Annual Report and Accounts to 17

Transcription

1 Annual Report and Accounts 2016 to 17 1

2 2

3 Sussex Community NHS Foundation Trust Annual Report and Accounts 2016 to 17 Presented to Parliament pursuant to Schedule 7 paragraph 25 (4) (a) of the National Health Service Act

4 2017 Sussex Community NHS Foundation Trust 4

5 You can view this report online at: For a summary version of this report please contact our communications and engagement team on or scftcommunications@nhs.net Please call : To get this report in large print or in Braille. For help to understand this report in a language that is not English. You can also contact us via social media: twitter.com/nhs_sct facebook.com/sussexcommunitynhs Sussex Community NHS Foundation Trust Brighton General Hospital, Elm Grove Brighton BN2 3EW 5

6 Table of Contents Introduction 4 Performance Report 14 Overview of our Trust 15 Key risks in delivery of our goals 20 Financial performance summary 24 Sustainability and financial performance 26 Our workforce 35 Accountability Report 36 Remuneration Report 37 Public/Stakeholder Engagement 45 Our People 47 NHS Improvement Single Oversight Framework 59 Directors Report and Annual Governance Statement 60 Statement of Accountable Officer s Responsibilities 81 Annual Governance Statement 82 Quality Report 93 Statement of Quality 94 Looking ahead 96 Looking back: a review of quality goals and performance 107 Mandatory statements 110 Other information 139 Annex 1- Statements from stakeholders 154 Annex 2 Statement of Director s responsibilities 161 Appendix 1 Local Clinical Audit 163 Appendix 2 Research activity 165 Glossary 190 6

7 Introduction Chair and Chief Executive s welcome Welcome to our annual report 2016/17, our first as a Foundation Trust. It is also our first as chief executive and interim chair, after our appointment in September 2016 and March 2017 respectively. We were both recruited from within and know the organisation, and the local health and care systems, well. It has been a year which has seen a lot of change and challenge for the National Health Service at a national and local level. There continues to be rising demand for services alongside pressure in funding for the health and care sector. We are also operating against the backdrop of a national shortage of nurses and other registered professionals. As a robust organisation we ve been well placed to continue our progress throughout this period. We are committed to working more effectively and efficiently, to continue to improve the quality of the services we provide with the resources we have. Quality focus Our highest priority is continuing the improvements we have delivered in the quality and safety of the services we provide our local communities. We have been improving continuously ever since our services were rated good by the Care Quality Commission in The improvements we ve made this year, particularly on pressure damage, falls, reducing avoidable infections, dementia care, dealing with complaints, and reducing our use of temporary agency staff, provide evidence our hard work is paying off. The plaudits for these successes must be shared across every part of the organisation from our brilliant clinical teams, to the sometimes overlooked support teams in areas like human resources, governance and facilities. We were delighted to win the Hospital Cleaning Award at this year s Health Business Awards in London which acknowledges the efforts of our facilities staff in recent years to raise standards in cleanliness and reduce the risk of hospital acquired infections. New improvement methodology To sustain our progress we have been working on a new programme to give our teams the structures, tools, and support needed to sustain this level of continuous improvement. We are involving colleagues across the organisation in the creation of this quality improvement methodology and are looking forward to seeing the first results of that work in 2017/18. 7

8 A leading NHS Trust on research in community settings We are extremely proud to be a leading NHS Trust on research in community settings and to be featured in the Top 10 NIHR league tables for NHS Trust research activities. Our research this year has contributed to improving care and treatment for progressive conditions. This encompasses adults with for example neurological conditions like Multiple Sclerosis or dementia, advanced cancer and Chronic Fatigue Syndrome. Our work with children involves those with complex disabilities and focuses both on the young person and their family. Innovative research activity over the last year has included research into end of life care, dental services, and development of a pirate themed app to support assessment of children with potential autism. Financial sustainability We are proud that these advances in the quality of our services have been delivered at the same time we have been focussed on improving our efficiency and financial performance. Our work on increasing the sustainability of our services meant that we were able to reduce costs last year by 10m. That means that despite 2016/17 being the toughest, financially, that we have ever faced our finances are in balance. That is a huge achievement, and it could not have been done without considerable hard work, and sacrifice, from our staff. Celebrating Successes In fact, our staff can be very proud of the many fantastic achievements over the last year which started as we became a NHS Foundation Trust on 1st April Becoming a foundation trust is never easy. All elements of the care we provide to our communities and the running of the Trust were reviewed, including the quality of our services, delivering sound financial performance, relationships with our partners, and our leadership and governance arrangements. Please do look at our year of achievement and success (page 5). It includes individual and team awards, new services being launched, and existing ones being revamped and improved. We recognise the contribution of all our staff who have risen to the challenge and who work hard to provide high quality services 24 hours a day, seven days a week. Our achievements are down to the hard work and dedication of each and every one of them. Workforce Recruiting the staff needed to deliver high quality services is one of the biggest challenges facing the NHS. 8

9 At Sussex Community this remains a huge priority for us. In the face of a national shortage of nurses, doctors and therapists we have been working hard to find solutions. We ve been looking at new ways of attracting people to our organisation which saw us launch our Because You Care recruitment campaign which helped us reach our target of hiring 90 new Health Care Assistants in February and March. This year we have also invested more than ever before in support to improve the health and wellbeing of our staff so that once we have recruited people we make sure they stay with us for the long-term. We re working to build a strong, stable, happy, and supported workforce which reduces our reliance on expensive temporary agency staff. We re making good progress not least in reducing our agency spend by a third since last summer. We hope you enjoy reading this annual report, and as always welcome your comments on our work. Siobhan Melia Chief Executive Stephen Lightfoot Chair 9

10 Our year of achievement and success Spring We become a Foundation Trust We were successful in achieving authorisation as an NHS Foundation Trust on 1 April To achieve authorisation all elements of the Trust s care and business were reviewed, including the quality of its services, financial performance, leadership and governance. We launch new school nursing text service ChatHealth is an award-winning school nurse messaging service for young people aged years. It s an easy way for young people to confidentially ask for help about a range of issues including mental health, or to make a face-to-face appointment with a school nurse. Over 800 young people had used the service in Brighton & Hove and West Sussex by April 2017 Caroline Lucas MP visits community services Caroline Lucas visited our Brighton based community, nursing and therapy teams who help support adults and children to live healthy, independent lives in their own homes; and support people to get back home after a period of hospital stay. Caroline said It was great to see these impressive local services in action. The work being done by these teams really is life-changing. Great Open Day at Lewes Victoria Hospital Over 100 people attended an Open Day at Lewes Victoria Hospital. Organised and supported by the Friends of Lewes Victoria Hospital and NHS staff, tours were given so people were able to see a range of NHS services provided at the hospital for the local community. Eight of our nurses receive prestigious Queen s Nurse award Eight of our nurses are awarded the prestigious title of Queen s Nurse from Chief Nursing Officer for England, Jane Cummings, at an event in London. The title of Queen s Nurse recognises continuing commitment to improving standards of care in the community and to learning and leadership. 10

11 Celebrating the Queen s 90 th Birthday Zachary Merton Hospital hosted a super 90 th birthday party for the Queen. Staff beautifully decorated and prepared the dining room and visitors helped to decorate the wards. The team wrote to the Queen and in December the Queen wrote back and said: "I send you my grateful thanks for the kind words you have sent to me on the occasion of my ninetieth birthday. Hearing the patient s story Parents came to our April Board meeting to tell us about the support and care their daughter had received from Seaside View Child Development Centre including physiotherapy, speech and language therapy, occupational therapy and community consultant services. They praised the services she had received and said that an early diagnosis had been key to her making the progress that she has made to date. Summer We launch new Diabetes Care for You service Our new community diabetes service is launched and available to people aged 18+ who live in Brighton & Hove and the High Weald, Lewes and Havens area of East Sussex. This consultant-led service, available for adults living with Type 1 and Type 2 diabetes, helps people to live well by offering advice and support to manage diabetes and meet personalised goals. Emotional and psychological care is available to support selfmanagement and improve wellbeing. Services for children and young people with special educational needs receive praise from Her Majesty s Inspector Ofsted and the Care Quality Commission published a report following new inspections of local areas services for children and young people with special educational needs and/or disabilities (SEND) in Brighton & Hove. The report gives high praise to services provided by the City Council and SCFT. It highlights effective close working with parents, children and young people, local children s groups, other NHS organisations and schools to provide better outcomes and improve the lives of children and young people. 11

12 Grand opening of new X-ray and Ultrasound at Bognor Regis War Memorial Hospital New state-of-the-art digital X-ray equipment is unveiled and is improving the reliability, speed and quality of diagnostic imaging. This was purchased thanks to a generous donation made by the Benjamin family who used to live in Bognor Regis. A new Ultrasound facility including new scanner and examination couch was purchased by the Friends of Bognor Regis War Memorial Hospital, with donations received from local people. Fifty staff awarded Care Certificate at special ceremony Congratulations to fifty healthcare support workers who become the latest to achieve the Care Certificate an assessment which demonstrates their competency and skill in providing safe, high quality care. Staff have to meet each of the 15 Care Certificate standards, including caring with privacy and dignity, awareness of mental health (including dementia and learning difficulties), safeguarding and infection control. Nurse training furthering careers We provide a range of student placements, development for staff at Bands 1 to 4 and university funding for staff to enter children s and adults nursing or to further their careers. Students and our staff can be assured of a range of learning opportunities and support from our qualified professionals. Karen (in the picture) trains and becomes a Health Visitor. Karen said Without the Trust s support there is no way I would have been able to progress my career to this extent. Brighton & Hove is best for breastfeeding for the second year Our breastfeeding team in the city has been named the top place in England for mums exclusively breastfeeding their very young babies for the second year running. Our health visitors, children s centre staff, nursery nurses, early year s educators and peer supporters offer a wide range of support to mums who want to start and continue breastfeeding their babies. Hearing the patient s story At the July Board meeting, JS spoke of his and his wife s experiences of using community services, both as inpatients at community hospitals and at home. He said that his wife had undergone a second hip replacement and had been scheduled to spend some preoperative time at Uckfield Hospital. He said that due to miscommunication between her GP and the hospital, his wife had not been admitted to Uckfield as planned and her operation had to be delayed. 12

13 He said that they had experienced different levels of care at two community hospitals and at home some poor and some excellent, and added that his experience of the Trust s PALS team had been excellent. Our Chief Nurse thanked JS for sharing his experiences and that patient feedback was invaluable in helping us to drive improvement where it is required. Autumn Expansion of Time to Talk service in West Sussex Our West Sussex Improving Access to Psychological Therapies (IAPT) service, known locally as Time to Talk, has been approved as one of the first 20 IAPT early implementer sites in England to expand its support to people living with long-term health conditions. In March 2017 we launched a new online self-referrals form as some clients find it difficult to make initial contact by phone and prefer to seek help and advice online. We win Finance Team of the Year award We win Finance Team of the Year at the Kent, Surrey and Sussex HFMA Branch Awards held. Our Finance Team won the award for their work in supporting frontline staff and managers across the Trust in continuing to provide excellent quality care and their role in supporting the Trust to achieve Foundation Trust status on 1 st April New Hospital@Home service for patients in Brighton & Hove We developed a Hospital at Home service, working in partnership with Brighton and Sussex University Hospitals NHS Trust, who provide services out of Royal Sussex County Hospital. This service delivers more complex care to patients in their own homes and frees up capacity, so the hospital can care for people with the greatest need for a hospital bed. Before, these people would have had a hospital stay, but many are now supported by our nursing and therapy staff at home, helping get many more people get out of hospital and back home sooner. Sussex Rehabilitation Centre working together with Albion in the Community Our Sussex Rehabilitation Centre which provides prosthetics to people who have lost a limb, have has been working closely with Albion in the Community over the past year to promote sporting activities which support rehabilitation. A new amputee football team was established, Brighton & Hove Albion Amputee FC, and they joined the England Amputee Football Association National League. The team played 13

14 their first game at the Amex Stadium against Arsenal in September. The enthusiasm and commitment shown by the players was inspiring. Innovative new service to improve end of life care launches Known as echo (end of life care hub for Coastal West Sussex), this new service aims to improve the coordination and delivery of end of life care for patients by linking key service providers together with a 24/7 telephone coordination hub. Staffed by trained nurses, echo acts as a point of contact for patients, carers, family members and healthcare professionals. echo nurses provide advice and support, refer or signpost to other services and mobilise rapid response teams. We get OUTSTANDING result for Stage 2 UNICEF Baby Friendly accreditation Our Healthy Child Programme in West Sussex received an outstanding result for Stage 2 Baby Friendly accreditation by UNICEF. Our Health Visiting and Infant Feeding Teams underwent a rigorous assessment process to provide assurance that they deliver the very highest standards of care. Stage 2 measures the level of knowledge and skills of our staff that provide breastfeeding support and care for pregnant women, mothers and babies. Hospital Cleaning Award win We won the Hospital Cleaning Award at the Health Business Awards in London. Patients expect hospitals to be clean. This award acknowledges the efforts made by our facilities staff in recent years to raise standards in cleanliness and thereby reduce the risk of hospital acquired infections. Hearing the patient story At the October Board meeting, ST spoke of her experience as a patient of the Trust s multiple sclerosis (MS) service in Worthing over the past 8 years. She said that she had been allocated a nominated specialist MS nurse for her care, who provided holistic support, as it had been proven that MS sufferers experienced better outcomes if they were supported holistically. She said that her nominated nurse had been a great source of help and guidance for her over the years. Winter We win two contracts to continue providing children s services We are awarded two contracts to provide the new 0-19 Public Health Community Nursing Services for families in Brighton & Hove and West Sussex. 14

15 Both contracts will create a more integrated service, bringing together health visiting, school nurses, and early help and prevention services into a single model of care. New and expanded Clinical Assessment Unit and new Piper Ward opens at Crawley Hospital A new and expanded Clinical Assessment Unit (CAU) and a new bedded unit named Piper Ward opens at Crawley Hospital. This is part of NHS Crawley Clinical Commissioning Group s plan to transform urgent care in Crawley. Medicines Optimisation in Care Homes service delivering effective outcomes This service, launched in July 2016, is working closely with 155 local care homes, GPs, patients and their carers to review prescribed medications to provide better health outcomes, avoid unnecessary admissions to hospital and overprescribing and wastage. The service ensures people living in care homes now receive an annual review of their medications. The service also provides education and training to care home staff. Staff Achievement Awards Over 200 members of staff came together to celebrate achievements across the Trust. Ten awards were presented to both individual and team winners. 65 staff were recognised for long NHS service of 20, 30, 40 and 50 years. At the ceremony more than 60 healthcare support workers and therapy technicians were also presented with their Care Certificate award. Connect with Dementia Youth Volunteers Introduced Our Voluntary and Community Development Team launch their first group of Connect with Dementia Youth Volunteers at Crawley Hospital and Zachary Merton Hospital in Rustington. Up to 40% of patients at our inpatient wards may live with dementia. Volunteers are ideally placed to try and support them by offering their time to help patients get involved in social activities, chat and most importantly, provide company. This can reduce some of the boredom that can be experienced in hospital and improves patient experience. It also enables youth volunteers to learn new skills. Next generation given the chance to become future Paralympians with new sports prostheses Children who have either been born without a limb or who have lost a limb have begun to receive new running and swimming blades from the NHS, in a move by the government to help a future generation of young people get active and even become the next Paralympians. 15

16 The introduction of children s sports prostheses on the NHS follows the creation of a 1.5 million fund by the Department of Health to help children run, swim and play sport using specialised sports prostheses. Our Sussex Rehabilitation Centre, based at Brighton General Hospital, fitted Ben, aged 13 from Brighton, with a new running blade to enable him to play football and run. He has now set his sights on the Paralympics. We're awarded the contract to continue delivering Oral Health Promotion Service in Brighton & Hove This service provides oral health promotion services covering good cleaning technique and we deliver demonstrations across a number of community venues across the city. Poor oral health isn t just bad for our mouths but can lead to a number of illnesses and diseases. Our aim is to help people care for their teeth, prevent tooth decay and avoid the need for further treatment. Kent, Surrey and Sussex Award Finalists We were shortlisted for the following four awards: Team Outstanding Achievement Clinical Practice for our Diabetes Care for You service; Inclusive Leader for Ellie Elkins, Infant Feeding Team Milk!; Excellence in Out of Hospital Call for OneCall Coastal and Enhancing Innovation through Collaboration for dementia work led by Lucy Frost. HSJ Patient Safety Award Finalist We ve been nominated for a Health Service Journal Patient Safety Award 2017 for our success in reducing pressure damage in local communities. In 2015/16 we reduced the number of pressure damage incidents in our organisation by 49% by increasing the number of risk assessments we undertake with patients and ensuring that all at-risk patients have an individual prevention plan. 16

17 Performance report 17

18 Overview of our Trust The purpose of the Overview is to give the user a short summary that provides them with sufficient information to understand the organisation, its purpose, the key risks to the achievement of its objectives and how it has performed during the year. Sussex Community NHS Foundation Trust was successful in achieving authorisation as an NHS foundation Trust on 1 April 2016, following a rigorous assessment of all elements of the Trust s care and business including the quality of its services, its financial performance, leadership and governance. As a Foundation Trust we are accountable to Parliament and regulated by NHS Improvement. We are still part of the NHS and must meet national standards and targets but we have more financial freedom to retain surpluses and choose how we reinvest this money. Our governors and members ensure that we are accountable and listen to the needs and views of our patients. The Trust is a public benefit corporation and its principal purpose is the provision of goods and services for the purposes of the health service in England. Before becoming a Foundation Trust the organisation was known as Sussex Community NHS Trust, which was established in October 2010 by integrating West Sussex Health and South Downs Health NHS Trust. We are the main provider of NHS community health and care services across West Sussex, Brighton & Hove and the High Weald Lewes Havens area of East Sussex, covering a population of around 1.3 million. We provide a wide range of medical, nursing and therapeutic care to over 9,000 people a day. Our expert teams help people plan, manage and adapt to changes in their health and care, to keep them in their own homes for longer, to prevent avoidable admissions to hospital and to minimise hospital stay. The quality of our care has been rated by the Care Quality Commission (CQC) as Good, and outstanding in parts of our end of life care services. What we do From our health visitors supporting new-born babies to our community practitioners (nurses and therapists) caring for the frail elderly and people nearing the end of their life, we look after some of the most vulnerable people in our communities. Our aim across all our services is to give people the certainty that when they need us, wherever they are, we will meet their needs with services of a high quality that are safe, effective and compassionate, which are provided with respect. We provide: 18

19 Community rehabilitation and support for people with complex health needs and long-term conditions or people needing end of life care. Community rapid response to assess and care for patients with urgent care needs, helping to keep them out of hospital. Intermediate care, offering short-term recovery and rehabilitation, keeping patients out of hospital where we can, or helping them to leave hospital when that is in the patient s best interest. Integrated discharge, working with patients, carers and hospital staff, to help a patient return home from a hospital stay as soon as possible. Health promotion, supporting people to improve health and wellbeing, for example through our prevention assessment teams. Coordinated and flexible service for families and children through our health visitors, for example, our breastfeeding support teams and our care for children with complex health needs. How we do it With quality as our top priority, we care for most people in their own homes or as close to home as possible including at our community hospitals, or in our bases at clinics and health centres. We put the people we care for at the centre of everything we do, wrap care around them and work closely with GPs, hospital trusts, local authority social care partners, voluntary organisations, other providers and commissioners to ensure people get the support they need. In total, we employ 4,835 people (including both full-time and part-time staff). We employ doctors, dentists, nurses and therapists, supported by experts in areas such as infection control, medicines management, information technology (IT), human resources (HR), service experience and finance. Many of our staff work in multidisciplinary and multi-agency teams combining a range of specialisms and backgrounds and linking closely with our health and social care partners to offer integrated, seamless services to our patients. Our vision Our vision is of a health and care system that has excellent care at the heart of the community. To move us in this direction, the Trust Board has set three strategic goals which explain what we need to do to achieve our vision: We will provide excellent care every time to reinforce wellbeing and independence. 19

20 Working with our partners we will personalise services for the individual. We will be a strong sustainable business, grounded in our communities and led by excellent staff. To guide our work, as we seek to achieve our goals, we will remain true to our core values: compassionate care caring for people in ways we would want for our loved ones working together as a team forging strong links with the people we care for, the wider public and our health and care partners, so we can rise to the challenges we face together. achieving ambitions for our users, for our staff, for our teams, for our organisation. delivering excellence because the people we care for and our partners deserve nothing less. The future Communities of Practice Communities of Practice is the name we give to the vision of how our organisation will work in the future. It is about creating a better way of working so that we can focus on the most important thing the individual needs of each patient. The aim is deliver person-centred coordinated care by asking the people we serve what matters to you,rather than what s the matter with you. If we are successful then we will bring together our own teams, and those from our partner organisations, to deliver services that are built around the needs of the patient. Much of this is already happening already across the Trust. We need your help to build on that experience and expertise and make sure we create new ways of working which are better for all who use our services and to make it easier and more efficient for us to do our jobs. They will ensure timely, standard and individualised referral to the right service first time through a single assessment process and onwards transmission to the CoP team ensuring high quality assessment, with reduced duplication. Communities of Practice will be multi-agency and multidisciplinary. They will bring together health, care and third sector professionals, including GPs, acute hospital colleagues, mental health and social care, to provide the right personalised care for each person. They will be based around communities which means a much more localised approach than we might be used to, and people will receive the care they need, as close to home as possible. Our partnerships We work with a range of different people and partner organisations to offer the right care, in the right place, at the right time, provided by the right professional. As part of our 20

21 strategy to deliver communities of practice, we are working together in more partnerships to deliver our strategic goals, to personalise care and achieve better health outcomes. Foremost, of course, are the people who use our services, their families and/or carers. A new approach to sustainability and transformation We continue to be committed to the development of a new approach to health and care services in our region through our local Sustainability and Transformation Partnership (STP). The Trust is fully engaged in the key STP governance and planning to ensure that our plans address the scale of challenges we collectively face as a health system over the coming years. The Sussex and East Surrey STP aims to make practical improvements such as making it easier to see a GP, speeding up the diagnosis of cancer and offering help faster to people with mental health illnesses. The STP also aims to encourage the public to take more responsibility for their own health and wellbeing. The STP brings together all organisations involved in delivering health and care services and represents a real shift in the way that the NHS works, with organisations collaborating to respond to the challenges facing local services and communities. No final decisions have been made about any services the Trust is responsible for and will not be made without our patients and public being given the opportunity to engage and voice their views. Clinical Commissioning Groups Every General Practice in England is part of a Clinical Commissioning Group (CCG). CCGs commission (plan and buy) the majority of health services, including emergency care, elective hospital care, maternity services, and community and mental health services for patients. There are five CCGs that commission care from SCFT, as set out in table 1 below. Table 1: CCGs that commission care from SCFT CCG Brighton & Hove CCG Coastal West Sussex CCG Crawley CCG Horsham and Mid Sussex CCG High Weald Lewes Havens CCG Areas covered The city of Brighton and Hove Arun, Adur, Bognor Regis, Chanctonbury, Chichester and Worthing Crawley Burgess Hill, East Grinstead, Haywards Heath, Horsham and the surrounding area Crowborough, Lewes, Uckfield and the surrounding area 21

22 NHS England and local authorities also commission services from the Trust and we work in partnership with a number of providers. In addition, we provide services to people living outside of these areas, including other parts of East Sussex. Our other key partners in 2016/17 included: NHS England. NHS Improvement. Our council/care partners: West Sussex County Council, Brighton & Hove City Council and East Sussex County Council. GPs across our area. Local NHS trusts (notably Brighton and Sussex University Hospitals NHS Trust, East Sussex Healthcare NHS Trust, Maidstone and Tunbridge Wells NHS Trust, Surrey and Sussex Healthcare NHS Trust, Sussex Partnership NHS Foundation Trust, South East Coast Ambulance NHS Foundation Trust and Western Sussex Hospitals NHS Foundation Trust). Higher education organisations Our other care partners, notably, local hospices and local residential and nursing homes. Sussex Musculoskeletal Partnership Central and HERE (formally Brighton and Hove Integrated Care Services (BICS)). Third sector organisations including Age UK East Sussex, Diabetes UK, Macmillan and the Martlets. Groups that can speak on behalf of people who use our services, including local Healthwatch, organised patient groups and scrutiny committees. We thank them all for their continued and committed support in helping us deliver quality services to the communities we jointly serve. Engaging with our MPs We have held a number of MP visits to see the services we provide in the community at our community hospitals. Scrutiny committees We have built strong relationships with our three health and overview scrutiny committees West Sussex Health and Adult Social Care Select Committee (HASC), Brighton & Hove Overview Scrutiny Committee (OSC) and East Sussex Health and Overview Scrutiny Committee (HOSC). These bodies consist of local councillors and hold NHS organisations to account for the quality of their services on behalf of their local public. 22

23 Healthwatch Healthwatch England is the independent consumer champion for health and social care in England to ensure the voice of the consumer is heard by the people that commission, deliver and regulate health and care services. Healthwatch England supports the range of local Healthwatch bodies across the country. We work closely with our local bodies, Healthwatch West Sussex, Healthwatch Brighton & Hove and Healthwatch East Sussex, welcoming their input as critical friends. As part of our ongoing relationship: Local liaison representatives from Healthwatch attended our regular meetings with patient representatives. We welcome Healthwatch to our events, such as our annual general meeting and meetings of the Trust Board held in public. We send regular news items about the Trust for inclusion in their communications. We engage with Healthwatch about service changes, and seek their comments Key issues and risks in delivering our goals and objectives Risk assessment Monitoring of issues and risks is a fundamental part of the Trust s clinical governance structure. To do this effectively the Trust holds a single risk register containing divisional risks, operational risks and strategic risks as described in the board assurance framework (BAF). The risk register forms the main repository for all risks within the Trust. Risks are reviewed by the trust-wide clinical governance group to gain assurance that controls and mitigating plans are suitable, sufficient and being appropriately monitored. Significant risks are reviewed, on a monthly basis, by the executive leadership team and where they are deemed to be a high risk to service delivery or patient care (15+), the risk will be escalated to the Board as part of the Integrated Performance Report. Any risk which is likely to impact on the delivery of the Trusts strategic goals and objectives is captured in the BAF. The BAF is a key assurance tool that ensures the Board has been properly informed about the totality of risks to achieving the Trust s strategic goals and objectives. It is reviewed by the executive leadership team on a monthly basis and quarterly by the Trust Board. The three key risks to delivering our strategic goals are: Workforce The Trust continues to face high vacancy levels, particularly in relation to registered nurses and especially at inpatient units which has also impacted on the Trust s ability to reduce agency expenditure. Finances The Trust slipped into deficit in quarter two and therefore for the majority of the year there has been a risk of not delivering the Trust s control total. In quarter 23

24 three the Trust revised its year end forecast to 86k surplus, against which it delivered a surplus of 103k. Sustainability and Transformation Partnership (STP) Plans The potential for significant service redesign that impacts negatively on the Trust, remains a key strategic risk as STPs evolve and the wider health economy continues to face substantial financial deficit and quality concerns. Financial performance summary After making enquiries, the directors have reasonable expectation that the 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. Key operational and performance highlights Key performance metrics are reported monthly to the Board and the public through an Integrated Performance Report. The report highlights performance against a range of measures. These include those set out in NHS Improvement s Single Oversight Framework but also a number of other indicators, agreed by the Board that reflect performance against the organisational objectives and the Care Quality Commission (CQC) domains of Safe, Caring, Effective, Responsive and Well led services. Metrics supporting the Single Oversight Framework NHS Improvement has implemented a new single oversight framework during 2016/17 as to assess the performance of both NHS Trusts and NHS Foundation Trusts. The framework replaced Monitor s Risk Assessment Framework and the Trust Development Authority s Accountability Framework. There are five themes within the Oversight Framework, including Operational Performance, Finance and Use of Resources and Quality of Care but also Strategic Change and Leadership and improvement capability. Single Oversight Framework - Operational Performance Metrics The Trust reports three metrics under this heading Domain Metric Annual Performance (%) Responsive Maximum time of 18 weeks from point of referral to treatment (RTT) in aggregate patients on an incomplete pathway Year End Target (%) 99.0% 92.0% 7% Variance to Target (%) Maximum 6-week wait for diagnostic procedures A&E maximum waiting time of 4 hours from arrival to % 99.5% -3.4% 98.2% 95.0% 3.2%

25 admission/transfer/discharge The Trust s performance on the 18 week referral to treatment and 4 hour A&E target has remained above the target metrics for every month of the year and has exceeded target for the year as a whole. 99.0% of patients received treatment within 18 weeks from referral and 98.2% of patients were seen within 4 hours in the Trust s Minor Injuries Units and Urgent Care Centre. It has been more challenging to meet the goal of ensuring all patients receive diagnostic procedures within 6 weeks of referral but over the final quarter of the year, we treated proportion 99.9% of patients against the 99.5% target. Performance in the earlier months of the year was impacted by difficulties in recruitment to specialist posts such as sonographers, but, with a focussed effort on improvement the number of people waiting longer than 6 weeks has reduced significantly. Single Oversight Framework Use of Resources We report metrics that indicate the Trust s financial performance in the Trust s monthly integrated performance report. There is further detail on the Trust s Use of Resources metrics in the Financial Sustainability section of the report on page 20. Single Oversight Framework Quality of Care Metrics The Trust routinely reports a range of other metrics that illustrate its health as an organisation. These metrics are listed under the five different domains against which the Care Quality Committee assesses the performance of healthcare providers: Safe, Effective, Responsive, Caring and Well-led. In addition, the Trust reports on specific Workforce metrics, with the recruitment and retention of the right number and quality of staff remaining one of the most complex challenges for NHS organisations. The table below sets out the performance metrics that the Trust routinely reports and which NHS Improvement will use to assess providers under the theme of quality, supporting the Quality of Care heading in the Single Oversight Framework. Domain Metric Annual Performance 25 Year End Target Variance to Target Safe Never Events (PL) Caring Complaints: inpatient complaints per 1,000 occupied bed days (OH) 0.20 No Target Patients Friends and Family Test Star Rating (OH) Patients Friends & Family Test - % Likely to Recommend (OH) 96.0% 90.0% 6.0%

26 Patients Friends & Family Test - % 0.7% 1.0% 0.3% Unlikely to Recommend (OH) Workforce Temporary workforce (Agency + Bank + Locum costs) as % of paybill (OH) 9.6% 11.0% 1.4% Annualised turnover rate **rolling % 12.0% -2.5% months average (OH) Sickness rate (OH) 4.9% 5.0% 0.1% No never events have been reported in 2016/17 compared to one in 2015/16. The Trust reports the number of complaints received for every 1,000 occupied bed days in its inpatient units. The figure of 0.20 complaints per 1,000 bed days is the same as in the previous year. There are a number of metrics relating to Patients Friends and Family tests. All of these show that the Trust has performed better than planned for 2016/ % of patients friends and family would recommend the services at Sussex Community Trust whilst 0.7% of friends and family would be unlikely to recommend. Although we are pleased that the vast majority of service users and those that are close to them would recommend our services we strive to ensure that 100% of patients receive the care and experience form our services that we can be proud of. Like all NHS providers the recruitment and retention of our staff remains a key priority but also provides challenges. 9.6% of our staff costs for 2016/17 were for temporary staff. This is an improvement on the 11% we targeted. However, we know that the proportion we spend on agency staff, rather than our own internal bank of flexible workers, is higher than it should be and the Trust will continue to look at all ways to improve the recruitment and retention of substantive staff. The turnover of staff also remains to high 14.5% of our staff left the organisation in the year. Although we are working hard to replace staff as efficiently as possible, we are also focussed on making sure that we retain the staff we already have and allow them to grow and develop within our organisation. The staff sickness rate for the year was 4.9%, just below our target. In 2017/18 we are increasing our musculoskeletal and wellbeing support for staff, targeting two areas contributing to our current sickness rates. In addition to the Single Oversight Framework metrics, the Trust reports a range of other performance metrics to its public Board. This includes data on delayed transfers of care, where patients in our inpatient beds are ready to be discharged but are unable to be until other services are in place to support them. For the year, 13.4% of bed days were used by patients in this position. This is much higher than the 7.5% which is nationally mandated, but performance has improved from 15% in September 2016 to 9.5% in February 2017, though it increased in March rising to 13.3% owing to a small number of complex discharges in the East Area where there are continuing capacity pressures. 26

27 The performance reflects the challenges to the health economy and in social care. The Trust will continue to work with its partner organisations in health and social care to continue the improvement in performance. Ensuring Financial Sustainability Despite continuing financial challenges in 2016/17 the Trust has delivered a small surplus for the financial year of 103k. This is lower than its original planned surplus of 2.4m, but against the backdrop of local and national financial and operation pressures, delivery of the surplus demonstrates the Trust s continued financial resilience and sustainability. The 103k surplus is our NHS control total performance. This is calculated in a different way to the position set out in the Trust s Statement of Comprehensive Income in its accounts. The table below sets out the difference between the two figures. Accounts Heading Value Explanation ( 000) Surplus/(deficit) for the year (2,712) This is the position per the 2016/17 Accounts - a deficit of 2,712k Adjustments 2,815 The impact of impairments to fixed assets of 2,758k and other adjustments excluded Surplus/(deficit) on a Control Total Basis from the control total 103 The control total surplus of 103k following relevant adjustments The Trust was unable to access any of the 1.97m Sustainability and Transformation funding that would have been available if it had met all its financial targets. However, it was able to implement 10.0m of in-year efficiency schemes, improving the Trust s underlying efficiency position, while ensuring no adverse impact to patient care. NHS Improvement measures our performance against five Use of Resources indicators. For 2016/17 the overall performance was 2, with the best possible performance being 1 and the lowest performance 4. UOR Indicators Indicator Full Year Full Year Target Actual Capital Servicing Capacity (times) 1 2 Liquidity Ratio (Days) 1 2 I&E Margin 1 2 I&E Margin Variance from Plan 1 3 Agency 2 3 Summary Financial Sustainability Risk Rating

28 As the table above shows, the areas where the Trust s performance fell below 2 related to the use of agency staff, where our spend was still higher than the nationally set target, and performance against plan, as we delivered a lower surplus than planned. Nearly 70% of the Trust s expenditure relates to its workforce. Recruiting sufficient staff to fill all of our vacancies remains one the key operational pressures and risks to the organisation in 2016/17. The amount that the Trust spent on agency staff to cover vacancies reduced steadily throughout the year, but it was still a significant cost pressure. In total we spent 8.4m on agency in the year compared to 9.28m in 2015/16 and we plan to reduce the number still further in 2017/18, to 6.2m through a range of schemes to improve recruitment and access to temporary staff. Despite the challenging environment we have delivered a number of key objectives that confirm our underlying financial strength. This puts us in a good position regarding our long-term financial sustainability: We delivered an adjusted retained surplus of 103k for 2016/17. This compared to a recurrent 1.2m surplus in 2015/16, and was a significant achievement in the current financial climate. We were successful in retaining status as provider of Healthy Child Programme children s services in West Sussex and Brighton and Hove, with a combined value of 16m. We invested 7.7m in capital schemes, including the Trust s buildings, information systems and clinical equipment to improve patient care. The Trust finished the year with cash of 4.8m in the bank. The Trust did not take out any new loans in the year. There have been no significant changes in accounting policies in the year. 2017/18 and beyond In 2016/17 we continued to deliver our commitments to our local health economies, while managing within our financial resources, allowing us to continue to provide high quality health within constrained resources. We will continue to actively engage with our health and care partners in the development of our plans to meet the priorities of the geographical area we serve through the Sustainability and Transformation partnership process. As set out above, we have successfully bid for and retained contracts to provide new services in West Sussex and Brighton & Hove and we will continue to look to develop new services, where opportunities arise often in partnership with other healthcare and wellbeing providers, including the third sector. In 2017/18, we plan to deliver an increase in surplus to 1.3% ( 2.9m) of our turnover, whilst maintaining investment in our clinical services. Delivery of the increased surplus 28

29 next year will require the Trust to continue to address its workforce risks, reduce agency pay costs and deliver greater efficiencies in procurement, estates and back office functions, working collaboratively with partners wherever possible. The continued drive, both nationally and locally, towards healthcare services increasingly being provided in the community rather than within hospital settings gives the Trust ever greater opportunities to grow and thrive as a financially sustainable organisation. Sustainability and financial performance - Delivering sustainable healthcare that cares for both people and the environment What is a sustainable community provider? There are lots of definitions of sustainability and it is a term that is being used more and more in the NHS. For our Trust, sustainability is shorthand for effective management of resources. Our approach to sustainability at SCFT means we must manage three related resource priorities to support delivery of excellent care in the heart of the community both now and in the future. We refer to these as our triple bottom line. We must: 1. Achieve long-term financial sustainability 2. Minimise our impact on the environment and natural resources 3. Create a happy, productive and sustainable workforce Since the Trust was formed in 2010 we have been developing a programme of work to ensure we re making progress on these resource priorities. This work programme is defined and led by our Sustainable Development Management Plan (SDMP), which we have called Care Without Carbon (CWC). CWC directly addresses one of our core strategic objectives, which is to be a strong, sustainable business, grounded in our communities and led by excellent staff. It comprises a seven step action plan that is designed to ensure that we are taking a coordinated approach, integrating sustainable development principles into our core operational activities across the Trust. Further information is available at Programme governance how we deliver CWC Our Environment & Transformation team is responsible for designing and implementing the CWC programme across the Trust. The team reports on progress directly to Trust Board through the Trust s Executive Sustainability Lead Mike Jennings (Director of Finance & Estates and Deputy Chief Executive). Each of the seven action areas is headed up by a named senior manager, who oversees the delivery of the action plan for their area and ensures the work is aligned with their department s own strategic priorities and work plans. The CWC governance structure is summarised in the infographic below. 29

30 2016/17 Overall sustainability performance summary We measure the overall impact of CWC against three key performance metrics: 1. Absolute (overall) CO 2 reduction; 2. Cost improvement (related to CO 2 reduction) 3. Improvement in workplace health and wellbeing 30

31 Between 2010 and 2016 we have reduced our absolute carbon footprint by 1,817 tonnes CO 2 e (21.8%), meaning we are still on course to meet our 2020 target of 34% reduction in carbon footprint against our 2010/11 baseline. This is despite taking on new community services in the High Weald, Lewes & Havens area of East Sussex in 2015, which we have included in our carbon footprint calculation for This includes energy consumed and waste generated in three new community hospital sites: Lewes Victoria, Crowborough and Uckfield. It also includes an increase in business mileage associated with a growth in staff and services. As a result of this we have undertaken an exercise to recalculate our carbon footprint baseline for The total estimated net financial saving associated with the CO 2 reduction reported above between 2010 and 2017 is 4.7m (against a total investment cost of ca. 1.02m). Wellbeing was measured for the first time in 2016/17, with a specific metric designed by the New Economic Foundation (NEF). The Trust scored 4.35/10 against a National average of 5/10. The National average is not NHS specific as SCFT is the first Trust to apply this metric. Measurement also revealed that staff involved in CWC s Dare to Care campaign scored 12% higher in this metric than those not involved. Further work with the Dare to Care campaign aims to bring the Trust average up to the National average for wellbeing. Further detail concerning our environmental performance and how we have achieved the reductions are included in the sections that follow. NOTE: Due to the date of publication of the annual report, we have estimated some of the data reported here. We will publish a full sustainability report, including a complete data set for 2016/2017, in the summer of We obtain annual external assurance to 31

32 validate accuracy of all the data. You can download all assurance reports from 2011 from our website: /17 Environmental performance summary In addition to measuring and reporting on our total CO 2 e emissions we also measure progress against a series of specific environmental Key Performance Indicators (KPIs). These have been chosen because they represent the Trust s primary direct environment impacts, as identified by our Environmental Management System (EMS) Impacts Register. These impacts also contribute to our overall carbon footprint and so by measuring our performance against these indicators throughout the year we are able to track progress towards annual CO 2 reduction targets, as well as manage any environmental compliance obligations. The environmental performance dashboard below provides a high level summary of progress towards our specific environmental goals for Where the in-year figure is marked green this indicates we are on, or ahead, of our target performance for that measure. Amber indicates we are within a 5% margin of the target performance for the year. Red indicates that we are behind where we want to be in order to achieve the 2020 target for that measure. As above, we have included performance data from our three new community hospital sites, which transferred to the Trust in We are working to implement improvement actions that will see a significant improvement in performance across all environmental impact areas during 2017/18. The only area where progress falls below the 5% performance margin is in reducting the grey fleet mileage (staff using their own vehicles for work). This is in spite of an annual decrease of almost 15% between and We are only 6.6% away from achieving our in-year target for this measure and as outlined in the Journeys summary below, we are embarking on a new travel programme in 2017 that we are confident will bring performance below the target INDICATOR KPI 2020 Target BASEYEAR Value 2020 Target Value Target Value Value CO2 Carbon Foot print t onnes CO 2e 34% 8,324 5,494 6,437 6,506 Energy Efficiency kgco 2e/m 2 34% Wat er Efficiency m 3 /m 2 34% Trust Vehicle Emissions gco 2e/km 34% Grey Fleet Mileage miles claimed 34% 4,693,757 3,097,880 3,629,839 3,867,889 General Wast e Recycled % recycled 75% 50% 75% 68% 66% Clinical & Offensive Wast e % offensive 75% 0% 75% 45% 57% 32

33 Summary of Performance Against our seven action areas 1. BUILDINGS Providing the workspace for low carbon care delivery with wellbeing in mind 2020 TARGET 34% reduction in CO 2 from our buildings The Trust has reduced absolute CO 2 from building related energy consumption by 26.8% between 2010 and 2016 (1,342 tonnes CO 2 per annum). That means the Trust is on course to achieve its 2020 target of 34% reduction from buildings. Alongside this we have achieved a 29.5% improvement in per m 2 energy efficiency and a 44.6% improvement in per m 2 water efficiency against our 2010 base year. As indicated previously, we have included emissions from our three new community hospital sites in the figures reported here. This has had an impact on our carbon reduction performance and has necessitated a recalculation of our baseline emissions. As a significant proportion of the healthcare estate we occupy is owned and managed by NHS Property Services (including these new facilities) this will be a key partnership for us going forward in our efforts to reduce carbon usage from our estate. During 2017 we plan to revise our Estates Strategy and we will use this as an opportunity to build even stronger links between the Trust s sustainable buildings objectives (reduced environmental impact, improved care and working environment for staff and patients and lower running costs) and the Trust s strategic estates development plan for the next 3 years. 2. JOURNEYS Maximising the health benefits of our travel and transport activity whilst minimising the environmental impacts 2020 TARGET 34% reduction in all measureable travel CO 2 As a community provider travel is a significant and necessary part of our business activity. Moving staff and materials around Sussex contributes over 20% to our direct carbon footprint and is a significant cost for the organisation, both financially and in terms of staff time. It therefore remains a key area of focus for us within CWC and we have pushed forward on a range of new and existing activities through our Business Travel Plan during The Travel Bureau we established in 2013 continues to act as the hub for travel planning and advice and support to our services to reduce travel and adopt more sustainable travel modes/options. Highlights from 2016/2017 include: The Trust now has 21 low emission pool vehicles, based at six different sites and all 33

34 deliver a healthy return on investment The Trust s first electric bike racked up 3,000 kms during its 24 months with Speech & Language Therapy. The bike has just been replaced and a second has been purchased, which is on a six-month trial with Occupational Therapists. The Trust has established an e-bug (electronic Bicycle Users Group) so we can communicate with cyclists across the Trust. NHS Property Services has provided newly refurbished changing areas, including showers at Horsham hospital More than 450 staff are now using lease cars instead of their own vehicles for work, delivering both a cost and carbon saving to the Trust The Travel Bureau is expanding its resources in 2017 to keep up with demand for low carbon and sustainable travel support. Since this work began we have reduced our travel carbon footprint by 24%, which means we re on track to meet our 2020 target of 34%. We have reduced our grey fleet mileage (staff using their own cars for Trust business) to 3.8 million miles and cut the engine emissions from our owned and leased fleet by 26.4% down to gco 2 /km. In 2017 we will launch a new and more ambitious Travel Transformation Programme, called Travel Light. This programme aims to further reduce solo car occupancy in order to reduce vehicle emissions and its contribution to local air pollution. Doing so should also bring the added benefits of reduced cost to the Trust and reduced demands on staff time, which supports our health and wellbeing agenda.# 3. PROCUREMENT Creating an ethical and resource efficient supply chain 2020 TARGET 34% reduction in CO 2 e from procurement & waste We have almost met our interim recycling target of 67.5% for 16/17 (recycled waste expressed as a proportion of all non-healthcare waste by weight). Our forecasted recycling rate for the year is 66%. We not only met our non-hazardous healthcare waste target of 45% (minimum volume of non-hazardous healthcare waste as a proportion of total bagged healthcare waste) but exceeded target by 12%. This has delivered a significant cost saving. Work is underway to bring waste management practices at the Trust s new services in High Weald, Lewes & Havens up to the standards achieved across the rest of the Trust s facilities. This will be a priority for 2017/18 and our aim is to increase Trust-wide recycling rate, including these three new community hospital sites, to 70% or above by the end of the year. 34

35 We committed to reporting on emissions from waste management and procurement this year. At the time of writing work we are still working to achieve this ambition. We have started to develop a new approach to measuring our supply chain carbon footprint. This has initially involved undertaking a high level review of carbon hotspots within a range of key product areas, including pharmaceuticals, medical devices & equipment and continence products using existing tools. Currently we are preparing a strategy for supplier engagement in order to build trust and collaboration with our suppliers towards achieving our goals for carbon reduction. Will intend to provide a more detailed update on this work in our Annual Sustainability Report, due to be published later in the summer. 4. CULTURE Informing, empowering and motivating people to achieve sustainable healthcare 2020 TARGET Engage with 100% of staff across the Trust on sustainability with measureable benefits Our unique Dare to Care staff engagement campaign continues to develop, encouraging and supporting staff to do things differently for a better working life and a greener NHS. Every dare supports our triple bottom line of cost savings, carbon reduction and improved wellbeing. The number of darers has doubled in the past 12 months, with just over 20% of staff now taking at least one dare. In total across the Trust s staff have taken 3,968 dares (individual actions or commitments). The campaign has also reached the wider NHS community in Sussex and beyond and in total 4,668 dares have been taken to date. Analysis on the outcomes of the campaign from the first 18 months showed it delivered additional carbon savings of 438 tonnes CO 2 e savings with associated cost savings. Further, it has significantly contributed to the health and wellbeing of those that took part (see Wellbeing section below for details). In the next 12 months the campaign will evolve to empower a Champions network across the Trust that we anticipate will drive even greater grassroots participation and action. This, along with a revamp of our Waste Management e-learning training programme, which will include a broader sustainable healthcare module, in 2017 will provide a significant boost towards achieving our 2020 target for this area. 5. WELLBEING Creating a better working life for our people 2020 TARGET Maintaining staff wellbeing above national average Wellbeing is a key part of CWC s triple bottom line aims. As such all our work has this as a goal, but the Dare to Care campaign in particular focuses on ways to improve wellbeing across the Trust. In 2016/17 we worked with the New Economic Foundation (NEF) to develop a metric for wellbeing, enabling us to create a mechanism for measuring progress 35

36 towards achieving improved workplace health and wellbeing as well as a providing a benchmark for the Trust. As a first for the NHS, we are not yet able compare this result to other Trusts, but plan to be able to do so in future. Our work with NEF resulted in a score of 4.35/10 for wellbeing, this compares to a national average (not NHS-specific) of 5/10. Those that took part in the Dare to Care campaign reported a12% uplift in wellbeing compared to non-darers. Darers also experienced a 16% increase in team bonding, 7% increase in physical activity, 11% reduction in stress, 15% improvement in concentration and a 6% increase in day to day happiness. This year we launched two Dare Challenges, Step Up and Sugar Smart, to tackle being more active and healthier eating. Step Up involved over 180 staff who walked in excess of 36,000 miles in 12 weeks. It is now running for a second time. Sugar Smart is ongoing with 40 staff participating to date. In the next 12 months we will develop more Dare Challenges, and we will deliver Wellbeing@Work Month in May 2017 to spotlight this topic. Our work links into the Workforce Wellbeing Working Group which ensures we are joined up with wider Trust aims and ambitions, in particular to aid meeting CQUIN outcomes with a wellbeing focus. 6. FUTURE Supporting a strong local health economy that serves our community now and in the future 2020 TARGET Reduce the carbon footprint of our Foundation Trust membership by 10% During 2016 we altered the name of this action area from Adaptation to Future. The work in this area still encompasses our Climate Change Adaptation Strategy but has been broadened to reflect our growing work on community and patient engagement as well as our ongoing work to embed sustainability in our clinical care model. During 2016 we have started work with CCGs and other local NHS partners to support patients and others in our community to live healthier lives and reduce their own environmental impact. Research undertaken with a small number of patient groups across Brighton & Hove demonstrated a high level of support for the Trust taking a more active role in promoting the benefits of low carbon, healthy lifestyles in the local community. This is something we are developing further during The Trust has also been successful in attracting a Darzi Fellowship to the Trust. This 12 month placement programme will begin in May 2017 with the focus of further integrating the Trust s sustainability objectives into its Communities of Practice clinical care model. 7. PIONEERING Leading the way in the NHS for sustainable healthcare policy and practice 36

37 2020 TARGET Recognised as a leading NHS service provider for sustainable development policy and practice The seventh area for action in our CWC action plan commits the Trust to continue to develop its approach to sustainable healthcare and pioneer new and innovative methods of achieving measureable improvements in our triple bottom line metrics (reducing the cost of care, reducing the environmental impact of care and enhancing health and wellbeing). We can report several examples that demonstrate our efforts to pioneer new techniques and ways of working at the Trust over the past 12 months. For example, our work with NEF has resulted in an NHS-specific methodology for measuring health and wellbeing in the workplace, providing a much more detailed assessment of opportunities and areas for improvement than has been previously available. In March 2017 we received recognition from the NHS Sustainable Development Unit (SDU) for the quality of our sustainability reporting. The SDU conducted an analysis of all provider and clinical commissioning group (CCG) annual reports to evaluate sustainability sections. Forty Trusts and forty CCGs (around 17%) have been selected for recognition out of 450 organisations across England, including SCFT. 37

38 Our workforce Our workforce and the needs of our patients are changing and so is the way we deliver care. Shortages of clinical staff nationally, an older workforce and changes to education pathways means our workforce profile is evolving. Pressures in secondary and social care and the emergence of new ways of working as part of our commitment to Communities of Practice require our staff to have new skills and for our skill-mix to see an increased proportion of unregistered clinical staff. As a Trust we value our staff and recognise they are our greatest asset. Our overall aim is to develop our staff, give them clear career pathways, provide them with the leadership, skills and knowledge they need to deliver the care our patients need now and in the future, to support their wellbeing and to recognise and value their diversity. Our workforce strategy describes the pathway to creating the workforce we need to deliver our vision of excellent care at the heart of the community. It sets out our strategic workforce priorities and the approach we will take to deliver those. It builds on our culture of innovation and continuous improvement, of openness and transparency, and of collaborative leadership, grounded in our values. The strategy builds on our strong foundations as a good employer and our values, and is key to the delivery of our Clinical Care Strategy. Workforce Vision We are proud of the care we provide our patients and our role in the health and care system. Our vision is to be the employer of choice for clinicians and support staff already employed by us, starting their career in the NHS or looking for a role that will fulfil their professional ambitions and meet their personal aspirations. We will continue to monitor our performance against other Trusts, through both the national staff survey and the Staff Friends and Family Test. We will continuously review what we do, what has worked and not worked well, and what improvements and innovation will help us improve in the future. We will monitor our workforce indicators to measure our performance against targets and celebrate success. 38

39 ACCOUNTABILITY REPORT 39

40 Remuneration Report The following tables detail the salaries, allowances and pension benefits of directors and senior managers within the Trust. It is the responsibility of the Remuneration Committee of Non-Executive Directors to oversee the pay arrangements of Executive Directors. The Remuneration Committee reviewed Directors remuneration following the authorisation of the Trust as a Foundation Trust on April 1st Benchmarking information identified that, prior to authorisation, salary levels for Directors had fallen well behind market rates and this posed a risk to the organisation in terms of its ability to retain and recruit the highest calibre individuals for these roles. For 2016/17 the Committee approved a performance related pay scheme, with payments made based on the achievement of agreed objectives that supported the strategic objectives of the organisation. However, no payments were made in 2016/17 as the Trust s financial position for the year was adverse to plan, which was a trigger for the payments to be made. The committee agreed that the salaries of Executive Directors should be increased to better reflect market rates. This has resulted in salary increases for all Executive Director posts, with the salary (based on the mid-point of the salary band) of the highest paid Director increasing from 137,500 in 2015/16 to 147,500 in 2016/17. The new salary structure reflects the complexity and scale of the roles at the Trust as well as bringing remuneration in line with comparable organisations in the NHS. For this reason it is appropriate that a salary is paid of more than 142,500 (the amount that currently equates to the Prime Minister s ministerial and parliamentary salary). The remuneration and terms and conditions of executive directors are determined by the remuneration committee which consists of all the non-executive directors and the chair. It is the responsibility of the Council of Governors to decide the remuneration and allowances and other terms and conditions of office of the chair and other Non-Executive Directors. They do not receive pensionable remuneration. Senior managers are subject to nationally determined pay scales and all executive director employment contracts include six months notice periods. Pay increases of senior staff are limited to those agreed in the national pay circular for staff covered by the Agenda for Change agreement. From April 2016, the Trust introduced an element of performance related pay for Executive Directors. The Trust s pension policies are detailed in note 8 of the Trust s published annual accounts. Senior managers remuneration The table below describes the components which make up the remuneration packages of senior managers, and how these offer support for the short and long term strategic objectives, how the component operates, the maximum payment, the framework used to assess the performance, performance measures, the performance period, the amount paid for the minimum level of performance. 40

41 Support for long and short term Trust objectives How the component works Maximum payment Framework used to assess performance Performance measures Basic Salary Ensuring recruitment and retention of high quality senior managers Through monthly payments Equal to basic salary Performance Related Bonuses Payment based upon delivery of Trust objectives Payment based on agreed criteria Based on a maximum value of 45k to be shared between all Directors Pension Benefits Ensuring recruitment and retention of high quality senior managers Through monthly payments Equal to basic salary Appraisal process Appraisal process Appraisal process Individual objectives agreed with Chief Executive and Board Individual objectives agreed with Chief Executive and Board Individual objectives agreed with Chief Executive and Board Performance Period Financial year Financial year Financial year Amount paid for minimum level of performance Zero Equal to basic salary, no performance related element Equal to basic salary, no performance related element Policy on payment for loss of office Notice of termination for Directors is made in writing as follows: Notice of termination by the Trust six months Notice of termination by the post holder six months Statement of Consideration of Employment Conditions Elsewhere in the Foundation Trust In considering any decision on Senior Managers pay the Remuneration Committee takes note of both the organisational and national context. Expenses of Governors and Directors Between April 2016 and February 2017 inclusive, there were 11 Directors in office. From March 2017, following the resignation of the Trust Chair, there have been 10 Directors in office (including the Deputy Chair as Acting Chair). A new substantive Trust Chair takes up post in June

42 There have been a number of resignations amongst Governors during , with bielections held to fill vacant posts. The number of Governors in office has therefore fluctuated in-year but the average number in office has been 18 (out of 22) posts Total Expenses for Directors paid in the year was 22,248 and for Governors was 569. Expenses paid to Directors and Governors Number Claiming (including directors who have now left post) Total ( 00) Directors Governors 3 6 Total

43 Salaries and allowances of senior managers (Information subject to audit) Salaries and Allowances Name Title Date started Salary ( 000, bands of 5k Expense Payments (taxable) Total ( s, to the nearest 100) Current Executive Directors and Senior Managers Perform ance Pay and Bonuse s ( 000, bands of 5k) Long Term Performanc e Pay and Bonuses ( 000, bands of 5k) All Pension Related Benefits ( 000, bands of 2.5k) Total ( 000, bands of 5k) Salary ( 000, bands of 5k) Expense Payments (taxable) Total ( s, to the nearest 100) Performa nce Pay and Bonuses ( 000, bands of 5k) Long Term Perform ance Pay and Bonuses ( 000, bands of 5k) All Pension Related Benefits ( 000, bands of 2.5k) Total ( 000, bands of 5k) Siobhan Melia Susan Marshall Richard Curtin Michael Jennings Dr. Susan Stone Gareth Baker Chief Executive Executive Director of Nursing Executive Director of Operations Executive Director of Finance, Facilities and Estates Acting Executive Medical Director Director of People and Strategy 01/05/ /04/ /01/ Executive Directors on Secondment /10/ N/A N/A N/A N/A N/A N/A 01/11/ N/A N/A N/A N/A N/A N/A 04/11/

44 Richard Quirk Executive Medical Director (On secondme nt with NHS from 01/11/201 6) Former Executive Directors 02/04/ Paula Head Jonathan Reid Ed Rothery Chief Executive Executive Director of Finance, Facilities and Estates Acting Director of Finance and Estates(fro m 13/06/ /10/201 6) Left 31/08/2016 Left 12/06/2016 Current Non-Executive Directors , N/A N/A N/A N/A N/A N/A Stephen Lightfoot Maggie Ioannou David Parfitt Elizabeth Woodman Acting Chair (from 01/03/201 7) Non- Executive Director Non- Executive Director Non- Executive Director 01/09/ /12/ /07/ /02/

45 Janice Needham Prof Chakravarthi Rajkumar Non- Executive Director (NED Designate 01/02/ /06/201 5) Board Advisor Former Non-Executive Directors 01/02/ /11/ Sue Sjuve Chair Left 28/02/

46 *Salary in this context includes the allowances paid to non-executive directors. Although non-executive directors do not receive a salary, their allowances are subject to UK taxation and so have been included under this heading. 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. These comparisons are based on the full time equivalent (FTE) remuneration, i.e. part time remuneration is grossed up to a full time equivalent. The mid-point of the banded remuneration of the highest paid director of Sussex Community NHS Foundation Trust in the financial year 2016/17 was 147,500 (2015/16 137,500). This was 6.2 times (5.7 times in 2015/16) the median remuneration of the workforce, which was 24,304 ( 24,063 in 2015/16). During the year no employees received more FTE remuneration than the highest paid director. Remuneration ranged from 15,251 to 150,000 (2015/16 11,496 to 134,561). Total remuneration includes salary, non-consolidated performance related pay and benefits in kind. It does not include employer pension contributions and the cash equivalent transfer value of pensions. 46

47 Pension benefits of senior managers (Information subject to audit) Name Title Start Real Increase in Pension at pension Age (bands of 2,500) Real Increase in Pension Lump Sum at pension Age (bands of 2,500) Total Accrued Pension at pension Age at 31 March 2017 (bands of 5,000) Lump Sum at pension Age related to Accrued Pension at 31 March 2017 (bands of 5,000) Cash Equivalent Transfer Value at 01 April 2016 Real Increase in Cash Equivalent Transfer Value Cash Equivalent Transfer Value at 31 March 2017 Employer's Contribution to Stakeholder Pension Current Directors and Senior Managers Siobhan Melia Susan Marshall Chief Executive 01/05/ Executive Director of Nursing 07/04/ Richard Curtin Michael Jennings Dr. Susan Stone Gareth Baker Richard Quirk Executive Director of Operations Executive Director of Finance, Facilities and Estates Acting Executive Medical Director Director of People and Strategy 09/01/ /10/ /11/ /11/ Executive Medical Director 02/04/ Former Directors and Senior Managers Paula Head Chief Executive Left 31/08/ Jonathan Reid Executive Director of Finance, Facilities and Estates Left 12/06/ Ed Rothery Acting Director of Finance and Estates 13/06/16-09/10/ Note: Non-executive directors do not receive pensionable remuneration and therefore are not included in the above pension benefit tables. 47

48 Cash Equivalent Transfer Value (CETV) This the actuarially assessed capital value of the pension scheme benefits accrued by a 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 the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which disclosure applies. The CETV figures and the 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 scheme or arrangement) and uses common market valuation factors for the start and end of the period. Public/ Stakeholder Engagement Report Patient Experience There are a number of areas and initiatives in which we have taken forward our work to continually listen, reflect and learn from our patients, carers and service users, using this to inform service developments and improvement. Examples of progress against out improvement priorities for 2016/17, as set out in our 2015/16 Quality Account include the following: A new Diabetes Network Group was established, including stakeholders and patients to help shape Diabetes Care for You services Focus on what matters to the patient, rather than focussing on what is the matter with the patient, by involving patients in their own goal setting to ensure that care focusses on what people want to achieve Collaborative working to develop a mobile app to improve the effectiveness and experience of children and their families in diagnosis of autism 48

49 Whilst always acknowledging complaints within two working days, we have significantly improved the time in which we investigate and formally respond to complaints A Trust-wide group has been set up to improve transition planning for children and young people with complex needs moving to adult services, or moving between services. Work has included the development and testing of pathways for children with different complex needs We have benchmarked our services, using NICE Guidance on transition, and approved local action plans in response to this, which are being implemented The CQC rated the responsiveness of SCFT s end of life care as outstanding in We are working to ensure this standard of care is delivered consistently to everyone of all ages and personal needs coming to the end of their lives, as well as those caring for them. For example, we launched an End of Life Care Hub (ECHO) in October 2016, to provide a centralised, single point of access for patients, their loved ones and carers across Coastal West Sussex. ECHO coordinates care, takes and signposts enquiries to help people to reach the most appropriate care and support. We also deliver a range of specialist training for staff, which has included caring for people with learning disabilities at the end of their lives. Working together with patient representatives, staff and key stakeholders, we have refreshed our Patient Experience Strategy (2013/18), renaming it the Patient and Carer Experience and Involvement Strategy (2017/20). The strategy has three overarching ambitions, namely: Communication - We want to improve the way we communicate with our communities, as well as modernising the way we collect and respond to feedback. Working together - We want to make best use of feedback from patients, carers and to support people to work together improve our care and services Excellent Compassionate Care - We want our patients and carers have a positive experience, first time and every time they come into contact with our staff. Patient surveys The Trust uses a range of means to gather patient and carer feedback on our services. Survey results and feedback actively inform areas in which we can both improve and share best practice across our services. For example: The Trust continues to consistently achieve high scores and positive feedback through our Friends and Family Test (FFT). Plans are in place to enhance the technology to invite FFT feedback such as by mobile texts and voice activated messaging. 49

50 The feedback gathered through the FFT is used across the Trust to stimulate local improvement and empower staff to carry out changes that make a real difference to patients and their care. Development of Patient Reported Outcome Measures (PROMs), using questionnaires, Friends and Family Test and other feedback relating to our diabetes pathway and leg ulcer services We use structured feedback interviews, for example, to assess the End of Life Care Hub Responding to complaints We take all complaints very seriously and thoroughly investigate all those received, aiming to respond to the complainant as quickly as possible and to learn from concerns raised. The Trust has a robust complaints management process, with challenging target timeframes in which to investigate and respond. Complaint response times improved significantly, consistently meeting our targets since July Our People (staff report) Employee health and wellbeing Sussex Community NHS Foundation Trust has a number of schemes in place to incorporate and develop a culture of wellbeing. Activity this year included: The launch of our Your Health, Your Wellbeing free staff health checks. The health check is underpinned by the motivational interviewing model which promotes individual change. The checks cover physical health and mental health/ wellbeing. Promoting active travel through our Dare to Care programme. We have dared staff to take a walk and take one less car journey. The Trust invested in an electric pool bike in partnership with the local council to encourage more staff to cycle to meetings. Free bike repair sessions were provided for cyclists and we are registered with the Brighton & Hove City Cycle Challenge to encourage more people to cycle. Running a Dry January campaign and a stop smoking programme is in place running up to national non-smoking day in March. Launching our menopause policy and information hub was published our intranet which has received excellent feedback 50

51 A successful two wave influenza vaccination campaign was delivered in October/November 2016 ensuring assess to the flu vaccine was accessible to all SCFT employees. This included offering the vaccine at meetings, clinics, training days and new staff induction. Our Occupational Health Physiotherapist has implemented pathway for employees to provide quick and easy access to physiotherapy Occupation Health psychologist provision has been increased. Alana Lowenburger is working with the Trust to ensure specific areas of need are identified and addressed Our Step Up challenge was launched across the Trust with 36,000 miles walked last year. Staff have twelve weeks to walk their chosen virtual route. It promotes personal fitness, saves money on fuel for less car use and helps reduce carbon footprint of staff. Our Sugar Smart challenge is now running across the Trust to support healthier eating, promoting an individual saving of 1kg of sugar in 5 weeks. Promoting healthier eating through meat free Monday and bring your own meal challenges. Staff are encouraged to make healthier eating choices, with recipes on our Care Without Carbon website, shared through newsletters and social media. Healthier eating helps tackle obesity, heart disease and diabetes. Promoting mental health by challenging staff to Make it Personal and Say Hello, to foster an open and approachable workplace culture where people feel that they can talk to colleagues. A Workout@Work Week in partnership with occupational health and physiotherapist teams across the Trust. We were able to offer staff opportunities to exercise at work and give information on the benefits of a more active lifestyle together with further guidance on how to achieve it. Participation was good with walking groups, keep fit classes and info stalls taking place that week. Supporting NHS Sustainability Day by inviting staff to choose active travel to work for the day instead of driving, to boost their own fitness and reduce air pollution around hospital facilities. The Trust led these events with other Trusts in Sussex for a joined up approach. Our Dare to Care team were available at staff inductions to engage staff in campaigns. The total number of staff taking on dares has increased, with 20% of staff now signed up to a dare. Our 2017 Wellbeing@Work Festival with a month of activities in May taking place right across the Trust with a focus on improving both mental and physical wellbeing 51

52 for staff. This includes four key roadshows at Brighton, Crawley, Bognor and Uckfield with both internal and external expertise available for staff to access. We worked with the New Economic Foundation to measure the impact of our Dare to Care campaign on staff wellbeing. The findings showed that darers benefited from: o o o o o 11% reduction in stress. 22% increase in sense of purpose at work. 7% increase in physical activity. 15% improvement in concentration. 16% increase in team bonding. Staff Benefits Our staff benefits lead meets with new staff every two weeks and provides information on staff wellbeing and the upcoming wellbeing events and conferences. We promote the My Trust Benefits website with gives national and local discounts for NHS staff. To support parents or carers of children within SCFT gives information on the three nurseries within the Trust. There is further information on Childcare vouchers and childcare information available. We provide regular retirement seminars to help staff plan their life after retirement so that we ensure that their wellbeing continues with life after work. We run a new starters survey to help us understand the needs of staff and any issues arising. This helps identify the key areas which need improving so that we can improve recruitment and retention Staff survey This year 2,208 colleagues took part in the staff survey our biggest sample ever. The results provide us with an overview of the experience of staff employed by SCFT. The full results can be viewed on the National Staff Survey website. In summary, SCFT s scores have remained stable since the previous year. In comparison with other Community Trusts and our local partners, we continue to perform strongly. We have improved in some areas, in particular the number of staff who report that they come to work when unwell (which has decreased significantly since 2015). We also had the highest score for community trusts in providing equal opportunities for career progression and support from immediate managers. However, there are also areas where we have not performed as well as we would like, and which we will need to focus on. For example, although we have improved since last year, 52

53 too many of our staff report experiencing harassment, bullying or abuse and physical violence from patients, relatives, members of the public or NHS staff. The areas in which SCFT compares most favourably with other community trusts in England are: Effective team working. Percentage of staff able to contribute towards improvements at work. Support from immediate managers. Percentage of staff believing their organisation provides equal opportunities for career progression or promotion. Recognition and value of staff by managers and the organisation. The areas in which we scored less favourably compared to other community trusts are below. It should be noted that the differences between SCFT and national averages are marginal or the same in each of these: Staff satisfaction with the quality of work and care they are able to deliver. Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months. Percentage of staff working extra hours. Percentage of staff experiencing physical violence from patients, relatives or the public in last 12 months. Percentage of staff reporting errors, near misses or incidents witnessed in the last month. The Trust reviews all findings closely, both to share and celebrate where we are doing well, but also to focus on areas in which we score less favourably than other community trusts so to seek improvements. Further work will be undertaken with staff in the coming year to further help our understanding and to identify areas for improvement to further improve staff experience. Staff Communications To strengthen staff engagement, we continue to improve the ways we communicate with staff, and promote good dialogue between staff and the senior team. The Trust s engagement with staff includes: The intranet is our main day-to-day communication tool, with real-time information published to help support staff. 53

54 We provide information in various formats including films and animation. In 2016/17 we produced 22 videos for staff. We deliver a weekly team briefing providing information for frontline staff, encourage discussion in teams and generate feedback. We send out a weekly message from our chief executive to all staff, linking what s going on within the Trust and locally to the national picture. We have annual staff awards and an employee of the month scheme, showcasing best practice and recognising achievement. We livestream all staff engagement events, and our Board meetings held in public with up to 400 people viewing each event via Facebook. We host staff Facebook groups with over 200 actively engaged members. Members of the Board and the executive leadership team visit services across the Trust. Leadership development The organisation offers a range of leadership opportunities for all levels of leader including courses, coaching and mentoring and an annual leadership conference. All staff have access to regular supervision and an annual appraisal. Support is also offered for team development. We have regular engagement events for staff to meet with the senior leadership team and these are now livestreamed. We re committed to strengthening the skills of our leaders: We continue to deliver training sessions to help managers with a range of management issues, including sickness and attendance, conduct and capability, managing difficult conversations, and general recruitment training and values based interview training. We held our annual leadership conference, with over 100 leaders benefiting from presentations and workshops We hold leadership development days to help managers update their skills and improve how they manage their team's performance Creating a new forum for senior leaders to engage in decision and strategy with the executive team Staff Friends and Family 81% of staff would recommend the Trust as a place to receive treatment and 61% would recommend the Trust as a place to work. 54

55 Overall numbers The table below sets out the average staff numbers for 2016/17(Information subject to audit). The total number of staff employed was 4,164 whole time equivalents (WTE), made up of 4,000 WTE permanently employed staff and 165 WTE temporary staff. 2016/ / /17 Staff Group Total Permanent Other Number Number Number Medical and dental Ambulance staff Administration and estates Healthcare assistants and other support staff 1,211 1, Nursing, midwifery and health visiting staff 1,420 1, Nursing, midwifery and health visiting learners Scientific, therapeutic and technical staff Healthcare science staff Social care staff Agency and contract staff 0 0 Bank staff Other Total average numbers 4,164 4, Of which Number of employees (WTE) engaged on capital projects Staff Costs* Permanent Other Total 000s 000s 000s Salaries and Wages 123, ,511 Social Security Costs 10, ,456 Pensions Costs (NHS Pension Scheme) 15, ,698 Pensions Costs (NEST Pension Scheme) Termination Benefits Temporary Staff - Agency/Contract 0 10,130 10,130 Total Gross Staff Costs 149,892 10, ,022 Split Between: Capitalised as part of Assets 678 1,659 2,337 Charged to Revenue 149,214 8, ,685 *(Information subject to audit) 55

56 Our staff gender distribution as *31 st March 2017 Headcount (primary assignments only) Category Total Female Percent (%) Male Percent (%) Executive directors % 4 67% Other senior 1, % % managers (Agenda for change bands 7-9 and senior medical and dental staff) All other employees 3,767 3,358 89% % Total 4,785 4,201 88% % Full time equivalent (FTE) Category Total Female Percent (%) Male Percent (%) Executive directors % % Other senior % % managers (Agenda for change bands 7-9 and senior medical and dental staff) All other employees 2,970 2, % % Total 3, , % % Staff Sickness Our overall rate for the year was 4.47% of working days against a target of 4%. This is in comparison to an overall rate of 6.2% for last year. We have supported our managers to help them better manage sickness absence with our central absence reporting service FirstCare and dedicated HR support. Total days lost due to sickness For the period1 st April 2016 to 31 st March 2017, our total WTE days lost was 40,964. The average working days lost per employee was 10.7, which was down from in 2015/16. Use of Agency and Bank Staff Over the last year we have decreased our use of agency staff by investing and making the best use of our in-house bank staff, Staff Direct. We have increased our Staff Direct department and number of bank staff to enable us to fill more shifts then ever with our own staff. This has already resulted in a decrease in agency use and better quality of care for our patients. Our year end revenue agency figure, as a percentage of overall revenue pay expenditure is 5.4%, a reduction from 2015/16 but above our target of 4%. Nationally the NHS continues to face a shortage of certain nursing and medical professions. We have had many recruitment days and events across Sussex with great success. 56

57 Expenditure on Consultancy The Trust spent 321k on external consultancy in 2016/17. This compared to 1,003k in 2015/16. Consultancy spend was primarily incurred in the implementation or roll out of new services such as community services in High Weald, Lewes and Havens or the new Diabetes contract but also specialist advice on the Trust s clinical care and associated strategies. Off Payroll Engagements As an organisation subject to HMT Guidance Managing Public Money, Sussex Community NHS Trust has a responsibility in safeguarding public interest. In May 2012, HMT carried out a review on the tax arrangements of senior public sector appointees. The aim of the review was to ascertain the extent of arrangements which could allow public sector appointees to minimise their tax payments, and make appropriate recommendations to address the problem. Sussex Community NHS FoundationTrust is committed to tackling all forms of tax avoidance and demonstrates a high level of scrutiny around tax arrangements of senior appointees in the Trust. The Trust operates a policy covering off payroll engagements. This policy provides guidance to ensure compliance with HMT s recommendations on tax arrangements for the following public sector appointees: Board members Senior officials with significant financial responsibility Engagements of more than six months in duration, for more than a daily rate of 220 The table below relates to all off-payroll engagements as of 31 st March 2017 for more than 220 per day that lasts for longer than six months: Number Number of existing engagements 26 Of which the number that have existed: For less than one year at the time of reporting 13 For between one and two years at the time of reporting 5 For between two and three years at the time of reporting 0 For between three and four years at the time of reporting 3 For more than four years at the time of reporting 5 Of the 26 engagements included above, 18 ended on the 31 st March 2017 when the individuals moved onto the Trust s payroll. 57

58 All existing off-payroll engagements have been subject to a risk based assessment of whether evidence is required that the individual is paying the right amount of tax and, where necessary, assurance has been sought. The table overleaf relates to all new off-payroll engagements, or those reaching six months in duration, between 1 st April 2016 and 31 st March 2017, for more than 220 per day which last for longer than six months: Number Number of new engagements, or those that reached six months in duration 18 Number of new engagements which include contractual clauses giving the 18 trust the right to request assurance in relation to income tax and National Insurance obligations Number for whom assurance has been requested 9 Of which: Assurance has been received 9 Assurance has not been received 0 Engagements terminated as a result of assurance not being received 0 The table below relates to off-payroll engagements of board members and senior officials with significant financial responsibility between 1 st April 2016 and 31 st March 2017: Number of off-payroll engagements of board members and /or senior officers with significant financial responsibility The total number of individuals both on and off-payroll that have been deemed board members and/or senior officials with significant financial responsibility, during the financial year Number 0 15 Exit Packages Exit Packages for the year totalled 215k for 5 staff (Information subject to audit). Exit package cost band (including any special payment element) Number of compulsory redundancies Number of other departures agreed Total number of exit packages < 10, ,001-25, ,001-50, , ,

59 100, , , , > 200, Total number of exit packages by type Total resource cost ( 000) /16 Exit package cost band (including any special payment element) Number of compulsory redundancies Number of other departures agreed Total number of exit packages Less than 10, ,000-25, ,001-50, , , , , , , > 200, Total Number Exit Packages by Type Total Resource Cost ( 000) Equality and Diversity SCFT s strategic ambition for equality is equitable care at the heart of all our communities. During 2016/17 we began to deliver this ambition and examples of progress are highlighted below, including: Accessibility improvements to signage and wayfinding for disabled people. The piloting of an independent learning disability quality check. The establishment of a supported employment scheme, with three people with learning disabilities given work placements, with one moving on to permanent employment. 59

60 Positive action for Black and Minority Ethnic (BME) staff to encourage applications to leadership development opportunities and individual advice. Quarterly reporting to Trust Board of racial equality within shortlisting to appointment rates for BME people. The establishment of a Lesbian, Gay, Bisexual, Trans and other sexual and gender minorities (LGBT+) Staff Network. The development of guidelines to support Trans patients, carers and workers. Equality and accessible information standards implementation. An audit of chaplaincy provision. A review of equality and diversity training. Anti-bullying and harassment workshop for leaders. Interpreting and translation contract management and staff guidance. Policies Trust policies, procedures, guidelines and tookits are reviewed on a rolling basis. During the year, the executive team met with staffside at the bi-monthly Joint Consultative and Negotiating Committee meetings to ratify a number of updated staff policies. Giving full and fair consideration to applications made by disabled persons The Equality and Human Rights policy contains sections on recruitment and selection and on offering and making reasonable adjustments in recruitment and employment to support managers and job seekers. We accept job applications in a variety of formats and operate a guaranteed interview scheme for disabled job applicants who meet the minimum criteria for the job as a disability confident employer. We lead an Employability Partnership to build relationships with local supported employment services and supported internship colleges. Last year we identified suitable trial roles, supported work trials to these roles and piloted our first working interview. We fund communication support for disabled people and make reasonable adjustments for job interviews to help overcome unfair disadvantage. Recruiting managers training includes learning outcomes around reasonable adjustments and was recently updated to include supported employment. Disability equality is part of statutory training for all staff, which is monitored by Trust Board monthly. 60

61 Policies applied during the financial year for the training, career development and promotion of disabled employees including continuing arranging training for employees who have become disabled persons Every effort is made to ensure that all our staff are treated fairly and equitably regardless of their individual characteristics and circumstances. All new employees are given training in relation to our values and the principles of treating others with dignity and respect. With specific regard to disabled employees or those who become disabled whilst working for us, we provide support and with advice from our Occupational Health department make reasonable adjustments and training as necessary to ensure these people can enjoy, or continue to enjoy a fulfilling career with us. Assessment for funding in relation to training has a robust process that requires management approval before funding panel consideration; there is no discrimination in relation to disability as it is assessed based on need in order to carry out the functions and expectations of the role Providing employees systematically with information on matters of concerns to them as employees We have a range of mechanisms that are in place throughout the year to encourage staff members to play a role in the activities and performance of the Trust; we consulted with staff on all changes which affected them through local organisational change processes, team briefings, individual meetings and staff surveys. These processes are detailed within our HR policies which are agreed in partnership at our Terms and Conditions group and Joint Consultative and Negotiating Committee. This group provided the formal mechanism for discussion in relation to pay/terms and conditions of service as well as matters relating to organisational change. Consulting employees or their representatives on a regular basis so that the views of employees can be taken into account in making decisions The Joint Consultative Negotiating Committee (JCNC) meets on a bi-monthly basis and is the forum through which SCFT brings together Trust executives and senior managers with union representatives to discuss matters of importance to staff relating to employment, terms and conditions of service, working arrangements and policies and procedures. This year, 25 policies were agreed and ratified. Health and safety and occupational health performance The Trust has formal policies and procedures in place for Health & Safety and specialists subjects (e.g. physiological wellbeing, COSHH, DSE, new & expectant mothers, young persons, sharp safety), which set out the roles and responsibilities for implementing the Trust s arrangements, including those for senior managers, line managers, all staff and specialist leads. The policies and procedures are authored and monitored by the specialist leads/departments (e.g. H&S, Fire, Security, Occupational Health) and in the case of health and safety, they present quarterly papers to the Health & Safety Committee. The Health and Safety Committee monitor quarterly performance (e.g. number of incidents, RIDDORs, risk assessment actions, audits, chair reports from medical device, 61

62 medical gas and radiation protection groups) and develops a work plan for the group to implement. Each year an annual health and safety report, on the previous year s performance and plans for the following year, goes to the Board. NHS Improvement's Single Oversight Framework The NHS Act 2006 states that the Chief Executive is the Accounting Officer of the NHS Foundation Trust. The relevant responsibilities of the accounting officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by NHS Improvement. NHS Improvement, in exercise of the powers conferred on Monitor by the NHS Act 2006, has given Accounts Directions which require Sussex Community NHS Foundation Trust (SCFT) to prepare for each financial year a statement of accounts in the form and on the basis required by those Directions. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of SCFT and of its income and expenditure, total recognised gains and losses and cash flows for the financial year. In preparing the accounts, the Accounting Officer is required to comply with the requirements of the Department of Health Group Accounting Manual and in particular to: Observe the Accounts Direction issued by NHS Improvement, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis. Make judgements and estimates on a reasonable basis. State whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual (and the Department of Health Group Accounting Manual) have been followed, and disclose and explain any material departures in the financial statements. Ensure that the use of public funds complies with the relevant legislation, delegated authorities and guidance. 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. 62

63 To the best of my knowledge and belief, I have properly discharged the responsibilities set out in the NHS Foundation Trust Accounting Officer Memorandum. Chief Executive Date: 31 May 2017 Director s Report and Annual Governance Statement How the Trust is governed The Trust s governance structure comprises its Board of Directors, Council of Governors and membership. The Board of Directors includes the Chair, Non-Executive and Executive Directors, and its primary role is to lead the Trust and set the Trust s strategic direction and objectives and ensure delivery of these within the available resources. The Trust also has a Council of Governors, which has defined statutory responsibilities and duties, including holding the Non-Executive Directors to account, individually and collectively, for the performance of the Board. The Council of Governors consists of elected and appointed representatives from members of the Trust, staff and stakeholder organisations. The membership of the Trust elects the Public and Staff Governors and it is part of the elected Governor role to represent the members of their constituencies and communicate their views to the Board. The Trust has a duty to ensure that its members are engaged in and kept up to date with developments within its services. The Trust s governance arrangements are strengthened by its close collaboration with key local health partners, including Clinical Commissioning Groups (CCG), NHS South (South East), NHS Improvement (South East Region), Health Education England Kent, Surrey and Sussex, HealthWatch, Sussex acute providers, GPs and mental health services providers, the local authorities and Health and Wellbeing Boards, and charitable and voluntary sector organisations working in the healthcare sector. The Trust also plays an active leadership role in the Sussex and East Surrey Sustainability and Transformation Plan (STP) programme and participates in local system resilience groups established to collectively deal with system pressures. Board of Directors Details of Board membership are given below. The Board comprises the Chair, five Non- 63

64 Executive Directors (NEDs), and five Executive Directors, including the Chief Executive. Other Executive Directors are: Director of Finance and Estates Medical Director Chief Nurse Chief Operating Officer The Chair and NEDs come from a range of professional backgrounds and succession planning is kept under review to ensure that NED skills and experience reflect the evolving needs of the Trust. The Chair and NEDs meet the independence criteria laid down in Monitor s Code of Governance (updated in July 2014). The Trust s Chair resigned following a successful terms in office in February The Deputy Chair assumed the role of Acting Chair and the Council of Governors commenced a process to recruit a new Chair. A new Chair has been appointed and will come into role on 1 June The Acting Chair has been with the Trust, as a NED, since 2013 and has significant Board level experience both as a NED and in executive roles in his previous career. The Trust appointed a new Chief Executive in September 2016 by promoting the then Director of Commercial Development. In addition, the previous Director of Finance and Estates resigned from the Trust in June 2016 and a successor was appointed, taking up his post in October In the intervening period the role was covered by an Acting Director of Finance. The Trust s Medical Director was on secondment to South East Coast Ambulance NHS Foundation Trust and an Acting Medical Director was in place this arrangement has now ended. Details of how the vacant posts were appointed are covered in the relevant sections of the report. The Board has in place a scheme of delegation and a schedule of powers and decisions reserved to the Board to ensure that decisions are taken at the appropriate level. Governors are provided with full details of the decision-making responsibilities of the Council of Governors at induction and regularly reminded of these throughout their tenure. During 2016/17, the Board s Committee structure remained the same as it was during the Trust s Foundation Trust application, as it was considered still appropriate to meets the needs of the Board. Following each Board meeting, members reflect on their own performance and that of the Board as a whole, to ensure that meetings remain effective, constructive and relevant. Responsibilities of the Board of Directors The Board of Directors main responsibilities include: 64

65 Provide active leadership of the Trust within a framework of prudent and effective controls which enables risk to be assessed and managed. Ensure compliance with the Trust s Licence, Constitution, and mandatory guidance issued by NHS Improvement (NHSI), all relevant statutory requirements and contractual obligations, and maintain registration with the Care Quality Commission (CQC). Set the Trust s strategic aims, taking into consideration the views of the Council of Governors, and ensure financial and human resources are in place to meet its aims. Ensure the delivery of safe healthcare services, high quality clinical outcomes, and a positive patient experience. Develop and maintain high standards of education, training and research. Set the Trust s culture, values and behaviours and maintain its position as a learning organisation. Uphold the NHS Constitution. Cooperate with health partners and other stakeholders. The Trust s income from the provision of goods and services for the purposes of the health service in England is greater than its income from the provision of goods and services for any other purpose. Board of Directors Appointment, Tenure and Appraisal The Council of Governors appoints NEDs, including the Chair. A Committee comprising the Chair and all other NEDs appoints executive appointments. The Council of Governors is asked to approve the appointment of the Chief Executive. All Board-level appointments are made using fair and transparent selection processes, with specialist HR input and external assessors utilised as required. Executive Director contracts do not have fixed terms. In accordance with Monitor s Code of Governance and good corporate governance practice, the Chair and NED positions have a fixed tenure with staggered terms in place to assist succession planning. NED tenure is subject to annual review and satisfactory performance appraisal and is generally for a period of 6 years maximum (served in discrete 2 or 3-year terms). With the agreement of the Council of Governors, it can be extended to a maximum of nine years in total. Tenure beyond six years must be deemed to be in the interests of the organisation and take into account the need to regularly refresh the composition and skill-set of the NED element of the Board. Early termination of NED appointments is a matter for the Council of Governors. The Trust s Constitution sets out the circumstances in which a NED contract may be terminated early and these terms are also included in NED Terms and Conditions. 65

66 Both Executive and Non-Executive Directors are subject to an annual performance appraisal, which is a formal process carried out against agreed objectives. The Chief Executive appraises other Executive Directors, the Chair appraises the Chief Executive and Non-Executive Directors and the Senior Independent Director appraises the Chair having taken into account the views of the Governors and other Directors. The outcomes of Executive Directors appraisals are shared with the Board of Directors Nominations and Remuneration Committee, and those of Chair and NED appraisals with the Council of Governors Nominations and Remuneration Committee. Board of Directors Profiles Chair Stephen Lightfoot appointed Acting Chair 01/03/17. Formerly Deputy Chair and NED, first appointed 01/09/13. Stephen started his working life as a nutritionist with Colborn-Dawes Nutrition, a subsidiary of the Roche global vitamin business. In 1986, he moved to the global pharmaceutical company Schering AG, rising to become commercial director with Schering Health Care in the UK. He then became UK managing director with the global pharmaceutical company Daiichi Sankyo, before becoming general manager of the global medical diagnostics business with GE Healthcare. Susan Sjuve appointed Chair 26/03/10. Resigned w/e 28/02/17. Sue has worked at executive and non-executive director level to lead strategic, operational and change management in commercial and not-for-profit bodies. She has particular experience and expertise in managing significant budgets, risk management and regulatory compliance. She started her working life as a research assistant in the Paediatric Research Unit at Guy s Hospital in south London. From Guy s she moved into the financial services sector, and has worked at senior level with the Woolwich, Barclays Bank and the National Australia Group. She has also worked with the integrated energy company, Centrica. Sue gained board level experience in banking and in the NHS as a non-executive director at NHS Surrey. She is a non-executive board member at Saxon Weald Homes Ltd, a social housing provider in Sussex and Hampshire, and also Chair of the Makaton Charity. Chief Executive Siobhan Melia appointed 01/9/16. Siobhan has a clinical background having worked as a podiatrist, before moving into senior clinical leadership and managerial roles within the NHS, including a board level position as professional executive committee chair at Berkshire East Primary Care Trust. Then moved into a strategic business leadership role and became deputy managing director/director for business and strategy at Berkshire East Community Health Services, before gaining commercial experience in the private sector. Returned to the NHS in 2013, 66

67 and has a particular interest in improving outcomes for patients through new commercial developments, developing strategic partnerships and enabling staff to innovate. Paula Head appointed 01/04/13, resigned 31/08/16. Paula complements her clinical background as a pharmacist with commercial experience and a record of achievement at board level with a number of NHS organisations. Previously director of transformation at Frimley Park Hospital, where she led organisational change and development, delivering efficiencies and service improvements and enhancing Frimley Park s reputation. In previous board level positions, first with Kingston Primary Care Trust (PCT) and then with Berkshire East PCT, she led strategy, business planning, contracting and performance. In both roles she managed community engagement programmes leading to the successful implementation of local service change, and served as deputy chief executive. Non-Executive Directors Maggie Ioannou appointed 01/12/13. Also Senior Independent Director. Maggie is a nurse by background, and has extensive professional leadership experience in community nursing, including at board level. In her last post she was director of nursing, quality and safety for Surrey Primary Care Trust (PCT). In this role she provided leadership on clinical quality and safety during a time of significant change, spanning the separation of the PCT s responsibilities to commission as well as providing community services, through to the transition to the new system of clinical commissioning groups, established in April David Parfitt appointed 01/07/14. David is a chartered accountant with broad commercial experience in complex and customer-orientated organisations undergoing significant change including the Granada Group, TSB Group and Lloyds Banking Group, where he became risk, control & and accounting director (retail). He brings strong experience in finance, human resources, organisational development, strategic and change management and governance. In addition, he has direct experience of the NHS, first as a non-executive director of Luton Primary Care Trust (PCT) and latterly as a lay member (audit and governance) of NHS Luton clinical commissioning group. Elizabeth Woodman appointed 01/02/15. Elizabeth brings legal knowledge and significant experience of working on strategy at senior and board level in large organisations. Elizabeth qualified as a solicitor in a magic circle City law firm and then moved to a tax practice at an accountancy firm requalifying as a chartered tax advisor. Elizabeth then became an executive remuneration consultant for a large firm of actuaries specialising in executive incentive schemes and board governance. She has spent much of her working life in professional publishing and online information businesses, bringing to market a number of successful online products aimed at professionals. Elizabeth was vice president accountable for revenue and strategy at 67

68 Thomson Reuters Legal, UK & Ireland until September Elizabeth combines her role at SCT with being chief executive of a well-known barristers chambers in London that specialises in public law. Janice Needham appointed 01/02/15 (NED designate from 01/02/ /06/2015) Janice is an independent management consultant working primarily in the not-for-profit sector, with notable clients including the Big Lottery Fund and the Carers Trust. She brings extensive and wide-ranging management and senior level experience gained across government, local council and the voluntary sectors. She has served on the management boards of three national charities, held a director level position with Voluntary Services Overseas (VSO) and worked as a statistician with the Department of Health. Owing to the departure of the substantive Chair at the end of February 2017 and the Deputy Chair acting up into that role, the Board is currently one NED short of its normal complement. Executive Directors Director of Finance and Estates: Mike Jennings appointed 10/10/16. Mike is a qualified accountant, who has lived in Brighton for 19 years. He began his accountancy career working in the financial services industry and joined Western Sussex Hospitals NHS Foundation Trust from Sussex Partnership NHS Foundation Trust in At Western Sussex he was Deputy Director of Finance and interim Finance Director before joining the executive team permanently in Mike joined Sussex Community NHS FT in October Director of Finance and Estates: Jonathan Reid 04/04/12 10/06/16 Acting Director of Finance and Estates: Ed Rothery 11/06/16 09/10/16 Medical Director: Richard Quirk appointed 02/04/12. Richard is a GP practicing in West Sussex, with special interests in child health and safeguarding, family planning, obstetrics and gynaecology. He trained in London and has most recently been clinical governance lead at the Trust s urgent treatment centre in Crawley. Richard has experience in governance in the education field and spent ten years providing medical advice to a television production company. Richard was seconded to South East Coast Ambulance Service as Improvement Director from October Acting Medical Director: Su Stone from 01/11/16. Chief Operating Officer: Richard Curtin appointed 09/01/12. Richard is a registered nurse with qualifications in leadership and business administration. He worked at Guy s & St Thomas NHSFT (GSTT) from 1997, where in his last role he led the clinical services strategy that underpins the successful integration of community services in Lambeth and Southwark into GSTT. Chief Nurse: Susan Marshall appointed 01/04/14. 68

69 With 30 years experience in both acute and community settings, Susan previously worked at the Black Country Partnership NHSFT, where she was director of nursing & professional practice. Susan is a registered general nurse, with qualifications in midwifery and health visiting. She offers a record of achievement in clinical leadership, operational management and governance, including the development of a clinical competency framework to strengthen nursing standards and enhanced professional leadership to drive patient safety. Susan brings particular interests in safeguarding, infection prevention and control and patient, carer and public engagement. Board of Directors and Council of Governors: Declarations of Interest The Trust maintains a Register of Interests of Directors and Governors, which is available for inspection on application to the Company Secretary. See website for our full register. Compliance with the Code of Governance Provisions Sussex Community 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 Statement on Directors Disclosures The Annual Report is required to include a statement that for each individual, who is a director at the time the report is approved, as follows: 69

70 So far as each director is aware, there is no relevant audit information of the which the (external) auditor is unaware; and The director has taken all the steps that they ought to have taken as a director in order to make themselves aware of any relevant audit information and to establish that the auditor is aware of that information. All Directors have confirmed the above statement. Attendance at Board Meetings Name Title Current tenure details Attendance at Board of Directors Non-Executive Directors Stephen Lightfoot Acting Chair from Appointed 01/09/13 10/10 01/03/17. NED, Deputy Chair / Chair Finance and Investment Committee Sue Sjuve Chair (to 28/02/17) Appointed 26/03/10 9 (out of 9) Elizabeth Woodman NED Appointed 01/02/15 10/10 Janice Needham NED Appointed 08/09/15 9/10 Maggie Ioannou David Parfitt Executive Directors NED, Chair, Quality Committee / SID NED, Chair Audit Committee Appointed 01/12/13 10/10 Appointed 01/07/14 10/10 Ms Siobhan Melia Chief Executive from 01/09/16 Commenced 01/09/16 Mr Mike Jennings Director of Finance Commenced and Estates 10/10/16 Mr Richard Curtin Chief Operating Commenced Officer 09/01/12 Ms Susan Marshall Chief Nurse Commenced 01/04/14 6 (out of 6) 5 (out of 5) 10/10 10/10 Dr R Quirk Medical Director Commenced 5 (out of 5) 02/04/12 Dr S Stone Acting Medical From 01/11/16 3 (out of 3) Director Mr J Reid Director of Finance and Estates 04/04/12 10/06/16 2 (out of 2) 70

71 Mr E Rothery Acting Director of 11/06/16 09/10/16 3 (out of 3) Finance and Estates Ms Paula Head Chief Executive 01/04/13 31/08/16 4 (out of 4) Council of Governors NHS Foundation Trusts are required to have a Council of Governors (CoG). CoGs have specific statutory duties as follows: Appoint and, if appropriate, remove the Chair. Appoint and, if appropriate, remove the other NEDs. Decide the remuneration and allowances and the other terms and conditions of office of the Chair and the other NEDs. Approve the appointment of the Chief Executive. Appoint and, if appropriate, remove the Trust s external auditors. Receive the Trust s annual accounts, any report of the auditor on them, and the annual report. Give views on the Trust s forward plans. Approve (or not) any increase by 5% or more the proportion of the Trust s total income in any financial year attributable to activities other than the provision of goods and services for the purposes of the health service in England. Hold the NEDs to account, individually and collectively, for the performance of the Board. Approve (or not) any proposal for merger, acquisition, separation or dissolution. Approve (or not) any significant transaction (as defined in the Trust s Constitution). To represent the interests of FT members and the public as a whole. Approve (jointly with the Board of Directors) any amendments to the Trust s Constitution. Further key functions for Governors are to: Act in the best interests of the Trust and adhere to its values and code of conduct. Feedback information about the Trust, its vision and its performance, to the members or stakeholder organisations that either elected or appointed them. Communicate with members and relay members views to the Board. 71

72 Develop and review the FT Membership Strategy, ensuring representation and engagement levels are maintained and developed in line with strategy. How the Board of Directors and the Council of Governors work together Governors are invited to attend and observe all Board of Directors meetings as part of their ongoing engagement and development with the Trust generally and Board specifically. A Governor also sits as a lay member on the Patient Experience Group and two Governors attend the Audit Committee as observers. The Trust encourages its Governors to engage with the public and members through the circulation of regular membership newsletters to which Governors contribute and by holding membership recruitment events on Trust sites and other regional fora. Governors are allocated time at each Board meeting to ask questions of the Board on behalf of members or to relay members views to the Board. In addition, Governors are able to contact Trust officers at any time outside formal meetings in relation to members feedback and/or questions. Governors provide the Trust with an independent quality assurance mechanism through the conduct of mock Care Quality Commission inspections of services that are carried out in conjunction with Board members and Trust staff. Governors also meet jointly with the Board every six months, to discuss areas of joint interest and promote closer working arrangements. These joint meetings facilitate the Governors duty to hold NEDs individually and collectively to account for the performance of the Board and provide NEDs with a medium for ascertaining and understanding Governors and members views. NEDs are also invited to attend formal Council of Governor meetings, Governor Committee meetings and membership events as additional opportunities to further these relationships. In the event of disagreement between the Council of Governors and Board of Directors, the Dispute Resolution process referred to in the Trust s Constitution (Annex 8) will be invoked. During 2016/17, the Council of Governors maintained two committees to progress various aspects of the Council s work: Nominations and Remuneration Committee to develop the selection and recruitment process for a new Chair, to review levels of Chair and NED remuneration and to review succession planning for the Board and the terms of existing NEDs. Further details of this Committee are set out below. Membership Task and Finish Group to review the Membership Strategy, to identify and pilot membership recruitment activities and to develop communications and engagement mechanisms with the membership. Council of Governors Elections and Tenure The Council of Governors consists of 22 Governors (12 Elected Public Governors, 5 Elected Staff Governors and 5 Appointed Governors). Staff and Public Governors are elected in accordance with the Trust s Constitution Election Rules. Initial elections to the shadow Council of Governors were held in November 2015 and further bi-elections to fill 72

73 vacant seats were held during 2016/17. Bi-elections were required as a result of Governors resigning for health-related and/or personal reasons. The Council currently has three Public Governor vacant seats for the Adur, Crawley and High Weald Lewes Havens (HWLH) constituencies, and one Staff Governor vacancy for Therapists, Allied Health professionals and Healthcare Assistants. Elections are planned for April/May Attendance at Council of Governor Meetings 2016/17 Members and Constituency Current Tenure Attendance at Council of Governors ELECTED GOVERNORS Andrew Partington Brighton and Hove Commenced 05/11/15 Andrew Halliday Adjacent Commenced 01/12/16 Wayne Hoban Worthing Commenced 05/11/15 David McGill Arun Commenced 09/09/16 David Romaine Brighton and Hove Commenced 05/11/15 Stan Pearce Brighton and Hove Commenced 05/11/15 Lilian Bold Horsham Commenced 05/11/15 John Nicholson Chichester Commenced 05/11/15 Edward Belsey Mid Sussex Commenced 05/11/15 3 Vacancies Adur, Crawley, HWLH STAFF GOVERNORS 6/6 0/2 3/6 1/2 5/6 5/6 5/6 5/6 4/6 Anita Sturdey Admin and Clerical Commenced 1/2 09/11/16 Ngaire Cox Nursing Commenced 3/6 05/11/15 Julie Warwick Nursing Commenced 4/6 05/11/15 Jennifer Parry Doctors and Commenced 5/6 Dentists 05/11/15 1 Vacancy APPOINTED GOVERNORS Pinaki Ghoshal Morwen Millson Brighton and Hove City Council West Sussex County Council Commenced 05/11/15 Commenced 05/11/15 3/6 3/6 73

74 Geraldine Hoban Horsham, Mid Sussex Clinical Commissioning Group Commenced 05/11/15 Paula Kersten Universities Commenced Aug 16 2/5 Lily Parsons Youth Governor Commenced March 17 1/1 Governors who left during the year Elizabeth Workman Adur 05/11/15-12/12/16 1/4 Angela Geogrant Crawley 01/12/16-13/01/17 0/1 Barby Dashwood- HWLH 05/11/15-12/12/16 3/4 Morris Ashley Robinson Admin and Clerical 05/11/15-13/03/17 3/4 Yvonne Palmer Therapist 05/11/15-13/03/17 2/5 Ruben Brett Youth Governor 01/03/16-13/03/17 2/5 2/6 Director Attendance at Joint Board of Directors/Council of Governors Meetings* Name Title Current Tenure Details Non-Executive Directors Attendance Sue Sjuve Chair 01/06/12-28/02/17 1/1 Elizabeth Woodman NED Commenced 2/2 01/02/15 Janice Needham NED Commenced 2/2 01/02/15 Maggie Ioannou NED, Chair, Quality 01/12/13 2/2 Committee / SID Stephen Lightfoot NED, Deputy Chair / 01/09/13 2/2 Chair Finance and Investment Committee David Parfitt NED, Chair Audit 01/07/14 2/2 Committee Executive Directors Ms Siobhan Melia Mr Mike Jennings Mr Richard Curtin Chief Executive from Commenced 1/9/16 01/09/16 Director of Finance commenced and Estates 10/10/16 Chief Operating commenced Officer 09/01/ /2 1/1 2/2

75 Ms Susan Marshall Chief Nurse Change of title wef 1/2 05/01/11 Dr R Quirk Medical Director Commenced 1/1 07/04/14 Dr S Stone Acting Medical 31/05/16 01/05/17 1/1 Director Mr E Rothery Acting Director of 11/06/16 09/10/16 1/1 Finance and Estates Ms Paula Head Chief Executive 08/04/13 31/08/16 1/1 Mr Jonathan Reid Director of Finance and Estates 08/04/13-13/06/16 0/1 * Note: Director attendance at solely Council of Governors meetings is not mandatory and Directors generally attend the twice yearly joint Board and Council of Governors meetings or where a specific topic impacting their area of responsibility is discussed. Nominations and Remuneration Committee The Nominations and Remuneration Committee (NRC) is a Committee of the Council of Governors (CoG). Its duties are to make recommendations to the CoG in respect of the following: Agreement of the terms and conditions, including remuneration, job description and person specification, of the NEDs. To receive details of the annual appraisals of the NEDs. To agree the selection processes for NED positions and implement them in order for them to make recommendations for appointment for approval by the Council of Governors. To agree any extensions of NED terms, subject to satisfactory annual performance appraisal and taking into account the needs of the Board. To regularly review the NED skills-set and succession planning arrangements. The NRC comprises the Chair, Lead Governor, one further Elected Public Governor, and one Appointed Governor. The Chief Executive, the Deputy Director of OD and HR and Company Secretary are also in attendance as required. The NRC convened three times during the period and reported back to the CoG after each meeting. The NRC meetings took place on 12 July 2016, 5 January 2017 and 28 February 2017 and the agendas related to the review of NED terms of office and remuneration for recommendation to the Council of Governors, and the agreement of the selection process for a new Chair. 75

76 Attendance at Nominations and Remuneration Committee Nominations and Remuneration Committee Number of meetings attended Sue Sjuve Chair (to 28/02/17) 2/2 Maggie Ioannou (NED, Senior Independent 1/1 Director) Pinaki Ghoshal Appointed Governor 2/2 Barby Dashwood-Morris Lead Governor (to December 2016) David McGill Lead Governor (from January 2017) 1/2 1/1 Wayne Hoban Public Governor 3/3 Membership of the Trust Foundation Trusts have a responsibility to engage with the communities that they serve and listen to community views when planning services. The Trust has two types of membership: public and staff. All staff automatically become members and the Trust encourages people who live within its constituency boundaries to register as public members. Membership demonstrates support for the Trust and the services it provides and gives members the opportunity to share their views with the Trust to help it best meet patients needs. Becoming a Member Registering as a public member is easy, free of charge and open to anyone aged over 16 years of age who lives in one of the Trust s public constituencies by picking up and completing an application form from community hospital reception areas or by applying online at ing SC-TR.SCTMembership@nhs.net or calling ext for an application form. Developing and Engaging the Membership The Council of Governors has established a Membership Task and Finish Group to keep the Membership Strategy under review and oversee membership communications, events and recruitment. Membership numbers have decreased slightly, a new strategy is planned in 2017 to address this. It is considered that the demographics and the large geographical area served by the Trust contributes to the challenges in membership recruitment. Membership engagement rather than size is the Trust s key focus, with future plans including a series of membership events held throughout the year, increased numbers of electronic membership newsletters produced, an online membership survey, and several Governor-led membership recruitment events held on Trust premises. 76

77 The Trust s first Annual Members Meeting (AMM) will be held in November 2017 in conjunction with the annual Staff Awards event. Holding the two events together will not only discharge the necessary regulatory formalities but give members and Governors the chance to meet with staff and hear examples of their work and achievements in the preceding year. The AMM will also showcase services to members through displays and stands and will provide members with an opportunity to pass any feedback they may have on services directly to Governors or Board members present at the event. Analysis of Membership at 31/03/2017 The following Analysis of Public Membership (Source: MES) provides details of the makeup of the Trust s current public membership compared to the eligible membership aged 16+ within its constituencies. Constituency 2016/ /16 Out of Area/Rest of England (inc. HWLH residents) Adjacent 100 N/A as new constituency created 16/17 Adur Arun Brighton and Hove 1,059 1,069 Chichester Crawley High Weald Lewes Havens (HWLH) 147 N/A as new constituency created 16/17 Horsham Mid Sussex Worthing Total Public Constituencies 5,035 5,154 Total Staff Constituencies 5,726 (headcount) 3,961 FTE Contacting Governors Governors names are available on the Trust s website: Correspondence for the attention of the Board of Directors or Council of Governors, or concerning membership issues, can be sent to SC- TR.SCTMembership@nhs.net or to the Company Secretary, Sussex Community NHS Foundation Trust, Trust HQ, Jevington Building, Elm Grove, Brighton BN2 3EW. 77

78 Auditors The Trust s audit services during 2016/17 were provided by: Internal Auditors: TIAA. The internal audit plan is risk-based and is developed annually by the internal auditors in conjunction with Executive Directors. The draft plan is then presented for agreement to the Audit Committee and any changes to the agreed plan in the course of the year also requires the Committee s agreement. The plan covers both clinical and non-clinical audit work, as well as areas which are considered by Executive Directors and/or auditors to be high risk or of concern. The Audit Committee reviews the performance of internal audit and their reports.. External Auditors: Ernst & Young In June 2016, the Council of Governors agreed to extend the Trust s existing contract with Ernst & Young for a further three years to 2018/19. The Audit Committee receives regular reports from the external auditors and monitors their performance. If the external auditors are requested to provide non-audit services, this has to be agreed by the Council of Governors and completed in line with the Trust s policy for External Audit Additional Services. Audit Committee The Audit Committee s purpose is to provide assurance to the Board regarding the effectiveness of the Trust s systems of governance and control across the full range of the Trust s responsibilities. It does this by receiving and testing assurance provided in relation to the establishment and maintenance of effective systems of governance, risk management, finance, counter-fraud, and internal control across the whole of the organisation s activities, and assures itself regarding the Trust s compliance with regulatory, legal and other requirements. The Audit Committee s remit encompasses healthcare assurance as well as the more traditional audit areas of finance and corporate governance. The Committee have regular meetings with the auditors without the presence of the Executive Directors. External auditors prepare and present an annual plan of work to review the financial management and reporting systems of the Trust in order to provide assurance that the annual accounts present a true and fair view of the results. Internal auditors assist the Audit Committee by providing clear statements of assurance regarding the adequacy and effectiveness of internal controls. The Director of Finance and Estates is professionally responsible for implementing systems of internal financial control and is able to advise the Audit Committee on such matters. 78

79 At its meetings of 11 April and 26 May 2017, the Committee considered the financial statements and agreed that they contained no significant issues that required addressing under the terms of the UK Corporate Governance Code 2012, para. C.3.8). The Committee regularly reviews its own performance. Representatives from the Council of Governors are routinely invited to attend and observe Audit Committee meetings. Membership and Attendance of Audit Committee Name Position Meetings Attended (out of a possible 6) David Parfitt Chair 6/6 Stephen Lightfoot (to 28/02/17) NED 5/6 Maggie Ioannou NED 6/6 Elizabeth Woodman (from 01/03/17) NED 0/0 Remuneration Report All figures within the Remuneration Report are extracted from the Annual Accounts 2016/17 and are subject to audit. Remuneration Committees The Trust operates two separate Committees to make recommendations with regard to the remuneration of Executive and NEDs. They are: Board of Directors Nominations and Remuneration Committee for Executive Director appointments. Council of Governors Nominations and Remuneration Committee for NED appointments. Non-Executive Director Remuneration The Council of Governors is responsible for determining and approving the remuneration of the Chair and Non-Executive Directors and does this based on the recommendations of its Nominations and Remuneration Committee. In July 2016, the Committee reviewed NED remuneration for 2016/17 and agreed increases that would bring levels of remuneration in line with benchmarking data for FTs of a similar size, type and location. Executive Director Remuneration Remuneration and Terms of Service for the Chief Executive and Executive Directors is considered by a Board of Directors Nominations and Remuneration Committee, with membership consisting of the Chair and Non-Executive Directors. During 2016/17, the 79

80 Committee met to review appraisals and remuneration of the Executive Director and to agree selection processes for a replacement for the Chief Executive and Director of Finance and Estates. The Committee s attendance record is set out below. The Combined Code of Corporate Governance, the NHS Foundation Trust Code of Governance and NHS Policy requires remuneration committees ensure levels of remuneration are sufficient to attract, retain and motivate directors of the quality needed to run the organisation successfully, but to avoid paying more than is necessary for this purpose. In order to fulfil this requirement, Executive Director salary levels are nationally benchmarked against similar trusts and this benchmark is used to inform the deliberations and decisions of the Committee. At the Committee s 2016/17 meeting, current benchmarking data was reviewed and it was agreed to increase the remuneration of the Executive Directors to bring them into line with peer organisations. Board of Directors Nominations and Remuneration Committee Name Position Meetings attended (out of a possible 3) Sue Sjuve Chair (to 28/02/17) 3/3 Stephen Lightfoot Acting Chair (from 01/03/17) NED/Deputy Chair (to 28/02/17) 3/3 Maggie Ioannou NED 2/3 David Parfitt NED 3/3 Elizabeth Woodman NED 3/3 Janice Needham NED 3/3 Policy on Remuneration of Senior Managers With the exception of Executive Directors, the remuneration of all staff is set nationally in accordance with NHS Agenda for Change (for non-medical staff) or Pay and Conditions of Service for Doctors and Dentists. The Board of Directors Nominations and Remuneration Committee approves any changes to the pay and terms and conditions of Executive Directors. Performance Related Pay (PRP) is not applicable for any Trust staff, including Executive Directors. 80

81 NHS Improvement Segmentation Segmentation The Trust s current segmentation is one. This segmentation information was the Trust s position as at 7 April Current segmentation information for NHS trusts and foundation trusts is published on the NHS Improvement website. HM Treasury charging guidance During the period April 2016 to March 2017, the Trust has complied with the cost allocation and charging guidance issued by HM Treasury. No political donations have been made during this period. Better Payment Practice Code The Trust s measure of performance in paying suppliers is the Better Payment Practice Code (BPPC). The code requires the Trust to aim to pay all valid invoices by the due date or within 30 days of receipt of a valid invoice, whichever is later. Better Payments Practice Code Number Value ( 000) Non NHS Total bills paid in the year 42,422 59,061 Total bills paid within target 38,955 50,615 Percentage of bills paid within target NHS Total bills paid in the year 1,481 20,471 Total bills paid within target ,049 Percentage of bills paid within target Total Total bills paid in the year 43,903 79,531 Total bills paid within target 39,766 66,664 Percentage of bills paid within target Health and Safety Responsibilities The Chief Nurse is the executive lead for risk and safety and reports in this regard to the Board, Audit Committee and Quality Committee. The Head of Patient Safety and Risk Management is responsible for the management of risk, health and safety and safety alert bulletins. 81

82 The Trust s Health and Safety Group (HSG) which is supported by a number of working groups, including the Medical Devices Group, the Resuscitation Group, and the Radiation Protection Group. All health and safety incidents are monitored through HSG, which reports to the Trust-wide Clinical Governance Group (TWCGG) and to the Board on an exceptions basis. Training All members of staff must attend Trust induction, which includes the management of risk and health and safety, with a particular focus on how to report incidents or near misses. Level 1 health and safety courses are run for managers. Risk assessment training courses are held regularly. Control of Substances Hazardous to Health (COSHH) assessor courses are delivered throughout each year. Conflict Resolution Training together with refresher training is mandatory for all frontline staff. Developments Work is ongoing to continually improve the Trust s health and safety. Each area of the Trust is required to report on their health and safety audit findings to the Health and Safety Group. The Trust has implemented on-line incident reporting which allows for the immediate reporting of all incidents and supports the efficient production of risk management reports for managers. There is a health and safety section on the Trust s intranet, which is regularly updated and contains a range of resources and information to help support and advise staff on safety issues. Information Governance Information Governance (IG) ensures necessary safeguards for, and the appropriate use of, patient and personal information. The Board ensures that all information used for operational purposes and financial reporting purposes is encompassed by, and evidence maintained of, effective information governance processes and procedures with risk based and proportionate safeguards. In order to demonstrate compliance with relevant information governance guidance and the Data Protection Act 1998, the Trust needs to be able to demonstrate that: Information governance policies and procedures are understood by all relevant staff and are operating in practice. Reliable incident reporting procedures are in place, with appropriate follow up. There have been no material breaches in data security (including personal data in transit) resulting in actual data loss. Risk assessments are undertaken and updated on a regular basis. Proper levels of security and access controls operate. 82

83 An information lead, with appropriate access to the Board including the delivery of periodic reports on governance issues, is in post. The Information Governance Toolkit is a performance tool produced by the Department of Health (DH). It allows NHS organisations to assess their compliance against relevant legislation, Government directives and other national guidance. The following table summarises the Trust s self-assessment with achieving compliance against the 39 requirements of version 14 of the Toolkit. Initiative Clinical Information Assurance Confidentiality and Data Protection Assurance Corporate Information Assurance Information Governance Management Information Security Assurance Secondary Use Assurance No of Requirements assessed below level 2 No of Requirements assessed at level 2 or above Total no of Requirements within the Initiative Overall Score % % % % % % Overall Result % There were two IG Serious Incidents Requiring Investigation (SIRI) during the year, with the final reports presented to the Serious Incident Review Group (SIRG) on 19 th April In March 2017, the Information Commissioner s Office (ICO) closed both incidents as requiring no further action. Below is a summary of all non-serious IG incidents reported within the Trust: INCIDENT CATEGORIES TOTAL Patient Information Sent Incorrectly/Inappropriately 78 Patient Documentation Lost 66 Patient Information Received Incorrectly/Inappropriately 52 83

84 Patient Documentation misfiled 46 Other Datix categories 46 Patient Documentation Inadequate / illegible / incorrect / wrong 30 Breach of Patient Confidentiality 26 Inappropriate Use of IT/Security Issues and Breaches 22 Patient Documentation Incomplete 13 Staff Information Lost 13 Patient Referral letter - missing / inadequate / wrong 11 Staff Information sent Incorrectly/Inappropriately 10 Patient incorrectly identified 8 Staff Info Received Incorrect/Inappropriate 8 Patient Documentation - delay in obtaining 7 Loss of IT Equipment 5 Patient Documentation - mislabelled 4 Patient Documentation - no access to 2 Patient Documentation Stolen 2 Staff Information Inadequate / illegible / incorrect / wrong 1 Statement of Accounting Officer s Responsibilities Statement of the Chief Executive's responsibilities as the Accounting Officer of Sussex Community NHS Foundation Trust The NHS Act 2006 states that the Chief Executive is the Accounting Officer of the NHS Foundation Trust. The relevant responsibilities of the accounting officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by NHS Improvement (NHSI). Under the NHS Act 2006, NHSI has directed Sussex Community 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 Sussex Community 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 NHSI, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis; Make judgements and estimates on a reasonable basis; 84

85 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; 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. Chief Executive Date: 31 May 2017 Annual Governance Statement Scope of responsibility As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS Foundation Trust s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the NHS Foundation Trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum. The purpose of the system of internal control The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal 85

86 control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of Sussex Community NHS Foundation Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in Sussex Community NHS Foundation Trust for the year ended 31 March 2017 and up to the date of approval of the annual report and accounts. Capacity to handle risk The Chief Nurse is the executive lead for risk management and is supported in this by the Heads of Quality Governance and Patient Safety and Risk Management. The Trust has a Trust-wide Clinical Governance Group, which reports to the Executive Committee and the Quality Committee of the Board. The Board and Audit Committee receive regular reports on the key risks facing the organisation at any point in time and also regularly review the Board Assurance Framework, which contains a risk assessment of the Trust s principal objectives for each year. The Board reviews and updates the Risk Management Strategy as required. The current strategy sets out the Board s requirement that a systematic approach to identifying and managing risks and hazards is adopted across the Trust and that systems are in place to mitigate those risks where possible. The strategy also stipulates that it is essential that all Trust staff are made aware and have an understanding of the procedures in place to identify, assess, monitor and reduce or control risk. Risk management training is included in all induction programmes and in key development courses. The Board receives risk management training and last received this formally in November The Trust s approach to risk management is pro-active and involves the following: Identifying sources of potential risk and pro-actively assessing risk situations, using the agreed Trust Risk Profiling, Assessment and Audit Tools and the Risk Evaluation Matrix; Identifying risk issues through serious incidents, adverse incidents, near misses, complaints and claims, the business cycle, and internal and external review reports; Investigating and analysing the root causes of risk events; Undertaking aggregated root cause analysis (considering risk events, complaints, claims and reporting of injuries, diseases and dangerous occurrences regulations (RIDDOR) data; Taking action to eliminate or at least minimise harmful risks; Monitoring the delivery and effectiveness of actions taken to control risk; 86

87 Learning from near misses, risk events, legal claims and complaints and sharing the lessons learned across the organisation and externally when this would be beneficial. The Trust has adopted a coordinated and holistic approach to risk and does not differentiate the processes applied to clinical and non-clinical issues. Common systems for the reporting, identification, assessment, evaluation and monitoring of risks have been developed within the Trust and apply to all risk issues, regardless of type. The effective implementation of the strategy facilitates the delivery of a quality service and, alongside staff training and support, provides an improved awareness of the measures needed to prevent, control and contain risk. To achieve this, the Trust: Ensures all staff and stakeholders have access to a copy of the Risk Management Strategy; Produces a register of risks across the Trust which is subject to regular review at Area level and, corporately, by the Executive Committee, Audit Committee and the Board; Communicates to staff any action to be taken in respect of risk issues; Has developed policies, procedures and guidelines based on the results of assessments and all identified risks to assist in the implementation of the strategy; Ensures that training programmes raise and sustain awareness throughout the Trust of the importance of identifying and managing risk; Monitors attendance at relevant Risk Management training sessions for all staff and ensures that non-attendance is followed-up; Ensures that staff have the knowledge, skills, support and access to expert advice necessary to implement the policies, procedures and guidelines associated with the strategy; and Monitors and reviews the performance of the Trust in relation to the management of risk and the continuing suitability and effectiveness of the systems and processes in place to manage risk. A training needs analysis has been carried out which reflects the level of risk management training required for all grades of staff, including Board members, throughout the Trust. Individual staff training records are clearly linked to, and monitored through, the system of performance appraisal in place across the Trust. The Trust involves its public stakeholders in managing risk in the following ways: Regular reporting to the Council of Governors on quality, finance and performance, with an emphasis on the reporting of risks, current concerns and complaints. 87

88 Governor attendance at key meetings pertaining to risk, including the Board and Audit Committee. Regular contract meetings with the Trust s commissioners to review performance against and risks relating to delivery of the contract. Consulting with its membership on key strategic direction decisions and any proposed major changes in service delivery. Regular attendance at, and presentations as required, to meetings of the local Overview and Scrutiny Committees. Joint working with other local and regional healthcare providers to shape optimum care pathways and mitigate risks associated with financial, safety and/or estates matters. The risk and control framework Risk Management All members of staff have an important role to play in identifying, assessing and managing risk. This can be achieved proactively, through risk assessment, or reactively, through review of risk events, complaints and legal claims. The Trust s Risk Profiling, Assessment and Audit guidelines set out the process for assessing all types of risk. To support staff in this role, the Trust provides a fair and consistent environment that encourages a culture of openness and willingness to admit mistakes. All staff are encouraged to report any situation where things have, or could have, gone wrong. At the heart of the Trust s Risk Management Policy is the desire to learn from risk events and near misses, complaints and claims, in order to continuously improve management processes and clinical practice. The Trust has in place clear policies and systems for identifying, evaluating and monitoring risk. Trust-wide risk profiling is an ongoing process within the Trust and managers are required to ensure that risk assessment and audit is undertaken within their areas of responsibility and that findings are acted upon and adequately monitored. Managers are also responsible for ensuring that all risk assessments are reviewed as required. The Trust s Risk Event Reporting and Evaluation Policy requires staff to report all adverse incidents, both actual and potential (near misses), and sets out the methodology and responsibilities for assessing and evaluating the risks identified by applying consequence and likelihood criteria to achieve a system of colour coding to prioritise risk by severity. The severity category will dictate at which level of the organisation the risk event is investigated and reported, with the lowest category (green) managed at local level and the highest (red and red +) managed at executive level with reports made to the Board and statutory external agencies. The same method of severity categorisation will be applied to risks identified through complaints and claims and will, with adverse incidents and risks identified from risk assessment and non-compliance with external assessment standards, populate the Risk Register. Risk appetite is also determined by severity category and, 88

89 whenever possible, all risks require some mitigating action to be taken to reduce or remove the risk. Specific risks identified by the Trust will be shared with any other relevant organisation working in partnership with the Trust. Likewise, the Trust expects that any relevant risks identified by partners will be shared with the Trust, in line with the Management of External Contractors Policy. In 2016/17, the Trust s main risks related to staffing levels, agency expenditure, the 6 weeks wait target for a diagnostic test, delivery of its Financial Recovery Plan and the pressures associated with working in a challenged healthcare system. The Trust is currently in NHS Improvement segmentation one. Future risks remain unchanged from 2016/17, with the exception of the diagnostics waiting times target, which is on a trajectory to return to compliance early in 2017/18. The Trust s long-term plans will be influenced by the outcomes of the Sussex and East Surrey Sustainability and Transformation Plan (STP). The Trust s Operational Plan 2017/19 and five year Strategic Plan reflects this potential for system fluidity. Risks to compliance with the NHS Foundation Trust License condition 4 (FT governance) The Board considers that there are no current or anticipated future risks to compliance with the Trust s Licence. The Trust is able to assure itself of the validity of its Corporate Governance Statement as required under NHS Foundation Trust condition Licence FT4 through the following mechanisms were utilised during 2016/17: a) The Board has an established Quality Committee to scrutinise any areas of concern arising from the Board s monitoring of a range of safety, quality and patient experience indicators. b) The Board carries out an annual review of members skills to assist with succession planning and identify when is the right time to bring in additional skills aligned to the next phase of the Trust s strategic development. c) The Board has maintained a strong emphasis on quality in its meeting agendas to ensure that quality is the focus of decision-making and planning. d) The Board has an executive lead for quality and clear accountability structures are in place for a quality agenda that is integrated into all aspects of the organisation s work. e) The Board carries out regular visits to services and inpatient units to meet with staff and patients and get feedback. Governors also carry out assurance visits. f) Annual workforce planning for clinical and non-clinical staff groups is carried out to ensure that the Trust has in place personnel on the Board, reporting to the Board and within the rest of the organisation, who are sufficient in number and appropriately qualified to ensure compliance with the Conditions of the Licence. 89

90 g) The Board has driven and overseen delivery of the 16/17 Operational Plan, demonstrating that the Trust can operate with efficiency, economy and effectiveness. h) The Board has maintained appropriate oversight of regulatory and inspection regimes including that of the NHS Improvement, the Care Quality Commission (CQC) and the MHRA, and has monitored the management of gaps where any have been identified. The Board encourages close working with regulators and inspectors to ensure that all requirements are met and quality standards are maintained at the highest level. i) The Board reviewed and refined the format of the Board Assurance Framework to make it a more meaningful document and ensure that Board members focus was on the key risks to delivery of the organisation s principal objectives at all times. j) The Council of Governors carried out an evaluation of its effectiveness early in 2017 and developed an action plan for improvement. The implementation of this action plan will commence into 2017/18. Quality Governance The Chief Nurse is executive lead for quality governance, supported as appropriate by the Medical Director and Chief Operating Officer. The Board receives and reviews an Integrated Performance Report, in which areas of good practice, issues of concern, and performance against all CQC Domains and quality metrics are reported. The Board also reviews specific examples of patient and staff feedback, both positive and negative, at each meeting, with a view of learning from this and ensuring that appropriate action is taken to safeguard quality and improve the patient and staff experience. A detailed Safer Staffing Report is presented to the Board every 6 months. The Board has established a Quality Committee to scrutinise the detail of quality governance in the organisation and provide additional assurance to the Board in this regard. The Quality Committee meets bimonthly and regularly receives reports on progress against both the Trust s Quality Improvement Plan and against its Quality Account Priorities. The Committee also carries out deep dive reviews of particular aspects of quality that are causing concern and receives exceptions reports from the Trust-wide Clinical Governance Group. The Finance and Investment Committee meets monthly and includes within its remit the monitoring of the Trust s Cost Improvement Programme (CIP). Many CIP schemes contain quality components and the quality aspects of each CIP scheme is assessed by group of senior executives to ensure patient safety and service quality are not compromised by the savings proposed. The Board is actively engaged in quality improvement and is assured that quality governance is subject to rigorous challenge through Non-Executive Director engagement and Chairing of the key Board-level committees. The Board reviewed Monitor s Quality Governance Framework as part of its Foundation Trust application in 2015/16 and was satisfied that the Trust s quality governance processes were in line with those set out in 90

91 the framework. It is considered that the scrutiny role of the Quality Committee enhances this position. Data quality, as it relates to the performance information provided, is monitored in-house by the Data Quality Team and by internal and external audit reviews. No significant concerns have been raised regarding the accuracy or completeness of the Trust s data. A Deputy Director of Informatics is in post and the remit for this role includes data quality and data security at an operational and strategic level. Risks to Data Security There has been one incident related to the loss of data in 2016/17. This was reported as a Serious Incident Requiring Investigation and was closed by the ICO as requiring no further action in March The Trust has implemented the NHS Information Risk Management Guidelines by establishing a register of key information assets, allocating each one to an information asset owner who reports to the Senior Information Risk Owner. Information risk management is reviewed and monitored by the Information Governance Group. The Trust has implemented and rigorously enforced the Information Risk and Information Security Policy to control where personal information is stored and to protect personal information that is stored on all portable data storage devices from unauthorised access, through the encryption of all portable devices and remote access personal computers. Other Control Measures 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 organisation s obligations under equality, diversity and human rights legislation are complied with. The Trust has undertaken risk assessments and Carbon Reduction Delivery Plans are in place in accordance with emergency preparedness and civil contingency requirements, as based on UKCIP 2009 weather projects, to ensure that this organisation s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with. Review of economy, efficiency and effectiveness of the use of resources The Trust produces detailed Annual Plans reflecting its service and operational requirements and its financial targets in respect of income and expenditure and capital investments. These plans incorporate the Trust s plan for improving productivity and efficiency in order to minimise income losses, meet the national efficiency targets applied to all NHS providers and fund local investment proposals. Financial plans are approved by the Board, after they have been assessed by the Finance and Investment Committee. 91

92 The in-year resource utilisation is monitored by the Board and its Committees through a series of detailed reports covering finance, activity, capacity, workforce management and risk. Monthly performance reviews are undertaken with each divisional and corporate team where their performance is assessed across a full range of financial and quality indicators, which in turn forms the basis of the monthly integrated performance report to the Board. The Trust is committed to the implementation of service line reporting and management as a way to assess and measure effective utilisation of resources. The Board is provided with assurance on the use of resources through a monthly report and the Finance and Investment Committee undertakes a more detailed monthly review. Reports are submitted to NHSI monthly and quarterly from which segmentation is assigned in line with the Single Oversight Framework (SOF). External auditors annually review the use of resources as part of their audit programme. Internal audit resources are directed to areas where risk is attached or where significant issues have been detected. Any concerns on the economy, efficiency and effectiveness of the use of resources are well monitored and addressed in a timely and appropriate manner. Information governance There have been two information governance serious incidents requiring investigation identified at the Trust in the year. These incidents were reported to the Information Commissioner s Office (ICO). One incident involved lost handover documents so patient confidentiality was breached. The other concerned records that were destroyed earlier than they should have been, so did not result in a breach of confidentiality. Full investigations were conducted and the results were presented to the Serious Incident Review Group. Final reports were submitted to the ICO and the incidents were closed as requiring no further action in March Annual Quality Report The Directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 to prepare Quality Report for each financial year. NHSI has issued guidance to NHS Foundation Trust boards on the form and content of annual Quality Reports which incorporate the legal requirements in the NHS Foundation Trust Annual Reporting Manual. The Trust s Quality Report priorities are selected following consultation with the Board, Council of Governors, clinicians and other relevant parties. Priorities that will require implementation over a period of years are carried forward into the following year, in addition to new priorities selected. The Chief Nurse is the executive lead for the Quality Report. The Trust s policies, procedures and clinical guidelines provide a robust foundation for and support the delivery of quality care. All policies, procedures and guidelines are stored on databases that are centrally coordinated to ensure the documents are kept upto-date and only current versions are available to staff. 92

93 Data collected to provide assurance of progress against priorities comes from a range of sources both internal and external. These include clinical audit, falls risk assessments, the Global Trigger Tool, performance metrics, and national patient and staff surveys. The data is used to provide the Quality Committee with quarterly reports on progress against the selected current year Quality Report priorities and to identify trends and any issues of concern. The Trust s Quality Report is shared with key stakeholders including the Council of Governors, CCGs, local Health Scrutiny Committees and Health and Wellbeing Boards, all of whom are invited to comment. The Quality Report for 2016/17 is subject to review by the external auditor. Review of effectiveness As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, clinical audit and the executive managers and clinical leads within the Trust who have responsibility for the development and maintenance of the internal control framework. I have drawn on the content of the Quality Report attached to this Annual Report and other performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Board, the Audit Committee, Finance and Investment Committee and Quality Committee, and a plan to address weaknesses and ensure continuous improvement of the system is in place. The Trust continually seeks to improve the effectiveness of its systems of internal control and put in place action plans to meet identified shortfalls. During the year, the Board has reviewed its governance arrangements and Committee structure, held reflective sessions on the conduct of each Board meeting, and tested and debated the sources and strengths of the various assurance mechanisms available to Board members, particularly with regard to assurance on quality. Board committees review their own performance and effectiveness and report the results to the Board. In addition, the Committee s minutes are presented to the Board together with a summary of their deliberations. Board meetings are open to the public and Audit Committee meetings are attended by nominated Governor Observers. Board Committees are chaired by Non-Executive Directors. The Board reporting cycle ensures that the Board receives regular reports from its Committees, monthly operational reports from Executives, quarterly Assurance Framework updates and planned half-yearly and annual reports on all issues regarding review, business and other operational issues, including compliance. The governance structure is as follows: The Board: The powers reserved to the Board are, broadly, regulation and control; appointments; strategy; business plans and budgets; risk management; financial and performance reporting and audit arrangements. 93

94 Audit Committee: provides assurance to the Board as to the effectiveness of the Trust s systems of governance and control across the full range of the Trust s responsibilities. It is authorised to investigate any activity within its terms of reference. It reviews the establishment and maintenance of an effective system of integrated governance, risk management, finance, counter-fraud, security management, and internal control across the whole of the organisation s activities, both clinical and non-clinical. It uses an assurance framework, internal and external audit reports, Board Committees work, assurances gained from the Board s business and the ability to question the Chief Executive regarding the Annual Governance Statement to support its work. The Committee undertakes an annual self-assessment of effectiveness and reports the outcomes of this to the Board in the Annual Report of the Audit Committee. Other Board Committees with a Controls Assurance Remit Finance and Investment Committee: the Finance and Investment Committee provides assurance to the Board but does not replace or remove the requirements for the Board to monitor financial, operational and workforce performance. The Committee provides scrutiny of such issues and makes recommendations to the Board to assist in decisionmaking. Specific areas scrutinised by the Finance and Investment Committee include financial planning, operational performance, agency expenditure, cash and treasury management, business case assessments, Estates and Informatics Strategies, and the delivery of efficiency and cost improvement programmes. Quality Committee: the Committee provides assurance that the Trust has an effective framework within which it can work to improve and assure the quality and safety of services it provides in a timely, cost-effective manner across business areas. This framework includes external validation and assessment; risk management; information governance; business continuity; clinical governance; health and safety; safeguarding children and vulnerable adults; and medicines management. The Committee assesses, reviews and monitors performance, internal control, risk management and assurance, external validation and assessment, annual reports and plans and national guidance and policy. Independent Review:The internal auditors have reviewed the adequacy of the controls and assurance processes in place. The Trust is committed to the continuous improvement of its risk management and assurance systems and processes, to ensure improved effectiveness and efficiency. My review is also informed by: Opinion and reports from Internal Audit, who work to a risk-based annual plan with topics that cover governance and risk management, service delivery and performance, financial management and control, human resources, operational and other reviews. The Head of Internal Audit Opinion for 2016/17 was as follows: Reasonable assurance can be given that there is a generally sound system of internal control, designed to meet the organisation s objectives, and that controls are generally 94

95 being applied consistently. However, some weakness in the design and/or inconsistent application of controls, put the achievement of particular objectives at risk. Opinion and reports from the Trust s external auditors. Quarterly performance management reports to NHSI. Department of Health performance requirements/indicators. Full compliance across all Care Quality Commission domains. Information governance assurance framework including the Information Governance Toolkit. Results of national patient and staff surveys. Investigation reports and action plans following serious incidents. Council of Governors reports. Clinical audit reports. Board Assurance Framework (BAF) The Trust has proactively recognised the need for ongoing development of the robustness of its systems of control and assurance and the monitoring of its risk registers and assurance framework to ensure they identify the changing impact and likelihood of risk and fully support the delivery of business objectives. During 2016/17, the BAF and governance processes identified key risks in the following areas: Financial sustainability. Workforce. System fluidity. No significant internal control issues and/or gaps in control were identified. Conclusion No significant internal control issues have been identified for the year ended 31 March 2017 and up to the date of approval of the annual report and accounts. Chief Executive 31 May

96 Quality Report 96

97 Part 1 Statement on Quality from the Chief Executive I am delighted to introduce the Quality Report/Account 2016/17 for Sussex Community NHS Foundation Trust (SCFT), which provides us with the opportunity to reflect on our quality achievements and successes over the last twelve months. It also allows us to identify areas where enhancements to quality can be made. This includes the agreed quality priorities for the coming year 2017/18. The Trust has continued to deliver effective, safe and efficient care for its patients throughout the year. High quality care is reinforced by an organisational culture that embraces the Trust s values - compassionate care, working together, achieving ambitions, delivering excellence - all of which are embedded within the Trust s appraisal system for staff. Additionally, the principle of working together is extended through collaboration with external health, social care and third sector organisations to enable the delivery of practical solutions to complex health and social care challenges. Evidence from the patient Friends and Family Test demonstrates that the services we provide are highly valued by our patients. This galvanises our commitment to ensure that the care we provide is not only of a high clinical quality, but also that patients have a positive experience of our services. We have revised our Patient and Carer Experience and Involvement Strategy to maintain and improve on this in 2017/18. Patient safety remains of paramount importance to the Trust. Throughout the year, the Board has received reports on a variety of patient safety metrics, several of which are included in this report. Trusts also learn from experience when things go wrong and we have strong governance, patient safety, incident reporting and patient experience systems that highlight areas for learning and improvement. In addition, the Trust has implemented a policy encouraging a culture of openness when things go wrong (the Duty of Candour). We also have an even more systematic and detailed method for logging information on incidents and investigating whistleblowing concerns (Freedom to Speak Up). Clinical audit and research has allowed us to measure our care against best practice leading to improvements in our services. Involvement in research has helped us to develop future treatment and improve our management of patients and their conditions. During the year, the Trust has: Met all of the quality standards set by the local Clinical Care Commissioning Groups (CQUINs) in year. Delivered the quality improvement priorities for 2016/17. Identified that 96% of those who responded to the Friends and Family Test during the year would recommend the Trust as a provider of care. Increased reporting of incidents whilst reducing harm, such as falls and pressure damage. 97

98 Improved participation in clinical research, contributing to improved clinical effectiveness and thereby patient outcomes and experiences of health locally, regionally and nationally. In line with national and locally identified areas where improvements to quality could be made, the Trust s Board of Directors and Council of Governors have agreed six new priorities and these are: information and awareness for parents on sepsis; patient information on discharge; psychological support tools for staff and caring for our staff so that they can care for others; vocational and volunteering opportunities for people with learning disabilities and underrepresented groups; establishing stronger links with external carer groups to ensure carers are supported; and making safeguarding personal by having an individualised approach to safeguarding. These priorities were proposed by stakeholders and staff following engagement events. Some of the priorities chosen are a continuation or extension of previous priorities. Examples include sepsis where last year we had a focus on adult services and this year we will focus on children s services. Similarly, last year we chose to focus Safeguarding on domestic abuse, whereas this year we are looking to improve our safeguarding processes and procedures to support Making Safeguarding Personal. As part of our continuous improvement journey, the quality improvement targets we have set ourselves are deliberately challenging; however, I am confident that, as in previous years, staff will rise to the challenges set in order to ensure SCFT s approach to quality continues to move forward. To support the objective of services moving from a CQC rating of "Good" (awarded in March 2015) to a rating of "Outstanding", the Trust has a five year Quality Improvement Plan (QIP), which clearly identifies the actions to be taken to improve quality and potentially enhance our CQC rating. We closely monitor our performance against this plan. On the basis of the process the Trust has in place for the production of the Quality Report/Account, I can confirm that to the best of my knowledge the information contained within this report is accurate. Siobhan Melia, Chief Executive 98

99 Part 2a Looking Ahead - Our Quality Priorities for Improvement in 2017/18 This section of the report outlines the annual key Quality Priorities outlined by the Trust to improve the quality of our services in 2017/18. We have developed our quality priorities in line with our long term Trust ambitions and Clinical Care Strategy which are based on patient safety, patient experience and clinical effectiveness. Stakeholder Engagement in Preparing the Quality Report/Account 2016/17 Clinicians, managers, support staff, Governors and Board members have all been invited to contribute to the 2016/17 Quality Report/Account, and identify priorities for improvement for 2017/18. External stakeholders who were invited to a workshop to discuss the development of the Quality Report/Account2016/17 included: NHS Healthcare Providers Brighton & Sussex University Hospitals NHS Trust East Sussex Healthcare NHS Trust South East Coast Ambulance NHS Foundation Trust Sussex Partnership NHS Foundation Trust Surrey and Sussex Healthcare NHS Trust Western Sussex Hospitals NHS Foundation Trust Healthcare Commissioners NHS Coastal West Sussex Clinical Commissioning Group NHS Crawley Clinical Commissioning Group NHS Horsham and Mid Sussex Clinical Commissioning Group NHS Brighton and Hove Clinical Commissioning Group NHS High Weald Lewes Haven Clinical Commissioning Group Other organisations Healthwatch - Brighton and Hove and East Sussex Healthwatch - West Sussex Crossroads 99

100 Carer Support - West Sussex Care for the Carers East Sussex Red Cross 100

101 Quality Priorities 2017/18 Safe Care Sepsis improve the availability of information and awareness around sepsis for parents Why have we chosen this? Improving the recognition and early treatment of sepsis is a national priority and last year we focussed on developing the tools and pathways to support early detection within clinical adult services. This year, we want to ensure that parents are informed about sepsis, and are provided with information on signs and symptoms including advice on what action should be taken. How will we achieve this? Clinical staff within Children s Services will receive additional training on sepsis so they can ensure this is communicated as part of the Making Every Contact Count initiative, where preventive information is shared with parents. In addition, information about sepsis will be provided in the Child Health Book. How will we measure this? We will measure our success using a survey of parents to understand if they feel informed and aware of sepsis. Safe transfer of care improve the information provided to patients on discharge to support a safe discharge and prevent unnecessary readmission Why have we chosen this? Improving safe transfers of care is a national priority and is part of the Safer Care Bundle, in which a structured process to improve patient flow in community hospitals and ensure patients are cared for in the right place for their requirements. Part of this work focusses on ensuring patients are discharged with the correct information for them and their carers to enable them to stay well cared for at home and prevent unnecessary readmission. How will we achieve this? As part of the Safer Care Bundle, we will review the discharge process checklist to align with best practice and develop patient advice and fact sheets, e.g. Your Care after discharge from hospital, that includes advice if things do not work as expected. How will we measure this? 101

102 We will measure this through the production of patient information, patient feedback and audit of discharge practice that will demonstrate patients have the necessary information to help them stay at home once discharged. Effective Care Making safeguarding personal an individualised approach to safeguarding adults within the Mental Capacity Act and Deprivation of Liberty Safeguards and ensuring the voice of the child is heard within the safeguarding children and young people process Why have we chosen this? Adults making Safeguarding Personal is an expectation contained within the Care Act 2014, placing a requirement that all providers of healthcare ensure individual wishes and expectations are taken into consideration to safeguard Empowerment, Proportionality, Protection, Partnership Working and Accountability towards those people being safeguarded. Children s Safeguarding hearing the voice of the child is paramount. Child centred safeguarding should be considered throughout all processes involving decisions that are deemed in the child s best interests. How will we achieve this? We will include the principles of Making Safeguarding Personal in our training and safeguarding supervision, including opportunities for learning from case reviews. We will review our processes to ensure people s wishes are heard. How will we measure this? Adults we will audit Section 42 enquiries, which establish whether action needs to be taken to prevent abuse or neglect, to ensure the principles of making safeguarding personal are evident and achieved where possible throughout the process. Children we will audit for the Signs of Safety and Strengthening Families, which is the international approach to ensure the voice of the child is evident throughout the decision making process. Staff well-being improving psychological support tools for staff and caring for our staff so that they can care for others Why have we chosen this? We recognise the importance of health and wellbeing for staff and the positive impact this has on delivering patient care. Psychological ill health is one of the top reasons for staff sickness absence and its effects can be far reaching for staff, their families and 102

103 colleagues. How will we achieve this? We plan to double our occupational health clinical psychology input from Aril 2017; the role has a dual focus, supporting the operational delivery of the staff health and wellbeing strategic actions around prevention and providing a more seamless referral and treatment route for staff who are unwell. How will we measure this? Measurements will be individual evaluation from 1:1 support; absence will be monitored and reported in relation to reduction in absence due to psychological ill health. Patient Centred Care Equality & diversity - improving vocational and volunteering opportunities for people with learning disabilities, autism and other socially marginalised groups Why have we chosen this? Employing people with learning disabilities, autism and other socially marginalised groups can support positive health outcomes; employment and a sense of belonging promotes individual independence, personal security and routine to people s lives and a sense of belonging; it builds confidence and provides the opportunity to make friends and build a social life. It can provide a largely untapped resource for an employer with a high proportion of people who want to work and also provide wider positive benefits to the community and economy. How will we achieve this? The Trust will increase the number of people with a learning disability, autism or from other socially marginalised groups who are in successful employment by a range of reasonable adjustments and positive action, including providing work placements, working interviews, job carving and other vocational opportunities. How will we measure this? We will see an increase in the number of people with a learning disability, autism or from other socially marginalised groups participating in Trust schemes to promote vocational opportunities, including those transitioning into employment, through placement and recruitment data. Carers - establishing our links with external carer groups to ensure carers are supported Why have we chosen this? The contribution of carers is growing and yet many carers struggle to get support from 103

104 health and care services, often seeing their own health and wellbeing suffer. Building on the success of our Carers Health Team, we want to ensure we support carers at a point of contact that meets their needs. Therefore, in addition to our support groups, we want to improve our links and presence with external carer groups to improve carer access to our health service expertise. How will we achieve this? We will develop formal links with local and national networks/groups that support carers and provide them with a direct contact into our services such as the Carers Health team and our Dementia Lead. How will we measure this? We will see an increase in the number of groups on which SCFT has a representative and seek carer feedback to ascertain the difference this has made for carers. All the priorities detailed above will be monitored quarterly by the Trust wide Clinical Governance Group and reported to the Board of Directors as part of the Quality Committee report. We will report on our progress against these priorities in our Quality Report/Account for 2017/18. Additional quality improvement goals are included in the Trust-wide Quality Improvement Plan available on our website: 104

105 Part 2b Looking Back - A Review of Quality Goals and Priorities for 2016/17 A Review of our Priorities for Quality Improvement in 2016/17 Table 1 summarises progress against improvement priorities set for 2016/17 in the 2015/16 report/account. Good progress has been made overall. Safe Care Sepsis in a community setting Expected Outcome There will be a reduction in the number of incidents reported relating to lack of recognition of sepsis. Pathways and guidance will be developed and implemented in practice to staff. A training course will be available to staff and staff in high risk areas will have been trained. What we said we d do We said we would: Design pathways and guidance for non-registered staff (using and adapting the Trust s sepsis guidance). Make adjustments to care pathways to reflect both community and bedded units. Promote awareness of sepsis at locality harm-free care meetings. Identify training needs, devise a training course and roll out a training programme. How did we do? Sepsis pathways for nursing staff (inpatient and community) and a traffic light recognition tool for other multi-disciplinary team (MDT) professionals and unregistered nursing staff have been developed and implemented in practice. A new template for incident reporting of sepsis has been developed and in place on the Data Information System (Datix). There have been no incidences of unrecognised sepsis this year to date; incident reports reflect increased staff awareness and recognition of sepsis and use of the sepsis pathways to inform clinical decision making.

106 Sussex Community NHS Foundation Trust Annual Report 2016/17 Deteriorating patient training (including recognition of sepsis) has been provided. This prioritised staff in inpatient units which had been identified as a key risk area. Deterioration awareness has also been incorporated into the resuscitation training. Safeguarding focussing on raising awareness of domestic abuse across Adult, Children s and Specialist Services Expected Outcome Safeguarding training will include identification and recognition of domestic abuse. Evaluation of training will show an increase in staff confidence in relation to domestic abuse recognition and escalation. What we said we d do Training in identification and recognition of domestic abuse will be included in mandatory and statutory safeguarding training. A domestic abuse toolkit will be available to staff as a resource to ensure effective signposting where domestic violence has been identified. The front page of the staff intranet will be used to raise awareness of domestic abuse. How did we do? Domestic Abuse awareness is integrated within all levels of safeguarding training for both adults and children. This includes the awareness of key indicators to recognise when dealing with both adults and child victims of abuse and action taken to support them. Bespoke and more in-depth training on domestic abuse is available to teams and this is undertaken by the safeguarding specialist nurses for both adults and children. Going forward, integrated adult and children safeguarding training will be delivered. Page 106

107 Sussex Community NHS Foundation Trust Annual Report 2016/17 Training statistics: Level Children Current % Target Adults Current % Target 1 100% 90% 100% 90% 2 100% 90% 98% 90% % 85% 88.2% 85% Domestic Abuse Toolkit - the Safeguarding Team has been working closely with the communications department to support easy access to the resources available and throughout the year has utilised front page banners on the staff intranet to alert staff to these. NICE Quality Standard QS116 Domestic Violence and Abuse A Multi Agency Working Action Plan is in place and being rolled out across the Trust in collaboration with key partner agencies as recommended by the quality standard. This includes: Creation of the Domestic Abuse Patient Care and Support Policy, which is being consulted upon prior to final approval and ratification. Review of the Human Resources policy in supporting staff who are victims or perpetrators of domestic abuse. MARAC (a MARAC is a regular local meeting to discuss how to help victims at high risk of murder or serious harm) guidance is published on the intranet. The safeguarding team receive police notifications (SCARFs) to identify risks to children living within an environment where Domestic Abuse has occurred and for staff visiting those areas within the community. Falls to further reduce the percentage of patients in our care who fall Expected Outcome The number of patients who fall within our care will be further reduced. This will be measured Page 107

108 Sussex Community NHS Foundation Trust Annual Report 2016/17 per 1,000 occupied bed days. What we said we d do Falls sensor devices will be evaluated for effectiveness, with recommendations for bedded units, which will be overseen by the Falls Prevention Steering Group, together with the revised falls risk assessment process that will trigger appropriate actions. How did we do? Falls are now measured per 1,000 occupied bed days (OBD). Whilst the total number of falls reduced only slightly from 433 to 427 for the same period April to November 2015/16 to 2016/17; falls with any harm fell from 93 to 60 (a 35% reduction) and falls with moderate harm reduced from 18 to 10 cases, representing 5.3/1,000 OBD. This is significantly below the target maximum rate of 7.5/1,000 OBD. A review of falls alert devices has been undertaken, including a scoping exercise and a trial of products in practice. Two separate devices of choice have been approved for use. A revised Falls Risk Assessment is in place and targets the key risk areas identified, namely: deterioration in patients medical condition; reduced cognition affecting patients ability to retain/follow guidance, e.g. using the call bell to summon help to mobilise safely; falls during independent mobilisation. The assessment is multi professional and integrated within medical, nursing and therapy documentation. Falls related to deteriorating patients have significantly reduced following implementation of training and increased medical input in falls risk assessment and care planning. Effective Care Patient Reported Outcome Measures (PROMs) relating to specialist services, e.g. diabetes pathway and leg ulcers Expected Outcome Page 108

109 Sussex Community NHS Foundation Trust Annual Report 2016/17 Outcome measures specifically relating to diabetes and leg ulcers will be established. Once established, these outcome measures will be reported on and care delivery effectiveness evaluated. This will be linked to patient satisfaction and experience feedback for the service. What we said we d do Patient reported outcome measures will be developed for the diabetes care pathway and for patients suffering from leg ulcers. How did we do? Nationally setting and measuring Patient Reported Outcome Measures is a challenge, especially in the community and SCFT is part of work to develop and pilot these indicators. During 2016/17, we focussed on two areas; diabetes and Leg ulcer management. Diabetes Patients using the Diabetes Care for You service are asked whether they were able to discuss their ideas and goals about the best way to manage their diabetes and if they felt confident in doing so. One of two means of service user feedback will be used, namely the PAID (Problem Areas In Diabetes) score and Diabetes Treatment Satisfaction Questionnaire, for which data will be collected data from March The first Diabetes Network Group took place on 21 December 2016, including stakeholders and patients to help shape Diabetes Care for You services. A further meeting is planned in April PROMS The proportion of people who report they discussed their ideas and goals about the best way to manage their diabetes Numerator The number of people who report a 4 or 5 star rating that they were involved as much as they wanted in their care and treatment Denominator The number of people who submit a patient experience questionnaire. Page 109

110 Sussex Community NHS Foundation Trust Annual Report 2016/17 The proportion of people who report they are confident to manage their diabetes The number of people who report they "definitely" feel confident to manage their diabetes The number of people who submit the patient experience questionnaire. Leg Ulcers Outcome measures specifically relating to leg ulcers have been added to the Friends and Family Test and distributed to SCFT Tissue Viability teams and leg ulcer clinic services for completion and return by service users. Questions focus on what matters to the patient enabling the service to evaluate the effectiveness of its care delivery, e.g. treatment options available; convenience of place of treatment; product choice and satisfaction around effectiveness of the treatment plan. Further work is under development to facilitate associated reporting and service evaluation. This is an area of work that is new and emerging and we will continue to develop this as part of our quality improvement journey. Autism Expected Outcome We will be actively involved with the development and implementation of a mobile app supporting effective diagnosis and improving the effectiveness and experience of the assessment process. Feedback from parents and professionals evaluating the impact of the mobile app on diagnosis will be positive. What we said we d do Working in collaboration with relevant specialists, parents, children and young people, we will actively support research to develop a mobile app that can be used by children, supporting effective diagnosis and improving the effectiveness and experience of the assessment process. Page 110

111 Sussex Community NHS Foundation Trust Annual Report 2016/17 How did we do? Work to develop a mobile app with parents and children to support more effective diagnosis of autism (research) continues. A medical student project is in progress to validate use in typically developing mainstream children. Feedback from school children and parents attending the clinic has been very positive. This will continue as part of the research and quality work stream. The development team presented a paper on the development of the app and early clinical experience with both clinician and parent feedback at the International Conference on Disability Virtual Reality and Associated Technologies, Los Angeles in September 2016 and subsequently received an international award for Best Short Paper. For further information see Complaints improve the response times for handling of complaints Expected Outcome Complaint response times will be reduced and the dissemination of learning from complaints will be enhanced. What we said we d do Develop a plan to regularly monitor and report on complaints to improve investigations and responses to ensure timely and robust learning is consistently achieved. How did we do? The performance indicator was included in the monthly Integrated Performance and quarterly Patient Experience Report to the Quality Committee. Complaint response times have improved significantly, meeting target response times since July Quarterly reports to the Trust-wide Clinical Governance Group and Quality Committee include a section on learning and actions from complaints. This is included in the Quality Governance Newsletter which is disseminated across the organisation to share ways we can improve our services. Page 111

112 Sussex Community NHS Foundation Trust Annual Report 2016/17 Risk Rating (NPSA) Target Response Time (working days) Q1 Average Response time % Response times met Q1 2016/17 Q4 Average Response time % Response times met Q4 2016/17 Level 1 15 days 25 days 25% 10.3 days 100% Level 2 35 days 55 days 26% 23.4 days 100% Level 3 60 days 79 days 27% 27.4 days 100% Patient Centred Care Patient Experience for vulnerable people, e.g. patients with learning disabilities and the development of a co-produced strategy Expected Outcome A revised patient experience strategy, produced in conjunction with users, will be published during 2016/17. There will be evidence of improvement in communications with patients, in particular those with learning disabilities. This will be measured through the Friends and Family Test and other patient and carer feedback mechanisms. What we said we d do The patient experience strategy will be reviewed and refreshed in co-production with patients, (including those with additional and specific needs) and patient advocates. The strategy will include, for example, means of improving patient information for those patients with learning disabilities. The Trust will engage appropriate specialists, patients and carers in this work. Page 112

113 Sussex Community NHS Foundation Trust Annual Report 2016/17 How did we do? Working together with patient representatives, staff and key stakeholders, we have refreshed our Patient Experience Strategy ( ), renaming it the Patient and Carer Experience and Involvement Strategy ( ). The strategy has three overarching ambitions, namely: Communication - we want to improve the way we communicate with our communities, and modernise the way we collect and respond to feedback. Working together - we want to make best use of feedback from patients and carers and to support people to work together improve our care and services. Excellent Compassionate Care - we want our patients and carers to have a positive experience, first time and every time they come into contact with our staff. FFT feedback has fallen during the year due to changes in the process and the move to a new contractor. This is now embedded. We have revised the methodology for collating patient feedback information and are now ready to embark on phase 2 of the project. Phase 2 of the Friends and Family Test methodology, which includes SMS text and voice activated messaging and online options for service users to respond, has been delayed. However, once introduced this is expected to further increase response rates. We have developed links with underrepresented groups, joining work around supporting equality and diversity with patient experience to ensure we hear from all people. This move has been positively received by members of the Patient Experience Group including independent advocacy, Healthwatch and patient members. Transition Planning for patients moving between and across services Expected Outcome A specific question will be added to our Friends and Family Test (FFT) asking patients to rate their experience regarding this specific aspect of their care. What we said we d do We will improve transition planning for children and young people with complex needs moving to adult services, or moving between services, with plans shared with all parties involved. Page 113

114 Sussex Community NHS Foundation Trust Annual Report 2016/17 How did we do? Transition assessment tool in place. Identifying health needs in transition tool has been developed. Pathways for children with different complex needs have been developed and are being piloted. A Trust-wide Transition Steering Group is in place, comprising adult and children s services and supported by additional working groups. NICE transition guidelines (published February 2016) have been benchmarked and local action plans approved and included in the Trust s Quality Improvement Plan, for implementation over the next two years. Productive collaborative working has commenced to engage with hospital providers and other agencies in the work. Feedback on transition across services is gained through parent feedback and formal feedback using FFT will be developed, enabling ongoing evaluation, specifically post transition from children s to adult services as the action plans are implemented. End of Life Care (EoLC) enhancing patient and carer experience Expected Outcome Additional tools will be included in training in end of life care for people with cognitive impairments and will be available as resources for staff. People identified as being at risk using the Frailty Tool will have an Advance Care Plan where appropriate. Feedback regarding EoLC will be consistently positive. What we said we d do We said we would: Improve the early recognition of people at the end of their life using the frailty tool. Ensure staff have the appropriate skills and training in order to deliver excellent care at the end of life to people with cognitive impairments such as dementia or learning disabilities. Page 114

115 Sussex Community NHS Foundation Trust Annual Report 2016/17 How did we do? Building on our work relating to end of life care, that was rated as Good or Outstanding by the CQC in our last inspection in 2014, we have worked to ensure care needs are identified early and care is personalised. We have developed Frailty training within the Trust to support the implementation of the Rockwood tool (Frailty risk assessment tool) in practice and this training is currently being rolled out to staff. Patients who are considered at risk following assessment receive advice and support, including the opportunity to write their own Advance Care Plan. An End of Life Care hub (ECHO) was launched in October 2016, providing a centralised, single point of access for patients, their loved ones and carers across Coastal West Sussex. ECHO coordinates care, takes and signposts enquiries to help people to reach the most appropriate care and support. The ECHO service is a unique partnership between SCFT, Acute Trusts and specialist palliative care providers and key to the service is the development of an Electronic Palliative Care Coordination System that maintains the Palliative Care register, in conjunction with a single multiple agency patient-centred health care record. Feedback is gathered through the Friends and Family Test and structured feedback interviews being conducted to assess the ECHO end of life care hub. Initial attempts at gaining feedback post bereavement proved difficult as relatives were reluctant to be approached for feedback. As a result no feedback attempts will be made until 6 months post death. Our training programme includes: Promotion and education on utilising the ECHO service to Communities of Practice Study day on End of Life Care for people with learning disabilities. Training on the redesigned Care Plan for the dying person delivered to Communities of Practice team. Changes to the delivery of Verification of Expected Death training throughout the Trust will include a clinical OSCE aspect to training, ensuring theory and practical training. Delivery of training on Allow a natural death/dnacpr delivered to doctors and senior staff in inpatient units Page 115

116 Sussex Community NHS Foundation Trust Annual Report 2016/17 Bespoke needs based education delivered to individual community nursing teams. Development of End of Life Care education session within the Dementia Education programme and delivered across the Trust The early recognition of people at the end of their life will continue to be a focus for us as part of our quality improvement journey. Duty of Candour (DoC) Sussex Community NHS Foundation Trust remains committed to developing a culture of openness and candour, dedicated to learning and improvement and constantly striving to reduce avoidable harm. To encourage an open culture of reporting and learning from incidents across the NHS the first national learning from mistakes league was published by the Department of Health in March SCFT was ranked outstanding and was in the top 10 Trusts (out of 230) in England for openness and transparency and our ability to learn from mistakes. Open and effective communication with patients begins at the start of their care and continues throughout their time within the healthcare system. This includes communications with patients and/or family members/carers if a patient has been involved in an incident, complaint or claim ensuring that patients, (their carers or family) receive an appropriate apology, are kept informed of the investigation, given the opportunity to participate, ask questions and are advised of the investigation outcomes and findings. Rigorous reporting of patient safety incidents is fundamental to an open culture. Activities SCFT has undertaken during 2016/17 to enhance duty of candour application standards include: Implementing a tracking facility relating to duty of candour communications on the Trust s incident reporting database - this ensures we can report against the standard and also supports continuity and consistency of SCFT staff contact with patients and carers. Holding a workshop for all levels of staff to share experience of applying duty of candour, highlighting any barriers or concerns and providing support and guidance to help staff to improve. The development of training resources and supportive guidance for staff. Page 116

117 Sussex Community NHS Foundation Trust Annual Report 2016/17 As part of our continuous improvement journey, we will repeat the audit of standards of Duty of Candour implementation in 2017/18 to ensure we have embedded the learning from 2016/17. Sign Up To Safety SCFT remains committed to the five Sign up to Safety pledges which are incorporated with the Trust s overarching approach to quality improvement namely: Putting safety first Continually learn Be honest Collaborate Be supportive SCFT is engaged in various local and national initiatives to improve the safety and quality in our services and share the learning with others. Examples of this include: Kent Surrey and Sussex Academic Health Science Network Patient Safety Collaborative work streams such as falls prevention, pressure damage and sepsis. Through this, SCFT secured funding to improve the prevention of falls, one of its quality priorities. Local Workforce Area Board that supports initiatives to improve the workforce. SCFT has secured funding to develop a Clinical Skills Hub to improve access and competencies across providers. Continued use of the validated tool Sit & See to identify best practice and areas for improvement in relation to compassionate care. Engagement of our Governors and Non-Executive Directors on internal assurance visits. Harm Free Care meetings where frontline clinicians and managerial staff meet to discuss safety initiatives, review all incidents reported over the previous month and share learning. Page 117

118 Sussex Community NHS Foundation Trust Annual Report 2016/17 Taskforce and steering groups that champion quality improvements and include a strong emphasis within SCFT on prevention to ensure, wherever possible, harm is prevented as well as reduced. Ensuring Safeguarding is embedded in everything we do to ensure we have the right training and tools to support staff to respond appropriately to Domestic Violence, vulnerable adults, children and young people, people who lack capacity to make an informed decision and PREVENT which is about safeguarding people and communities from the threat of terrorism. Central Alert System The Department of Health (DH) Central Alert System (CAS) is designed to rapidly disseminate important safety and device alerts to nominated leads in NHS Trusts in a consistent and streamlined way for onward transmission to those who need to take action. Trusts are required to acknowledge receipt of each alert and respond as relevant within specified timescales. Table 2 shows SCFT consistently achieving requirements in 2016/17 Table 2: Summary of SCFT responses to CAS Alerts received annually since 2016/ / / /17 Total number of alerts received Acknowledged within 2 working days 157 (99%) 132 (100%) 139(100%) Found to be applicable to SCFT 11 (7%) 33 (25%) 41 (29.4%) Applicable alert responses within prescribed timescales 11 (100%) 33 (100%) 41 (100%) Source: SCFT Safety Alert System Datix/Safeguard system) All safety alerts are discussed through the relevant governance forum to seek assurance that appropriate action has been taken in response to alerts. SCFT has representation on the NHS Improvements national patient safety advisory panel which provides expert stakeholder input into the advice and guidance to improve safety and reduce risk across the healthcare system. The panel activity is Page 118

119 Sussex Community NHS Foundation Trust Annual Report 2016/17 supporting a general review of the approach and response to the National Patient Safety Alerting System (NaPSAS). Care Quality Commission (CQC) SCFT is required to register with the Care Quality Commission. The Trust has 14 registered locations and is registered to carry out the following regulated activities: Nursing care Family planning services Treatment of disease, disorder or injury Surgical procedures Diagnostic and screening procedures The Trust was inspected in December 2014 under the Chief Inspector of Hospitals regime. Four groups of services were inspected: community health inpatient services; community health services for adults; community health services for children young people and families and end of life care. The inspection focused on the five key questions: Are services safe? Are services effective? Are services caring? Are services responsive? Are services well led? In March 2015, England s Chief Inspector of Hospitals rated the Trust as Good for each domain and achieved an overall rating of Good. End of life care was rated Outstanding for responsiveness. Page 119

120 Sussex Community NHS Foundation Trust Annual Report 2016/17 A number of strengths were highlighted in the report. These included our caring and compassionate services; Trust leadership, staff engagement and culture; and the Trust s detailed vision and strategy to meet the needs of the communities we serve. An area for improvement was patient safety in inpatient units in relation to reducing the incident of missed medication and standardised record keeping and the Trust developed an action plan to improve the quality of these services. These actions were incorporated into the overarching Trust Quality Improvement Plan and progress on them is reported quarterly through the Trust Wide Clinical Governance Committee and the Quality Committee to the Board. The Trust continues to improve patient safety through progress in areas such as, Harm Free Care that includes a reduction in missed medication doses by adapting and implementing a Medicines Safety Thermometer to focus staff attention and track progress as practice improves. In addition to the work around standard records, we recently developed an integrated medical, nursing and therapy inpatient record to reduce unnecessary duplication for the patient and the clinician and ensure the patient record is holistic and individualised. The Trust undertakes proactive internal Assurance Reviews to self-assess its service user, visitor and staff safety; clinical effectiveness; and service user experience against the CQC outcomes. Any areas identified for improvements are followed up ensuring remedial actions are completed. Page 120

121 Sussex Community NHS Foundation Trust Annual Report 2016/17 Part 2c Mandatory Statements relating to the Quality of NHS Services Provided Statements of Assurance from the Board During 2016/17, Sussex Community NHS Foundation Trust provided and/or subcontracted over 100 relevant health services. SCFT has reviewed all the data available on the quality of care in these relevant health services. The income generated by the relevant health services reviewed in 2016/17 represents 84.1% of the total income generated from the provision of relevant health services by SCFT for 2016/17. Clinical Audit (National and Local) and National Enquiries Clinical audit measures the quality of care and services against agreed standards, and suggests or makes improvements where necessary. During 2016/17, five national clinical audits and national confidential enquiries covered relevant health services that SCFT provides. During that period SCFT participated in 100% of national clinical audits and national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible and relevant to participate in. The national clinical audits and national confidential enquiries that SCFT was eligible to participate in during 2016/17 are as follows: National Audit of Dementia (pilot) National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis. Sentinel Stroke National Audit Programme (SSNAP). National COPD Audit Page 121

122 Sussex Community NHS Foundation Trust Annual Report 2016/17 The National Audit of Intermediate Care (NAIC). (Audit did not run during 2016/17.) The national clinical audits and national confidential enquiries that SCFT participated in, and for which data collection was completed during 2016/17, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. National Clinical Audits and National Enquiries 2016/17 Participatio n % Cases Submitte d National Audit of Dementia (pilot) 40 N/A National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis. 34 N/A Sentinel Stroke National Audit Programme (SSNAP). 92 N/A National COPD Audit 95 Tbc National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) 20 N/A We participated in one National Confidential Enquiry into Patient Outcomes and Death (NCEPOD). As part of this, a review was undertaken on 20 case notes. The age range for these patients was from 104 to 59 years, with the average age being 79.3 years. There was an equal mix of review completed by both doctors and nursing staff. The length of stay varied from 4 days to 4 months. Most of the admissions were during day time but a third still occurred after 2000 hrs. When reviewed, the spread and number of deaths in different in - patient unit did not identify a common theme. Death was anticipated in all cases and it was not avoidable in any of the cases. National audit reports that were published during 2016/17 and relevant to SCFT services were reviewed by SCFT and examples of actions SCFT has taken in response to national audits are summarised below. Page 122

123 Sussex Community NHS Foundation Trust Annual Report 2016/17 The reports of three national clinical audits were reviewed by the provider in 2016/17 and SCFT intends to take the actions tabled below to improve the quality of healthcare provided. Examples of actions taken in response to National Clinical Audit / Confidential Enquiries outcomes Title Chronic Obstructive Pulmonary Disease (COPD) Audit (Royal College of Physicians) Actions Providing early supportive discharge pathways. Developed and implemented admission avoidance programmes linked to case finding and enhanced case management for patients at particular risk of hospital admission. Improved end of life care planning. National Audit of Unstageable Pressure Ulcers (Tissue Viability Society) There were no specific recommendations following the national audit, however SCFT undertook their own internal clinical audit and deep dive review and identified the following actions: a revised approach to incident reporting of unstageable Pressure Damage to enable outcome monitoring; and bespoke advice on the prevention of pressure damage on heels accessible via the intranet. National Audit of Dementia (pilot) Learning from the national audit demonstrated that; The Butterfly scheme is effective in supporting staff to respond appropriately to people with dementia and SCFT has implemented this scheme across all inpatient units. The evidence that an education programme is key to changing practice and SCFT has developed and implemented a 3 tier programme in line with the National Skills Framework. Enhancing the environment is essential to providing a care setting conducive to people with a cognitive impairment and SCFT has developed and implemented a Dementia Friendly approach to the Page 123

124 Sussex Community NHS Foundation Trust Annual Report 2016/17 care environment, with murals in key areas such as day rooms. SCFT has identified seven National audits scheduled to occur in 2017/18 where SCFT will be eligible and appropriate to participate. Audit Type Falls and Fragility Fracture Audit Programme Learning Disability Mortality Review Programme (LeDeR) National Chronic Obstructive Pulmonary Disease Programme (COPD) National Diabetes Audit -adults National Heart Failure Audit Sentinel Stroke National Audit Programme National Audit of Intermediate Care There were 30 audits listed on the SCFT Trust Wide (local) Clinical Audit plan. The outcomes of local clinical audits are overseen by the Clinical Effectiveness Group and some examples are included below. Audit Description Healthcare Records Audit Includes compliance with standards relating to; Health Records, Information governance, core standards and Clinical best practice Outcomes and recommendations Records show that holistic assessment, individualised care planning and appropriate clinical care are delivered in the majority of cases. Areas for improvement included; Continued roll out of standardised mental health assessment and specific care planning around reduced cognition. These Page 124

125 Sussex Community NHS Foundation Trust Annual Report 2016/17 actions fit with ongoing improvements to support mental health in physical health services. Transfer Information Discharge from SCFT services in the majority of cases is planned and takes place following a multi-disciplinary care planning/review meeting in accordance with the service pathways protocols and procedures. The planning actively incorporates the views of patients and their family and carers. Areas for improvement included a formal review of SCFT Admission, Clinical Handover of Care and Discharge of Patients Policy and continued focus on the Safer Care Bundle. A list of audits undertaken is included in appendix 1 at the end of this report/account. There are 20 trust wide audits currently listed on the 2017/18 schedule which were approved by the Quality Committee in March Research SCFT recognises that clinical research is central to the NHS. It is through research that the NHS is able to offer the best treatments and services and improve people s health. Organisations that take part in clinical research are actively working to improve treatments, intervention and services offered to patients. Participation in clinical research in SCFT gives patients access to the latest treatments in development and improves clinical effectiveness. The number of patients receiving relevant health services provided, or subcontracted, by SCFT in 2016/17 that were recruited during that period to participate in research approved by a research ethics committee was 562. In addition, 41 carers and 102 clinical staff and health professionals were recruited to studies approved by the Health Research Authority, making a total of 705 participants to 27 studies. Page 125

126 Sussex Community NHS Foundation Trust Annual Report 2016/17 Twelve research studies involved adult services encompassing palliative care, neurological and psychological services and specialist community nursing services, including bladder and bowel, dementia and community inpatient services. We undertook thirteen studies in children s services involving rehabilitation and child development services and paediatric dental services. Figure 1 below shows those clinical services involved in research and the respective number of participants. Figure 1 Clinical Services and number of participants Involved in Research 2016/17 SCFT staff successfully applied for seven grant funding awards either as the Chief Investigator or as a co- applicant, amounting to a value of over 844,000. Dr Sarah Crombie and Dr Will Farr attained nationally competitive British Association of Childhood Disability-Castang Fellowship awards to develop future research leaders in childhood neurodisability. Outputs and impact of research work and activity SCFT s increasing participation in clinical research is contributing to improving clinical effectiveness in the Trust and building research capacity and infrastructure to support clinical and health service research. The Trust continues to build research capacity with a growing number of staff leading research studies as chief investigators, as co-applicants on research grants, and as site principal investigators leading the implementation of our research studies. This growth is reflected in increasing publications both as a lead or co-author, Page 126

127 Sussex Community NHS Foundation Trust Annual Report 2016/17 conference presentations and awards received by SCFT research staff. See Appendix 2 for more information on our research activity, which includes 15 published articles, 13 published conference abstracts written, or contributed to by SCFT research and other staff and 26 incidents where staff were invited to present research findings as an invited speaker or through poster presentation. Our dissemination demonstrates our commitment to improving patient outcomes and experiences across health and social care locally, regionally and nationally. Commissioning for Quality and Innovation (CQUIN) A proportion of Sussex Community NHS Foundation Trust s income in 2016/17 was conditional on achieving quality improvement and innovation goals agreed between SCFT and any person or body they entered into a contract, agreement or arrangement with for the provision of relevant health services, through the Commissioning for Quality and Innovation payment framework. Page 127

128 Sussex Community NHS Foundation Trust Annual Report 2016/17 Within its contract with the main CCGs, the following schemes were agreed for this year and next: Patient Safety 2016/ /18 Improving patient care and flow- Safer Care Bundle to support safe discharge and transfer Increase Abdominal Aortic Aneurysm Screening Programme uptake and screening uptake and improve access for hard to reach groups School Aged Immunisation Programmes Develop an action plan to increase uptake for school aged immunisation programmes outside of primary care Supporting proactive and safe discharge Preventing ill-health by risky behaviours alcohol and tobacco Patient Experience Patient Activation and Collaborative Care Planning :Develop knowledge and confidence needed for patients to self-manage long term conditions and improve their outcomes and experience Develop and implement improvement plans that support the delivery of integrated care across organisations for specified pathways Specialised Commissioning of Communication Aids Augmentative and Alternative Communication (AAC) - demonstrate patients have access to information, receive timely assessment and treatment; and learning is shared with other national providers Personalised care and support planning Clinical Effectiveness Page 128

129 Sussex Community NHS Foundation Trust Annual Report 2016/17 Introduction of staff health and wellbeing initiatives Quarterly Highlighting of Unimmunised to GP Practices- Introduce an improved alert system to GPs to increase uptake Improving the assessment of wounds that have failed to heal/ Further details of the agreed goals for 2016/17 and for the following 12 month period are available electronically at: The CQUIN schemes continued to attract 2.5% income in 2016/17, equating to approximately 3,000,000, compared with 2015/16 where the core contract equated to 3,009,000, with additional NHS England funding for specialist and public health schemes of 374,000, with SCFT receiving the full value. CQC Sussex Community NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is GOOD. In addition, SCFT has no conditions on its registration and the CQC has not taken any enforcement action against SCFT during 2016/17.SCFT has not participated in any special reviews or investigations by the Care Quality Commission relating to the following areas during 2016/17. However, Ofsted and the Care Quality Commission (CQC) conducted an inspection in summer 2016 to judge the effectiveness of the local area of Brighton and Hove in implementing the disability and special educational needs reforms as set out in the Children and Families Act The report noted that children and young people in Brighton and Hove, who have special educational needs and/or disabilities, benefit from strong support from the health service, for example, health passports ensure that practitioners are aware of children and young people s needs, and how to communicate with them. In addition, families were very positive about the specialist dental and continence services run by SCFT. Page 129

130 Sussex Community NHS Foundation Trust Annual Report 2016/17 Parents consistently reported that the impact of services provided improved the lives of children and young people who have special educational needs and/or disabilities and their families, particularly for families with children or young people who require a health plan. Inspectors reported excellent delivery of the healthy child programme, with all statutory visits for the under-five population taking place, with robust arrangements in place ensuring all new families moving into Brighton are visited, meaning that families with children who are not meeting their early milestones are identified in a timely manner. Inspectors noted that the robust health screening available supports early identification, for example, of infants having, or likely to have, special educational needs and/or disabilities, where immediate referral is made to the Seaside Child Development Centre, meaning that timely support is offered from the specialist health visitor both prior to and after birth. The hearing screenings for new-born babies, carried out by midwives are similarly effective, ensuring children who have hearing difficulties gain early access to more specialist assessments. Parents were positive about the specialist advice and support they receive during this early period of diagnosis. Inspectors reported that practitioners work in a cohesive and flexible way to meet the needs of families, children and young people, including through multi-disciplinary assessments. Inspectors noted that SCFT school nurses act effectively on information gathered through health questionnaires for children in their first year of primary or secondary school and that where necessary, well-coordinated healthcare plans are drawn up to support individual children s identified needs, with the plans being discussed appropriately with parents and school staff. The full report and recommendations can be found at: nt_local_area_send_inspection_in_brighton_and_hove.pdf The Trust is expecting a CQC inspection in Quarter 2, 2017/18. Page 130

131 Sussex Community NHS Foundation Trust Annual Report 2016/17 NHS Number and General Medical Practice Code Validity SCFT submitted records during 2016/17 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data. See Tables 3 and 4 below. SCFT submitted records during 2016/17 to the Secondary Uses service for inclusion in the Hospital Episode Statistics, which are included in the latest published data. Table 3: The percentage of records in the submission file that included the patient s valid NHS number between 2014/15 and 2016/17*. 2014/ / /17* For admitted patient care 100% 99.6% 99.9% For outpatient care 99.8% 99.8% 99.9% For accident & emergency care 99.3% 81.0% 88.8% Source: Latest published Secondary User Service data* up to Month 12/March 2017 Table 4: The percentage of records in the submission file that included the patient s valid General Medical Practice Code between 2014/15 and 2016/17*. 2014/ / /17* For admitted patient care 99.3% 99.5% 99.5% For outpatient care 99.3% 99.4% 99.4% For accident & emergency care 100% 91% 97.1% Source: Latest published Secondary User Service data* up to Month 12/March 2017 Information Governance Assessment Report Sussex Community NHS Foundation Trust s Information Governance Assessment Report overall score for 2016/17 was 77% and was graded green, indicating a satisfactory score. However we are still taking measures to improve this, such as exploring different approaches to learning and sharing such as case studies, to enhance staff understanding. This compared to 76% in 2015/16. Page 131

132 Sussex Community NHS Foundation Trust Annual Report 2016/17 Payment by Results SCFT was not subject to the Payment by Results clinical coding audit during 2016/17 by the Audit Commission Data Quality The table below sets out the trust s four strategic objectives for data quality and associated actions for the period 2014/19. Objective Further Information Actions To enable data to be generated as close to at source as possible. Data quality is best when it is captured directly by the person who performs the activity, at the time the activity takes place. Deployment of a new clinical information system throughout the trust, enabling staff to record accurate, timely and complete data against the patient record. Roll out of a mobile working solution to community-based staff, significantly improving data quality by enabling data to be recorded wherever possible at the point of patient contact. Page 132

133 Sussex Community NHS Foundation Trust Annual Report 2016/17 To ensure continuous improvement occurs in the quality of data. To ensure that data collection and use is matched to business requirements. Ensure all staff are actively aware of the importance of data quality and understand their responsibilities for data quality in relation to their services. Ensure staff have the tools to enable them to monitor and improve their own performance. Ensure that staff are trained and supported to use electronic data capture. Sometimes data is collected but not used effectively, for instance poor quality data may render it useless; it may be collected for historical reasons but no longer used; it may duplicate other Raise awareness of data quality via management awareness days, intranet, user groups, and increased use of Business Intelligence (BI) tools and data quality reports. Provide feedback to managers and leaders on data quality in relation to recorded activity and key performance indicators captured via electronic systems. Develop and promote use of dashboards and self-serve reporting to empower staff to review and make corrections to data for their services. Develop standard operating procedures and provide a range of training options and materials, tailored to service and staff roles, to support staff in the use of all trust IT systems. Includes: formal and refresher training for clinical information systems; basic computer skills training; understanding of data and use of BI tools; e-learning and self-teach; inbuilt help and access to Frequently Asked Questions (FAQs). Work with commissioners to ensure that service specifications only contain relevant and measurable activity and key performance metrics. Work with services to develop metrics that add value and provide meaningful ways of evaluating quality of service. Continuously review data captured Page 133

134 Sussex Community NHS Foundation Trust Annual Report 2016/17 System changes must be communicated in an effective and timely manner to ensure those collecting data are as informed as possible. data; it may be badly analysed and presented. The trust will devise and document a robust change control process in a new policy. and reported to ensure that it remains appropriate, meaningful, relevant, timely and accurate. A change advisory board meets weekly to discuss and approve any system changes. All clinical changes are directed to the clinical information assurance group for ratification. Reporting Against Core Indicators Since 2012/13 NHS trusts have been required to report performance against a core set of indicators using data made available to the trust by the Health and Social Care Information Centre (HSCIC). These are set out below, together with SCFT performance. The core indicators relevant to community services appear below. Hospital Readmissions (Indicator 19) The percentage of patients aged: (i) 0 to 15 and (ii) 16 or over readmitted to a hospital which forms part of SCFT within 28 days of being discharged from a hospital which forms part of the trust during 2016/17. SCFT does not have any hospital inpatient units for children and young people The table below shows community hospital readmission numbers and % readmissions within 28 days of discharge, by quarter for 2016/17. These figures include our 16 bedded units on 11 different community sites. Page 134

135 Sussex Community NHS Foundation Trust Annual Report 2016/17 Community Hospital Readmission numbers and rates for SCFT bedded units at end of 2016/17 Apr Sept 2015 Oct 15 Mar Apr Sept 2016 Oct 16 Mar No of readmissions within 28 days of discharge Total number of discharges % readmissions within 28 days of discharge ,592 1, ,059 1,920 3, % 11.84% 10.34% 10.93% 8.13% 9.60% Source: Sussex Community On-Line Analysis and Reporting (Scholar). SCFT considers that this data is not a useful indicator in relation to demonstrating the quality of community services. The number of readmissions is approximately 10%. This is indicative of the increasing frailty of the group of patients admitted to community inpatient beds and is a reflection of the aging population serviced by the trust. SCFT aims to support as many people as possible to return to their own home. However, the increasing dependency of these patients sometimes means that discharge is not successful, requiring readmission to a community hospital. This often serves to prevent further deterioration of a patient s health that may otherwise require admission to an acute hospital. We recognise that there are some current variations within our hospitals as to recording discharges and readmissions, for example where patients transfer to acute hospitals for short periods for tests and investigations and then return to the community hospital. This accounts for a proportion of the readmissions indicated in the table, but due to legacy systems it s not possible to give an exact percentage. The Trust intends to improve the quality of its services by undertaking additional work to further review this information in order to establish a clearer understanding of the reasons for readmissions and how this can be improved. Page 135

136 Sussex Community NHS Foundation Trust Annual Report 2016/17 Incident Reporting SCFT remains committed to establishing and implementing a culture that consistently monitors and reviews incidents and near miss events that result in, or have the potential to result in injury, damage or loss to ensure; the safety of patients, staff (including volunteers and contractors) and the public; and the delivery of quality patient centred services, which achieve excellent results and promote the best possible use During 2016/17 there were a total of 7,862 incidents reported on the SCFT risk management system; this was in comparison to 6,672 reports during 2015/16. A high level of reporting typically demonstrates a commitment to an open and transparent culture and a strong organisational ethos of patient safety, where staff are engaged in reporting and that reporting is acted upon and monitored. This is particularly notable as SCFT switched reporting systems during the year, which can often result in a reduction in reporting; however we sustained and improved our reporting in this period. Additional triage and review processes have been introduced during the year, which have supported our understanding that the higher levels of reporting are indeed linked to a good safety culture and not linked to an increase in safety concerns. Patient Safety Incidents (Core Indicator 25) This indicator measures the number and, where available, the rate of patient safety incidents that occurred within SCFT during 2016/17, plus the number and percentage of patient safety incidents that resulted in severe harm or death. The data in table 5 is extracted from information supplied by National Learning and Reporting System. Given the significant variation in service provision and contract specifications by different Community Trusts, SCFT has shown for comparison two Community Trusts with the highest and lowest number of patient safety incidents reported. Table 5 shows national comparisons with the highest and lowest numbers of incidents reported by eighteen NHS Community Trusts submitting data over the same reporting period. Page 136

137 Sussex Community NHS Foundation Trust Annual Report 2016/17 Table 5: Comparative incident reporting data for community Trusts April 2015 to September 2016 Indicator Performance 2015/ / /17 Q1 & Q2 Q3 & Q4 Q1 & Q2 Number of Incidents reported SCFT 1,778 1,194 1,165 National Av 1, ,825 Highest 5,344 5,866 5,190 Lowest Severe PSI (Number of incidents reported) SCFT National Av Highest Lowest Severe PSI (% of incidents reported) SCFT National Av Highest Lowest Death PSI (Number of incidents reported) SCFT National Av Highest Lowest Death PSI (% of incidents reported SCFT National Av Page 137

138 Sussex Community NHS Foundation Trust Annual Report 2016/17 Highest Lowest Death/Severe PSI (Number of incidents reported) SCFT National Av Highest Lowest Death/Severe PSI (% of incidents reported SCFT National Av Highest Lowest Source: NRLS website The rate of incidents per 1,000 occupied bed days metric is no longer used by Community Trusts for the following reason: The NRLS cluster group for NHS Community trusts was created following the formation of new NHS organisations as a result of the Transforming Community Services programme. Due to structural changes within these organisations, with many no longer having inpatient alongside diverse services; mean this cluster cannot be described as a homogenous group. We have been aware for some time that due to the variation in services provided by organisations within the NHS Community trust cluster, reporting rates have either not been calculated, or do not fully reflect your organisation s reporting culture. A comparative reporting rate per 1,000 bed days is not appropriate within this cluster and comparing all community trusts based on this rate will be misleading. For the March 2017 release, no reporting rate will be calculated for this cluster in the OPSIR workbook and the comparative reporting rate chart generated by the Explorer tool in the PDF report has been removed. This may change in the future as we look at a more appropriate method for comparing NHS community organisations. (Explanation sent via entitled, NRLS Information Update: Changes to the Page 138

139 Sussex Community NHS Foundation Trust Annual Report 2016/17 Organisation Patient Safety incident reports (OPSIR) for NHS Community Trustsfrom NHS IMPROVEMENT - T1520, dated ). SCFT considers that this data is as described for the following reasons: the overall number of reported patient safety incidents sits within range of other community trust providers. The stable level of SCFT reporting indicates a consistent trust wide approach to reporting standards. We recognise the reduction in total incidents reported during Quarters 3 & /16 to NRLS; this was associated with the implementation of a more robust scrutiny process and triage to reduce duplication of incidents and correct incidents erroneously attributed to SCFT that occurred outside of our care. This system also supports timely flagging of any patient harm incidents to senior clinicians, thereby ensuring oversight of patient safety. SCFT intends to continue to closely monitor this metric within quarterly reports. The low level of harm demonstrates SCFT's ongoing commitment to strengthen the delivery of harm free care, sustaining and building on previous successes in reducing pressure damage and falls incidents. SCFT intends to continue to provide ongoing analysis of incident reports through Harm Free Care meetings and clinical governance committee structures enabling both local and trust wide shared learning alongside the development and promotion of quality improvement initiatives. In July 2016 SCFT introduced a new electronic risk reporting system (Datix). Despite the inevitable challenges of introducing a new system there was no impact in the level of reports submitted during the transition period. Further opportunities for sharing lessons learned and best practice have included; Immediate changes to practice implemented in the relevant service. Locality governance meetings and cascade of information and knowledge from these meetings to relevant teams. Trust Wide learning and changes through the Trust Wide Clinical Governance Group. Promotion of lessons identified including themes, through information pages on the Trust intranet, clinical governance newsletters and the Trust s weekly update newsletter. Patient stories in relation to Serious Incidents presented at the board on a quarterly basis. Page 139

140 Sussex Community NHS Foundation Trust Annual Report 2016/17 SCFT is required to report all Serious Incidents (SIs) onto the national Strategic Executive Information System (STEIS) and to our Clinical Commissioning Groups (CCGs) in line with the NHS England Serious Incident Framework. All Serious Incidents are investigated to establish their root cause and contributory factors and to identify actions and learning to reduce, where possible, the likelihood of a re-occurrence. All SI reports are scrutinised and approved by the Trust s Serious Incident Review Group to ensure consistency, identify trends and themes and enable trust wide improvement from lessons identified. The approved reports are then submitted to the CCG for external scrutiny. The Trust remains compliant with this obligation and has consistently worked within the agreed timeframes. In 2016/17, 39 SIs were raised, 4 of these have been downgraded by the CCG, leaving a total of 35. This is in comparison to 2015/16 year where 56 SI s were reported; six downgraded leaving a total of 50. At the time of this report 11 of the 39 incidents are currently under investigation. Fig. 2 shows a breakdown of the top seven SI categories reported during 2016/17 in comparison to those reported in 2015/16. There were (15) falls-related SIs declared during 2016/17, this is in comparison to 24 falls-related SIs declared in 2015/16. There was also a reduction in both category three and category four declared pressure damage. There were three delayed treatment incidents which included a potential delay in management of sepsis which was subsequently downgraded as it was established this was not the case. Page 140

141 Sussex Community NHS Foundation Trust Annual Report 2016/17 There was an increase in delayed diagnosis SIs, two of which related to the delayed diagnosis of fractures. A third case related to a potential missed opportunity for ongoing referral following an incidental finding during ultrasound scanning for Abdominal Aortic Aneurysm (AAA) screening. However, the subsequent investigation established this was not case and this was supported by the external review of events by the AAA Programme Board (managed by Public Health England (Screening and Immunisation)). SCFT therefore requested the CCG to downgrade the incident from SI status. There was one medication serious incident declared which related to an administration error. Actions plans in response to Serious Incident learning are developed from all investigations. Assurance that these are implemented is monitored by the Trust wide Clinical Governance Group. Page 141

142 Sussex Community NHS Foundation Trust Annual Report 2016/17 Part 3 Other Information In this section we will report on the quality of services we provide by reviewing progress against indicators for quality improvement, and feedback from sources such as incident reporting, service user and staff feedback. We have included indicators that we know are meaningful to our staff, our Council of Governors, commissioners and people who use our services. We have included three key measures from the quality domains; patient safety, patient experience and clinical effectiveness, some of which reflect the quality priorities. As set out in national guidance, the Trust s external auditors, Ernst and Young LLP (EY), have tested two mandatory indicators relevant to the Trust and one local indicator selected by Trust Governors. Mandatory Indicator (Effectiveness) 1. Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the reporting period mandatory indicator. CLINICAL EFFECTIVENESS Incomplete pathways within 18 weeks Why did we choose this measure? The Trust continues to perform significantly better than the national average, though the number of people waiting has increased during the year. The table below shows the numbers of patients waiting from referral to start their elective treatment (incomplete patient pathways) up to M12 / March 2017 for our consultant-led services. SCFT rate Apr 15 Sept SCFT rate Oct 15 Mar 2016 SCFT rate at end Mar 2016 SCFT rate Apr 16 Sept SCFT rate Oct 16 SCFT rate at end Mar 2017 Page 142

143 Sussex Community NHS Foundation Trust Annual Report 2016/ Mar 2017 Total number of patients waiting to start their treatment (incomplete patient pathways). 19,319 20, ,935 23,560 3,904 % of patients who were waiting less than 18 weeks from referral to treatment (against target 92%). 99.6% National average: 99.5% National average: 99.4% National average: 99.4% National average: 98.7% National average: 97.5% National average: 93.0% 92.0% 91.5% 91.3% 90.1% 90.3% Number of patients who were waiting over 18 weeks from referral to treatment Referral to Treatment (RTT) Waiting Times, England Unify2 data collection RTT, National average up to Mar 17 SCFT is taking the following actions to improve the percentage of patients who wait less than 18 weeks from point of referral to treatment, and so the quality of its services: weekly monitoring of electronic records by the performance team; circulation of figures to services, indicating which patients do not have appointments booked / outcomes recorded; follow up with the services to ensure that electronic records are updated to give accurate reflection of the position; recording of exceptions / reasons for any actual breaches, retained as Page 143

144 Sussex Community NHS Foundation Trust Annual Report 2016/17 evidence and to promote understanding of reasons; reducing reporting errors Mandatory Indicator (Person Centered and Responsive Care) 2. Percentage of patients with a total time in Minor Injury Units (MIU) and Urgent Treatment Centres (UTC) of four hours or less from arrival to admission, transfer or discharge selected to report on an aspect of the Trust s person centred care and responsiveness. As the Trust does not provide accident and emergency services, the Governors, in consultation with the auditors, selected to audit the same type of measure, but for our MIU and UTCs. Minor Injuries Units and Urgent Care Centre Attendance Patients waiting four hours or less before being seen and treated Why did we choose this measure? Delivering care in the right place, at the right time, is a key priority for SCFT and whilst not having Accident and Emergency (A&E) Departments, the Trust plays a valuable part in preventing unnecessary A&E attendance in our neighbouring acute trusts. SCFT operates five Minor Injuries Units (MIU) and one Urgent Care Centre (UCC) at Crawley Hospital. The hours of opening depend upon what has been commissioned locally. The table 7 below shows attendance numbers and percentage of patients seen within 4 hours, by month in 2016/17 up to M12/March 2016 at our 5 Minor Injuries Units and 1 Urgent Care Centre on 6 different community sites. Table 7: A&E Attendances at the end of 2016/17 SCFT rate Apr 15 Sept 2015 SCFT rate Oct 15 Mar 2016 SCFT rate at end Mar 2016 SCFT rate Apr 16 Sept 2016 SCFT rate Oct 16 Mar 2017 SCFT rate at end Mar 2017 Total attendances in 33,855 49,724 9,330 55,246 49,343 8,981 Page 144

145 Sussex Community NHS Foundation Trust Annual Report 2016/17 Type 3 Departments Other A&E/Minor Injury Unit % Percentage of patients in 4 hours or less (against target 95%). 99.0% National average: 99.0% National average: 98.3% National average: 98.6% National average: 97.6% National average: 95.7% National average: 94.2% 89.7% 87.3% 90.5% 87.8% 90.0% Number of patients who were waiting over 18 weeks from referral to treatment A&E Attendances and Emergency Admissions, NHS England - National average up to Mar 17 The percentage of patients seen at our five Minor Injuries Units and one Urgent Care Centre within 4 hours has decreased. This is mainly as a result of the Trust revising the method of reporting for UCC. We have replaced the service s own report with one that is run directly from SystmOne. Historically we believe the service was under-reporting long waits and we believe this to be more accurate. An audit is planned on Month 12 figures, using the revised methodology. Local Indicator (Safe and Sustainable Care) The Trust Governors selected to audit the percentage of inpatients that fell in our community hospital inpatient services as an indicator of safe care and sustainable improvement. The data for all indicators selected in Part 3 Other Information - is governed by standard national definitions. Page 145

146 Sussex Community NHS Foundation Trust Annual Report 2016/17 PATIENT SAFETY Falls Why did we choose this measure? Patient falls have both human and financial costs. For individual patients, the consequences can range from distress and loss of confidence, to injuries that cause pain and suffering, loss of independence and, occasionally, death. These incidents can also bring about feelings of anxiety and guilt for the patients relatives and hospital staff. NHS organisations can incur additional costs relating to extra treatment, increased lengths of stay, complaints and, in some cases, litigation. We have been working to reduce falls within SCFT as part of our Quality Priorities, focussing in 2015/16 on reducing total falls occurring in our care and in 2016/17 we focussed on reducing falls with harm in our inpatient units. We reported on our reduction of falls with harm in section 2; however in this section we have provided the falls data against the national benchmark. Falls: total inpatient falls per 1,000 occupied bed days for SCFT was 5.83* compared with the national benchmark of 7.5 (). There was no comparative metric for falls per 1000 occupied bed days for the previous year. This measure was introduced for 2016/17. Source Datix *Data as of Month 12, 2016/17. Pressure Damage Why did we choose this measure? Preventing and reducing pressure damage has been a national and local priority for several years and SCFT has made good progress against this objective since The Trust developed and implemented a Pressure Damage Prevention Operational Framework to define the standard we expect in SCFT. We took part in national research as a pilot site, and implemented the validated pressure damage risk assessment tool developed as a result of this. We worked with carers to identify what guidance and support would be helpful for them as part of preventing pressure damage and shared our learning with other providers across the region. Our success has been recognised nationally and we are proud to report that we are finalists in the prestigious national Health Service Journal Awards for Patient Page 146

147 Sussex Community NHS Foundation Trust Annual Report 2016/17 Safety in the Community. Pressure damage 2014/ / /17 Category 3&4 inpatient and community Category 2 inpatient units Category 2 community Total Source: Datix and safeguard database Medication Safety Thermometer- average number of missed doses per patient in 24 hours Why did we choose this measure? Delivering the right medicine at the right time underpins best practice in medicines administration and improves patient experience and outcomes. As part of our improvement journey, SCFT developed and implemented a Medicines Safety Thermometer as a measuring tool for improvement focussing on missed doses. Sharing information directly with staff improves responsibility and accountability in medicines administration and has led to a reduction in the number of missed doses. Medication Safety Thermometer (inpatients) Average number of missed doses in 24 hours per patient 2015/16 was Average number of missed doses in 24 hours per patient 2016/17 was Source: Medication Safety Officer, Medicines Management Team Clostridium Difficile infections in inpatient units Page 147

148 Sussex Community NHS Foundation Trust Annual Report 2016/17 Why did we choose this measure? Clostridium difficile, also known as C. difficile (or C. diff), is a bacterium that can infect the bowel and cause diarrhoea. The bacteria often live harmlessly because the other bacteria normally found in the bowel keep it under control. However, some antibiotics can interfere with the balance of bacteria in the bowel, which can cause the C. difficile bacteria to multiply and produce toxins that make the person ill. This occurs mainly in elderly and other vulnerable patient groups especially those who have been exposed to antibiotic treatment, but it can spread easily to others. In order to continually improve, each C. diff case is investigated and the results reviewed to determine whether the case was linked with a lapse in the quality of care provided to patients. During 2016/17, our Infection, Prevention and Control team led on the Root Cause Analysis (RCA) of five patients who were identified as having C. diff infection whilst in our bedded units. 2015/ /16 Domain Indicator Description YTD Safe Safe Clostridium Difficile in inpatient unit identified in SCFT care, RCA led by SCFT Clostridium Difficile in inpatient unit due to SCFT lapse in care Source: Sussex Community On-Line Analysis and Reporting (Scholar). 2016/ /17 Domain Indicator Description YTD Safe Clostridium Difficile in inpatient unit identified in SCFT care, RCA led by SCFT Page 148

149 Sussex Community NHS Foundation Trust Annual Report 2016/17 Safe Clostridium Difficile in inpatient unit due to SCFT lapse in care Source: Public Health England Data Capture system and Sussex Community On-Line Analysis and Reporting (Scholar) Full investigations have identified some learning points which have been incorporated into the statutory training program. In addition, we have undertaken the following actions; Prescribing training to relevant staff by the antimicrobial pharmacist. The C.diff procedure was updated and a poster to prompt staff to test for C.diff has been produced. Our C.diff reduction plan continues and our Antimicrobial Pharmacist reviews the Medicines Safety Thermometer in relation to compliance with antimicrobial prescribing to support any improvements required. We also continue to work closely with other members of the local health economy to reduce the occurrence of this disease. PATIENT EXPERIENCE Staff Friend and Family Test Why did we choose this measure? In SCFT, we recognise that staff engagement and individual and organisational outcome measures, such as patient satisfaction and safety are closely linked. We recognise the importance in the staff voice in improving patient care and experience and act on feedback from staff to improve the quality of our services. Along with the Staff Survey, SCFT uses Staff FFT to inform the work of the Healthier Workforce Group to ensure we improve how we support staff, so they can deliver the standards of care they aspire to. Table 6 (below) shows that (85%) would recommend the Trust as a provider of care to their family or friends. This shows progressive improvement year on year, from 68% in 2013, 72% in 2014 and 81.5% in 2015/16 and was higher than the 80% national average for community trusts Staff Friends and Family SCFT rate National Best performing Worst performing Page 149

150 Sussex Community NHS Foundation Trust Annual Report 2016/17 Test (FFT) 2016/ /17 average Community Community Trust Community Trust Percentage who recommend the Trust as a provider of care. 85.5% 82% 95% Wirral Community NHS Foundation Trust 73% Central London Community Healthcare NHS Trust Percentage who recommend the Trust as a place to work. 68% 58% 77% Derbyshire Community Health Services NHS Foundation Trust 41% Bridgewater Community Healthcare NHS Foundation Trust Source: NHS England Q1 and Q2 2016/17 Note: Following a review undertaken by NHS England the Lead Official for Statistics has concluded that the characteristics of the Friends and Family Test (FFT) data mean it should not be classed as Official Statistics. Results cannot be used to directly compare providers because of the flexibility of the data collection methods, the differences in sampling approaches and the variation in the composition of local workforces. *=Trusts with over 30 responses. Patients Friends and Family Test Why did we choose this measure? 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. The feedback gathered through the FFT is being used across the Trust to stimulate local improvement and empower staff to carry out changes that make a real difference to patients and their care. Services are using the information to produce a you said, we did poster which describes feedback gained through FFT and what the service has done to address the issue. Receiving feedback is vital in improving our services and supporting patient choice and to support this we are exploring alternative means of participation, including text messaging, Page 150

151 Sussex Community NHS Foundation Trust Annual Report 2016/17 voice messaging and on line responses, thereby offering greater options for service users to provide feedback on their experience of care, with real time reporting available for staff. SCFT continues to strive to improve patient experience and has successfully maintained a high rating across 2015/16 and 2016/17. We will continue to work to ensure our services and care delivered meets the expectation of those who use our services. SCFT overall rating for 2015/16 was Percentage of people likely to recommend 95.5% SCFT overall rating for 2016/17 was 4.83 Percentage of people likely to recommend 95.8% Overall Star Rating 2016/17 Total Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar /16 Total Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Source: Sussex Community On-Line Analysis and Reporting (Scholar). % Likely to Recommend 2016/17 Total Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 95.9% 97.5% 97.2% 95.7% 96% 91.1% 95.8% 96.1% 94.7% 95.6% 96.7% 96.8% 96.5% 2015/16 Total Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 95.5% 96.2% 96.3% 94.6% 95.1% 95.9% 94% 94.1% 95.2% 96.3% 95.6% 95.8% 97.2% Source: Sussex Community On-Line Analysis and Reporting (Scholar). Page 151

152 Sussex Community NHS Foundation Trust Annual Report 2016/17 Complaints Why did we choose this measure? SCFT welcomes the valuable information gathered through our complaints process as this is used to inform service improvements and ensure we provide the best possible care to the people using our service and their carers. Last year, the most common category of complaint was staff attitude and following some focussed work around this issue, together with the introduction of our Patient Experience Training, this has reduced significantly. In addition, with improved service information around community nursing services, complaints relating to this service have decreased during 2016/17. A total of 228 complaints were received during the year. This is a decrease of 28 complaints (a 10.9% decrease). However, we recognise we have more work to do and have revised our Patient and Carer Experience and Involvement Strategy to outline ways we can improve. Source: Datix and safeguard database Complaint Categories by Number 2016/17 Communication 48 Admission & Discharge 6 Appointments/waiting times 38 Falls 2 Nursing care 32 Medication 2 Staff Attitude 22 Access to Treatment 1 Page 152

153 Sussex Community NHS Foundation Trust Annual Report 2016/17 Clinical Treatment 17 Consent 1 Diagnosis 17 Discrimination 1 Patient Care 15 Estates & Facilities 3 Equipment & Appliances 16 Transport 1 Duty of care 6 Total 228 Source: Datix database Complaint Categories by Number 2015/16 Communication 42 Admission & Discharge 7 Appointments/waiting times 37 Falls 2 Nursing care 29 Medication 7 Staff Attitude 34 Access to Treatment 8 Clinical Treatment 21 Consent 1 Diagnosis 22 Discrimination 5 Patient Care 21 Estates & Facilities 8 Equipment & Appliances 12 Transport 0 Duty of care 0 Total 256 Source: Datix database Page 153

154 Sussex Community NHS Foundation Trust Annual Report 2016/17 Improving Access to Psychological Therapies IAPT Why did we choose this measure? IAPT services provide evidence based treatments for people with anxiety and depression. Prompt treatment can improve people s outcomes, helping them to find or stay in work and contributing to good mental health. Measure WAITING TIME TARGETS: Target / Limit Referral To Treatment < 6 Weeks (HSCIC Method) 75% 97% 100% Referral To Treatment < 18 Weeks 95% 83% 96% Source: Sussex Community On-Line Analysis and Reporting System (Scholar). NICE Guidance SCFT has a systemic process in place for the dissemination, review, implementation and monitoring of applicable NICE guidance and use of the guidance to assess practice. Local Governance Groups are responsible for monitoring progress and implementation of NICE Guidance, overseen by the Clinical Effectiveness Group and Trust Wide Clinical Governance Group. Staff Care Staff Survey The national Staff Survey is undertaken and published annually and gives an indication of how staff rates the organisation in a number of key areas. The findings provide valuable feedback and help us to understand more about our staff experience of working for the Trust. The statement of approach to staff engagement and feedback arrangements in place, alongside key priorities and targets for the Trust are included in the Trust s Annual Report. However, in line with national guidance we have included two specific indicators relating to this: KF26 percentage Page 154

155 Sussex Community NHS Foundation Trust Annual Report 2016/17 of staff experiencing harassment, bullying or abuse from staff in the last 12 months and KF21 percentage of staff believing that the Trust provides equal opportunities for career progression or promotion. Key Finding KF26 percentage of staff experiencing harassment, bullying or abuse from staff in the last 12 months. Average (median) for community Trusts SCFT in 2015 SCFT in % 22% 21% KF21 percentage of staff believing that the Trust provides equal opportunities for career progression or promotion. 90% 95% 92% The Trust s staff survey engagement events have enabled us to identify key themes and develop actions for improvement in these areas, one of which is inclusion. We held a workshop on the subject jointly run by our Equality and Diversity lead and Head of Security. As a result there are a number of initiatives underway to support this, including LGBT+ (L=Lesbian, G=Gay, B=Bisexual and T=Transgender and the PLUS includes EVERYONE else) and BAME (Black, Asian and minority ethnic) networks; this is being monitored by the equality, diversity and inclusion group. We have also included an "Expect respect zero tolerance statement on our staff expectations of values and behaviour and introduced a Freedom to Speak Up Guardian as part of our Raising Concerns policy. Our Chief Executive is reinforcing the need for an open and transparent culture through weekly communications and engagement events, such as a bi-monthly all staff exchange, where staff can raise questions directly with the executive directors. Our Wellbeing Health and engagement group will continue to review this and propose further actions where appropriate. Page 155

156 Sussex Community NHS Foundation Trust Annual Report 2016/17 Safe Care Avoidable Deaths SCFT's Mortality Review Group reviews the deaths of inpatients in our community hospitals. Those deaths which were unexpected each undergo a detailed review, known as root cause analyses through the serious incident investigation process. In 2016/17 there were four unexpected deaths on our community hospital inpatient units, all of which were investigated and any learning taken from these incidents. Healthcare Associated Infections (HCAIs) In 2016/17, our Infection Prevention and Control (IP&C) Team were involved in four Post Infection Reviews (PIR) assigned to the CCG. The patients had Methicillinresistant Staphylococcus aureus (MRSA) blood stream infection. One of the patients was in a SCFT bedded unit. No lapses in the quality of care provided by SCFT were identified and learning included improved documentation. Never Events Never events are serious medical errors or adverse events that should never happen to a patient. There have been no Never Events reported by SCFT during the reporting period. Conclusion This Quality Report/Account 2016/17 reports on SCFT s progress and performance against a wide range of priorities and indicators over the last year. These achievements have been made as a result of the commitment from our staff to deliver excellent care. Continuous improvement is a collective responsibility and we will continue to nurture and develop this culture as the Trust progresses in its quality improvement journey. Our ambition is for more and more of our services to be rated as Outstanding against Care Quality Commission standards and requirements. Achievement of the improvement priorities for 2017/18 will contribute toward this aim. We will continue to monitor progress against these and look forward to reporting on our progress in the 2017/18 Quality Report/Account. This Quality Report/Account has been prepared in accordance with the Department of Health s Quality Account Toolkit, first published in December 2010 and available Page 156

157 Sussex Community NHS Foundation Trust Annual Report 2016/17 electronically at and NHS Improvement s Detailed requirements for Quality Accounts for Foundation Trusts 2016/17, available electronically at Annex 1 Statements from commissioners, local Healthwatch organisations and Overview and Scrutiny Committees Where 50% or more of the relevant health services that the NHS foundation trust directly provides or sub-contracts during the reporting period are provided under contracts, agreements or arrangements with NHS England, the trust must provide a draft copy of its quality report/account to NHS England for comment prior to publication and should include any comments made in its published report. Where the above does not apply, the trust must provide a copy of the draft quality accounts/report to the clinical commissioning group which has responsibility for the largest number of people to whom the trust has provided relevant health services during the reporting period for comment prior to publication and should include any comments made in its published report. NHS foundation trusts must also send draft copies of their quality report/account to their local Healthwatch organisation and overview and scrutiny committee (OSC) for comment prior to publication, and should include any comments made in their final published report. The commissioners have a legal obligation to review and comment, while local Healthwatch organisations and OSCs will be offered the opportunity to comment on a voluntary basis. Page 157

158 Sussex Community NHS Foundation Trust Annual Report 2016/17 The organisations invited to review and comment on SCFT s Quality Report/Account 2016/17 were: Healthwatch Brighton & Hove Healthwatch East Sussex Healthwatch West Sussex West Sussex County Council HASC Brighton & Hove City Council s Health and Wellbeing Overview and Scrutiny Committee (HWOSC) East Sussex County Council s Health Overview and Scrutiny Committee (HOSC) NHS Brighton & Hove Clinical Commissioning Group NHS Coastal Clinical Commissioning Group NHS Crawley Clinical Commissioning Group NHS High Weald Lewes Havens Clinical Commissioning Group NHS Horsham and Mid Sussex Clinical Commissioning Group Comments received can be read in the following pages. Annex 1a Comments from Healthwatch Brighton & Hove Overall Comments These comments are from Healthwatch Brighton and Hove (HWBW). They relate to the overall services provided by the Trust as the data in the Quality Report is not specific to the Brighton and Hove Healthwatch area. The report is comprehensive and shows considerable improvement in many areas from 2015/2016. The CQC report is particularly encouraging with Good in almost all categories; and the aspiration of the Trust to move to Outstanding in all areas is to be applauded. Page 158

159 Sussex Community NHS Foundation Trust Annual Report 2016/17 HWBW, due to its extensive remit, has been unable work in partnership with the Trust as much as it would like, but hopefully in the future will be able to develop closer links and more joint working over the extensive range of services provided by the Trust. Detailed Comments There are some areas of the report that appeared a little unclear, or where more information would have been more helpful. Page 11. Safe Transfer of Care. It was not clear about what is being measured. It appeared that it was discharge levels; but also transfer in is an important opportunity to consider the strength of the overall transfer process in and out of community hospitals/in-patient units. Page12. Staff Well Being. The doubling of occupational health clinical psychology is excellent but it would have been helpful to know from what to what was the increase. If it was from 1.1 WTE's to 2.2 WTE that in itself would be helpful, but if it was from 5 to 10 WTE that would be even more impressive. Page 13. Patient Centred Care-Equality & Diversity. We were unaware that the Trust had vocational schemes to assist some of the marginalised groups get into employment. It would be helpful to have some detail of those schemes. Appendix G-Falls. The reporting on Falls seems to imply an increase in more serious impact of falls as the total decline from 433 to 427 with decreases in falls with any harm from 93 to 60 and falls with moderate harm from 18 to 10 seems to imply that falls from serious harm (implied missing category of falls) increased from 322 to 357. It would be helpful to understand if this is the case or our interpretation of the data is incorrect. Appendix G-Autism. The development of a greater number of user friendly tools aimed at the young, such as apps, seems to be a way forward and we are encouraged by your work in this area. Appendix G-Complaints. Massive improvement, congratulations. It demonstrates a real commitment to learning from patients and service lapses. Appendix G-Transition Planning. This has always been a challenging area and the setting up of a Trust-wide Transition Steering Group is to be commended. Page 159

160 Sussex Community NHS Foundation Trust Annual Report 2016/17 Appendix G-End of Life Care. It is clearly evident why you were rated excellent in this area, and the sensitivity to the bereaved through no feedback attempts will be made until 6 months post death is a credit to the Trust willingness to listen to service users/carers. Appendix H-Research and CQUIN. It is good that your commitment to quality and improvement is rewarded through some income generation (7 grant funding awards 0.8M; and 3.0M from CQUIN). Appendix H-Readmissions. The 10% rate is hard to evaluate when it is not compared to other Trust services so HWBH is not sure if it is good, bad or normal. Appendix I-Patient Safety-pressure damage. This has been a challenging area and the improvement is commendable. Appendix I-Incomplete pathways within 18 weeks. It would have been helpful to have a more detailed analysis of those patients who waited more than 18 weeks as an aid in overall service and pathway improvement. If this has been done internally it would be helpful to know of any learning that may have come out of this analysis to assist in the overall community 18 week target for all providers. Appendix I-Staff Care-Staff Survey. One of the areas not covered in the Quality Report is sickness levels of staff and HWBW would appreciate some information on how the Trust is addressing this area as it has been a challenging target for Health Trusts over the years. Summary In conclusion, the HWBW board link to the SCFT has only just seen this report and was unable to comment earlier on the contents and hopefully we will be able to provide more comprehensive comments in the future in a more timely manner. Annex 1bComments from Healthwatch West Sussex As the independent voice for patients, Healthwatch West Sussex is committed to ensuring local people are involved in the improvement and development of health and social care services. For several years now, local Healthwatch across the country have been asked to read, digest and comment on the Quality Accounts, which are produced by every NHS Provider (excluding primary care and Continuing Healthcare providers). In West Page 160

161 Sussex Community NHS Foundation Trust Annual Report 2016/17 Sussex this translates to seven Quality Accounts from NHS Trusts. Each document is usually over 50 pages long and contains lengthy detailed accounts of how the Trust feels it has listened and engaged with patients to improve services. Each year, we spend many hours of valuable time reading the draft accounts and giving clear guidance on how they could be improved to make them meaningful for the public. Each year we also state that each and every Trust could, and should, be doing more to proactively engage and listen to all the communities it serves. Whilst we appreciate that the process of Quality Accounts is imposed on Trusts, we do not believe it is a process that benefits patients or family and friend carers, in its current format. This format has remained the same despite Healthwatch working strategically on this for over two years. We have reducing resources and we want to focus our effort where it has the most effect on patient care and we do not believe quality accounts have this impact. This year we have been more proactive in our own engagement with local people in their communities, more direct in our influencing work and more critical of how commissioners and providers are communicating with local people. These activities have been a positive process and we feel a better use of our resource. We remain committed to providing feedback to the Trust through a variety of channels to improve the quality, experience and safety of its patients. Annex 1c Comments from East Sussex Health Overview and Scrutiny Committee Thank you for providing the East Sussex Health Overview and Scrutiny Committee (HOSC) with the opportunity to comment on your Trust s draft Quality Report 2016/17. On this occasion the Committee has not provided a statement as we do not have any specific evidence to submit to you. However, we look forward to an ongoing involvement in the development of future Trust Quality Reports. Please contact Claire Lee, Senior Democratic Services Adviser, on , or Harvey Winder, Democratic Services Officer, on , should you have any queries. Page 161

162 Sussex Community NHS Foundation Trust Annual Report 2016/17 Annex 1d Comments from West Sussex Health and Adult Social Care Select Committee Thank you for offering the Health & Adult Social Care Select Committee (HASC) the opportunity to comment on Sussex Community NHS Foundation Trust s (SCFT) Quality Account for HASC agreed last year that formal responses from the committee to Quality Accounts (QA), from last year onwards, would only be forwarded to NHS providers where HASC had undertaken formal scrutiny within the previous financial year. Therefore, as the committee did not scrutinise any services directly provided by SCFT in , the committee will not be making any comments this year. Annex 1e Comments from Crawley, Horsham & Mid Sussex, Brighton & Hove, Coastal, and High Weald Lewes Havens Clinical Commissioning Groups The commissioners welcome the opportunity to provide this statement for Sussex Community Foundation Trust (SCFT) 2016/17 annual Quality Account, and were pleased to be invited to attend the Quality Account Stakeholder event held in February 2017, identifying the quality priorities for 2017/18. We acknowledge the continuing ambition for improvement and pleased to see a continued focus on three key measures from the quality domains; patient experience, patient safety and clinical effectiveness. In addition acknowledge the progress made in all of the 2016/17 quality improvement priorities. All commissioners would like to congratulate the trust on an international award for a 'Best Short Paper '. Developing a mobile app supporting effective diagnosis and improving effectiveness and experience of the assessment process for autism. As well as a priority for 2016/17, the commissioners acknowledge the app still needs further development and are pleased to see this is included as an on-going priority for 2017/18. All CCGs note the challenges and the changing landscape across the Sussex footprint but also recognise it gives an opportunity to map our local populations as set out in The Five Year Forward View', and the new approach to sustainability and transformation. The commissioners would like to have seen the progression of the Page 162

163 Sussex Community NHS Foundation Trust Annual Report 2016/17 communities of practice in the 2017/18 Quality Account as the future vision for the communities of practice was first outlined in the 2016/17 report. We do though recognise that there has been significant quality improvement over the last year particularly noted in Safeguarding, the CQUINS achievement and the inclusion of Staff Health and Well Being. We also acknowledge that further work needs to be done if the trust wants to be an outstanding organisation,and we therefore look forward to working with SCFT as they implement the Quality priorities and improvements set out for 2017/18. The Commissioners are pleased to endorse this Quality Account and we look forward to continuing our relationship so we can all drive forward the quality improvements for our local populations, and across the wider health system. Annex 2 Statement of Directors Responsibilities for the Quality Report The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations to prepare Quality Accounts for each financial year. NHS Improvement has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation trust boards should put in place to support the data quality for the preparation of the quality report. In preparing the Quality Report, directors are required to take steps to satisfy themselves that: the content of the Quality Report meets the requirements set out in the NHS foundation trust annual reporting manual 2016/17 and supporting guidance the content of the Quality Report is not inconsistent with internal and external sources of information including: o board minutes and papers for the period April 2016 to May 2017 o papers relating to quality reported to the board over the period April 2016 May 2017 Page 163

164 Sussex Community NHS Foundation Trust Annual Report 2016/17 o feedback from commissioners dated 02/05/2017 o feedback from governors dated 13/03/2017 o feedback from local Healthwatch organisations undated but received on 09/05/2017 and 08/05/2017 o feedback from Overview and Scrutiny Committee dated 26/04/2017 o the trust s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated May 2017 o the [latest] national patient survey please see pages 40 and 43 o the [latest] national staff survey please see pages 40 and 43 o the Head of Internal Audit s annual opinion of the trust s control environment dated April 2017 CQC inspection report this is not applicable to the Trust as CQC stopped Intelligent Monitoring reports in 2015 in preparation for a new model of inspection. Trust inspection under new model imminent. 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 as the trust is currently not reporting performance against the 62 day cancer wait time indicator, due to it being not applicable to SCFT s patient cohort, or fully reporting against the 28 day readmissions indicator due to (for reasons, please see page 30), the directors have a plan in place to remedy this and return to full reporting by undertaking additional work to further review this information in order to establish a clearer understanding of the reasons for readmissions and how this can be improved and reported. 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 NHS Improvement s annual reporting manual and supporting guidance (which incorporates the Page 164

165 Sussex Community NHS Foundation Trust Annual Report 2016/17 Quality Accounts regulations) as well as the standards to support data quality for the preparation of the Quality Report. The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report. By order of the board Stephen Lightfoot Chairman Siobhan Melia Chief Executive Page 165

166 Sussex Community NHS Foundation Trust Annual Report 2016/17 Appendix 1 Local Clinical Audit SCFT develops an annual schedule of trust wide clinical audits which is driven by national best practice guidance, monitoring effectiveness of changes introduced associated to quality improvements, lessons identified from investigations and audit and assurance review outcomes. The scheduled is agreed via the organisations usual governance committee structure. There are 20 trust wide audits currently listed on the 2017/18 schedule which was approved by the Quality Committee in March The outcomes of local clinical audits are overseen by the Clinical Effectiveness Group. To promote consistent practice across teams, all audit findings and recommendations are also discussed in service governance groups and the learning shared via various trust-wide operational clinical forums. Table 8 lists the number of local clinical audits undertaken by SCFT in 2016/17. Table 8: Local Clinical Audits National Audit of Dementia (Pilot) Chronic obstructive pulmonary disease re-audit Parkinson's Disease Sentinel stroke national audit programme (SSNAP), includes SINAP Vulnerable Groups (Learning Disabilities, Autism, Dementia) Rheumatoid and early inflammatory arthritis Pressure damage - Wound care outcomes of unstageable pressure damage NHS SI framework timeframe compliance Omitted Doses NEWS (National Early Warning Score) Compliance Transfer information - standards of access to required patient information/resources on transfer into SCFT bedded units Page 166

167 Sussex Community NHS Foundation Trust Annual Report 2016/17 Discharge information - Compliance with expected standards of patient care on discharge out of SCFT bedded units Wound classification - Doppler tests within timeframes Duty of Candour Trust wide Catheter Care standards re-audit Sharps safety Compliance Falls prevention/care management Assessment standards re-audit Nutrition and Hydration Healthcare Records Annual Audit adults Information Governance, Core Standards, Clinical Standards, plus focussed topics Healthcare Records Annual Audit adults Core Standards Healthcare Records Annual Audit adults Clinical Standards Healthcare Records Annual Audit adults Focussed topics Healthcare Records Annual Audit Children s Healthcare Records Annual Audit Specialist Services Infection Prevention and Control annual clinical practice and environmental audit programme A re-audit of the guidelines for SLTs on the effective transition of children from the Early Years Service to the School Service Re-audit of selecting appropriate recall intervals for patients in special care dentistry service, in accordance with NICE guideline CG19 Patient X-ray Dose Audit for New Siemens Room BWMH to establish DRLs (Diagnostic Reference Levels) Are Police reports (SCARF s Single combined Assessment of Risk Form s) Page 167

168 Sussex Community NHS Foundation Trust Annual Report 2016/17 reviewed and discussed as per the 2014 domestic abuse guidelines? Appendix 2 Research Grants Awarded Research Activity SCFT staff successfully applied for seven grant funding awards either as the Chief Investigator or as a co- applicant. These total a value of over 844k (see table 9 below). Dr Sarah Crombie and Dr Will Farr attained nationally competitive British Association of Childhood Disability-Castang Fellowship awards to develop future research leaders in childhood neurodisability. Table 9: Research Grants Awarded 2016/17 Study Title Source of Grant Award holder Period of grant Managing clinical uncertainty for older people admitted to community in patient units: development, implementation and evaluation of the SPACE toolkit to improve communication and palliative care HEE/NIHR ICA Programme Senior Clinical Lectureship Evans, C. 01/06/ /05/2021 How Much Does it Cost the NHS to Assess a Child for Possible Autism? Royal College of Paediatrics and Child Health (RCPCH)-Paul Polani award Male, I. 25/07/2016 2S EDUCAT (Empowerment of disabled Co-financed by the Interreg 2 Lead partner: Groupe HEI-ISA-ISEN 13/07/ /07/2020 Page 168

169 Sussex Community NHS Foundation Trust Annual Report 2016/17 people through the user coproduction of assistive technology) Seas Mers Zeeën Programme 1.8m. (France) Project partners: Sussex Community NHS Foundation Trust; University of Kent; East Kent Hospitals University Foundation Trust; Catholic University Leuven (Belgium); Voka Chamber of Commerce (Belgium). Physio First Data for Impact study Physio First (Organisation of Chartered Physiotherapists in Private Practice in UK) Bryant E, Murtagh S & Olivier G (University of Brighton) Aug 2016 July ,000 How do different neurodisability services meet the psychosocial support needs of children/young people with feeding disabilities and their families: a national survey and case study approach to mapping and costing service NIHR HS&DR Grant 376,000 Dr Gillian Craig and team at City University, Diane Sellers Co-Applicant and PI 1/1/016-31/12/2017 Page 169

170 Sussex Community NHS Foundation Trust Annual Report 2016/17 models, care pathways and the child and family experience What interventions, which could be delivered at home by parents, are available to improve eating in young children with neurodisability and are suitable for investigation in pragmatic trials? NIHR HTA Grant 308,000 Dr Parr and team at Newcastle University, Diane Sellers Co- Applicant 1/06/ /05/2019 To develop mini-edacs - an Eating and Drinking Ability Classification System for young children with cerebral palsy aged between 18 and 36 months Nutricia 31,216 Diane Sellers 01/05/2017-1/11/2018 Primary STEM: Mini Scientists Review Panel Nuffield Foundation seed funding Farr, W. 01/02/2017 Research Studies The Trust conducted 22 research studies in 2016/17: 18 for adults; 15 for children and one trust-wide and as shown in tables 10 a-c. Table 10 a): Studies conducted in services for Adults Page 170

171 Sussex Community NHS Foundation Trust Annual Report 2016/17 Title of Study OPTCare Neuro C-CHANGE Workstream 4: Testing a case-mix classification in palliative care (cohort study) Chief Investigator & affiliation Prof Irene Higginson King's College London Dr Fliss Murtagh, King's College London Funding source NIHR Health Services & Delivery Research Programme (HS&DR) National Institute for Health Research (NIHR) C-CHANGE Workstream 3: Testing a case-mix classification in palliative care (cohort study) Dr Fliss Murtagh, King's College London National Institute for Health Research (NIHR) Trajectories of Outcome in Neurological Conditions Feasibility study of the use of the GekoTM device for faecal incontinence in older people living at home or in Care Homes Professor Caroline Young, Walton Centre NHS FT Prof Christine Norton, King's College London Motor Neurone Disease Association SBRI Palliative long term abdominal drains versus repeated drainage in individuals with untreatable ascites due to advanced cirrhosis Dr Sumita Verma Brighton Medical School NIHR An observational study investigating the prevalence and impact of alcohol related problems in cancer patients and their no professional caregivers Dr Katherine Webber, Royal Surrey County Hospital NHS Foundation Trust Alcohol Research UK A study to understand and optimise a community hospital care in the NHS Dr John Young, Academic Unit of Elderly Care and Rehabilitation, University of Leeds NIHR Health Services and Delivery Research Programme Music and Dementia Feasibility Study Dr Catherine Evans King's College London SCFT Page 171

172 Sussex Community NHS Foundation Trust Annual Report 2016/17 The potential impact on access, outcomes and cost of using low-intensity internet-delivered cognitive behavioural therapy (icbt) for people in IAPT services as a prequel to high intensity therapy (HIT) for depression and anxiety disorders Dr Derek Richards, SilverCloud Health No Funding An anonymous survey of mindfulness and self-compassion in adults offered psychological therapies in the NHS Dr Tamara Leeuwerik, University of Sussex Economic and Social Research Council Doctoral Programme AND Sussex Partnership NHS Foundation Trust Evaluating the effectiveness and costeffectiveness of BSL (British Sign Language) IAPT (Improving Access to Psychological Therapies): Modelling BSLIAPT and Standard IAPT as accessed by Deaf people Prof. Alys Young University of Manchester NIHR Health Services and Delivery Research Programme (HS&DR) Positive Outcomes: a UK PROM for people living with HIV - development, face and content validity Richard Harding, King's College Hospital British HIV Association The Lived Experience of impaired sensation in the feet related to Multiple Sclerosis Dr Pirjo Vouskoski, University of Brighton SCFT Current Beliefs and Clinical Practice of Physiotherapists in the United Kingdom towards Sacroiliac Joint Dysfunction Dr Erin Byrd, Plymouth University No Funding A Qualitative Study; the lived experience of patients with toe amputation as a result of diabetes Dr Christopher Morriss-Roberts, University of Brighton SCFT Table 10 b): Studies conducted in services for Children Page 172

173 Sussex Community NHS Foundation Trust Annual Report 2016/17 Title of Study Comparison of a new with standard child and family primary care service to reduce the re-occurrence of childhood dental caries (Dental RECUR Trial) Epilepsy in infancy: relating phenotype to genotype Chief Investigator & affiliation Professor Cynthia Pine, Salford Royal Foundation Trust Professor J Helen Cross, UCL Funding source National Institute for Health Research Charles Wolfson Foundation Genetics of Obesity Standing frames as part of postural management for children with spasticity. What is the acceptability of a trial to determine the efficacy of standing frames? Professor Stephen O'Rahilly, Metabolic Research Dr Jill Kisler, Newcastle upon Tyne Hospitals NHS Foundation Trust Medical Research Council National Institute for Health Research Health Technology Assessment Programme (NIHR HTA) How do different neurodisability services meet the psychosocial support needs of children/young people with feeding disabilities and their families? A national survey and case study approach to mapping and costing service models, care pathways and the child and family experience Dr Gillian M Craig, City University London TBC Children with Attention Deficit Hyperactivity Disorder (ADHD) in transition from children s services to adult services Prof Tamsin Ford, University of Exeter Medical School National Institute for Health Research Page 173

174 Sussex Community NHS Foundation Trust Annual Report 2016/17 The Eating and Drinking Ability Classification System for cerebral palsy: a study of stability and associations with growth over time Dr Diane Sellers, Sussex Community NHS Foundation Trust Polani Award, British Academy of Childhood Disability Improving clinical practice for babies with hearing loss Passive Enhanced Safety Surveillance (ESS) of Quadrivalent Live Attenuated Influenza Vaccine (QLAIV) Fluenz Tetra in Children and Adolescents during the early 2016/2017 Professor Kevin James Munro, University of Manchester Prof Saad Sjakir, Drug Safety Research Unit National Institute for Health Research (NIHR) AstraZeneca UK Limited Identifying appropriate symbol communication aids for children who are non-speaking: enhancing clinical decision making A study to explore the experiences of young people aged years with neuromuscular disorders of their journeys from childhood to adulthood Dr Janice Murray, Manchester Metropolitan University Ms. Laura Golbert, University of Brighton No Funding No Funding An Epidemiological ASD Study and Establishing a Research Database A Feasibility Study of Virtual Reality as a Therapeutic Intervention in Children with Ambulatory Cerebral Palsy Jeremy Parr, Newcastle University Dr W Farr, Mid Sussex Child Development Centre Autistica SCFT Page 174

175 Sussex Community NHS Foundation Trust Annual Report 2016/17 Pilot Study to Investigate the Potential use of the Pirate Adventure Social Communication Assessment Tool as an Adjunct to Current Initial Assessment of a Child Referred with Social Communication Difficulties Dr William Farr, Sussex Community NHS Foundation Trust SCFT How do patient and carer-held beliefs about medication administration in domiciliary care affect Multi-compartment Compliance Aid (MCA) initiation and use? Lucy Simkins Western Sussex Hospitals NHS FT Table 10 c: Study delivered to staff across the Trust Title of Study Chief Investigator & affiliation Funding source A definitive randomised controlled trial investigating two online well-being interventions to reduce NHS staff stress Miss Heather Taylor, University of Sussex (Funded by ESRC and Headspace) NIHR RfPB Outputs and impact of research work and activity SCFT s increasing participation in clinical research is contributing to improving clinical effectiveness in the Trust and building research capacity and infrastructure to support clinical and health service research. Dr Diane Sellers continues to lead work associated with the Eating and Drinking Ability Classification System (EDACS) for people with cerebral palsy. National and international interest in EDACS continues to grow: EDACS has been downloaded more than 3,000 times from the website the site received more than 11,000 hits in 2016; EDACS is now available in 8 new languages; work is progressing with international research groups to develop EDACS in 14 other languages. Page 175

176 Sussex Community NHS Foundation Trust Annual Report 2016/17 Participation as a study site for an international study, Pressure Ulcer Risk Assessment Framework (PURAF) on the assessment of risk to pressure area damage, led to revision of the Trust s processes of assessing risk to pressure area damage and implementation of the study s findings Optimising palliative care for older people in community settings: a phase II feasibility trial developing and evaluating a new short term integrated service (OPTCare Elderly) (Funder NIHR RfPB) led by Dr Catherine Evans, involved the development and feasibility evaluation of a service reconfiguration called Short-term integrated palliative and supportive care (SIPScare). SIPScare involved provision of specialist community palliative care for up to three visits to provide comprehensive assessment and management of symptoms and concerns, multi-disciplinary review by the specialist team, and integrated working with GPs and community nursing services. The trial completed to target with 50 older people, and 19 carers randomised to receive SIPScare or usual care. Our preliminary findings show SIPScare was acceptable to patients and families, and feasible for the specialist palliative care teams to deliver through integrated working with GPs and community nurses. The findings indicate potential benefit of SIPScare on the main outcome explored of five key symptoms. Published abstract available Evans et al Palliative Medicine 2016, 30(6): NP21. The feasibility trial findings informed the design of a definitive trial OPTCare Neuro that is examining the effectiveness and cost-effectiveness of SIPSCare for patients with neurological conditions. Sussex Community NHS Foundation Trust is one of the five study sites for OPTCare Neuro (funding NIHR HS&DR). OPTCare Elderly and OPTCare Neuro are informing practice and policy on new models to deliver palliative care to people with non-malignant advanced conditions. In 2016, we published the papers reporting the development phase of SIPSCare. The papers detailed: 1) Factors associated with transition from a community setting to hospital at the end of life for people aged 75 years or over. This paper reports a mortality follow back survey (n=443) with important recommendations on priorities to enable people to remain in community settings at the end of life including improving breathlessness services, identification of a skilled key worker to, e.g. coordinate care, and training for staff on communication of difficult conversations and anticipatory care planning for older people with uncertain illness trajectories (Bone, Evans et al JAGS (11): ); 2) Development of SIPScare involving consultations with key stakeholders comprising families, carers, patients, clinicians, lay representatives Page 176

177 Sussex Community NHS Foundation Trust Annual Report 2016/17 and researchers. The findings showed the acceptability of specialist palliative care for older people with advanced non-malignant conditions, likely benefit of improving management of unstable symptoms and concerns and increasing opportunity for skilled conversations on future care for people with uncertain illness trajectories. The findings modified the delivery of SIPSCare (Bone, Evans et al Age and Ageing 2016, 45(6): ). Development of feasibility evaluation of a new tool, the Symptom and Psychosocial Assessment and Communication Evaluation (SPACE), to improve anxiety and distress during uncertain recovery for older patients in community hospitals. (Funder HEE/NIHR Senior Clinical Lectureship). This is a joint study between King s College London and Sussex Community NHS Foundation Trust. The study commenced June 2016 for five years led by Dr Catherine Evans. The work intends to improve the communication and assessment of older people admitted to community hospitals, in order to reduce the anxiety and distress for them and their families or those close to them. We focus on older people where there is uncertainty as to their recovery or continued deterioration leading eventually to the end of life. We believe that this represents the area of greatest need. This also responds to national priorities for research on improving access to palliative care for all, training for staff to deliver, and the assessment and treatment of discomfort. The work commenced with analysis of national data on community hospital admissions for older people for one year after their admissions, and death registrations, to understand what usually happens to them. This will help us understand for example, when, and where people died and priorities to improve communication on patient discharge. A Feasibility Study of Virtual Reality as a Therapeutic Intervention in Children with Ambulatory Cerebral Palsy We surveyed families to find out home use of games consoles for children with Cerebral Palsy: There was a keen interest (31%) in the use of VRT amongst primary school-aged male children with CP, particularly those with a fair level of walking ability. 90% of homes have some sort of commercially available console, but few are using them or have been advised to use them for any sort of therapy. Families that have taken part in therapy using active games consoles report fair to good response in motor function with few problems. Page 177

178 Sussex Community NHS Foundation Trust Annual Report 2016/17 There is growing interest in using active computer games as part of therapy. This study explored whether a clinical trial was possible to achieve testing therapy using the Nintendo Wii Fit at home for children with cerebral palsy. Thirty children with cerebral palsy took part. They were randomly allocated to either a therapist-directed games group or a group with freedom over games choice. Both groups were asked to play for 30 minutes, 3 times per week, for 12 weeks. Overall 70% of children completed the study, and 60% of recommended play was completed, with few problems. The intervention was inexpensive, but real potential for physical improvement in children with CP cannot be known from this trial. The findings suggest a larger trial to test whether therapy using active computer games is effective to improve movement ability is feasible. However we also identified ways to improve the design of such a trial. Further research is now needed to compare how effective therapy is with active games consoles with standard physiotherapy for children with Cerebral Palsy. The Trust continues to build research capacity with a growing number of staff leading research studies as chief investigators, as co-applicants on research grants, and as site principal investigators leading the implementation of our research studies. This growth is reflected in increasing publications both as a lead or co-author, conference presentations and awards received by SCFT research staff. See table 11, which lists 15 published articles, 13 published conference abstracts written, or contributed to by SCFT research and other staff and 26 incidents where staff were invited to present research findings as an invited speaker or through poster presentation. Our dissemination demonstrates our commitment to improving patient outcomes and experiences across health and social care locally, regionally and nationally. Table 11: Publications in Peer Reviewed Journals Publication Title Authors Journal Year Published Effects of running-bike use on motor function, bone health and quality of life in children with cerebral palsy, GMFCS Levels IV and V: pilot Bryant E, Cowan C, Crombie S and Walker- Bone K Physical & Occupational Therapy in Paediatrics (under review) 2017 Page 178

179 Sussex Community NHS Foundation Trust Annual Report 2016/17 study The Brighton musculoskeletal Patient Reported Outcome Measure: an assessment of validity, reliability and responsiveness Bryant E, Murtagh S, Olivier G et al. Clinical Rehabilitation (under review) Patient and carer involvement in evaluating a tooth brushing programme for children and young people with neurological motor impairment Emanuel R, Ray- Chaudhuri E, Parry J, Borthwick L, Sellers D, Dobson S Journal of Disability and Oral Health (under review) 2017 Development of a caregiver-reported measure to support systematic assessment of people with dementia in long-term care: the Integrated Palliative care Outcome Scale for Dementia Clare Ellis- Smith; Catherine J Evans, et al. Palliative Medicine doi: / Published online Factors Associated with Transition from Community Settings to Anna E. Bone, Catherine J. Journal of the American Geriatrics Society Page 179

180 Sussex Community NHS Foundation Trust Annual Report 2016/17 Hospital as Place of Death for Adults Aged 75 Years or Older: A Population-Based Mortality Follow-back Survey Evans, et al. 64(11): doi: /jgs Published online Developing a Model of Short-term Integrated Palliative and Supportive Care for Frail Older People in Community Settings: Perspectives of Older People, Carers and Other Key Stakeholders Anna E. Bone, Catherine J. Evans, et al. Age and Ageing. 45(6): doi: /ageing/afw124 Published online How integrated are neurology and palliative care services? Results of a multi-centre mapping exercise Liesbeth M. van Vliet, Catherine J. Evans, et al. BMC Neurology 16(1):63 doi: /s Published online Of apples and oranges: Lessons learned from the preparation of research protocols for systematic reviews exploring the effectiveness of Specialist Palliative Care. Jan Gaertner, Catherine J. Evans, et al. BMC Palliative Care 15(1): 43 doi: /s y Published online Therapeutic potential and Farr W, Male British Journal of 2016 Page 180

181 Sussex Community NHS Foundation Trust Annual Report 2016/17 ownership of commercially available consoles in children with cerebral palsy I, Green D, Morris C, Gage H, Bailey S, Speller S, Colville V, Jackson M, Bremner S, Memon A Occupational Therapy, Accepted/In press Methodological Constraints when using Digital Technology in Clinical Trials, Farr W, Male I, Green D, Morris C, Gage H, Bailey S, Speller S, Colville V, Jackson M, Bremner S, Memon A In submission Journal of Mobile Technology in Medicine Paul Polani Award: How Much Does it Cost the NHS to Assess a Child for Possible Autism? Male I, Farr W, Gowling E, Gage H, Gain A, Dr Ian Male British Academy of Childhood Disability Newsletter, Summer Initial findings-the experience of play of 6-12 year olds with cerebral palsy Graham N, Mandy A, Clarke C and Sellers D British Journal of Occupational Therapy (vol. 79, pp ) Page 181

182 Sussex Community NHS Foundation Trust Annual Report 2016/17 Reliability, construct validity and usability of the Eating and Drinking Ability Classification System (EDACS) among Dutch children with Cerebral Palsy van Hulst K, Snik D, Jongerius P, Sellers D, Erasmus C and A Geurts Dysphagia (under review) 2017 The eating and drinking ability classification system for cerebral palsy: a study of reliability and stability over time Sellers D, Bryant E, Hunter A et al. Developmental Medicine & Child Neurology (under review) Questions about aspiration for children with eating, drinking, and swallowing difficulties Sellers, D Dev Med Child Neurol. 58(6):530. doi: /dmcn Published online Table 12: Published Abstracts Publication Title Authors Journal Year Published The SEEN study: a population-based study of neurobehaviour in young children with epilepsy and a comparison group with non-epilepsy related neurodisability. Reilly C, Atkinson P, Memon A, Gillberg C, Neville B, Das KB, Jones C & Poster presentation at the American Epilepsy Association meeting in Houston Texas-Abstract published in the American Epilepsy Association meeting Houston Texas 2016 Page 182

183 Sussex Community NHS Foundation Trust Annual Report 2016/17 Published abstract Poster Scott RC Emotional functioning, fatigue and stress in parents with early onset epilepsy: a populationbased study Published abstract- Poster Jones C, Atkinson P, Reilly C, Gillberg C, Scott R, Memon A, Neville B Abstract published in Developmental medicine and Child Neurology. Jan 2017, Vol 59 Supplement 1, Pg 26 Poster presentation at the BPNA annual meeting Cambridge Patients expectations of physiotherapy treatment for musculoskeletal conditions. Published abstract Platform presentation. Bryant E, McCrum C, Murtagh S et al. Physiotherapy. Abstracts of the ER-WCPT 2016 (European Region World Congress Physical Therapy) Conference. Physiotherapy 2016 (vol 102) s1 e22-e Impact of using an online standardised data collection system in private physiotherapy practices in the UK: practitioners views. Published abstract Poster Bryant E, Murtagh S, Olivier G et al. Physiotherapy. Abstracts of the ER-WCPT conference, Liverpool, November Physiotherapy 2016 (vol 102) s1 e111-e Integrating Palliative Care into Neurology Services: what do the professionals say? (Published abstract) Nilay Hepgul, Catherine Evans, et al. Palliative Medicine Abstracts of the 9th World Research Congress of the European Association for 2016 Page 183

184 Sussex Community NHS Foundation Trust Annual Report 2016/17 Palliative Care (EAPC), 30(6): NP19-NP20 doi: / Feasibility of Delivering a Model of Short-term Integrated Palliative and Supportive Care for the Frail Elderly with Noncancer Conditions in Community Settings: a Phase II Randomised Trial (OPTCare Elderly Study) (Published abstract) Catherine J. Evans, et al. Palliative Medicine Abstracts of the 9 th World Research Congress of the European Association for Palliative Care (EAPC), 30(6): NP21 doi: / Part 1: Mapping Complexity of Needs in Palliative Care: A Qualitative Study of Stakeholder Perspectives (Published abstract) Sophie Pask, Catherine Evans, et al. Palliative Medicine Abstracts of the 9 th World Research Congress of the European Association for Palliative Care (EAPC), (6): NP42-NP43 doi: / Measures to Assess Commonly Experienced Symptoms for People with Dementia in Long- Clare Ellis- Smith, Catherine J Palliative Medicine Abstracts of the 9 th World Research Congress of the 2016 Page 184

185 Sussex Community NHS Foundation Trust Annual Report 2016/17 term Care Settings: a Systematic Review (Published abstract Poster) Evans, et al. European Association for Palliative Care (EAPC), 30(6): NP103- NP104 doi: / A Measure to Support Systematic Assessment of People with Dementia in Care Homes: The Palliative Care Outcome Scale (POS) For Dementia Assessment (POS-Dema) (Published abstract Poster) Clare Ellis- Smith, Catherine J Evans, et al. Palliative Medicine Abstracts of the 9 th World Research Congress of the European Association for Palliative Care (EAPC), 30(6): NP104 doi: / Part 2: Measuring Complexity of Needs in Palliative Care: A National Qualitative Study of Stakeholder Perspectives (Published abstract Poster) Cathryn Pinto; Catherine J. Evans, et al. Palliative Medicine Abstracts of the 9 th World Research Congress of the European Association for Palliative Care (EAPC), 30(6): NP126- NP doi: / Developing a Model of Short-term Integrated Palliative and Supportive Care for The Frail Elderly with Non-Cancer Anna Bone, ; Catherine J Evans, et al. Palliative Medicine Abstracts of the 9 th World Research Congress of the European Association for 2016 Page 185

186 Sussex Community NHS Foundation Trust Annual Report 2016/17 Conditions in Community Settings: Perspectives of Older People, Carers and Key Stakeholders (OPTcare Elderly Study) (Published abstract Poster) Palliative Care (EAPC), 30(6): NP127-NP128 doi: / A Systematic Review: Spirituality Assessment Tools in Adult Palliative Care (Published abstract Poster) Shabnam Nawaz, ; Catherine J. Evans, et al. Palliative Medicine Abstracts of the 9 th World Research Congress of the European Association for Palliative Care (EAPC), (6): NP203- NP204 doi: / Table 13: Research and Study Presentations Presentation Title Venue Authors Year How confident are you in your assessment skills for prescribing postural management equipment? (Workshop presenter) Association of Paediatric Physiotherapists Annual Conference 2016 Neurodisability From Birth to Transition Anderson L, & Chantry J 2016 Brighton Page 186

187 Sussex Community NHS Foundation Trust Annual Report 2016/17 Racerunning, from therapy to participation. 28 th Annual Meeting of the European Academy of Childhood Disability, Stockholm Bryant L, Bjork L and van Schie P 2016 (Instructional workshop presenter) The use of standardised data collection in private physiotherapy practice to provide information for clinicians, clinics and private practice organisations. Platform presentation. IFOMPT 2016 (International Federation Orthopaedic Manipulative Physical Therapists) Conference. Glasgow Bryant E, Moore A, Murtagh S, et al 2016 Patients expectations of physiotherapy treatment for musculoskeletal conditions. Platform presentation. ER-WCPT conference 2016 (European Region-World Congress Physical Therapy) Liverpool Bryant E, McCrum C, Murtagh S, et al Management of Growth and Development. (Invited speaker) Association of Paediatric Physiotherapists Annual Conference 2016 Neurodisability From Birth to Transition Brighton Campbell V 2016 Page 187

188 Sussex Community NHS Foundation Trust Annual Report 2016/17 Factors related to high tech AAC use in Adults with neurodegenerative conditions. (Poster presentation) Communication Matters 2016 National AAC Conference at Leeds University Foy C & Cowan D 2016 The Commissioning of Specialised AAC and EC Services what does it mean for wheelchair services? Postural Management Group Conference 2016 Griffiths H & Cowan D 2016 Understanding frames: Implementation of standing frames as part of postural management for children with cerebral palsy in the classroom European Academy of Childhood Disability. Amsterdam Goodwin J, Lecouturier J, Crombie S, Smith J, Cadwgan J 2017 Understanding frames: Implementation of standing frames as part of postural management in cerebral palsy European Academy of Childhood Disability. Amsterdam Goodwin J, Lecouturie, J, Crombie S, Smith J, Cadwgan J 2017 Using Peer Supervision Within a Community Research Nursing Team challenges, resilience and reward National NIHR CRN Research Nurse Conference Birmingham Duffield, A 2016 Page 188

189 Sussex Community NHS Foundation Trust Annual Report 2016/17 Short-term integrated palliative care for frail older people in community settings OPTCare Elderly Feasibility Phase II trial Invited speaker Primary Care Research Meeting, NIHR CRN Kent, Surrey and Sussex, Charis Centre Crawley Evans C J 2017 Clinical academics as innovative change agents and leaders Invited speaker International Collaboration for Community Health Nursing Research (ICCHNR) Symposium, University of Kent Evans C J 2016 Feasibility of delivering a model of short-term integrated palliative and supportive care for the frail elderly with non-cancer conditions in community settings: a phase II randomised control trial (OPTCare Elderly) Oral conference presentation 9 th World Research Congress of the European Palliative Care Association Evans C J, et al Current issues and challenges in research on virtual reality therapy for children with neurodisability, ICDVRAT 2016, Los Angeles Farr W, Male I, Green D, Morris C, Gage H, Bailey S, Speller S, Colville V, Jackson M, Bremner S, Memon 2016 Page 189

190 Sussex Community NHS Foundation Trust Annual Report 2016/17 A Pirate adventure assessment software: a new tool to aid clinical assessment of children with possible autism to appear Int J Disability and Human Development ICDVRAT 2016, Los Angeles Jordan, E, Farr W, Male I 2016 The Future of Home and School Use of Commercially Available Consoles for Rehabilitation in Children with Cerebral Palsy Invited Speaker University of Brighton Celebration of Research Conference in College of Life, Health and Physical Sciences (1 st July 2016) Farr W 2016 New Approaches to Paediatric Neurodisability What is the role of virtual reality National Medical Student Paediatric Conference, Brighton and Sussex Medical School Farr, W, Male I, Green D 2016 Barriers and facilitators to physical activity participation and engagement in Wii-Fit home therapy programme for children with cerebral palsy Accepted as oral presentation at the annual meeting of the European Academy of Childhood Disability (2017) Jabar M, Farr W, Morris C, Bremner S, Male I, Green D 2017 Page 190

191 Sussex Community NHS Foundation Trust Annual Report 2016/17 What is complex in neurodisability? (Poster presentation) British Paediatric Neurology Association National Conference 2016 Khan Y 2016 Polani Award Presentation: The Eating and Drinking Ability Classification System for people with cerebral palsy: a study of stability and associations with growth over time British Academy of Childhood Disability Annual Scientific Meeting, Manchester Sellers D, Bryant E, Campbell V, Hunter A and Morris C 2017 The Eating and Drinking Ability Classification System for people with cerebral palsy: a study of stability and associations with growth over time. Brighton and Sussex Medical School Paediatric Neonatal Research Symposium Sellers D, Bryant E and Morris C 2016 Instructional Course: Classifications of Function in 21 st Century: What are they good for? European Academy of Childhood Disability / International Cerebral Palsy Conference, Stockholm Rosenbaum P, Cooley Hidecker M-J, Palisano R, Eliasson A and Sellers D June 2016 Eating and drinking classification system for people with cerebral palsy: what is it good for? Part of the Nutricia Paediatric Symposia Series: a practical MDT approach to managing infants and children with complex Sellers, D 2016 Page 191

192 Sussex Community NHS Foundation Trust Annual Report 2016/17 feeding challenges. London, Dunblane & London Making Decisions Mental Capacity Act and Consent (Invited speaker) Association of Paediatric Physiotherapists Annual Conference 2016 Neurodisability From Birth to Transition, Brighton Springham F 2016 Page 192

193 Sussex Community NHS Foundation Trust Annual Report 2016/17 Appendix 3 Glossary of Terms Term Assurance Care Quality Commission - CQC Chronic Obstructive Pulmonary Disease - COPD Clinical Audit Description Providing information or evidence to show that something is working as it should, for instance the required level of care, or meeting legal requirements. The independent health and social care regulator for England. COPD is a lung disease characterised by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible. The more familiar terms 'chronic bronchitis' and 'emphysema' are no longer used, but are now included within the COPD diagnosis. A process used to improve the quality of care by reviewing the care given against explicit criteria. Analysis of the results is then used to highlight any gaps. An action plan can then be put in place to address those gaps and then a re-audit takes place to review whether those actions have worked to plug the gaps identified. A clinical audit can also highlight good practice, which can then be shared across SCFT. National clinical audits are largely funded by the Department of Health and commissioned by the Healthcare Quality Improvement Partnership (HQIP) which manages the National Clinical Audit and Patients Outcome Programme (NCAPOP). Most other national audits are funded from subscriptions paid by NHS provider organisations. Priorities for the NCAPOP are set by the Department of Health with advice from the National Clinical Audit Advisory Group (NCAAG). Clinical Coding Clinical Commissioning Groups - CCGs Clinical Effectiveness Clinical Governance Instead of writing out long medical terms that describe a patient's complaint, problem, diagnosis, treatment or reason for seeking medical attention, each has its own unique clinical code to make it easier to store electronically and measure. Groups of GPs who are responsible for designing local health services in England. Is the clinical intervention used doing what it is supposed to? Does it work? Clinical governance is a systematic approach to maintaining and Page 193

194 Sussex Community NHS Foundation Trust Annual Report 2016/17 improving the quality of patient care within the NHS. Clostridium Difficile - C. difficile Commissioning Commissioning for Quality and Innovation - CQUIN Community Information Dataset - CIDS Data Warehouse Department of Health - DH Healthwatch Improving Access to Psychological Therapies - IAPT Information Governance Toolkit Intranet Methicillin-Resistant Staphylococcus Aureus - MRSA Metrics A contagious bacterial infection, which can sometimes reproduce rapidly especially in older people who are being treated with anti-biotics and causes potentially serious diarrhoea. The process of buying health and care services to meet the needs of the population. It also includes checking how they are provided to make sure they are value for money. A payment framework, which commissioners use to reward excellence, by linking a proportion of the Trust s income, to its achieving set local quality improvement goals. CIDS makes locally and nationally comparable data available on community services. This helps commissioners to make decisions on the provision of services. In computing, a Data Warehouse is a database used for collecting, and storing data so it can be used for reporting and analysis. A UK government department responsible for government policy for health and social care matters and for the National Health Service (NHS) in England. Healthwatch England is the independent consumer champion for health and social care in England. It ensures the overall views and experiences of people who use health and social care services are heard and taken seriously at a local and national level. A national programme including Time to Talk. A system that allows NHS organisations and partners to measure themselves against Department of Health Information Governance policies and standards. An intranet is a computer network that uses Internet technology to share information between employees within an organisation. SCFT s Intranet system is called the Pulse. Staphylococcus aureus (Staph) is a type of bacteria that is commonly found on the skin and in the noses of healthy people. Some Staph bacteria are easily treatable, while others are not. Staph bacteria that are resistant to the antibiotic methicillin are known as Methicillin-resistant Staphylococcus aureus or MRSA. Measures, usually statistical, used to assess any sort of Page 194

195 Sussex Community NHS Foundation Trust Annual Report 2016/17 performance such as financial, quality of care, waiting times, etc. NHS England - NHSE NHS Improvement - NHSI National Institute For Health Research - NIHR National Institute for Health & Care Excellence - NICE National Patient Safety Agency - NPSA National Reporting and Learning System - NRLS Patient Advice & Liaison Service - PALS The Pulse Research NHS England leads the National Health Service (NHS) in England. We set the priorities and direction of the NHS and encourage and inform the national debate to improve health and care. NHS Improvement is responsible for overseeing foundation trusts and NHS trusts, as well as independent providers that provide NHS-funded care. They offer the support these providers need to give patients consistently safe, high quality, compassionate care within local health systems that are financially sustainable. By holding providers to account and, where necessary, intervening, they help the NHS to meet its short-term challenges and secure its future. A government body that coordinates and funds research for the NHS in England. An independent organisation responsible for providing national guidance on promoting good health, and on preventing and treating ill health. Leads and contributes to improved and safe patient care by informing, supporting and influencing organisations and people working in the health sector. An NHS national reporting system, which collects data and reports on patient safety incidents. This information is used to develop tools and guidance to help improve patient safety. A service providing a contact point for patients, their relatives, carers and friends where they can ask questions about their local healthcare services. The Trust s intranet for staff. Research is the discovery of new knowledge and is a core part of the NHS, enabling the NHS to improve the current and future health of the people it serves. Clinical research means research that has received a favourable opinion from a research ethics committee within the NRES. Information about clinical research involving patients is kept routinely as part of a patient s records. Tbc To be confirmed. YTD Year to date is the term used to describe data from the beginning of the year to the current time not necessarily year end. Page 195

196 Sussex Community NHS Foundation Trust Annual Report 2016/17 Page 196

197

198

199

200

201

202

203

204

205

206

207

208

209

210

211

212

213

214

215

216

217

218

219