Family Test (FFT) is an important feedback tool that supports the fundamental principle that people who use NHS services should have the opportunity to provide feedback on their experience. FFT is a quick and simple survey used to collect feedback from patients. One of the advantages of FFT over other patient feedback tools is that patients are able to provide feedback in near real time, making results quickly available to staff. This allows timely action to address poor experiences and celebrate and promote good practice. A variety of methods are used to display results and any action taken based on the feedback is displayed in a number of formats that include You said.we Did posters and Tops and Pant displays in children s services. To ensure collection methods are available and suitable for those areas new to FFT collection we have undertaken a whole system review of the different needs of each patient group, types of collection methods available and required and how reports are generated and accessed. This work, completed in 2015/16, will provide a platform to increase response rates and capture narrative comments that can be used to make further service improvements to improve patient experience. 237

238 FFT Response and Results Area Response Rate In-patients* 15.42% 93.50% Emergency Departments* 9.42% 89.09% Outpatients N/A 86.26% Community N/A 95.74% Maternity N/A 95.5% *Target response rates were not set in 2015/16. Percentage of patients who were likely and extremely likely to recommend our services Food and Hydration We are committed to ensuring that all patients who require assistance with eating and drinking get the appropriate support. To ensure that everyone on a ward focuses on our patients nutrition, we have Protected Meal Times where routine work in a ward ceases (i.e. ward rounds, drug rounds, etc.) and staff concentrate on serving meals and supporting patients who require assistance to eat and drink. Our key standards include: Assessing patients needs before their meals arrive and ensuring they are prepared for the meal service. Using red trays to identify patients who need assistance and the allocating a member of staff who will provide this assistance. Malnutrition Universal Screening Tool (MUST) and Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP) Within CMFT the MUST and STAMP tools are used to review all adults and children admitted to the hospital to assess any risks regarding their nutrition. Baseline audits undertaken in January 2016 within the adult ward areas showed that whilst the number of MUST assessments completed is above 75%, more work is required to ensure they are always accurate and complete. Within the children s wards, audits undertaken during 2015 showed similar fluctuations in the consistency of the STAMP assessments, particularly in relation to reviews within the specified timescales. In response to this audit finding a specific section on the importance of nutrition and assessment has been introduced within the local induction programme. This intervention has led to significant progress being made on the completion rates of both initial and repeat STAMP assessments. During 2016/17, we will continue to focus on the quality and accuracy of information documented within the Malnutrition Universal Screening Tool within the adult ward areas and the Screening Tool for the Assessment of Malnutrition in Paediatrics within the children s wards. 238

239 This work will be supported by our specialist nurses who will focus on increasing awareness of the importance of ensuring the MUST and STAMP assessments are completed accurately and delivering training to ensure our staff are skilled in assessing and managing our patients nutrition. Routine audits will be completed throughout 2016/17 to measure the effectiveness of these interventions. The Dining Experience It is important that food and snacks are presented and served to patients in a timely manner to ensure their dining experience is enjoyable. During the past twelve months the following initiative and improvement programmes have been undertaken to improve the patient dining experience: Extension to the times of the electronic meal ordering process (MAPLE); providing more flexibility to patients when ordering their meals Introduction of snack rounds in a number of adult areas and snack and milkshake rounds in children s areas Microwaves have been replaced by ovens to improve consistency of reheating Workshops have been held between Sodexo staff and Nursing staff to improve integrated team work A dedicated Patient Catering section has been established on the Sodexo Helpdesk for staff to raise and address any concerns about meals A Facilities Management (FM) Pledge has been developed and prominently displayed on each ward to inform patients of the service they can expect; An improved range of sandwiches has been introduced A dedicated children s oncology menu has been introduced that includes a cooked breakfast and a wider range of snacks A new menu has been developed in the Royal Manchester Children s Hospital to provide hot meals at both lunch and dinner time. Feedback from our patients about the quality of the meals shows us that patient satisfaction has improved this year. in 2016/17: Blue Patient Experience Tracker feedback Turquoise - Ward Managers Quality of Care Round Priorities for 2016/17 To ensure continuous improvement of the patient dining experience, and in collaboration with our PFI Partners, we have committed to the following initiatives Perfect Dining Week: a designated week in the year that is committed to providing the perfect dining experience. Lessons learnt from the week will inform a detailed action plan to help us to continue to improve. 239

240 Ward by Ward Reviews of the Dining Experience: including meal timings, menu choices and integration of ward and catering teams. Supporting hydration A key area of improvement during 2015/16 has been the implementation of new ways of observing and recording patients fluid balance and hydration across the organisation. This work is an extension of a programme of improvement undertaken during 2014/15, in response to previous incidents and data from our Quality of Care Rounds. This data showed us that accurate monitoring of fluid balance and hydration needs of patients was inconsistent and highlighted that the number of steps in the processes and procedures that were being used were contributing to this issue. During 2015 the new hydration documentation was successfully rolled out across the adult wards. The implementation of the new processes was supported by members of the Acute Care Team and Specialist Nurses, who delivered a bespoke training packages to ensure all ward staff felt both confident and competent in using the new documentation/tools. To support implementation of the new process a hydration pathway has also been developed to guide and support staff and provide an overview of the processes to follow dependent upon the level of hydration monitoring the patient requires. The pathway is used in conjunction with the relevant new hydration or fluid balance chart and hydration tool. Overall the feedback from staff has been positive and associated training continues to be delivered to individual wards as required. New Hydration Pathway Regular audits are being undertaken across adult wards so that we can monitor the effectiveness of the new documentation and tools and review compliance with monitoring, recording and escalating concerns relating to hydration needs. During 2016/17 we will work with our children s ward teams to review and develop appropriate tools for children. 240

241 Inter-related work programmes: Falls, Continence and Acute Kidney Injury (AKI) In addition to the work being undertaken directly relating to Nutrition and Hydration, a number of interrelated initiatives are also being undertaken as part of broader work programmes for falls, continence and Acute Kidney Injury (AKI). These include an initiative on Ward 45 and 46 of the introduction of decaffeinated hot drinks. Over the coming months the effectiveness of the pilot will be monitored closely and audited against a defined criteria. Patient and relative feedback will also be reviewed. If our evaluation shows that this initiative has led to better outcomes for patients we will look to implementing a wider roll out in 2016/17. The Trust is committed to reducing patient falls and for the period 2015/16 we set a target to reduce the incidence of patient falls by 5%. In order to support the reduction of patient falls a number of workstreams were developed and implemented within the divisions which included the development of divisional action plans. Improvement methodology was utilised and divisional reduction trajectories to reduce patient harm from falls were set. Divisional action plans were requested to establish local implementation strategies and monitor the effectiveness of these at a local level. The effectiveness of these were monitored through a number of inter-related forums including the trust harm free care group, falls steering group and delivered by the corporate falls action plans. The total number of patient falls for 2015/16 was 2,008, a reduction in numbers of patient falls from 2014/15 of 270 patient falls, an 11.8% decrease in the falls rate overall. Actions implemented to prevent patients from falling included the implementation of a Patients Falls Accountability Meeting, to review incidents where patient have sustained harm from a falls to ensure lessons are learnt and shared, the implementation of a revised falls care plan to direct nursing care at ward level, promotion of the patient information safety video, an emphasis on recording patients lying and standing Blood Pressure to detect patient who may be a risk of dizziness, and increased use of sensor alarms to alert staff when patients move and an increased use of low rise beds to ensure patients at risk of falling from their bed are not at risk of falling from a height and therefore less risk of harm or injury. Complaints, Concerns, Compliments & the Complaint Handling Service The Patient Services team continues to build upon the comprehensive review of the Trust Patient Advice and Liaison Service (PALS) that commenced in 2014/15. During this financial year, efforts have continued to improve complaint acknowledgement and response times and to work towards on-going improvements in quality across the Trust s services. Formal Complaints, PALS Concerns and Compliments The availability and quality of complaints data and reporting has improved during the year, allowing the Corporate team and the Divisions to gain further insights into the common causes of complaints and how we can use this data to drive improvements, both in the services we provide and in our complaints handling processes. 241

242 The Trust publishes in-depth quarterly complaints reports and an annual complaints report. The reports include a wide variety of information regarding Formal Complaints, PALS Concerns, and Compliments and how we use the learning from these to make improvements and celebrate achievements. Table 1 provides a comparison of the number of Formal Complaints, PALS concerns and Compliments received by the Trust for the past four years. Table 2 presents data for Formal Complaints in 2015/16 in the context of the clinical activity undertaken within the Trust and Diagram 1 presents the top nine themes for Formal Complaints during 2015/16. Table 1 Formal Complaints, PALS concerns and Compliments Formal Complaints PALS Concerns Compliments * * * 604 * Compliments received have only been recorded since 2015/16 Table 2 Formal Complaints received in context of Clinical Activity In-patient Formal Complaints received(fc) 446 Episodes Finished Consultant Episodes (FCE) 281,818 Outpatient Appointments A&E Attendances Rate of FCs per 1000 FCEs 1.58 Formal Complaints received (FC) 481 Number of appointments Rate of FCs per 1000 appointments 0.29 Formal Complaints received (FC) 109 Number of attendances Number of FCs per 1000 attendances 0.36 Diagram 1 242

243 Parliamentary and Health Service Ombudsman (PHSO) Following completion of the local resolution process for a complaint (i.e. an appropriate level of investigation and response by the Trust), if complainants remain dissatisfied, they can ask the PHSO to investigate their complaint and it s handling by the Trust. Table 3 shows the number of Trust complaint cases closed 2015/16 or under on-going investigation by the PHSO at the end of 2015/16. Table 3 Closed and current PHSO cases Current cases under investigation at end of 2015/16 Closed cases Number fullyupheld Number partly-upheld Number notupheld During 2015/16, the PHSO published numerical data on all the complaint cases it reviews, investigates and either up-holds, partially-upholds or does not uphold. Table 4 shows the numbers of cases in these categories from CMFT compared to other Shelford Group NHS Trusts (a group of ten leading NHS multi-specialty academic healthcare organisations). The final two columns set this data against the clinical activity of the Trusts. Table Enquiries received Cambridge University Hospitals NHS Foundation Trust Oxford University Hospitals NHS Trust University Hospitals Birmingham NHS Foundation Trust The Newcastle Upon Tyne Hospitals NHS Foundation Trust Guy's and St Thomas' NHS Foundation Trust Central Manchester University Hospitals NHS Foundation Trust University College London Hospitals NHS Foundation Trust Sheffield Teaching Hospitals NHS Foundation Trust Imperial College Healthcare NHS Trust King's College Hospital NHS Foundation Trust Enquiries PHSO accepted for investigation Investigations fully or partly upheld Investigations not upheld Enquiries per 10,000 clinical episodes Enquiries accepted per 100,000 clinical episodes

244 Patient feedback via Patient Opinion, NHS Choices and Healthwatch During 2015/16 the Trust increased its responsiveness to patient feedback that is posted on three patient feedback websites. When a patient or member of the public posts either positive or negative feedback on patientopinion.org.uk, NHSChoices or healthwatch.co.uk these posts are sent to the respective clinical division for investigation (if appropriate) and to provide feedback. The learning from this feedback is then fed into local teams so that any identified improvements to the service can be made. As part of this work, the Trust increased its subscription level with Patient Opinion which allows multiple users to post feedback directly within the site and therefore provides a much more responsive service. Tell Us Today The Tell Us Today service provides in-patients with a central telephone number by which they can access a senior member of staff within the hospital, within an hour. This enables swift, local resolution of any concerns which can be dealt with prior to them escalating into more formal complaints. The service to date has been rolled out in all in-patient areas and of the calls received, only a very small percentage have been escalated into formal complaints. The types of call are logged and monitored to ascertain any emerging common themes that demonstrate an area for improvement. PALS and Complaints developments During 2015/16 there have been a number of developments within the PALS and Complaints Service. A new Trust Complaints, Concerns and Compliments Policy has been published along with two new PALS leaflets, one of which is an easy-read version. In addition to this, the external PALS and Complaints website has been updated and is now located via a link from the Trust homepage (one click away). As part of this work, a selection of lessons learned from complaints have been published on the website and a new quarterly newsletter entitled, Patient Experience Matters has also been published within the Trust to share learning from complaints. In November 2014, the PHSO, Healthwatch and the Local Government Ombudsman jointly published My Expectation for Raising Concerns and Complaints. This document provides trusts with a framework for a user-led vision for raising concerns and complains and is based upon the five steps of the complaints process. The five steps are: Considering a Complaint; Making a Complaint; Staying Informed; Receiving Outcomes and; Reflecting upon the Experience The framework is based upon the experiences of users of complaints services and explicitly states how a quality service should operate. 244

245 Further to this, NHS England published Assurance of Good Complaints Handling for Acute and Community Care a toolkit for commissioners, in November This document outlines how Clinical Commissioning Groups might assure the quality of the complaints procedures in the Trusts from which they commission services. The Patient Services team has therefore used both these publications to undertake a review of the PALS and Complaints processes within the Trust. This piece of work has been carried out in conjunction with managers, staff and users of the service which will inform the PALS and Complaints development and improvement programme for 2016/17. PALS office move During 2016, work started on the design phase to relocate the PALS office from a corridor at the rear of the Manchester Royal Infirmary to a new, central, more visible location at the New MRI Entrance. The area identified for the move, which was previously a shop, is being re-fitted to house a new PALS office and the adjacent reception desk will also be re-fitted and staffed as part of this relocation. Building work is due to be completed by June Education Programme A programme of education for PALS Case Managers, Divisional Complaints Coordinators and other key staff directly involved in responding to complaints was developed and delivered in 2015/16. The programme included sharing and learning from complaints across divisions, a master-class on writing letters and summarising meetings with complainants and a session on developing bespoke reports within the Safeguard complaints management system. A further programme is currently under development for 2016/17 and provisionally includes mediation skills development, further sessions on writing high quality complaints responses and an educational session from the PHSO. Feedback from CQC Inspection The CQC use concerns raised by people and those close to them who use our services to help them understand the quality of care that is provided and how responsive our services are to people s needs. Following the recent CQC inspection of our hospitals and community services, the inspectors identified that the handling of Complaints is well managed and that the processes for responding and learning from complaints and concerns is embedded across the organisation. In their report the CQC specifically identified: People knew how to raise concerns or make a complaint. The Trust encouraged people who used the services, those close to them or their representatives, to provide feedback about their care. Information about how to complain, how to contact the PALS team and provide feedback was available and widely displayed. Staff understood the process for receiving and handling complaints and were able to explain how information about complaints were discussed with staff to aid future learning There was a strong commitment from staff to learn from complaints There was evidence of improvements made as a direct result of concerns raised. 245

246 Compliments were displayed in many areas. Next steps The Patient Service Team will continue to develop and improve our complaints handling process in line the Patient Experience Matters branding to ensure that a user-led service is truly provided to complainants. Dementia- John s Campaign John s Campaign was founded in 2014 by the daughter of a patient based on the key principle of families/carers having the right to stay with patients with dementia when they are admitted to hospital. The principles of the campaign are based on the concept that parents are encouraged to stay with their children when they are admitted to hospital. Whilst patients with dementia are not children, their vulnerability and the distress they experience when admitted to the unfamiliar hospital environment impacts on their recovery, experience and the experience of their families. John s Campaign looks to address this by allowing families of patients with dementia to stay with them using a carer s passport, allowing them to be involved in their care resulting in better quality care and improved outcomes. What has the Trust done? Given the older age profile of the patients cared for at Trafford Hospital, the hospital signed up to the John s Campaign principles committing to implement open visiting across all ward areas and support families/carers where they wished to be involved in care delivery. The teams used the Carers Passport, which is a card given to the family members enabling them to be identified as carers, who have access to the ward whenever required. The passport and accompanying poster were initially trialled on Ward 6, and has now been adopted across all inpatient areas at Trafford Hospital. Relative and visitor leaflets have been updated to promote with families/carers the commitment to open visiting and family involvement in care. Ward nursing and medical staff have been supported throughout the implementation to enable them to engage with the commitment and provide reassurance when concerns or issues with open visiting have been raised. As part of the implementation across the Trafford Hospital, the League of Friends funded 13 family/carer portable beds in May These are available on all wards across the hospital so that in the event of a carer needing to stay overnight this can be facilitated. The feedback from ward managers, families and carers has identified that where visiting was flexible and families were involved in care a number of benefits resulted: Patients who require assistance to eat, eat better with their family support especially if family members are eating with them at the time. Wards provide meals/drinks to carers where this is identified as part of the patients care needs Patients appeared less distressed and disorientated Improvements in patient care were seen, with a reduction in patient falls when data was reviewed following the pilot on Ward 6 246

247 Families/carers report feeling better supported and part of care delivery for their family member Staff report that they welcome families/carers contribution to supporting their family member or providing care, and acknowledge the impact that this change has had on improving the experience for the patient and family members. Plans for 2016/17 Continue the evaluation of benefits to John s Campaign at Trafford both for patients and their families Identify appropriate wards on central site where using John s Campaign model would benefit patients and carers, supporting implementation and evaluation in these areas Other news and achievements Manchester Acute Kidney Injury Strategy (MAKIS) A Quality Improvement Programme to reduce the incidence and impact of AKI in CMFT. Acute kidney injury (AKI) is a rapid reduction in kidney function resulting in difficulties in clearing excess water, electrolytes and toxins. It is very common amongst patients admitted in hospital. AKI occurs in 1 in 5 patients in most UK hospitals, including ours. Whilst two thirds of these patients come to hospital with AKI (community acquired), a significant proportion is still developed during their in-patient stay (hospital acquired AKI). AKI has significant consequences including prolonged hospital stay, increased risk of long term kidney damage (chronic kidney disease) and significantly increased risk of death. A local audit at our hospital in 2013/14 exposed significant deficiencies in the identification, management and follow up of AKI cases. In recognition of this, the Trust setup an AKI team (Manchester Acute Kidney Injury Team - MAKIT) tasked with addressing this important clinical issue. MAKIT aimed to achieve the following key objectives by the end of 2015: Improvement in AKI detection: 100% recognition of all AKI cases within 24 hours Improvement in fluid and drug management in AKI: 95% appropriate management Reduction in new cases (incidence) of AKI: 10% reduction in total number of cases of AKI Reduction in length of stay (LOS): 10% reduction LOS of patients with AKI Shortening time to recovery: 20% reduction in AKI days (the total number of days spent in AKI). 247

248 To achieve these, a multifaceted AKI quality improvement programme was implemented. Key aspects of this include: The development and implementation of a bespoke electronic alerts system for AKI. This system outperforms other such alerts developed elsewhere by detecting 100% of cases of AKI The development and implementation of a 10 point simple Priority Care Checklist (PCC) to improve reliability and consistency of AKI care A multipronged awareness and education programme using various media and methods The use of two AKI clinical nurse specialists to assist ward teams Setting up of a network of pharmacists to assist with AKI notifications and medication reviews. The monitoring of AKI management and patient outcome data over the past two years shows significant improvements in all the above key metrics as shown in the table. These improvements have resulted in 60 fewer AKI cases and 6 fewer deaths per month. MAKIT has won several local and national awards for its achievements. Key metrics, targets and current attainment Metric Targets by 31/12/15 Attainment/ Reduction AKI Detection 95% 100% Fluid Assessment 95% 100% Drug Review 95% 99% AKI incidence 10% Reduction 18% AKI LOS 10% Reduction 22% AKI Days 20% Reduction 28% AKI Deaths 10% Reduction 13% The LOS graph show convincing reduction from 22.3 days previously to 17.2 days since hospital wide implementation in February 2015 (23% reduction). In 2016, MAKIT plans to consolidate and sustain these interventions and improvements across all areas of CMFT including Trafford, but also to assist other hospitals across greater Manchester in implementing similar AKI improvement programmes. MAKIT members receiving their Improvement Science Certificates from Professor Peter Trainer of Manchester Academic Health Sciences Centre (MAHSC). From left: Robert Henney, Susan Heatley, Marc Vincent, Rachael Challiner, Leonard Ebah, Peter Trainer, Prasanna Hanumapura and Deryn Waring. 248

249 End of Life Care (EoLC) Our Vision We will ensure that all patients under the care of CMFT, their families and carers, receiving palliative and end of life care are listened to and cared for compassionately by staff with the right skills. We will adhere to best practice guidance where available, and deliver holistic patientcentred care that recognises individual circumstances and addresses diverse needs. We will ensure that the patient and their family/carer receive the care and support that meets their identified needs and preferences, ensuring respect and dignity is preserved both during and after the patient s life. Our Strategic Aims To provide personalised care at the end of life for our patients and the people identified as important to them (their family, loved ones, friends and carers) both in hospital and in their own homes To ensure the care provided to our patients and their families is aligned to our Trust values of compassion, dignity, respect, consideration, empathy and pride. To ensure our staff are prepared and supported, to provide high quality palliative and end of life care To ensure that patients are supported in their choice of place to die whenever possible To ensure that the care we provide is evidence based and, where possible, contribute to the development of evidence based palliative and end of life care. Progress during 2015/16 There has been a significant amount of work undertaken by Trust staff during 2015/16 to improve end of life care for our patients during the last year of life and following death. This includes: Ratified Palliative and End of Life Care Strategy (EoLC) and group strategic plans at Quality Committee Revised terms of reference for the Adult Palliative and EoLC group led by Consultant in Palliative Care Establishment of a new Babies, Children & Young People Palliative and EoLC group led by a Consultant Chair of Resuscitation Committee is a member of Executive EoLC Oversight Group, in order to progress changes to practice in relation to resuscitation status and limitations of care planning with patients Implementation of the Adult Priorities for Care for the Dying Person individualised care plan and communication record across acute wards and community settings Matron for Adult Palliative and EoLC commenced in post January

250 Nursing and Midwifery Trust wide launch of the priorities/principles of EoLC One Chance to Get it Right Brilliant Basics session in January 2016 Adult EoLC ward/department champions role established with specific training/study session being held at the end of March 2016 Additional T34 syringe drivers purchased and equipment library organised to ensure all patients have rapid access to effective pain management Successful application made to NHSIQ Transform Programme (Phase 3) to support programme of work in relation to advance care planning with patients and their families Revised and updated policies and guidelines available through the Specialist Palliative Care website to support evidence based quality end of life care The Trust Spiritual Care Team has extended its service to our patients living in our local community The Trust is working with central Manchester CCG to deliver the EPaCCS (Electronic Palliative Care Co-ordination System) to improve the communication between health care professionals and support patients' wishes at end of life. Work will continue during 2016/17 79% of adult patients known to the community Macmillan specialist palliative care team were supported to die in their place of choice Bereavement Midwives Service has received national recognition through a number of national awards Commenced work on the development of a postgraduate community palliative care module for health professionals in collaboration with Manchester Metropolitan University Palliative and End of Life Care teaching sessions for our junior doctors and medical students are in place. Commitments for 2016/17 Delivery of end of life care working programmes aligned to our Palliative and End of Life Care Strategy. Development and implementation of performance dashboard for EoLC to enable monitoring of specific standards (i.e. patient dies in preferred place of care) Development of an appropriate mechanism for gaining family feedback in relation to their experience of EoLC, in order to inform future programmes of work. Assurance Sample audit undertaken in February 2016 following introduction of Adult Priorities for Care of Dying Person individualised care plan demonstrated improvements in documented against all the standards. Trust wide end of life care audit planned for month of April 2016 the results to which will inform the End of Life group work programmes. A questionnaire has been developed asking carers and relatives their experience in the EOLC plan, management and care delivered to their loved one. Relatives consent to this at the point they collect the death certificate and the questionnaire sent to them 2 weeks following the death. 250

251 Feedback from CQC inspection The CQC agreed with our assessment of End of Life Care. They observed caring and compassionate staff delivering high quality care but wanted the Trust to provide better guidance for staff and review resources for palliative care. This work is now well underway. Transition of Care for Young People Transition of care refers to the coordination and continuity of health care when moving from one healthcare setting to another or home. For example, older adults who suffer from a variety of health conditions often need health care services in different settings to meet their many needs. For young people, the focus is on moving successfully from child to adult health services. The Trust identified earlier in the year that although, on the whole, our practice in transition service is good, it lacked consistency across all services. This was also the view expressed by the CQC at their last inspection of our Trust in November The CQC was of the view that we could improve our transition service, by standardising the quality of transition services across the organisation to the same high level provided in some areas. What we have done so far? Two groups have been established to oversee and lead on the improvement plans: a Strategic group led by an Executive Director - Professor Robert Pearson, Medical Director and an Operational Group led by Sue Lunt, Hospital Director at RMCH. The Trust has developed a Transition Strategy aligned with the recently published NICE guidelines on transition (Transition from Children s to adults services for young people using health or social care services). 251

252 The Strategy has been written to bring together key areas of work and in doing so aims: To provide safe and effective transition from children s services to adult services for all young people with complex and/or long term conditions To ensure young people are prepared for transition to adult services To care for young people and their families in adult services without any loss in the quality of services provided and a good patient experience. At the time of writing the strategy is currently out for consultation across the various clinical specialties in the Trust, after which, it will be implemented across relevant services. Urgent and Emergency Care The Trust seeks to provide safe, effective and responsive care to all urgent and elective patients. To do this we ensure effective inter-agency working on Urgent and Emergency Care in Central Manchester. This issue has the most senior level of commitment, focus and oversight across Central Manchester including independent advice and assurance. 2015/16 has been a challenging year for us with the non-elective workload and pressures facing the Trust, and in particular the MRI, being significant and above that being experienced by other Trusts locally in terms of number of attendances, acuity and admissions. We have therefore undertaken a programme of actions, including shorter-term tactical responses and longer-term transformation schemes. Robust governance arrangements are in place to ensure that all risks are identified and managed as rapidly and effectively as possible. In order that our patients are seen as quickly as possible by the most experienced and skilled clinician, the Trust streams care for emergency patients through the specialist hospitals, where they are required. Urgent care pathways are now well developed in the Royal Manchester Children s Hospital, the Manchester Royal Eye Hospital, Saint Mary s Hospital and our Cardiac Services within Manchester Royal Infirmary (MRI). Trafford Urgent Care Centre supports our patients who access Trafford Hospital. The Emergency Department at the MRI is our largest emergency access area and sees around 400 patients each day. Work has continued to strengthen our staffing within Emergency Services and look into innovative ways of responding to the needs of our patients. The Trust has a number of transformation plans in place that will deliver greater access to healthcare on a day care basis, enabling those fit to return home to do so and avoid overnight admission. The transformation plans are themed across the MRI and are aligned to our Trust Vision and Values. The diagram below sets out those values alongside the strategic priorities for the MRI. 252

253 The Emergency Gynaecology Unit within Saint Mary s Hospital is a 24 hour walk in service led by Nurses who have expertise in early pregnancy problems from abdominal pain to vaginal bleeding. The nursing team will arrange scans and follow up appointments and provide practical and emotional support throughout this often distressing time. The unit sees 12,624 new attendances and 11,955 follow up appointments per year. One partner of a patient wrote to us and said: Attending the emergency gynaecology unit is a potentially terrifying experience for anyone, my wife had cause to attend when she had some bleeding in the early stages of pregnancy and we were seen promptly and professionally. The reassurance, management and follow up were all excellent and you should be proud of the staff on the unit and the sonography staff who did my wife s scans. In 2015/16 we have seen an increase in demand on the Paediatric Emergency Department service and this has impacted on our ability to meet the emergency department target, but we are continuously working on ways to ensure that all patients are seen as quickly as possible. We are really proud of our Paediatric Emergency team, and our consistently high quality of care. We have implemented a new House Keeper role in the department following children s and family feedback, and continue to look for innovative ideas to improve the quality of the service we provide. We are currently working up plans to increase the physical capacity of the department. Trafford Urgent Care Centre provides access to medically-led services for both injuries and illness. The service is enhanced for the population by direct access to the acute medical unit via GP and community services. 253

254 The current model was implemented following the Trafford New Health Deal. The attendances have been in line with the projections within the model. The model was enhanced during the process, both in staffing and opening hours. Though it has been difficult to attract and retain suitable medical staff, we have provided a high standard of care and service. This has been evidenced by the high patient satisfaction levels of users of the service. There are clear pathways of care for people who attend and need a higher level of care than can be provided. In line with the original consultation, the model is now being reviewed with the CCG. This is to ensure the modelling of numbers and acuity are accurate. This will lead to an evaluation of model 3 that was included in the original consultation. The Emergency Eye Department treats 25,000 patients each year, and these patients travel from all over the North West of England to benefit from our expertise. In 2015/16, 99.91% of these patients have been seen and treated within four hours, only 21 people have waited longer, and 97% would recommend us as a place for treatment to their family and friends. The service at Manchester Royal Eye Hospital is internationally renowned and we receive visits each year from professionals around the world looking to learn from what we do. The team is closely knit from medical staff, nurse practitioners, acute optometrists and administrative support, ably supported by a state of the art ophthalmic imaging service. The service goes from strength to strength and major successes this year include Mr John Uddin completing his Advanced Nurse Practitioner training; the appointment of Miss Reshma Thampy as a second Consultant with a special interest in this area; the introduction of an award-winning patient pager service, allowing patients to leave the department while waiting without fear of losing their place, and the launch of an out-reach service at Altrincham General Hospital. Further improvements are planned for 2016/17, including new staff rotas, enhanced triage, improvements for doctors in training and better links with community optometrists and eye services at other Trusts. Feedback from the CQC inspection The CQC rated our Urgent and Emergency services overall as requires improvement. This was due to a number of factors but the main concern was patient flow across our hospitals and staff capacity to deal with this. It is envisaged that the improvement plans for 2016/17 outlined above will address the issues identified by the CQC. Informatics Update Adoption of pioneering applications CMFT is an NHS pioneer in adopting Patientrack, an electronic track and trigger system with automated alerts. The system presents to front line staff a patient s observations and identifies patients whose condition is deteriorating, alerting medical staff via a range of electronic devices. 254

255 The system is operational 24 hours a day, 7 days a week and improves monitoring of conditions and early intervention. We re already seeing the benefits; with 80% of observations (e.g. blood pressure, heart rate) completed on time, the Trust can see which patients have had their observations carried out, the completeness and timeliness of those observations and the responses to those observations. Analysis has also demonstrated an overall fall in risk of death over the study period and cardiac arrests fell from approximately 300 per year to approximately 60. "Recognising when a patient's health deteriorates and responding in a timely fashion has been one of our national priorities in acute in-hospital care for the past 18 months. Patientrack has proved invaluable to clinical staff in our transformation of this pathway and I personally I m delighted to see the patient benefits mirror those in the trial." Jane Eddleston, Clinical Lead for Critical Care at CMFT and Department of Health Adviser for Critical Care. Building the future We ve started our journey towards having an Electronic Patient Record (Chameleon). With all our internal developments we re aiming to make working lives easier and bring benefits to patients, staff and the Trust as a whole. To make sure we re doing this, we re not developing any of this in isolation. We re working in partnership with a lot of people from a variety of clinical and non-clinical roles across the Trust. This approach worked very well in the development of Chameleon View which went live across the Trust last year. I am a consultant Urologist at MRI and have been using Chameleon for the past couple of weeks. I spend a significant amount of time dealing with patient investigation results and having these results available on the same platform as clinic letters, discharge summaries and operation notes is already making this task significantly easier. I am very grateful to the team that developed Chameleon. Mr Iain McIntyre, Consultant Urological Surgeon, Manchester Royal Infirmary Having access to Chameleon View is great. This morning it helped me solve a problem that would ve taken me much longer and would ve meant opening up two systems. And, best of all, it meant that we stopped a child having an unnecessary blood test. Steve Bellfield, Healthcare Support Worker on Ward 76 Chameleon View: Brings together key clinical information from existing systems into a single view eliminating the need for clincal staff to open multiple systems Provides robust security access allowing only those with legitimate access to view patient records 255

256 Reduces reliance on the paper case note Provides opportunities for some to move to paper-lite or even paperless practice. Integrated Clinical Environment One of the biggest successes for the Trust and Informatics was the implementation of a new system (Sunquest Integrated Clinical Environment (ICE)) used by staff to order tests e.g. X-rays, and to refer patients to services such as Community Midwifery, Continence Advisor, and District Nursing. With nearly 9,000 registered users, we now see on average 7,757 orders a day placed for tests and requests (pathology, radiology and service referral). The new system offers many benefits: It s easy to use and find information Requesting tests and service referrals is quicker Results can be shared across primary care (e.g. GPs) and secondary care (e.g. hospitals and clinics) Continued improvement to patient safety with labels for tests being printed at the patient s side Reducing the amount of paper used Integration with the Trust Electronic Patient Record (EPR): Chameleon View enabling the presentation of results in both tabular and graphical formats. We switched from our old system to the new system overnight. It was the most technically and logistically challenging implementation we ve ever faced. It was true team work between Informatics, clinical and front line colleagues which made it such an overwhelming success. On the day of implementation over 60 Floorwalkers offered help and support 24/7 during 335 shifts to make sure front line staff were fully supported. I just wanted to feedback regarding the ICE floorwalkers this week who have, without exception, been very helpful and supportive and quick to respond at all times. Please thank them for their support and good humour during the transition. Peter-Marc Fortune, Consultant Paediatric Intensivist Integrating Care We have supported the development of an integrated care record for at risk patients. This brings together key information from health and social care provider systems into a single care record which can be accessed by relevant care professionals. After a successful pilot, GP practices in the area can now use these records to develop care plans for patients who are identified as being at risk of unscheduled or unplanned care. Care plans can be shared and accessed by other professionals, including community nurses, social workers and community mental health workers. So far around 6,000 care plans have been created by GPs in the city and there are around 900 registered users of the system. Safeguarding This joint project between Saint Mary s and Informatics involved colleagues from across the Trust and was supported through the Trust s Adult and Children s Safeguarding Groups. 256

257 Informatics staff reviewed the national reporting requirements and then worked with Faye Macrory (Female Genital Mutilation (FGM) lead) to agree how we could collect the information and how the information would be used to help safeguard these vulnerable patients. We then developed an online data collection tool and in the first six months (September 2014 to March 2015) identified 191 eligible FGM patients. Winning first prize at the British Journal of Midwifery Practice Awards From left to right Peggy Mulongo, FGM Mental Health Practitioner; Faye Macrory, Consultant Midwife; Dr David Foster, Department of Health Deputy Director of Nursing Going Digital An overarching priority is for Informatics to play an integral role in breaking down traditional IT, information and communication boundaries between healthcare professionals, patients, service providers and all organisations involved in the care of the patient. We will enable this service transformation and integrated working through: Providing a single clinical view of the patient through the Chameleon Electronic Patient Record and integrating best of breed systems and technologies. Providing business intelligence, predictive analysis, and big data solutions. We will ensure that Going Digital, our Annual Plan, is deliverable and sustainable by: Providing a contemporary and integrated technical framework with technical resilience, performance and infrastructure. Innovating, developing and managing programmes such that the transformation of processes is safe, sustainable and always aiming to be thinking ten steps ahead. Having the best structures and business approach to position Informatics for future challenges: o Finance o Governance, Risk and Control o Our People o Communications and Engagement o Sustainability. 257

258 3.13 Divisional Reports Our Trust has nine clinical Divisions as demonstrated in the diagram below. Each of the divisions has a unique identity and provides a specialist service but they all share one aim: to be the best at what they do. CLINICAL AND SCIENTIFIC SURGICAL SERVICES ROYAL MANCEHSTE R MEDICINE AND COMMUNIT SPECIALIST MEDICAL SERVICES SAINT MARYS HOSPITAL MANCHESTE R DENTAL HOSPITAL TRAFFORD HOSPITALS MANCHESTE R ROYAL EYE Here is a summary of some of the ongoing work within the nine divisions. Medicine and Community Services Outcomes of last year s 3 top priorities 2015/16 1. Focus on recruitment and retention of staff, alongside the development of new models of nursing care - the Division has continued to progress the recruitment of nursing staff, including overseas recruitment. Recruitment and retention remains a challenge and the Division will continue to consider innovative ways in which to attract staff across nursing and provide opportunities for development to support retention. 2. Reduce the number of beds within the Division as part of the transformation project in order to improve staffing levels across the permanent medical wards - although this year we have made significant improvements in safely reducing capacity and risk assessed plans for removing capacity continue with evidenced reductions in length of stay, we have had to manage different challenges in terms of demand management, with CPE cohorted areas currently utilising much needed bed and workforce capacity and this remains a challenge for the Division. 3. Improvements in infection control practice across the Division and a reduction in hospital acquired infections - CPE remains a challenge across the Division with an increase in acquisitions. The Division continues to undertake audits to monitor compliance with hand hygiene and PPE practices to support improvements to be made. 258

259 The Clinical Head of Division is the interim medical lead for Infection Control and ensures that clinical leadership and support is provided for this area of work. 3 main outcomes from the Divisional Quality Review Acute Services Review 1. Generally, staffing shortfalls were cited as an issue that prevented progress towards making improvements in the Division. Reduced staffing levels led to some delays in providing elements of care and ability to attend training sessions. 2. Medication storage across wards and services including medications delivered by pharmacy were left unattended, medication cupboards were unlocked and there were issues with staff unable to access keys in a timely manner in order to unlock medication fridges. 3. Administrative/clerical staff in the Emergency Department stated they felt morale was low and there was a lack of leadership being demonstrated. Community Services Review 1. IT remains a concern and issues for community staff include on-going problems with connectivity to the Trust computer network, compatibility with other electronic systems and the time taken to address these problems due to services being off site. 2. Support for staff regarding change management in relation to the Integrated Team establishment and Health & Social Care integration in Issues with the community estates including overcrowding, poor building fabric and inadequacy of availability of space. Responses to address the outcomes Acute Services 1. On-going recruitment initiatives to continue across acute services for nursing and medical staff. Medical recruitment has been undertaken in India and is now moving through the recruitment process. Overseas recruited nurses are now being placed within ward areas and are undergoing any training required. Continuation of daily review of staffing across all areas, escalation process for the use of temporary staff and scrutiny of e-rostering system. 2. Divisional Medicines Management action plans in place to address issues alongside matron reviews of medication storage including fridge temperature checks. Audit also in place regarding storage of medication once delivered by Pharmacy. 3. The Emergency Department have undertaken a review of the management structure for administration and nursing staff to provide support to all staff and completed bespoke management sessions with admin staff, including taking into consideration the recent Aston Programme (team building, leadership and management structure programme) and stress survey results. 259

260 Community Services 1. Divisional Informatics Group continues to monitor progress with improved corporate IT support and understanding of the issues. The directorates have an escalation process in place for any support required with IT issues. 2. As the Integrated Teams become established, staff have been encouraged to raise any concerns via the monthly ask the management sessions, through their line manager or at their individual team meetings in order to address any concerns about premises and roles moving forward into the new model. Regular estates planning meetings and site visits are held in partnership with Manchester City Council and NHS Property Services. 3. Community services continue to escalate issues and ensure the estate priorities have a high profile. An estates specific action plan is in place and leads have been identified for each of the community estates and properties to ensure that any issues can be addressed. Improvements from Clinical audit, incidents, complaints and claims 1. A support process has been implemented for discharging patients who have CPE to nursing homes, due to families and patients experiencing long delays in the discharge planning process. 2. Senior review process within the Emergency Department implemented for the review of x-ray results in order to reduce the risk of any missed diagnoses and subsequent delays in treatment. 3. Due to an acknowledged gap in staff awareness regarding the Do Not Attempt CPR Policy, discussions took place across the whole multi-disciplinary ward team about this. New booklets were ordered and are available on every ward. Emergency call 2222 posters have been updated and provided to ensure staff had access to the correct emergency information. Top 3 risks 1. Patient safety is at risk when demand within the Emergency Department outweighs the capacity available. This continues to be a risk for the Division and has been acknowledged as an MRI-wide risk due to issues with bed capacity and flow of patients. 2. The estates risk within community services has been updated to accurately reflect the concerns identified. Some aspects of the estates are acknowledged as not fit for purpose and work continues between the Trust and NHS Property Services to ensure actions are put in place to improve both safety and cleanliness of the estates, as well as support staff to deliver safe patient care in these settings. 3. Infection control continues to be a risk for the Division due to the number of CPE acquisitions across the acute services. This is actively managed with the involvement of senior medical and nursing staff alongside the Corporate Infection Control team. 260

261 Division s top 3 priorities for next year 2016/17 1. The recovery of the financial sustainability and position for the Division, including the closing of trading gap and turnaround initiatives. 2. Responding to changing commissioner requirements for community and urgent care services with a significant shift in sub-acute provision into a community provision, as well as the requirements for acute services, including Healthier Together and the Single Hospital Service. 3. To continue to recruit and retain a competent, capable workforce that will support our provision of our core service contracts, as well as delivery of radical reform in the future. Royal Manchester Children s Hospital Outcomes of last year s 3 top priorities 2015/16 1. Infection Prevention & Control (IPC): improvement measures include a trial of Surficide technology (using ultra violet light to decontaminate areas), a range of interventions to reduce Central Line Acquired Blood Stream Infections (CLABSI) within Critical Care with a plan for roll out across RMCH (also part of the Making it Safer Together paediatric patient safety collaborative), and nursing investment to support the IPC agenda. 2. Food and Drink: participation in the 2015 CMFT Nutrition and Hydration Week (including food tastings and senior staff involvement in food service process to get first hand experience and feedback from patients and families), new menus introduced in RMCH (November 2015) and a plan for evaluation, and re-convening of the RMCH Patient Dining Group to support collaborative working between staff involved in the food service process. 3. Workforce: nursing workforce programme in place to support recruitment and retention including: majority of wards have a Band 6 educator role in place to support newly qualified staff, offer of alternative shift pattern for in-patient areas which provides additional cover within existing establishments and accelerated programme for conversion of RGN to RSCN. Successful recruitment within a challenging national context to Consultant posts in Respiratory Medicine and Cardiology. 3 main outcomes from the Divisional Quality Review 1. Cleanliness and tidiness 2. Secure storage of case notes on Ward Recording of drug fridge temperatures. Responses to address the outcomes 1. Cleanliness and tidiness: cleanliness issues shared with Sodexo, on-going monitoring programme and participation in CMFT wide SHINE programme (focus on working jointly with Sodexo to drive improvements) and escalation as required. Tidiness: focus on de-cluttering ( Dump the Junk ). 261

262 2. Ward 76 case note storage: interim measures (frosting of glass for area where notes were stored within cages ) and long term solutions implemented or in progress. (alternative storage in secure office area by main reception desk on short stay area, Day Case discharge notes are locked away and lockable cupboards ordered). 3. Drug Fridge Temperature: all drug fridges within RMCH were reviewed, signage provided to support appropriate recording of temperature and CMFT Temperature Record Book implemented. Audit planned. Improvements from Clinical audit, incidents, complaints and claims 1. Audit: change to practice as a result of audit of ultrasound screening for liver disease in paediatric cystic fibrosis, with reduced costs for the service and reduction in unnecessary scans. 2. Incidents: ammonia testing procedures reviewed, and learning (ammonia testing should be undertaken as a matter of urgency in any child with an unexplained depressed level of consciousness) shared at a Grand Round and more widely by the North West and North Wales Paediatric Transfer Service (NWTS). 3. Complaints: additional equipment ordered for Ward 75 (reclining chairs), environmental improvements at the Winnicott Centre Top 3 risks 1. Staffing (having the right staff in the right place at the right time, to deliver the right care). Vacancies/gaps in staffing impact adversely on patient care and experience, achievement of hospital activity targets, and the ability to release staff to undertake training. National shortages in paediatric services for nursing and medical staff makes recruitment and retention more challenging. 2. Limited capacity for in-patient admissions, particularly during the winter months when demand is higher. This impacts adversely on: Patient care and outcomes (such as delays in admission for surgery or diagnostic tests; or patients being admitted to a ward not usually associated with the specialty looking after them) Patient experience (making it more difficult to allocate each patient a bed space which is appropriate for their age, developmental needs and gender) Achieving activity targets. 3. Delivery of a balanced budget. 262

263 Division s top 3 priorities for next year 2016/17 1. Infection Prevention & Control 2. Environment (making RMCH more friendly for children and young people, including launch of storybook to obtain feedback from pre-school patients) 3. Workforce. Feedback from CQC Inspection RMCH was inspected by the CQC as part of the Trust comprehensive inspection in November They commented on RMCH having caring, committed and compassionate staff that treated people with respect. The Child & Adolescent Mental Health Services (CAMHS) was rated as Outstanding as they were seen to continually review, adapt and extend the services they provide to meet the changing needs of their patient population. The service had developed standardised, integrated care pathways, delivered by multi-disciplinary/multiagency teams, to provide effective care for patients with complex health needs. Manchester Royal Eye Hospital Outcomes of last year s 3 top priorities 14/15 1. Continue to develop the Listening and Learning Programme, both staff and patient focussed; inclusive of the launch of the MREH Twitter account and introduction of the patient pagers. Since the launch our followers have increased month on month. During November 2015 our Tweets accumulated 33,500 impressions with an average engagement rate of 2.6%. We were mentioned 74 times by other people, gained a further 35 followers and our profile was visited 1,986 times. Patient pagers are now in all clinic modules within the MREH and the Peter Mount Building. This allows patients who are attending for multiple appointment slots to move freely from the clinics without fear of missing their appointment. The pagers have received two Trust awards, Transform Together hosted by the Transformation Team and the Sodexo Dignity Award at the Nursing and Midwifery Conference. They have also been highly Commended by the national Vision 20:20 Conference and have been nominated for a national Patient Experience Network Award. Bimonthly staff focus groups continue to be held by the Divisional Director to ensure that staff are aware of Trust and wider NHS developments. MREH had the highest return rate for the Trust patient satisfaction survey, demonstrating an exceptional level of staff engagement. 263

264 2. Continue to develop the workforce to ensure this is fit for purpose for the future NHS; developing roles and responsibilities saw the graduation of two Advanced Nurse Practitioners (ANP) within the MREH. Job plans are now in place to ensure that their skills are fully utilised in nurse led clinics and minor operation theatre lists. One ANP will be undertaking clinics in our satellite centre at Altrincham General Hospital, which has been opened to help ease the capacity pressures within the MREH. In addition, we have increased the number of nurse led injectors to support the ever-increasing Macular Treatment Centre Clinics. This service has recently been extended to Trafford General Hospital, providing care closer to patient s homes. 3. Continue to learn from feedback/develop new methods of obtaining feedback and show improvements in patient and staff experience; supported by the Trust Values and Behaviours and the Nursing and Midwifery Strategies. The MREH continues to actively utilise all communication strategies, such as the formal, Trust complaints and PALS service, Friends and Family Test and NHS Choices, and informal routes such as Twitter. In addition, MREH worked with Healthwatch to host a patient feedback week during October The information received during this week and responses from the MREH and other Trust departments will be published by Healthwatch. During February 2016, we also held an event in conjunction with the Transformation Team to gather the opinions of both staff and patients to develop future services. 3 main outcomes from the Divisional Quality Review 1. Security of medical records 2. Patient experience in the out-patient areas 3. Infection control. Responses to address the outcomes 1. Security of medical records: Lockable cupboards and trolleys have been installed in the out-patient areas. Medical records are also stored behind reception desks or in locked rooms if not required that day. This process is audited regularly to ensure standards are maintained. 2. Patient experience in the out-patient areas: There has been considerable expansion of services to off-site areas to help reduce the overcrowding and long waits in out-patient areas. Staff in the outpatient areas have instigated a rounding schedule whereby they inform patients at check-in and on an hourly basis of any delays to appointment times. An electronic Patient Experience Tracker has now been purchased for the children s area in Clinic H. This has questions that are more appropriate for children to answer and results are displayed for staff and patients to see. New toys have been purchased and there is an on-going replacement programme. The implementation of virtual clinics for patients with certain conditions has reduced the number of hospital visits for some patients whilst maintaining safety. 264

265 3. Infection Control: A review of cleaning methods for reusable lenses has been undertaken and amendments to this process implemented. A full appraisal of the options available for cleaning vs. single use items is currently being undertaken. During International Infection Control Week, the Division reiterated the bare below the elbows directive, empowering staff to challenge colleagues to ensure compliance. Improvements from Clinical audit, incidents, complaints and claims 1. Safe Site Surgical Checklist: As a result of a never event last year the MREH has developed a new checklist for the insertion of implants and correct site of surgery. This ensures that when decisions are made to change a procedure mid-point, additional time out is taken to ensure that everything is present and correct. 2. Pain Control: Pain control in both in-patient and outpatient areas continue to feature in complaints. A Divisional Pain Sub Group has now been instigated as part of the Trust Brilliant Basics Programme and a number of initiatives in all areas have been introduced. Results via the patient experience tracker data are encouraging. Top 3 risks Patient safety continues to be the top objective for MREH. Incidents, complaints and claims are continuously monitored and managed by the Divisional Clinical Effectiveness Board and themes and learning shared widely amongst teams. 1. Capacity and space in the out-patient clinics can result in delayed follow up appointments and subsequent treatment. Recent high level incidents have identified that patients lost to follow up have increased. 2. Lack of a clear standard operating procedure for the management of patients who do not attend (DNA) appointments has also resulted in delays to treatment. 3. Unavailability of medical records both paper and electronic continues to present clinicians with difficulties when treating patients. Division s top 3 priorities for next year 2016/17 1. Outpatient Improvement Programme Using information from the Patient Experience Trackers, complaints and incidents and a co-ordinated approach by the MREH and Transformation teams, a large project focusing on the patient journey through the outpatient service is being developed. A process of experience based design, patient and staff stories and mystery shoppers have helped formulate a detailed plan for work over the next 12 months, focussing on health records, patient access, patient management, specialist customer care and clinic H redesign. 2. Theatre Improvement Programme Commenced last year, the theatre improvement plan will continue during 2016/ /16 saw the introduction of a Surgical Admissions Lounge on Ward 55 which ensures a seamless admission process for patients and staff. 265

266 Further developments will increase theatre activity and productivity by reducing turnaround times and preventing cancellations by improving the preoperative assessment process. 3. Expansion of the Trust Accreditation Programme to Theatres and Outpatient areas As part of the Trust s overall Improving Quality Programme the outpatient and theatre areas will now be included within the accreditation process. Departments will be assessed on their ability to respond to patient and staff feedback and improvements made from the experiences of both. Whilst both areas continually strive to provide the best care, this process of assessment is new and staff are keen to be involved in the process. University Dental Hospital of Manchester (UDHM) Outcomes of last year s 3 top priorities 2015/16 1. Continue to develop the Listening and Learning Programme, staff and patient focused. The Twitter account is now in use allowing patients and carers to see information regarding upcoming events and leave feedback regarding treatment. Bimonthly staff focus groups continue to be held by the Divisional Director to ensure that staff are aware of Trust and wider NHS developments. The Patient Listening Event is now an annual occurrence. The UDHM Quality Forum focusses on both staff and patient satisfaction with regular reviews of the Staff Pulsecheck data and You Said, We Did initiative. 2. Continue to develop the workforce to ensure this is fit for purpose, developing new roles and responsibilities saw the first Registered Dental Nurses attend the Trust Preceptorship Programme, a programme that has recently been expanded to support newly qualified practitioners from a variety of disciplines. A newly appointed consultant in the Emergency Dental Clinic is leading work on a new trauma network and we have appointed the first Consultant in Special Care Dentistry in the city. A designated Specialist Dental Nurse has been employed at the Peter Mount Building which has improved both staff and patient experience within the Maxillo Facial Department. Dental Nurses have continued to develop extended skills in intravenous cannulation and radiology. 266

267 3. Continue to learn from feedback/develop new methods of feedback and show improvements in patient and staff experience. Improvements to internal and external signage have been made and further plans to engage with Manchester Council are in progress. CMFTVs are now installed in all clinics providing a platform for staff to provide health education information to patients. Additional patient experience trackers have now been purchased to improve the amount of feedback acquired that is also clinic specific. The Endodontic clinic continues to use bespoke feedback that demonstrates high levels of patient satisfaction. Improvements to the telephone system for patients wishing to change appointments/contact the hospital have been made. 3 main Outcomes from the Divisional Quality Review 1. Security and storage of medical records. 2. High numbers of cancelled appointments and high DNA rates. 3. Storage of medication. Responses to address the outcomes 1. Security and storage of medical records. Lockable cupboards have been installed in the clinic areas. Medical records are also stored behind reception desks or in locked rooms if not required that day. This process is audited regularly to ensure standards are maintained. Electronic patient records are now in use in many areas with further roll out planned during 2016/ High numbers of cancelled appointments and high DNA rates. A review of the patient reminder service has been completed and this resulted in the division changing the frequency of reminders and the wording of the text messages that are sent to encourage patients to attend their appointments. Paediatric patients booked for elective procedures are also being called 2-3 days prior to their appointments to reduce the DNA rate, which allows us enough time to fill all slots. 3. Storage of medication. A full review of the storage of medication has been undertaken in collaboration with the Pharmacist. New drug fridges have been purchased and robust processes are in place to monitor their usage and safety. Improvements from Clinical audit, incidents, complaints and claims 1. Correct site surgical checklist: UDHM is considered as the lead in patient safety in the UK. It has developed and presented a Safer Site Surgical Checklist to ensure enhanced patient safety that is now widely adopted across the UK. 2. Review of weight limits for all dental chairs: Robust processes introduced to ensure that weight limits are not exceeded and all staff are fully aware of restrictions, following the collapse of a dental chair whilst a patient was receiving treatment. Top 3 risks Patient safety continues to be the top objective for UDHM. Incidents, complaints and claims are continuously monitored and managed by the Divisional Clinical Effectiveness Board and themes and learning shared widely amongst teams. 267

268 1. Access to General Anaesthetic lists, particularly for paediatric patients, is causing long waiting times for patients. Work is ongoing with the Anaesthetic Department to resolve this issue on a long term basis, whilst short term measures to manage this are undertaken. In addition, a shortage of trained nurses in the main MRI Theatres and a cap on nursing agency costs has also led to cancelled theatre lists. 2. Activity and subsequent income has been lower than forecast during 2015/16 leading to long waiting lists in some specialities. Recruitment of key personnel has now been achieved and waiting times expected to reduce. Additional activity is also being undertaken at Trafford General Hospital where possible and a number of mega-weeks are planned. 3. Age of the building and issues with asbestos management mean that any renovations are difficult and time consuming, but work on the 2 nd floor clinics has now commenced. Division s top 3 priorities for next year 2016/17 1. Purchase of equipment. Plans are in place to purchase 10k worth of equipment per month on an ongoing basis to ensure that sufficient stock and replacement of worn out equipment is maintained. 2. Recruitment of clinical staff. Active recruitment of staff to manage the demands of the service will continue. Ensuring that UDHM is a safe and attractive place to work will encourage applications from current trainees. 3. Agreement of local tariffs for treatment. To ensure adequate income for specialist procedures within the UDHM, tariffs will need to be reviewed and agreed. As a part of this work, a process of Service Line Reporting has commenced to identify treatments and services that improve patient experience and remain profitable. Trafford Hospitals Outcomes of last year s 3 top priorities 2015/16 1. Productivity and efficiency in Manchester Orthopaedic Centre. A 13 week engagement programme with Four Eye commenced in August 2015 with a detailed project plan in place.a scheduling tool was implemented to maximise scheduling opportunities based on individual consultants operating times. This resulted in an increase in cases scheduled each week. Weekly activity targets ( Magic Numbers ) were communicated and monitored against, through the weekly scheduling meeting. A new role was developed within pre-operative assessment services to oversee the pre-operative pathway for major cases e.g. joint replacement and hip arthroscopy. An extra nurse started on the ward between 7.00 and 9.00am to support ward nurses admitting patients in a timely manner. 268

269 An escort role was also introduced to reduce delays in transferring patients to and from theatre. These changes resulted in improvements in productivity and efficiency in our orthopaedic theatres. 2. Addressing the financial deficit and resolving outstanding clinical model issues. Robust plans were developed and these will continue to address the financial deficit in 2016/17, including Outpatient transformation, implementation of Urgent Care Centre Model 3 (Nurse led) and delivery of orthopaedic elective plans. Plans also include the development of a resilient team through recruitment and retention to deliver the financial plans. 3. Progressing the development of becoming a Centre of Excellence for elderly care and rehabilitation. Trafford Hospital is committed to becoming an Age Friendly Hospital and centre of excellence for frail elderly and rehabilitation care. Approval has been gained to appoint to a Nurse Consultant post for Older People and Frailty, the first in the hospital. It is anticipated the post holder will drive the older age agenda forwards. Wards 2, Complex Discharge and Ward 4, General Medicine successfully attained Gold Accreditations during 2015/16 and will be applying for the Quality Mark Elder Friendly Wards, a nationally approved quality improvement programme. The hospital committed to supporting John s Campaign and welcomes carers to stay with patients suffering from dementia, including an overnight stay. In recognition of the impact of hospital admission on patients, and possible social isolation of relatives/carers, the hospital undertook an open visiting pilot project on Ward 1, Stroke Unit. Outcomes included a reduction in falls, formal complaints and improved communication with families. As a result of the successful pilot, open visiting will be rolled out across all in-patient areas during 2016/17. 3 main Outcomes from the Divisional Quality Review The Quality Review Team reported that they generally had a very positive visit to Trafford Hospital. They noted that the welcome and the responsiveness of all groups of staff was impressive. Most of the teams remarked that for most of the areas, they would recommend the services at Trafford Hospitals to family and friends. The main concerns raised were as follows: 1. The World Health Organisation (WHO) checklist was not being used in Endoscopy. 2. Staffing levels were noted to be low in some areas due to vacancies and sickness absence. 3. Privacy in outpatient areas was recognised as a concern. Consultations can be overheard as the doors are of poor quality. 269

270 Responses to address the outcomes 1. The WHO checklist was implemented in Endoscopy with support from the Division of Specialist Medicine in October Compliance with the checklist is audited monthly and the results monitored by the Clinical Effectiveness Committee. Discussions are in progress to adapt the checklist to better suit the patient pathway in Trafford Endoscopy suite. 2. Nursing recruitment and retention action plans are in place and overseas recruitment is underway. 3. Staff are aware of the issues and take care to maintain confidentiality as much as possible. Music is also played in the outpatient areas to help to mask conversations. There are longer term plans in the Estates Strategy to refurbish the outpatient area. Improvements from Clinical audit, incidents, complaints and claims 1. A number of complaints were received in relation to the phlebotomy service. A Phlebotomy Service Action Plan was developed as a result which included a full service review, reconfiguration of teams, customer service training, improvements to signage and provision of better information for patients and GPs. Further work is in progress to address accessibility of the service for people of working age. 2. Following an incident, a clear pathway was produced for the management and transfer of patients with possible cervical spine injury following an in-patient fall. This pathway includes guidance on cervical spine immobilisation, log rolling and use of the scoop stretcher. The guidance also includes when to suspect a cervical spine injury and the key signs to aid recognition of a cervical spine injury. Top 3 risks Trafford Division has identified three key risks: 1. Sustainability of the Urgent Care Centre: If the Division is unable to provide adequate numbers of junior and middle grade doctors the viability of the Urgent Care Centre is at significant risk. Active recruitment into the vacant roles is in progress and the Division of Medicine and Community is trying to assist where there are gaps in the rota. 2. Electronic sign off of test results: The process for the electronic sign off of test results is currently being reviewed through a Task and Finish Group led by the Clinical Head of Division and overseen by the Divisional Clinical Effectiveness Committee. 3. Compliance with correct site surgery procedures: A Task & Finish Group has been established to undertake the development of local safety procedures for invasive procedures across the division over the next six months. This involves clinicians and frontline staff who undertake the invasive procedures. Division s top 3 priorities for next year 2016/17 1. Integration of services improvement in the delivery of services and reduction of waste. 270

271 2. Financial viability to meet financial targets and be a financially viable Division. 3. Further development towards becoming a Centre of Excellence for elderly care and rehabilitation Clinical and Scientific Services Outcomes of last year s 3 top priorities 2015/16 1. Patient Experience Data: All outpatient areas are now collecting patient experience data using various/multiple methods. There has been extensive work carried out by the teams to ensure data collection against the outpatient standards, and this is becoming embedded within departments. All inpatients are being offered the opportunity to answer the friends and family test which has received excellent results. In line with the Trust patient experience communication framework, directorates are beginning to display this information for patients and visitors using the Trust branded formats which has been well received. There is ongoing work to update CMFTV s within the Division to ensure up to date and relevant information is displayed. 2. Response to Cancer Survey: The Divisional Cancer Survey Action plan has been a standing agenda item on the Divisional Quality Board with directorates providing regular updates on progress. As a result of this work, we have seen big improvements to patient information provided in advance of tests/procedures. The radiology team have filmed a patient undergoing a CT, MR, Ultrasound and X-ray so that patients can view these before coming for their scans. The move to the new CRIS facility has had a big impact on patient experience and with pathways currently being developed; this facility will be able to provide further services in the coming year. Procedures that previously required an in-patient stay are being carried out as day cases including some liver biopsies. Patient satisfaction with this service is very high. The majority of the action plan is complete with the exception of the purchase of the additional MR scanner which is ongoing. 3. Improve patient information: Neurophysiology has produced a photographic walk through of the department for patients (in particular children and those with learning disabilities). Better signage and maps have been produced for a number of departments to better aid patients find their way around the hospital. The radiology team have launched their internal website with details of all tests carried out in the department, links to leaflets which can be printed for patients as well as waiting times and information on referring for tests. 271

272 Sections of this website will be available on the internet for public access in the near future. In collaboration with the Patient & Carer Forum, Critical Care have developed information leaflets for patients and relatives regarding delirium. 3 main outcomes from the Divisional Quality Review Overall the team found the majority of staff to be very helpful and welcoming and morale seemed to be very good. Staff acknowledged improvements that had been made since the last quality visit and were very positive about these. The team found good evidence of multi-disciplinary working and a culture of continuous improvement. Minor areas for improvement include: 1. Radiology waiting area, dark and dingy not a great patient environment. 2. Poor communication, training and support around end of life in Critical Care. 3. Pharmacy Outpatients struggling to meet 20 minute turnaround time. Responses to address the outcomes 1. Radiology waiting area received new flooring and new chair covers. The corridor leading to Radiology is currently being refurbished and the possibility of a staff photography/art competition is being discussed within the team. 2. The issues relating to comments from relatives regarding communication have been fed back to nursing and medical staff via a number of forums. Additional training has been provided particularly in relation to care after death. The daily core huddle has been updated to ensure that each patient receiving end of life care and their families are spoken to by the nurse in charge and consultant for the day to ensure their needs are being addressed. 3. The pharmacy team is working closely with the Lloyds team to review fluctuating clinic loads to ensure staff can be allocated to more busy periods. The use of the tracking screen for patients prescriptions has been welcomed by patients and reduced the number of enquiries/complaints regarding this. Improvements from Clinical audit, incidents, complaints and claims 1. Keepsafe Boxes in Critical Care - As a result of a number of complaints/ instances where patients personal items have gone missing, the department have introduced keepsafe boxes. These are at each bedside and are locked boxes which can house small items such as patients glasses, watches, dentures etc. 2. Updated prescription standards on Critical Care and monthly audits Following a complaint regarding a prescription error, the critical care team reviewed the prescribing standards for the units and updated them. These have since been reissued to staff and a zero tolerance approach introduced. 272

273 The Unit Pharmacist is also carrying out monthly retrospective audits against the prescription standards and feeding back to staff regarding any issues. 3. Improved Core Huddles on Critical Care End of life care/ communication. Following a number of complaints regarding communication during end of life care, the Critical Care team have updated their core huddle agenda to include a prompt for the Nurse in Charge and the Consultant of the day to ensure they have introduced themselves personally to family members. The Nurse in Charge and Consultant will also ask the family if they have any questions or concerns. 4. Changes to Ultrasound scan - Within the ultrasound room usual practice was for the screen to be switched on and in full view of the patient whilst the sonographer is checking for any problems. Unfortunately this particular patient was suffering a miscarriage and said they knew straight away that something was wrong from looking at the screen and this was very distressing. Sonographers are now leaving the screen switched off until they have checked whether everything is ok and only after that they are asking the patient if they wish to see the screen. 5. Update to Home Visit Policy for AHP s. Following an incident involving a patient who fell in their home, the Policy has been updated to state that patients should not be left unattended when there are two members of staff visiting a patient. One member of staff should always stay with the patient. Top 3 risks 1. Radiology reporting timescales and MR capacity. 2. MEAM medical device maintenance schedule 3. Resuscitation Service (Resuscitation Trolley Audits, defibrillators, Trustwide DNAR Audit) Division s top 3 priorities for next year 2016/17 1. Improvements to Staff Recognition processes: We currently receive compliments for staff via a number of channels and plan to streamline the process in which we recognise staff in order to improve staff satisfaction and morale. We aim to provide real-time feedback where possible and formally recognise outstanding practice. 2. Patient Experience Communication framework: In light of the Trustwide framework which has recently been established, the Division will be developing various work streams to ensure adherence to the framework. These include continued patient involvement events, improvements to staff forums and core huddle briefings, use of corporately branded information for patients such as the you said, we did posters and better use of the CMFTV s. 273

274 3. Continue to develop CRIS day case services to enhance the patient experience: Work is currently underway to develop the clinical pathways for patients requiring lung biopsy and renal angiography to support patient admission to CRIS as a day case rather than an in-patient. Saint Mary s Hospital Outcomes of last year s 3 top priorities 2015/16 1. Embedding the Equality, Diversity and Inclusion objectives in conjunction with the Quality Strategy and the Nursing and Midwifery strategy Use of quality bus to deliver key messages to staff using the values and behaviours framework is embedded. During Equality, Diversity and Inclusion Week the focus was on dress code and perceptions of discrimination. The Division has 14 equality advocates who have attended initial training. EDS evidence for the year demonstrates we are achieving all the standards. 2. Reducing short term sickness, maintaining good levels of staff retention and motivation through staff engagement and embedding the values and behaviours framework. Recruiting to turnover Managing sickness in line with policy, support for managers provided on managing sickness and absenteeism Student summer evaluation forum held Nursing and midwifery staffing being supported to undergo revalidation Values and behaviours framework incorporated into all work streams and disseminated at every opportunity Staff supported to attend frontline leadership course. 3. Service development: Improving quality the quality of services provided led by the Quality Improvement and Directorate management teams, engaging with staff to streamline pathways The Division has: Rolled out an appointment reminder service to help patients remember when their appointments are and to improve clinic usage. Worked with colleagues from radiology to align clinic appointments with ultrasound appointments where possible in both Obstetrics and Gynaecology to reduce the time patients have to spend in outpatients. Rolled out ipads to our community midwifery teams to enable them to access vital patient information whilst working in the community, helping them to provide more informed care. 274

275 3 main outcomes from the Divisional Quality Review 1. Demand and staffing 2. Safeguarding 3. NICE guidance and audit Responses to address the outcomes 1. Demand and staffing A workforce plan has been developed for gynaecology nursing An obstetric and neonatal strategy to manage capacity and demand has been endorsed by the executive team. 2. Safeguarding Compliance for level 3 safeguarding has continued to improve and is monitored monthly. A Divisional safeguarding work plan is in place. 3. NICE guidance and audit Improved engagement of clinical teams and good performance against the Divisional audit forward plan. Improvements from Clinical audit, incidents, complaints and claims 1. Improvements in VTE management in Gynaecology: Education package for all ward based staff on the use of anti-embolism stockings undertaken. Patientrack system is now being used to record VTE assessments to promote completion of accurate and timely VTE assessments and sharing of information between clinicians. It is anticipated this will lower the risks to patient safety associated with preventable VTE. 2. Reduction in stillbirths in Obstetrics: All cases are reviewed as part of the risk management process; research clinics and excellent bereavement service are in place. Education for staff is ongoing to increase detection of small gestational age (SGA) babies/saving Babies Lives in the North Of England (SaBINE). 3. Launch of wound care standards in Obstetrics and Gynaecology to reduce the risks of surgical site infections. 4. Audit, subsequent actions and re audit of pain management and provision of analgesia in post-operative neonates has demonstrated a marked improvement of pain management in NICU. 5. Improvements in compliance with Safe Surgical Check List (SSCL) both in and out of theatre settings. Top 3 risks 1. Midwifery and medical staffing and Obstetric capacity. There has been an increase in the numbers of women booking at Saint Mary s Hospital from 5,000 to 9,000 in the last six years. A further increase in 2015/16, along with an increase in the induction of labour rate, combined also with a delay in the ability to recruit midwives and medical staff. 2. Patient results in Gynaecology are not managed in a timely manner and this has led to some patients incurring delays in their treatment or a missed opportunity for treatment. 275

276 3. The lack of availability of junior medical staff on the Newborn Intensive Care Unit (NICU) and the post natal wards to meet increasing demand as a result of increasing birth rate and complexity of patients. Division s top 3 priorities for next year 2016/17 1. To complete and implement Local safety standards for interventional procedures(locssips) across the division and look at developing and implementing a model for improvement and engagement using human factors to help support prevention of never events. 2. Service development - continue to improve the quality of our services and effectively encourage stakeholder participation. 3. Commit to driving safe and effective efficiencies throughout the Division. Division of Specialist Medicine Outcomes of last year s 3 top priorities 2015/16 1. The Division has developed plans to address the shortfall of bed and workforce capacity across medical specialty services, in particular for Clinical Haematology and Cardiology patients. The clinical team have developed a business case, which was approved by the Trust Board in November 2015, to support the redesign and reconfiguration of the Bone Marrow Transplant Unit and Clinical Haematology Day Unit. Temporary PODs have been installed in the Haematology Unit to provide single room facilities for our patients in the interim to the main reconfiguration being commissioned over the next 12 months. For the Manchester Heart Centre, the redesign of Wards 3&4 to assist in managing access and capacity issues, have also been the focus for the approach through the Division to mitigate risks. 2. All areas engaged in the Shine project - Health Records improvement plan, identifying key touch points causing friction for frontline staff, resolving, improving access and content of notes. The development and implementation of the ICE electronic ordering system has improved the requesting process for diagnostic tests for our patients. 3. Work continues with all specialty teams across the MRI to deliver care to The Right Patient at the Right Time in the Right Bed, through The Perfect Week exercise and also by closer working with acute medicine to improve safe management of outlying medical patients within/out of the Division. Clinical teams have engaged in reviewing pathways of care that cross Division boundaries. 276

277 3 main outcomes from the Divisional Quality Review 1. The Division had very positive feedback from patients as part of the Quality Review, in particular commending staff for their flexibility and kindness to patients, sometimes in difficult circumstances such as short staffing and lack of bed capacity, and the impact of CPE outbreaks. Main areas for improvement related to addressing some concerns surrounding Safe Surgery Checklist with Cardiac Catheter Laboratory and Endoscopy. The consultants have led the actions here to address and improve these procedures to ensure that interventional procedures are safer. 2. The capacity risks relating to beds and workforce and some infrastructure were recognised, and as described above the Division has developed improvement plans and have approved investment to improve these areas significantly over 2016/ Some further improvement is required surrounding medication and health records storage and these are being addressed, led by Ward Managers and supported by the multi-disciplinary ward teams. Responses to address the outcomes 1. Safe Surgery Checklist fully implemented across the Division and assurance provided by monthly audit of compliance in Cardiac Surgery, Catheter Labs, Dermatology and Endoscopy, led by specialty matrons and respective consultant clinical leads. 2. A specialty cohort area has been developed on AM3 for managing haematology patients, to improve capacity and access to service, whilst the above improvements are being commissioned. 3. Focused improvement work regarding medication and health records storage implemented within the Division. Improvements from Clinical audit, incidents, complaints and claims 1. The overall themes emerging from complaints and incidents are highlighting that the main areas of risks are bed capacity, access and waiting times for patients, and workforce shortages in particular nursing staff. Improving information for patients related to specific services, including treatment effects and any potential adverse risks re medication are to be given to patients. 2. The implementation of the ICE system has also highlighted the need for a focus on review of wrong blood in tube incidents, which identified the need to increase monitoring by Ward Managers and Matrons. 3. Significant improvements have been enabled to reduce patient falls and pressure ulcer prevention through two nurse led campaigns called respectively Catch me if you can and Move and Groove. Top 3 risks 1. The risks presented by CPE have been significant and have remained a key of our improvement work to reduce risks of transmission between patients, and CPE acquisitions, particularly in at risk patient groups e.g. Bone Marrow Transplant patients 277

278 2. The impact of lack of bed capacity and nursing workforce shortfalls increase the Division s risk of failing to achieve financial and productivity targets, due to a lack of capacity in terms of beds and medical workforce in key speciality areas. 3. A third and connected key risk to the above relates to lack of access to services, leading to increased waiting time and a potential impact on reputation of Trust/Division/Directorate/Speciality. Division s top 3 priorities for next year 2016/17 1. Delivering Inpatient services across all our medical specialty services at local and tertiary level, safely and through the right sized bed and workforce levels. 2. Delivering Outpatients Transformation improvement projects within the Division. 3. Improving patient access to services and reducing waiting times. Division of Surgery Outcomes of last year s 3 top priorities 2015/16 1. Working towards developing single specialty wards (e.g. Vascular Surgery) and redeveloping the space vacated by ENT Outpatients in July Vascular and Head and Neck have moved into the ENT refurbished area. Much more detailed planning has taken place over the last twelve months utilising each specialities length of stay and comparing this against the Shelford Group average. This has allowed us to map numbers of beds required for each speciality against available ward areas. Changes have been recommended and we are in the process of planning additional ward/ speciality moves, which will start to take place from April Improving the recruitment and retention of nursing staff against the backdrop of national shortages. This remains a priority and is still an ongoing risk in 2016/ Improving the engagement of clinical staff in the business of the Division, especially the Clinical Effectiveness and Quality agenda. Directorate Clinical Effectiveness meetings are now in place, led by the clinical lead for each speciality. Top 3 areas of success 2015/16 1. The continued prevention of hospital acquired infections and improvements in processes for the management and control of infection - especially with regards to CPE, MRSA and C. Difficile infections. We have continued to use a cohorted ward for CPE patients and this has supported the reduction in CPE acquisitions for the divisions. Plans are being reviewed currently to reduce the number of available cohorted CPE beds within surgery and possibly share this facility with another division to ensure that it is used to its full capacity. 278

279 2. Opening of additional ward capacity to accommodate new services in the Division, providing a much more robust plan to move towards speciality specific wards such as the Vascular Ward and Head and Neck ward which is now fully established. 3. The introduction of the Structured Ward Round initiative within Urology led by a consultant, which has led to significant improvements in the quality of patient care as well as a safer approach to care. This will be rolled out to all surgical specialities during main outcomes from the Divisional Quality Review 1. Use of pathways not evident in any consistent way (sepsis, acute abdomen, appendicitis) throughout the Division. 2. There was a varied standard throughout the Division in relation to storage of patient records and patient confidentiality. 3. Associated decision-making and feedback to patients in the Emergency Surgical Trauma Unit receiving units, Surgical Admissions Lounge and Day Surgery Unit requires improvement. Responses to address the outcomes 1. Clinical Head of Division to take this issue up with clinical leads for each directorate and ensure compliance with the pathways through audit. A task and finish group, headed by the Clinical Head of Division, is to be set up to embed the use of the Acute Abdomen Pathway into routine non-elective surgical practice. Throughout the Division ERAS+ is progressing with procedure specific integrated care pathways, improved documentation and education of clinical staff. 2. Elective Treatment Centre (ETC) to mirror good practice identified on Ward 14 with regards to storage and security of notes (notes on ETC found to be left on nurses station where security was not effective). To ensure notes are securely stored in the OPD, OPD Matron and Operational Manager to audit and action. Quality Matron and Clinical Effectiveness Lead to perform regular divisional walk rounds and discuss the results of their findings and recommend actions at monthly senior nurse meeting and Directorate CE Meetings. 3. All medical and nursing staff to ensure that the plan of care for patients is documented and communicated with the patient accurately and in a timely manner. Ward Matrons and senior sisters to ensure staff are aware of the correct information required by patients. Medical staffing lead to ensure that changes to patient s plans are communicated with the patient and documented accordingly. Improvements from Clinical audit, incidents, complaints and claims 1. New Divisional Consultant Clinical Audit lead identified, with the establishment of a Divisional Audit Board. Each Directorate has identified a Deputy Audit Lead. 279

280 The Division has reinstated its Joint Divisional Audit Days, where the whole division attend generic sessions at the beginning of the Audit Day and then separate into individual directorates for speciality specific information, audit and review. 2. VTE Assessment - Develop and implement a Standard Operating Procedure setting out standards required for patients admitted as emergencies with blocked arteries. Reinforce with the surgical team, at Audit Day and juniors meetings, that thrombolysis should be prescribed promptly on admission. 3. Delay in Lysis Administration - Discuss the feasibility of introducing a treatment protocol that will enable thrombolysis to be commenced within the Radiology Department. Develop a protocol to escalate delays in transferring urgent patients to a ward environment whether due to a lack of beds or unavailability of trained staff. Additional training to be provided to the trained staff on the Vascular Ward to ensure that all are competent in the administration of thrombolysis. 4. Wound Care - Review arrangements for escalating concerns to the senior medical team. Develop and implement a wound management pathway for patients with complex wounds to include input from the specialist Tissue Viability Team and other essential stakeholders at the outset. Review the Terms of Reference of the MDT with a focus on ensuring appropriate management plans are agreed and implemented for patients with complex wounds, and that a consultant is assigned to co-ordinate and oversee ongoing care. This will be supported by the newly implemented Consultant Led Ward Rounds in each speciality. Complaints General Surgery - a complaint was received that related to poor communication from the General Surgery secretarial team in terms of answering the telephone and passing messages to the consultants, which included telephone manner/customer service. The root cause analysis investigation showed, these issues occurred when the secretaries were stretched due to annual leave and difficulties in prioritising workload. As a result of this complaint, the department have now implemented a buddy system whereby secretaries are split into formal pairs which mean that they do not take annual leave at the same time, providing cross cover for each other for typing and telephone duties. The secretaries also now have protected telephone time slots to allow them to fully dedicate themselves to providing more effective communication that will support an excellent customer service. Urology - there have been a number of complaints from patients regarding patient satisfaction during their in-patient stay. 280

281 As a result of these complaints, from 1 st April 2016, a consultant of the week rota has been implemented whereby there will be a dedicated consultant to cover the ward each week. This will provide improved communication, senior cover and continuity of care will in turn reduce delays in senior clinical review, planning care, and organisation of the discharge process. It is also hoped that this initiative will reduce overall patient s length of stay. Trauma & Orthopaedics - a complaint was received that related to a patient experiencing a two week delay for trauma surgery after a fall at work which resulted in a broken wrist. As a result, the Directorate Manager for Trauma and Orthopaedics is working very closely with colleagues at Trafford Hospital to ensure that patients are booked in for trauma surgery early post injury to reduce waiting times at the MRI. An action plan has been developed to improve the trauma service generally and a more robust system for managing peaks in trauma demand has been implemented. The Trauma and Orthopaedic service will also transfer to Trafford Hospital completely from April Top 3 risks 1. Finance - The Division has experienced specific challenges in 2015 to ensure that adequate revenue is identified and obtained to provide its services. It will be at risk if it does not identify and implement solutions to ensure that services are delivered within its budget whilst also ensuring that they are safe for our patients and of high quality. 2. Nursing and medical staff recruitment and retention. 3. Capacity Increased length of stay, trust wide capacity issues and outlying patients within the division creating a pressure and underperformance in the elective surgical programme. Division s top 3 priorities for next year 2016/17 1. Service expansion Bolton Vascular Service transfer, Renal Transplant Service expansion, supporting the Healthier Together Programme. 2. Creating Capacity - Reduction in overall patient LOS supported by the ERAS + programme, consultant of the week initiative and the completion of Speciality Based Wards project. 3. Focus on the recruitment and retention of nursing and medical staff against the backdrop of national shortages. 281

282 3.14 Data Assurance Processes and Information Governance Central Manchester University Hospitals NHS Foundation Trust submitted records during 2015/16 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 include: the patient s valid NHS number are: Admitted patient care 98.4% Accident & Emergency 87.6% Outpatients 98.7% the patient s valid General Practitioner Registration code are: Admitted patient care 99.7% Accident & Emergency 99.3% Outpatients 99.6% The overall Data Validity Score for all data items for all three datasets for the Trust was 97.4%, compared to a Greater Manchester average of 96.9% and a National average of 96.2%. Central Manchester University Hospitals NHS Foundation Trust Information Governance Assessment Report overall score for 2015/16 was 74% and was graded Satisfactory. All indicators achieved level 2 or above. The Trust is continuing to build on its information governance practices, ensuring that it has a full understanding of its systems and data flows, thereby identifying, managing and mitigating potential risks. Central Manchester University Hospitals NHS Foundation Trust will be taking the following actions to improve data quality: Data Assurance Group Action Plans will be introduced with the aim to improve NHS Number coverage and GP accuracy. Demographics Awareness sessions will be made available to key staff and the Data Quality team will continue to conduct regular audits of patient information completion, timeliness, and accuracy. Work will continue to assess the accuracy of HRGs and ensure any HRG errors are followed up and corrected in a timely manner. During the second quarter of 2015/2016, a comprehensive review was undertaken of ward processes with regard to the recording of Admissions, Transfers, and Discharges on Trust systems. Recommendations and actions reported to the Informatics Strategic Board will be followed, improving documentation and guidance, identification and provision of education, spot checks, and improved use of IT. NHS Number coverage will be improved through extending National Spine batch tracing against the Walk-In Centre patient records. Monitoring of GP correspondence coverage for A&E discharge notifications, outpatient attendance and discharge letters, and inpatient discharge summaries. 282

283 Central Manchester University Hospitals NHS Foundation Trust was not subject to the Payment by Results clinical coding audit during 2015/16 by the Audit Commission. Information Governance Information Governance is included in the Trust s corporate induction and annual mandatory training packages, ensuring that all staff are aware of the importance of confidentiality and security of information and how to handle and manage confidential, personal and sensitive information. Staff with specific information governance remits are also required to undertake further specialist training via the national Information Governance training tool. The Trust Information Governance group has divisional representation and this provides the framework for awareness and standardisation, as well as monitoring compliance and progress throughout the Trust. We are continuing to build on our information governance practices, ensuring that CMFT has a full understanding of its systems and data flows, thereby identifying, managing and mitigating potential risks. Commissioning for Quality and Innovation (CQUIN) Central Manchester University Hospitals NHS Foundation Trust income in 2015/16 was not conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework because the Trust opted to take up the Default Tariff option offered by NHS England. The default tariff did not carry the provision for Commissioning for Quality and Innovation funding and therefore Central Manchester University Hospitals NHS Foundation Trust was not eligible for Commissioning for Quality and Innovation conditional payments Our People Our people are the driving force behind what we deliver as a Trust for one another, our patients and our community. By supporting our people in becoming the best at what they do they will deliver the highest quality care and experience for our patients. The CMFT People Strategy is being developed with people across the organisation: staff, patients, students and trainees, and wider partners. The three-year strategy outlines how we are working together to create the right values culture so that all of our staff can succeed in delivering our vision and priorities. It sets out our commitment to and our priorities for leading and enabling our staff to succeed now and in the future. What follows is an overview of these priorities and some key highlights from 2015/

284 Anticipating and understanding how our workforce needs to change so that we have the skills and flexibility to continuously provide the highest quality of care. We have and will continue to work with partner organisations across the city to better understand how our workforce will change and develop in light of the changes to the way that health and social care will be delivered across the region from April. This means looking at new more flexible roles and identifying the skills, knowledge and experience they will need to deliver new models of care. A transformation of our Adult Community services is underway in line with the city strategy for Living Longer Living Better and delivery of care in integrated teams to a population of around 50,000. In partnership with the University of Bolton, the Trust has developed a noncommissioned nursing programme, in order to increase the supply of newly qualified nurses for CMFT. This will help the Trust address the medium to long term workforce supply needs. We will also continue to deliver our successful Return to Practice programme to enable nurses to return to the profession. Making sure that we have the best people in the right roles and with the rights skills Having the right staffing and skills levels optimises the contribution staff are able to make. We have developed workforce plans for all areas that are aligned to our hospital business plans and we have invested in an electronic rostering system that has been used by our nursing team to ensure that we have the right levels across all our wards. Our Electronic Rostering team won a prestigious annual award this year for putting patients at the heart of workforce planning. Attracting and recruiting new high calibre people whilst at the same time supporting the career development of our existing staff. We have introduced creative and modern ways to attract and recruit staff including developing our Proud to Care campaign which has been very successful in recruiting 480 Band 5 nurses both domestically as well as from Europe and India. We have started to introduce assessment and selection processes that embed our values and all new staff receive a copy of our values on their first day at work. This ensures any new recruits know what is expected of them and are able to contribute to shaping a compassionate care culture. We have recruited 13 new graduates onto our own graduate development programme following the success of our first cohort. We also support regional and national graduate development schemes. Central Manchester is a recognised apprenticeship training provider offering accredited level 2 and 3 programmes within health and social care, pharmacy and business administration. This year 190 apprentices are on programmes. Increasing access to apprentice positions across the Trust will be a priority over the next 12 months. 284

285 We are committed to providing outstanding employment opportunities for our local communities. In 2015/16 we offered 227 placements to people from our local communities and over 170 of them went on to become full time employees. We also operate two other access to work schemes focusing on young people with learning disabilities and young people leaving the care system as well as offering over 700 work experience opportunities a year. We know that we already have some of the best people working in our hospitals and so it is essential we ensure they have the support to develop and grow their careers. We have introduced a number of initiatives over the last year to support the retention of our talented workforce. Some examples of these initiatives are the development of a Nursing & Midwifery retention strategy, undertaking more structured exit interviews and questionnaires, providing education and training support and celebrating achievements. Further developing a workplace that encourages creativity, innovation and supports the health and wellbeing of our staff so we are better able to meet the needs of our patients. Further developing a high performing inclusive and values based culture has been a top priority for us this year. Almost 1,000 staff have in the last 12 months received training in Living our Values ensuring we further embed a strong patient and customer focus. Our CQC inspection has encouraged all of us to look at where we are clearly demonstrating our values and where we can make improvements that make a difference to patient and staff experience. We have strengthened our appraisal process so all staff are able to demonstrate how they live our values on a day to day basis and are supported by their managers to set clear goals and objectives aligned to the Trust s strategic priorities. This year in our staff survey 93% of staff said that they had received an appraisal in the last 12 months which is above the national average. We continue to invest in developing strong leadership and effective people management. Almost 500 staff have now completed a leadership and management programme and 250 of these are medical staff who are critical to leading our hospitals and shaping the future of care. This year we introduced the Foundation and Intermediate Leadership Programmes, designed and delivered by CMFT staff to support frontline and new managers. We have supported our staff to develop their skills in leading change and implementing quality improvements so that more people can work with our patients to improve outcomes. We have engaged in different ways with our staff to identify ways to support them and maintain their health and well-being. Our Occupational Health service provides confidential and impartial health advice to all staff and to line managers to protect and promote their health, safety and wellbeing at work. 285

286 This is done in a number of ways including offering fitness for work assessments, providing advice on rehabilitation and adjustments at work as well as immunisation and vaccination screening programmes. Our Staff Support Service provides support to individuals and teams on managing under pressure and maintaining healthy and effective team working. As well as providing training to promote psychological health and wellbeing. We ran a very successful influenza vaccine campaign in order to protect patients and staff. 72% of Health Care Workers that provide direct patient care were vaccinated compared to the national average of 47% Encouraging and developing our people to be more involved in making decisions that affect them and our patients and recognising and rewarding achievement that drives excellent patience experience and outcomes. Seeking the views of our staff is critical to understanding what challenges they face and how we can improve. As well as the annual national staff survey this year we introduced a quarterly electronic staff pulse check. This asks staff a range of questions particularly focussed on their view of CMFT as a place to receive care and to work. The pulse check has helped us gather the thoughts and ideas of staff more frequently and enabled us to respond more quickly. The results of the 2015 annual staff survey show that we are making real progress despite the challenges we have been facing. Staff are very proud to work here, they feel supported by their colleagues and would readily recommend our services as a place to receive care. Every year we recognise the great achievements of our staff who every day go that extra mile to deliver excellent patient care. This year, 430 staff nominated a colleague for a We re Proud of You award and over 200 staff attended a sponsored We re Proud of You gala event where their success was acknowledged by the Chairman and the Executive Directors. National Staff Survey responses 2015 In 2015, a random sample population of 850 CMFT staff were asked to complete the annual staff survey. Nationally the response rate decreased from 42% to 41%. The CMFT response rate decreased from 44% to 42%. The Trust response rate remained above the national average. Response Rate Trust National Average Trust National Average Trust Improvement or Deterioration 44% 42% 42% 41% CMFT achieved a response rate of 42% which is 2% lower than This was 1% above the national average of 41% 286

287 Indicator Outcome/s CMF T 2014/ 15 Staff Survey Key Finding 26 percentage of staff experiencing harassment, bullying or abuse from staff in the last 12 months. Staff reporting that they had experienced harassment bullying or abuse from staff increased by 4% and is now the same as the national average. CMFT 2015/16 National Average 2015/16 Highest Performing Trust (Acute and Community) 2015/16 20% 24% 24% 17% 37% Lowest Performing Trust (Acute and Community) 2015/16 Staff Survey Key Finding 21 - percentage of staff believing that the organisation provides equal opportunities for career progression or promotion Staff believe that they have access to these opportunities 87% 86% 87% 94% 70% Summary of performance Since 2014 there has been a statistically significant increase in staff recommending CMFT as a place to work or receive treatment; from 3.63 to This is ranked above the average for all Acute and Community Trusts which is When considering all 33 key findings, the Trust is now better than average for 17 out of the 32 indicators and below the average for 4 indicators. Since the 2014 staff survey there has been a statistically significant positive change to 4 key findings and there are no statistically significant negative changes in key findings. The table below details our best and worst scores when compared to other Acute and Community Trusts in England Top 4 Ranking Scores 2014 Trust Acute and Community Trusts KF29. Percentage of staff reporting errors, near misses or incidents Trust Acute and Community Trusts Trust Improvement or Deterioration 93 94% 90% Improvement by 1% witnessed in the last month KF8. Staff satisfaction with level of responsibility and involvement Improvement by 0.10 KF6. Percentage of staff reporting good communication between senior 32 39% 30% Improvement by 7% management and staff KF11. Percentage of staff appraised in last 12 months 84 93% 86% Improvement by 9% 287

288 Bottom 4 Ranking Scores 2013 Trust Acute and Community Trusts KF28. Percentage of staff witnessing potentially harmful errors, near misses or incidents in last month KF23. Percentage of staff experiencing physical violence from staff in last 12 months KF24. Percentage of staff / colleagues reporting most recent experience of violence KF20. Percentage of staff experiencing discrimination at work in last 12 months Trust 32% 34% 29% 4% 3% 2% 66% 50% 52% 10% 11% 10% Acute and Community Trusts Trust Improvement or Deterioration Deterioration by 2% Improvement by 1% Improvement by 16% Deterioration by 1% *Discussions with Picker, the organisation that co-ordinates the national annual Staff Survey, have highlighted that the data required to complete the Acute and Community Trusts is not currently produced. The reason for this is that the Acute and Community Trust group was created in 2015 and there are no computed figures for 2014 to compare against. NHS England are raising this issue directly with Monitor. Staff Engagement Score Over the last 12 months several initiatives have been rolled out in an attempt to address key staff concerns, such as survey confidentiality, as well as providing additional ways throughout the year for staff to feedback their opinions through a number of mechanisms including the staff survey, staff family and friends test and corporate and local staff engagement sessions. Many actions have been taken as a direct result of staff suggestions and this has led to the increase in our overall staff engagement score from 3.76 to 3.89 which is better than average for Acute and Community Trusts and in the top 20% for all Acute Trusts. Response Rate Trust 2014 national Average 2015 Trust 2015 national Average Trust Improvement or Deterioration Trust score increased by National average increased by

289 3.16 Glossary of Definitions AKI Term Bacteraemia Care provider Catheter Associated Urinary Tract Infection (CaUTI) Clinical Clostridium difficile Condition COPD Core Values CQUIN Dementia Emergency readmissions Falls Harm Improving quality programme (IQP) HSMR Length of stay (LOS) Monitor Mortality MRSA NCEPOD Never Events Definition Acute Kidney Injury is a rapid reduction in kidney function resulting in difficulties in clearing excess water, electrolytes and toxins. It is very common amongst patients admitted in hospital. The presence of bacteria in the blood. An organisation that cares for patients. Some examples of which are hospital, doctors, surgery or care home An infection believed to have been caused by a urinary catheter Relating to the care environment A type of infection. Symptoms of C. difficile infection range from mild to severe diarrhoea An illness or disease which a patient suffers from Chronic obstructive pulmonary disease. The name for a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease. A group of ideals which the Trust believes all staff should exhibit 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 specialised areas of care. Is a syndrome (a group of related symptoms) that is associated with an on-going decline of the brain and its abilities Unplanned readmissions that occur within 28 days after discharge from hospital. They may not be linked to the original reason for admission Unintentionally coming to rest on the ground, floor/lower level, includes fainting, epileptic fits and collapse or slip An unwanted outcome of care intended to treat a patient An approach taken to bring about quality improvement in our clinical areas using specific improvement tools Hospital Standardised Mortality Ratio. A system which compares expected mortality of patients to actual The amount of days that a patient spends in hospital Monitor was established in 2004 and authorises and regulates NHS Foundation Trusts. Monitor works to ensure that Foundation Trusts comply with the conditions they have signed up to and that they are well led and financially robust. Mortality relates to death. In health care mortality rates means death rate. Methicillin-resistant Staphylococcus aureus- is a bacterium that is found on the skin and in the nostrils of many healthy people without causing problems. However, for some people it can cause infection that is resistant to a number of widely used antibiotics National Confidential Enquiry into Patient Outcome and Death. Reviews the management of patients, by undertaking confidential surveys and research. These are largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented 289

290 Term NHS Professionals (NHSP) Patient safety incidents Pressure ulcer Patient reported outcome measures (PROMs) R Codes Root Cause Analysis (RCA) Safety thermometer SHMI Sunquest Integrated Clinical Environment (ICE) The Trust Urinary Catheter Venous thromboembolism (VTE) Vein Definition Specialist organisation within the NHS recruiting and supplying temporary doctors, nurses, and corporate staff Is any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS care sometimes known as bedsores or pressure sores, are a type of injury that affect areas of the skin and underlying tissue, caused when the affected area of skin is placed under too much pressure. They can range in severity: Grade One Discolouration of intact skin not affected by light finger pressure Grade Two Partial thickness skin loss or damage Grade Three Full thickness skin loss involving damage of subcutaneous tissue Grade Four Full thickness skin loss with extensive destruction and necrosis (dead tissue Tools which help us measure and understand the quality of the service we provide for specific surgical procedures. They involve patients completing two questionnaires at two different time points, to see if the procedure has made a difference to their health. R Codes are clinical codes used to record a patients signs & symptoms i.e. Chest Pain, Abdominal Pain etc. A systematic method of doing an investigation that looks beyond the people concerned to try and understand the underlying causes and environmental context in which the incident happened. 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 Standardised hospital mortality index. A system which compares expected mortality of patients to actual mortality (similar to HSMR). A system to request and report radiology and pathology investigations and to order a wide range of service referrals. Central Manchester University Hospitals NHS Foundation Trust. A Foundation Trust is part of the National Health Service in England and has to meet national targets and standards. NHS FoundationTrust status also gives the organisation greater freedom from central Government control and financial flexibility. A device which is placed into a patient s bladder for the purpose of draining urine A blood clot formed within a vein A blood vessel that carries blood towards the heart 290

291 Part Three: Other Information 3.17 Performance of the Trust against Selected Metrics The following information sets out the Trust s performance against 10 important indicators which have been selected in conjunction with the Governors, other key stakeholders and the Board of Directors. You will see that the information is presented to show results over three years and where possible we have provided results from other Trusts so that a comparison against performance is possible. Overall the results demonstrate year on year improvement and we will continue to focus our efforts to ensure even better results. We value the feedback from our patients which we continuously use to improve care and treatment. The results featured below in the areas of nutrition and hydration has seen a slight deterioration this year and therefore will be a feature of targeted improvement efforts. Patient Safety Measures Clinical Effectivene ss Improvement in VTE risk assessments carried out Reduction in hospital acquired grade 3 or 4 pressure ulcers Reduction in serious patient safety incidents resulting in actual harm (those graded at Level 4 or 5) Reduce hospital standardised mortality ratio (HSMR) Reduce Summary Hospital Mortality Indicator (SHMI) Data Source Trust Data Trust Data Trust Data Dr Foster Dr Foster 2014/ /16 Latest Available Benchmark Indicator Comments 96% 96% 95% DOH Data This year has seen a 68% decrease in grade 3/4 pressure ulcers The number of severe harm has remained at the same level as the previous year. Note: This includes a number of unconfirmed cases pending investigation Target is national Target is national 291

292 Percentage of patient deaths with palliative care coded at either diagnosis or specialty level Improve stroke care audit composite score Data Source Dr Foster National Audit Data 2014/ /16 Latest Available Benchmark none - Q4 (Calendar year Oct- Dec)-51.9 (Grade D) Q4 (Calend ar year July- Sept) 61.2 (grade c) - - Patient Increase 90.20% 90.49% 85% (local Experience overall target) Measures satisfaction expressed with pain management Increase 93.40% 92.85% 85% (local overall Locally target) satisfaction collected expressed with fluids and nutrition provided data via electronic tracker devices Increase overall satisfaction with the cleanliness of the ward or department 94.36% 94.90% - Indicator Comments 3.18 Performance of the Trust against national priorities and core standards Infection Control Reduction of the number of Clostridium Difficile cases (Intelligent Board) Clostridium Difficile Infection per 100,000 bed days in patients aged 2 or over Data Source 2014/ /16 Latest Available Benchmark Trust Data Indicator Comments 292

293 Cancer Waiting Times Referral To Treatment Urgent Care (Trust Total) Urgent Care (Trafford WIC - Mastercall) Reduction of the number of MRSA cases (Intelligent Board) Maximum waiting time of two weeks from urgent GP referral to first out-patient appointment for all urgent suspected cancer referrals Maximum 31 days from decision to treat to start of treatment extended to cover all cancer treatments Maximum 31 days from decision to treat to start of subsequent treatment Surgery Maximum 31 days from decision to treat to start of subsequent treatment Chemotherapy Maximum waiting time of 62 days from urgent referral to treatment for all cancers Maximum waiting time of 62 days from cancer screening programme 18 weeks maximum wait from patients not yet treated Maximum waiting time of 4 hours in A&E from arrival to admission, transfer or discharge Maximum waiting time of 4 hours in A&E from arrival to admission, transfer or discharge Data Source 2014/ /16 Trust Data 7* 5 0 Open Exeter Cancer Waiting Times system Open Exeter Cancer Waiting Times system Open Exeter Cancer Waiting Times system Open Exeter Cancer Waiting Times system Open Exeter Cancer Waiting Times system Open Exeter Cancer Waiting Times system Latest Available Benchmark Indicator Comments 94.9%* 95.4% 93% Measured Quarterly 97.5%* 97.3% 96% Measured Quarterly 96.9%* 96.0% 94% Measured Quarterly 100% 100% 98% Measured Quarterly 84.4%* 84.3% 85% Measured Quarterly 77.6%* 87.5% 90% Measured Quarterly UNIFY2 92.3%* 92.3% 92% Measured Monthly Sitrep 94% 94% 95% Measured Quarterly Sitrep 100% 100% 95% Measured Quarterly 293

294 Statements from Governors, Commissioners, local Healthwatch organisations and Overview and Scrutiny Committees 3.19 Feedback from Governors Governors in the Patient Experience Group focus on all aspects of the Trust s Quality Strategy, ensuring that providing the highest standard of care to our patients and their families remains a top priority at CMFT. A new Patient Experience Framework is being rolled out across the Trust, and this process will be complete by June The aim is to gather patient feedback, consultation outcomes and suggestions in a single place, so the information can be used to improve overall patient experience across CMFT with Governors actively participating in several Patient Experience Workshops in order to support CMFT in developing a new approach to patient experience. During 2015/16, Governors have made a significant contribution to reviewing and supporting a wide range of initiatives designed to improve key elements of the patient experience at CMFT. These included communication, food, response to complaints and discharge planning. For example, Governors heard about work being done by the Trust Transformation team to improve the experience of people attending outpatient appointments, especially around better communication and customer care. Related work is also being done to make the process of discharging in-patients run as smoothly as possible, including reducing waiting times at the pharmacy. In relation to clinical quality, Governors have been closely monitoring progress in meeting national Harm Free Care standards on preventing ulcers, falls and catheteracquired urinary tract infections. We gained positive assurance about CMFT s performance, which is above the national average. We also received updates on CMFT s programme to support patients reaching the end of their lives and their families. Priorities of Care for the Dying Person replaces the Liverpool Care Pathway, and is tailored to each individual s needs and wishes. An update on the new system for providing real-time responses to concerns and complaints from in-patients and their families demonstrated how it is delivering results. The Tell Us Today phone line, which offers a response by a senior nurse or manager within one hour, is being rolled out across all in-patient services. Trafford Hospital was an early pioneer, and initial figures showed that 36 phone calls were made but only three per cent of the concerns raised went on to become formal complaints. A Governor is also a member of the Trust s Complaint Scrutiny Group which reviews the Trust s complaints processes in order to enhance performance and further improve patient experiences. Governors were pleased to receive an update on improvements made to patient food provision, and to learn that all wards are actively monitoring areas such as food delivery and staff availability to assist patients to ensure performance is consistent. 294

295 Input by Governors to ward accreditations has proved valuable, and we were also happy to have the opportunity to speak to Care Quality Commission (CQC) inspectors about quality issues during the Trust s inspection in November The CQC rating of Good was very much welcomed by Governors and reflects very positively on CMFT s commitment to high quality standards. Peter Dodd, Chair of the Patient Experience Group 25th April 2016 Future focus on quality Each year, Governors play an important role in identifying and prioritising quality indicators and quality priorities. The Council of Governors took part in a Forward Planning Workshop in January 2016, which was a very interactive forum for Governors to share their feedback on the quality reporting process. It was a very positive and wide-ranging session with plenty of suggestions from Governors, which also contributed to the Trust s operational plan for 2016/17 as well as the Quality Report 2015/16, with Governor feedback being used to identify and prioritise quality priorities and an indicator (chosen by Governors). In a recent Governor Survey (March 2016), our Governors cited that they are encouraged to actively participate in our Quality Reporting process so as to identify a local quality indicator. (90% response rate). The Foundation Trust Membership team also ran a new forward planning survey in winter 2015/16. This was positively received, with around 340 members and the public participating. The views and suggestions received were captured as part of the Trust s Membership Forward Plan Report, which highlighted the key priorities of our members (public and staff) and the wider public and is considered by our Board of Directors and Governors as part of the Annual Forward Planning process. As part of this feedback, we also received a range of suggestions to improve CMFT s services further, which will be taken forwarded as part of the Trust s Quality and Transformation work programmes. David Edwards, Lead Governor 25th April

296 3.20 Commissioner s Statement Central Manchester Clinical Commissioning Group response to the CMFT Quality Account 2015/16 Central Manchester Clinical Commissioning Group would like to thank Central Manchester University Hospital NHS Foundation Trust (CMFT) for their detailed and comprehensive account of their hard work to improve the quality and safety of services for the patients and communities they serve. The Quality Account for 2015/16 reflects the national and local priorities of CMFT within the wider healthcare economy, and is reflective of the priorities that we as commissioners have identified for our local populations. We are pleased to note that CMFT has received a rating of Good overall following the Care Quality Inspection in the autumn; this puts the Trust in the top 10% of all acute Trusts in the country. We would like to commend the Child and Adolescent Mental Health Services teams who received a rating of Outstanding for their services to children and young people. The diligence and commitment of staff at CMFT is a credit to the Trust. We continue to be impressed to the Trust s dedication to education and professional development of its staff. We would particularly like to acknowledge CMFT s commitment to supporting and developing the clinical leaders of tomorrow through its leadership programmes. The success of CMFT s undergraduate Medical Education Programme which has been recognised by General Medical Councils for its teaching skills and resources has achieved a 99% pass rate and the Medical Education team has received four awards at the Medical Education conference regarding its ingenuity and commitment in the development and training of doctors. CMFT have welcomed the commissioner programme of quality and safety walkrounds. The quality and safety walk-round of Children s Hospital and the Maternity unit provided commissioners with the opportunity to speak with patients/families and staff at the Trust and to see at first hand the dedication of front line staff to deliver great care to their patients. The walk-round team were impressed with the leadership across the Children s Hospital and Maternity unit and the friendliness and openness of the staff. The parents and children who the team spoke to were impressed on the whole with the excellent standards of care in the areas that were visited. During 2015/16 we have been pleased to see the Trusts further development of its complaint processes, with a real focus and continued commitment to improving the timeliness of responding to complaints and scrutiny of complaints that have not been answered within the Trust established response periods. It is clearly evident that the Trust is committed to patient safety. We note that CMFT have committed to the Sign up to Safety Campaign and this this has made a significant impact on improvements within the Trust. We would like to commend the patient safety initiatives that have been undertaken this year, and highlight the following programmes: We highly commend the strategy developed and implemented by CMFT in relation to the management of Acute Kidney Injury (AKI). The improvements made have 296

297 resulted in 60 fewer AKI cases and 6 fewer deaths per month. CMFT have also won several local and national awards for its achievements in this area. Obstetrics is another area where patient safety initiatives have led to a reduced number of fetal death in utero. Outstanding progress has been made in relation to reducing pressure ulcers both in the acute and community setting. We acknowledge the innovative work undertaken by the Infection Prevention and Control/ Tissue Viability Team to support front line staff and raise public awareness of how to reduce the risk of pressure ulcer. Additionally we would congratulate CMFT s patient safety culture in relation to developing and promoting an incident reporting culture to improve learning and support improvements in patient safety and its openness when investigating incidents It is unfortunate that CMFT did not achieve their ambition to reduce the number of Never Events to zero in 2015/16. This remains a priority for the Trust. We would like to acknowledge their high level of openness and transparency in reporting these. The CCG will continue to work with the Trust to ensure that the serious incident and Never Event themes identified are addressed and the learning from these is implemented and embedded into the culture of the Trust. CMFT have always been at the forefront of engaging with patients, capturing real time patient experience data from every patient and using innovative approaches to make real change within the Trust based on this feedback. We are pleased to see that this remains a priority for the Trust in the coming year. CMFT has an extensive audit programme and the progression of this demonstrates the commitment to improving quality by front line staff of all disciplines. There has been a significant amount of work undertaken by the Trust with regard to improving end of life care and we have been pleased to note the publication of a three year end of life care strategy. Steering groups for end of life care have been reestablished with separate groups also set up to look at the needs of children and young people and adults. The Trust continues to develop clinical pathways to optimise end of life care CMFT have had the largest number of cases of Carbapenamase-producing Enterobacteriaceae (CPE) of any Trust. CPE is the name given to gut bacteria which have developed resistance to a group of antibiotics called carbapenems. Infections caused by CPE bacteria can usually still be treated with antibiotics. We would like to commend the work CMFT have undertaken in relation to CPE. The Trust has invested considerable resource in the identification and control of CPE. We would also like to acknowledge the pressures the management of CPE have placed on CMFT. We note that this has also been recognised by CQC. As commissioners, we have worked closely with CMFT over the course of 2015/16, meeting with the Trust regularly to review the organisations progress in implementing its quality improvement initiatives. We are committed to engaging with the Trust in an inclusive and innovative manor. We are very pleased with the level of engagement from the Trust and hope to continue to build on these relationships as we move forward into 2016/

298 The CCGs are not responsible for verifying data contained within the Quality Account; that is not part of these contractual or performance monitoring processes. Dr Mike Eeckelaers Chair of Central Manchester Clinical Commissioning Group 29th April

299 3.21 Feedback from the Health and Wellbeing Scrutiny Committees Manchester City Council Health Scrutiny Committee - Response to Central Manchester Foundation Trust Quality Accounts 2015/16 Dear Central Manchester University Hospitals NHS Foundation Trust, As Chair of the Health Scrutiny Committee I would like to thank you for the opportunity to comment on the Central Manchester Foundation Trust Draft Quality Accounts for 2015/16. Copies of the draft quality accounts were circulated to members of the Committee for consideration and comments received have been included below. We would like to submit the following commentary to be included within your final published version. The Committee noted that the statement from the Chief Executive and the Executive Medical Director sets a tone of directness and transparency in the Quality Accounts and that the statement identifies achievements around the issues of Mortality, Patient Safety and Harm Free Care and Medical Education. The Committee welcomes the continued commitment to improvement to the quality of services and care, and welcomed the described outcomes of the Trust Quality Reviews and the measures identified to address issues identified. The Committee further welcomes and supports the Board of Directors clinical objectives for 2016/17. The Committee welcomed the results of the recent Care Quality Inspection that rated the Trust as Good placing you in the top 10% of large acute Trusts in the country. The Committee were particularly pleased to note that the Child and Adolescent Mental Health Services received a rating of Outstanding. The Committee further welcomed the recognition that patients presenting with both physical and mental health problems do not always receive the correct support and acknowledge that a plan has been implemented to address this. The Committee fully support this initiative and look forward to learning of the outcomes of this work at a future meeting of the Committee. The members recognise that the Emergency Department experiences significant daily pressures upon the service, and the Trust highlights the increase in attendances, and the acuity and admission rates of attendees in the 2015/16 year. The Committee visited this Department during this municipal year and would once again like to extend its thanks for what was an insightful visit. The Committee were disappointed to note that the CQC had rated this area of activity as Requires Improvement, however note that a strategy has been identified to address this. The Committee noted that the reported percentage of patients readmitted to hospital within 28 days indicates that the numbers are below the expected figures for 2015/16, however it would assist the reader if comparative data against other local hospitals is provided. 299

300 The Committee noted that despite these pressures upon the Emergency Department improved services are reported at the Emergency Gynaecology Unit, the Paediatric Emergency Department and the Emergency Eye Department. The Committee found the detail of the Trust s divisional reports in Section 13 helpful and clear in setting out the priorities, outcomes, challenges and risks for each of CMFT s 9 divisions. The Committee also noted that a number of thematic priorities and challenges exist across more than one division, and that these remain consistent with last year s report. The Committee welcomes the reported work of the Transformation Team, and the report details the many areas of on-going work, such as the development of the patientrack system and integrated care. The Committee recognise and support the continued development of an integrated Health and Social Care model to improve the health outcomes for all the residents of Manchester. The Committee further noted the improvements reported in the documentation available in community settings, such as the information regarding pressure ulcers that have improved the standards of care within the community care setting. The Committee remain concerned about the impact of staffing across the Trust, a problem no means unique to the Trust, but highlighted by the CQC as a concern. The Committee therefore welcomes the significant work that has been put in to developing medical education standards for Junior Doctors, ensuring that staff are well developed and retained. The members further supported the development of the recording system, shared amongst a range of health professionals to develop care plans to prevent those patients identified as being at risk of being admitted to unscheduled or unplanned care. The Committee welcome the improvements described to reduce the number of incidents of Acute Kidney Injury and congratulate the team noting that they had been recognised nationally for this work. The Committee were disappointed that the Trust s priority around improving Medication Safety was not met, but are reassured that the Trust has a strong focus on implementing lessons learned. The Committee were also disappointed that the number of reported Never Events was 6 against the target of 0, however noted that none of these had resulted in serious harm and that measures have been implemented to address and monitor this situation. The Committee welcomes the continued work underway to improve End of Life Care, as highlighted in last year s comments also. The Committee welcomed the Trust s response to the CQC s reporting that more work needed to be done to improve the standard of care experienced by young people transitioning into adulthood. Overall the Quality Accounts are positive and reflect the successful operation of a large and complex organisation serving many thousands of patients in an efficient 300

301 and compassionate manner. Throughout the document numerous examples are provided that demonstrate that the organisation is committed to, and actively encourages and responds to feedback from patients, staff and carers across a range of services. Councillor Bev Craig, Chair of the Health Scrutiny Committee 12th May 2016 The Trafford Health Scrutiny Committee Dear Central Manchester University Hospitals NHS Foundation Trust, The Trafford Health Scrutiny Committee: welcomes John s campaign for dementia patients and the arrangement for carers to stay overnight at Trafford General Hospital. welcomes the appointment of a nurse consultant for older people and frailty. notes the launch of an outreach eye clinic at Altrincham General Hospital. is pleased to see the Orthopaedic Centre has increased cases. The transfer of trauma and orthopaedic service to Trafford General Hospital is particularly pleasing. has some concerns of the downgrading of the Urgent Care Centre, but acknowledge this will be scrutinised by the Joint Health Scrutiny Committee with Manchester. notes that CMFT have consulted with the Committee on changes to services ina timely manner. They have listened to the Committee s concerns and have acted where possible. When informed of the closure of Stretford Memorial Hospital, the Chair and Vice-chair of the Committee expressed concerns about the loss of the phlebotomy service which meant local people had to travel. CMFT listened to these concerns and were able to arrange the service from a local GP Practice. Another phlebotomy service has since commenced at another local clinic. Chris Gaffey, Democratic and Scrutiny Officer 12th May 2016 No comments on the draft Quality Report were received from Healthwatch Manchester or Healthwatch Trafford. 301

302 3.22 Statement of Directors Responsibilities in Respect of the Quality Report 2015/16 Introduction Monitor has published guidance for the external audit on Quality Reports for 2015/16. A detailed scope of work for NHS Foundation Trust auditors has been detailed in the guidance. The report from the external auditors on the content of the Quality Report will be included in the Annual Report and the report will highlight if anything has come to the attention of the auditor that leads them to believe that the content of the Quality Report has not been prepared in line with the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2015/16. The Trust is also required to obtain external assurance from its external auditor over at least two mandated indicators and incidents of severe harm included in its Quality Report. As a minimum, the outcome of this external exercise over the indicators should be a Governors report to Monitor and the Trust s Council of Governors. Auditors Report on the 2015/16 Performance Indicators The Auditors have undertaken testing of the systems to support the preparation of the mandated indicators included in the 2015/16 Quality Reports as follows: 18 weeks Referral to Treatment A&E four hour wait Friends and Family Test. Recognising the concerns raised in the previous year s quality accounts regarding RTT data quality, the Trust has implemented additional training solutions, improved performance reporting and formal sign off processes at period ends. The steps taken have been subject to internal audit reporting, which has provided the audit committee with the overall outcome of significant assurance. This programme of improvement and follow-through has been recognised by the external auditors despite the overall modified opinion for 2015/16. The recommendation is that ongoing assurance is provided by the internal audit programme set for 2016/17. In terms of the A&E indicator, the Trust recognises the limitation of scope barriers which has proved challenging for a complete audit a position highly prevalent across the NHS. But there are also qualitative improvements in administrative practice that can be made which will to stand up to future scrutiny. The internal audit programme will similarly be used as the vehicle to provide the assurance moving forward. Delegated Authority and Recommendation The Board of Directors at its meeting on 9th May 2016 delegated authority to the Audit Committee to sign off the Annual Report and accounts. Within the Annual Report, the Quality Report has been presented and the Audit Committee, on behalf of the Board, was asked to confirm that the requirements of the Quality Report have been complied with. 302

303 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 (Quality Report) for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual Quality Reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation trust boards should put in place to support the data quality for the preparation of the Quality Report. In preparing the Quality Report, directors are required to take steps to satisfy themselves that: The content of the Quality Report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2015/16 and supporting guidance; The content of the Quality Report is not inconsistent with internal and external sources of information including: o Board minutes and papers for the period April 2015 to May 2016 o Papers relating to Quality reported to the board over the period April 2015 to May 2016 o Feedback from commissioners o Feedback from governors o Feedback from a local Healthwatch organisation o Feedback from Overview and Scrutiny Committee o The Trust s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009 o The 2015 national patient survey o The 2015 national staff survey o The Head of Internal Audit s annual opinion over the Trust s control environment o The CQC Comprehensive Inspection Report The Quality Report presents a balanced picture of the NHS foundation trust s performance over the period covered; The performance information reported in the Quality Report is reliable and accurate; There are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice; The data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and The Quality Report has been prepared in accordance with Monitor s annual reporting guidance (which incorporates the Quality Accounts regulations) (published at as well as the standards to support data quality for the preparation of the Quality Report (available at The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report. 303

304 By order of the Board.. Steve Mycio OBE Chairman 26 th May Sir Michael Deegan CBE Chief Executive Officer 26 th May

305 Independent auditor s report to the Council of Governors of Central Manchester University Hospitals NHS Foundation Trust on the quality report We have been engaged by the Council of Governors of Central Manchester University Hospitals NHS Foundation Trust to perform an independent assurance engagement in respect of Central Manchester University Hospitals NHS Foundation Trust s quality report for the year ended 31 March 2016 (the Quality Report ) and certain performance indicators contained therein. This report, including the conclusion, has been prepared solely for the Council of Governors of Central Manchester University Hospitals NHS Foundation Trust as a body, to assist the Council of Governors in reporting Central Manchester University Hospitals 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 2016, 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 Central Manchester University Hospitals NHS Foundation Trust for our work or this report, except where terms are expressly agreed and with our prior consent in writing. Scope and subject matter The indicators for the year ended 31 March 2016 subject to limited assurance consist of the national priority indicators as mandated by Monitor: Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the reporting period; and, Percentage of patients who spent 4 hours or less in Accident & Emergency. We refer to these national priority indicators collectively as the indicators. Respective responsibilities of the directors and auditors 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 issued by Monitor. 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 ; the quality report is not consistent in all material respects with the sources specified in Monitor s Detailed requirements for quality reports 2015/16; 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 and the six dimensions of data quality set out in the Detailed guidance for external assurance on quality reports. 305

306 We read the quality report and consider whether it addresses the content requirements of the NHS Foundation Trust Annual Reporting Manual, and consider the implications for our report if we become aware of any material omissions. We read the other information contained in the quality report and consider whether it is materially inconsistent with: o board minutes for the period 1 April 2015 to 9 May 2016; o papers relating to quality reported to the board over the period 1 April 2014 to 9 May 2016; o feedback from Commissioners, dated 29 April 2016; o feedback from Governors, dated 25 April 2016; o feedback from Health and Wellbeing Scrutiny Committees, dated 12 May 2016; o the Trust s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated April 2016; o the national patient survey, dated May 2015; o the staff survey, dated 22 March 2016; and, o the Head of Internal Audit s annual opinion over the trust s control environment dated April 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. 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. 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; testing key management controls; limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation; comparing the content requirements of the NHS Foundation Trust Annual Reporting Manual to the categories reported in the quality report; and reading the documents. A limited assurance engagement is smaller 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. 306

307 Limitations Non-financial 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. The scope of our assurance work has not included governance over quality or nonmandated indicators which have been determined locally by Central Manchester University Hospitals NHS Foundation Trust. Basis for qualified conclusion 18 week referral to treatment indicator The annualised 18 week referral to treatment indicator is calculated as an average based on the percentage of incomplete pathways which are incomplete at each month end, where the patient has been waiting less than the 18 week target. We have tested a sample of 25 pathways which were listed as incomplete at a month end, selected on both a random and risk focussed basis from a total population of 523,797 pathways which were incomplete at a month end. In 15 cases, subsequent validation with the Trust identified that it was incorrect for the pathway to contribute to the indicator at a number of month ends. This is because pathways were started in error, or a pathway failed to be updated as closed following the first definitive treatment. Additionally, in 5 cases, we were unable to confirm the date of referral to supporting documentation. Our procedures included testing a risk based sample of items, and so the error rates identified from that sample cannot be directly extrapolated to the population as a whole. As a result of the issues identified, we have concluded that there are errors in the calculation of the maximum time of 18 weeks from point of referral to treatment in aggregate patients on an incomplete pathway indicator for the year ended 31 March We are unable to quantify the effect of these errors on the reported indicator. 307

308 A&E four-hour wait indicator The annualised Accident and Emergency (A&E) four-hour wait indicator is calculated as a percentage of the total number of unplanned attendances at A&E for which patients total time in A&E from arrival is four hours or less until discharge, transfer, or admission as an inpatient. We have tested a sample of 25 unplanned A&E attendances during the year. Our testing identified that the Trust does not retain a full audit trail for adjustments made following validation of apparent breaches. Complete documentation is not available to evidence the rationale for amending individual A&E attendance durations. As a result there is a limitation upon the scope of our procedures which means we are unable to complete our testing and are unable to determine whether the indicator has been prepared in accordance with the criteria for reporting A&E 4 hour waiting times. Qualified conclusion Based on the results of our procedures, except for the effects of the matters described in the Basis for qualified conclusion section above, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2016: 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 ; the quality report is not consistent in all material respects with the sources specified in Monitor s Detailed requirements for quality reports 2015/16; and the indicators in the quality report subject to limited assurance have not been reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual. Deloitte LLP Chartered Accountants Leeds 27 May

309 INDEPENDENT AUDITOR 'S REPORT TO THE BOARD OF GOVERNORS AND BOARD OF DIRECTORS OF CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Opinion on financial statements of Central Manchester University Hospitals NHS Foundation Trust In our opinion the financial statements: give a true and fair view of the state of the Group and Trust's affairs as at 31 March 2016 and of the Group's and Trust's income and expend iture for the year then ended; have been properly prepared in accordance with the accounting policies directed by Monitor - Independent Regulator of NHS Foundation Trusts; and have been prepared in accordance with the requirements of the National Health Service Act The financial statements comprise the Group and Trust Statements of Comprehensive Income, the Group and Trust Statements of Financial Position, the Group and Trust Statements of Changes in Equity, the Group and Trust Statements of Cash Flows, and the related notes 1 to 44. The financial reporting framework that has been applied in their preparation is applicable law and the accounting policies directed by Monitor - Independent Regulator of NHS Foundation Trusts. Certificate Going concern We certify that we have completed the audit of the accounts in accordance with the requirements of Chapter 5 of Part 2 of the National Health Service Act 2006 and the Code of Audit Practice. We have reviewed the Accounting Officer's statement' on page 19 that the Group is a going concern. We confirm that: we have concluded that the Accounting Officer's use of the going concern basis of accounting in the preparation of the financial statements is appropriate ; and we have not identified any material uncertainties that may cast significant doubt on the Group's ability to continue as a going concern. However, because not all future events or conditions can be predicted, this statement is not a guarantee as to the Group's ability to continue as a going concern. Independence Our assessment of risks of material misstatement We are required to comply with the Financial Reporting Council's Ethical Standards for Auditors and we confirm that we are independent of the group and we have fulfilled our other ethical responsibilities in accordance with those standards. We also confirm we have not provided any of the prohibited non-audit services referred to in those standards. The assessed risks of material misstatement described below are those that had the greatest effect on our audit strategy, the allocation of resources in the audit and directing the efforts of the engagement team. 309

310 Risk NHS revenue and provisions There are significant judgements in recognition of revenue from care of NHS service users and in provisioning for disputes with commissioners due to: the complexity of the Payment by Results regime, in particular in determining the level of overperformance and revenue to recognise; the judgemental nature of provisions for disputes, including in respect of outstanding under and overperformance income; and the risk of revenue not being recognised at fair value due to adjustments agreed in settling current year disputes and agreement of future year contracts. Details of the Group's income from activities of 820.0m is shown in note 2.1 to the financial statements. NHS debtors of 18.7m are shown in note 21 to the financial statements. Provision for impairment of receivables of 4.5m are shown in note 21 to the financial statement and includes nil in relation to commissioners and 1.8m with other NHS bodies. The Group earns revenue from a wide range of commissioners, increasing the complexity of agreeing a final year-end position. The majority of the Group's income comes from NHS England, NHS Central Manchester CCG, NHS North Manchester CCG, NHS Salford CCG, NHS Stockport CCG, NHS South Manchester CCG, NHS Tameside and Glossop CCG and NHS Trafford CCG, increasing the significance of associated judgements. The settlement of income with Clinical Commissioning Groups continues to present challenges, leading to potential for disputes and delays in the agreement of year end positions. Details of the Group Other Operating Income including any contractual settlements arising in the year are shown in note 2.1 to the financial statements. How the scope of our audit responded to the risk We evaluated the design and implementation of controls over recognition of Payment by Results income by walking through the process to invoice for baseline contracted activity and both under and overperformance. We performed detailed substantive testing on a sample basis of commissioner contracts and tested the recoverability of baseline contract income through the year. We also tested a sample of partially completed spells at the year-end for recoverability of overperformance income and adequacy of provision for underperformance through the year, and evaluated the results of the agreement of balances exercise. We challenged key judgements around specific areas of dispute and actual or potential challenge from commissioners and the rationale for the accounting treatments adopted. In doing so, we considered the historical accuracy of provisions for disputes and reviewed correspondence with commissioners. We performed detailed substantive testing of the judgement around the recognition in the current year of other operating income relating to contractual settlements. In doing so we considered the profile of costs to be incurred. 310

311 Risk Property valuations The Group holds land and property assets within Property, Plant and Equipment at a modern equivalent use valuation of 569.5m (2015: 553.1m). The valuations are by nature significant estimates which are based on specialist and management assumptions (including the selection of an alternative site, floor areas for a Modern Equivalent Asset, the basis for calculating build costs, treatment of value added tax in relation to assets held under PFI, and the remaining life of the assets) and which can be subject to material changes in value. As detailed in note 1.6 Critical Accounting Judgements and Key Sources of Estimation Uncertainty, the Group has reassessed a number of valuation assumptions in the current year, including the adoption of a modern equivalent asset valuation based on an alternate site. The net valuation movement on the Group's estate shown in note 10 Impairment of Assets is an impairment of 11.4m. How the scope of our audit responded to the risk We evaluated the design and implementation of controls over property valuations, and tested the accuracy of process adopted by the Group to update the valuation property on an alternative site basis using index and locality factors provided to the Group, adopt useful economic life recommended by the District Valuer, and identify assets that are impaired. We used Deloitte internal valuation specialists to review and challenge the appropriateness of the index and locality factor by benchmarking the revaluations performed against other organisations at 31 March 2016, and the approach adopted by the management to identify an alternate site. We challenged the Group's assumption that an.alternative, lower value, site could be used in calculating a Modern Equivalent Asset value by critically evaluating whether the alternative site would be viable given the scale of the Group's estate. We assessed the appropriateness of the use of existing floor areas the Group has used for the alternative site valuation in calculating a Modern Equivalent Asset valuation by considering the detailed justification of the uncertainty of the scope and scale of services that may arise as part of the Manchester devolution process. We reviewed the disclosures in notes 1.6 Critical Accounting Judgements and Key Sources of Estimation Uncertainty and Note 10 Impairment of Assets and evaluated whether these provide sufficient explanation of the basis of the valuation and the judgements made in preparing the valuation. We assessed whether the valuation and the accounting treatment of the revaluation gains and impairment were compliant with the relevant accounting standards, and in particular whether impairments should be recognised in the Income Statement or in Other Comprehensive Income. 311

312 Last year our report included one other risk which was not included in our report this year in relation to financial sustainability. The 2014/15 Audit Code of Practice for NHS Foundation Trusts included, but was not limited to, a requirement to report by exception in our audit on any matters that we identify that indicate the Trust had not made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. In November 2015, the National Audit Office issued guidance on the 'value for money' work that auditors are required to do. As part of our risk assessment process we identified financial resilience as a potential area that we may be required to report on by exception. We re-categorised this risk from being a significant risk for the financial statement audit to a value for money report by exception risk. The description of risks above should be read in conjunction with the significant issues considered by the Audit Committee discussed on page 119. These matters were addressed in the context of our audit of the financial statements as a whole, and in forming our opinion thereon, and we do not provide a separate opinion on these matters. Our application of 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 both in planning the scope of our audit work and in evaluating the results of our work. We determined materiality for the Group to be 7.7m (2014/15: 7.7m), which is below 1% of revenue and below 3% of equity (2014/15: 1% of revenue and below 3% of equity). Revenue was chosen as a benchmark as the Trust is a non-profit organisation, and revenue is a key measure of financial performance for users of the financial statements. We agreed with the Audit Committee that we would report to the Committee all audit differences in excess of 250,000 (2014/15: 153,000), as well as differences below that threshold that, in our view, warranted reporting on qualitative grounds. We also report to the Audit Committee on disclosure matters that we identified when assessing the overall presentation of the financial statements. 312

313 An overview of the scope of our audit Our group audit was seeped by obtaining an understanding of the Group and its environment, including group-wide controls, and assessing the risks of material misstatement at the Group level. The focus of our audit work was on the Trust, with work performed at the Trust's head offices in Manchester directly by the audit engagement team, led by the audit partner. We performed specified audit procedures on the Trust's subsidiary, Central Manchester University Hospitals NHS Foundation Trust Charity, where the extent of our testing was based on our assessment of the risks of material misstatement and the materiality of the charity to the Group. Our audit work for the Charity was executed at a materiality level of 3.8m (2014/15: 3.8m), which was lower than group materiality. At the Group level we also tested the consolidation process and carried out analytical procedures to confirm our conclusion that there were no significant risks of material misstatement of the aggregated financial information of the remaining components not subject to audit or audit of specified account balance.s. The audit team included integrated Deloitte specialists bringing specific skills and experience in property valuations and Information Technology systems. All testing was performed by the main audit engagement team, led by the audit partner. Opinion on other matters prescribed by the National Health Service Act 2006 Matters on which we are required to report by exception Annual Governance Statement, use of resources, and compilation of financial statements In our opinion: the part of the Directors' Remuneration Report to be audited has been properly prepared in accordance with the National Health Service Act 2006; and the information given in the Performance Report and the Accountability Report for the financial year for which the financial statements are prepared is consistent with the financial statements. Under the Code of Audit Practice, 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, is misleading, or is inconsistent with information of which we are aware from our audit; the NHS foundation trust has not made proper arrangements for securing economy, efficiency and effectiveness in its use of resources; or. proper practices have not been observed in the compilation of 313

314 the financial statements. We have nothing to report in respect of these matters. We are not required to consider, nor have we considered, whether the Annual Governance Statement addresses all risks and controls or that risks are satisfactorily addressed by internal controls. Our duty to read other information in the Annual Report Under International Standards on Auditing (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 ; 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 consider whether 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 and whether the annual report appropriately discloses those matters that we communicated to the audit committee which we consider should have been disclosed. We confirm that we have not identified any such inconsistencies or misleading statements. Respective responsibilities of the accounting officer and auditor As explained more fully in the Accounting Officer's Responsibilities Statement, the Accounting Officer is responsible for the preparation of the financial statements and for being satisfied that they give a true and fair view. Our responsibility is to audit and express an opinion on the financial statements in accordance with applicable law, the Code of Audit Practice and International Standards on Auditing (UK and Ireland). We also comply with International Standard on Quality Control 1 (UK and Ireland). Our audit methodology and tools aim to ensure that our quality control procedures are effective, understood and applied. Our quality controls and systems include our dedicated professional standards review team and independent partner reviews. This report is made solely to the Board of Governors and Board of Directors ("the Boards") of Central Manchester University Hospitals NHS Foundation Trust, as a body, in accordance with paragraph 4 of Schedule 10 of the National Health Service Act Our audit work has been undertaken so that we might state to the Boards 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 Boards as a body, for our audit work, for this report, or for the opinions we have formed. Scope of the audit of the financial statements 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 314

315 mis-statement, whether caused by fraud or error. This includes an assessment of: whether the accounting policies are appropriate to the Group's and the Trust's circumstances and have been consistently applied and adequately disclosed ; the reasonableness of significant accounting estimates made by the Accounting Officer; and the overall presentation of the financial statements. In addition, we read all the financial and non-financial 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. Paul Thomson, A C A (Senior Statutory Auditor) for and on behalf of Deloitte LLP Chartered Accountants and Statutory Auditor Leeds 27 May

316 5. Foreword to the accounts The Summary Financial Statements on the following pages are key extracts from the annual Accounts of the Trust for the financial year ending 31st March A full copy of the Accounts is available, free of charge, by written application to the Chief Accountant, Central Manchester University Hospitals NHS Foundation Trust, K Block, Wilmslow Park, 211 Hathersage Road, Manchester. M13 0JR. Alternatively, an electronic copy can be found at We certify that the Summary Financial Statements on pages are extracts from the annual Accounts of the Trust, as approved by the Board of Directors. Sir Michael Deegan CBE Chief Executive Officer 26th May 2016 Adrian Roberts Executive Director of Finance 26th May 2016 The following summary accounts disclose the Trust s financial position alongside that of the Group (which is the Trust and the CMFT Charity combined). The basis of arriving at the Group figures is as follows. The Charity s own Accounts figures are adjusted firstly for one difference in Accounting Policy (relating to expenditure accrued by the Charity for future commitments - such accruals are not permitted under the Trust s and the Group s Accounting Conventions). Secondly the Charity s Accounts figures are adjusted in respect of transactions and balances between the two bodies, which are eliminated on Consolidation. The resulting figures for Income and Expenditure; gains and losses; assets and liabilities; reserves; and cash flows, are then consolidated with those of the Trust, to form the Group Accounts. 316

317 6. Summary financial statements STATEMENT OF COMPREHENSIVE INCOME FOR THE PERIOD ENDED 31 MARCH / / / /15 Trust Group Trust Group NOTE Operating Income from Continuing Operations 2 967, ,627 1,054,698 1,058,577 Operating Expenses of Continuing Operations 3 (961,128) (965,703) (928,510) (933,573) Operating Surplus before finance costs 6,266 5, , ,004 Finance Costs: Finance Income Finance Expense - Financial Liabilities 9 (29,591) (29,591) (28,770) (28,770) Finance Expense - Unwinding of Discount on Provisions 28.2 (45) (45) (117) (117) Public Dividend Capital Dividends Payable (6,111) (6,111) (5,064) (5,064) Net Finance Costs (35,476) (34,830) (33,712) (33,019) (Deficit)/Surplus for the Year (29,210) (28,906) 92,476 91,985 Other Comprehensive Income Amounts that will not be reclassified subsequently to income: Revaluation Reserve Movements 9,944 9,944 4,812 4,812 Other Reserve Movements Amounts that will subsequently be reclassified to income and expenditure: Other Reserve Movements 0 (656) Total Comprehensive (Expense)/Income for the Period (19,266) (19,618) 97,288 97, /16 The reported deficit after impairments was 29.2m as a result of the reduction in the value of its non-current assets. The Trust made a trading deficit of 18.5m before taking any account of donated asset income, non-operating income, revaluation and impairments. 2014/15 The Trust made a technical surplus of 92.5m as a result of a net increase in the value of its property. This is a reversal of a previous impairment charged to the Statement of Comprehensive Income (SOCI). The Trust made an operating surplus of 4.1m after taking account of donated asset income, non-operating income, revaluation and impairments. 317

318 STATEMENT OF FINANCIAL POSITION AS AT 31 MARCH March 2016 Trust 31 March 2016 Group 31 March 2015 Trust 31 March 2015 Group NOTE Non-Current Assets Intangible Assets 11 2,822 2, Property, Plant and Equipment 12.1 & , , , ,239 Investments , ,959 Trade and Other Receivables 20 5,360 5,360 3,053 3,053 Total Non-Current Assets 629, , , ,246 Current Assets Inventories 19 10,178 10,178 10,616 10,616 Trade and Other Receivables 20 52,184 53,807 47,183 47,111 Non-Current Assets Held for Sale ,335 1,335 Cash and Cash Equivalents 23 73,628 76,417 91,967 96,076 Total Current Assets 136, , , ,138 Current Liabilities Trade and Other Payables 24.1 (100,472) (100,942) (101,627) (102,032) Borrowings 25 (10,549) (10,549) (10,855) (10,855) Provisions 28.1 (2,897) (2,897) (3,471) (3,471) Total Current Liabilities (113,918) (114,388) (115,953) (116,358) Total Assets less Current Liabilities 651, , , ,026 Non-Current Liabilities Trade and Other Payables 24.1 (1,513) (1,513) (4,321) (4,321) Borrowings 25 (371,439) (371,439) (363,788) (363,788) Provisions 28.1 (7,193) (7,193) (5,991) (5,991) Total Non-Current Liabilities (380,145) (380,145) (374,100) (374,100) Total Assets Employed 271, , , ,926 Financed by Taxpayers' and Others' Equity Public Dividend Capital 196, , , ,296 Revaluation Reserve 30 45,679 45,679 38,387 38,387 Income and Expenditure Reserve 29,574 29,574 56,132 56,132 Charitable Fund Reserves 0 17, ,110 Total Taxpayers' and Others' Equity 271, , , ,925

319 318 STATEMENT OF CHANGES IN EQUITY 2015/16 Public Revaluation Income and Total Charity Total Dividend Reserve Expenditure Reserve Capital Reserve Trust Trust Trust Trust Group Taxpayers' and Others' Equity at 1 April ,296 38,387 56, ,815 18, ,925 (Deficit)/Surplus for the Year 0 0 (29,210) (29,210) 304 (28,906) Transfer from Reval Reserve to I&E Reserve for impairments 0 (2,652) 2, arising from consumption of economic benefits Revaluations 0 9, , ,944 Public Dividend Capital (PDC) received Fair Value losses on Available-for-Sale Financial Investments (656) (656) Taxpayers' and Others' Equity at 31 March ,039 45,679 29, ,292 17, ,050 Public Revaluation Income and Total Charity Total 2014/15 Dividend Reserve Expenditure Reserve Capital Reserve Trust Trust Trust Trust Group Taxpayers' and Others' Equity at 1 April ,403 33,575 (36,344) 189,634 17, ,287 Surplus / (Deficit) for the Year ,476 92,476 (491) 91,985 Impairments and Reversals 0 4, , ,812 Public Dividend Capital Received 2, , ,893 Fair Value gains on Available-for-Sale Financial Investments Taxpayers' and Others' Equity at 31 March ,296 38,387 56, ,815 18, ,925 Descriptions of the nature and purpose of each of the above Reserves is given at Note 42 to these Accounts. Revaluations for the Trust relate to Property, Plant and Equipment, whereas those of the Charity relate to Investments.

320 STATEMENT OF CASH FLOWS FOR THE PERIOD ENDED 31 MARCH / / / /15 Trust Group Trust Group Cash Flows From Operating Activities Operating Surplus from Continuing Operations 6,266 5, , ,004 Operating Surplus 6,266 5, , ,004 Non-Cash Income and Expense Depreciation and Amortisation 25,656 25,662 25,018 25,023 Impairments 15,063 15,063 21,885 21,885 Reversals of Impairments (3,698) (3,698) (95,781) (95,781) Non-Cash Donations/Grants Credited to Income (633) (633) (12,189) (12,189) Increase in Trade and Other Receivables (7,560) (9,004) (5,496) (5,671) Decrease/(Increase) in Inventories (94) (94) (Decrease)/Increase in Trade and Other Payables (2,447) (2,633) 12,251 12,549 Increase in Provisions Net Cash Generated From Operations 33,668 31,702 72,270 71,214 Cash Flows From Investing Activities Interest Received Purchase of Financial Assets (239) (239) 0 0 Purchase of Intangible Assets (2,770) (2,770) (46) (46) Purchase of Property, Plant and Equipment (22,638) (22,638) (40,575) (40,702) Receipt of Cash Donations to Purchase Capital Assets 1,533 1, Net Cash Used In Investing Activities (23,843) (23,197) (40,382) (39,816) Cash Flows From Financing Activities Public Dividend Capital Received ,893 2,893 Loans Received 18,200 18,200 28,300 28,300 Loans Repaid (5,143) (5,143) (8,265) (8,265) Capital Element of Private Finance Initiative Obligations (5,712) (5,712) (5,752) (5,752) Interest Paid (1,843) (1,843) (1,508) (1,508) Interest Element of Private Finance Initiative Obligations (27,564) (27,564) (27,262) (27,262) Public Dividend Capital Dividend Paid (6,845) (6,845) (3,990) (3,990) Cash Flows Used In Other Financing Activities Net Cash Used In Financing Activities (28,164) (28,164) (15,427) (15,427) (Decrease) / Increase in Cash and Cash Equivalents (18,339) (19,659) 16,461 15,971 Cash and Cash Equivalents at Start of Financial Year (April 1st) 91,967 96,076 75,506 80,105 Cash and Cash Equivalents at End of Financial Year (March 31st) 73,628 76,417 91,967 96,

321 Auditor s Liability There is no specified clause in the Trust s or the Group s contract with the External Auditors, Deloitte LLP, which provides for any limitation of the Auditor s liability in either 2015/16 or 2014/15 321