Walsall Healthcare NHS Trust Annual Report and Accounts 2016/17.

Transcription

1 Wasa Heathcare NHS Trust Annua Report and Accounts 2016/17

2 Wasa Heathcare NHS Trust Annua Report 2016/17 CONTENTS Wecome 3 1. Performance Report 6 Overview 7 Chief Executive s Statement on Performance 7 Purpose and Activities of Wasa Heathcare NHS Trust 8 Key Issues and Risks 18 Performance Summary 19 Performance Anaysis Accountabiity Report 23 Corporate Governance Report 24 Directors Report 24 Chair and Chief Executive 24 Trust Board Composition 24 Audit Committee Composition 29 Company Directorships and Other Significant Interests 29 Persona Data Reated Incidents Reported to the Information Commissioner's Office 31 Statement of Discosure to Auditors 32 Statement of Chief Executive s Responsibiities as the Accountabe Officer 33 Governance Statement 34 Scope of Responsibiity 34 Introduction 34 Governance Framework 37 Board and Committee Structure 39 The Risk and Contro Framework 48 Significant Issues 49 Discharge of Statutory Functions 54 Remuneration and Staff Report 55 Remuneration Report 55 Remuneration Poicy 55 Fair Pay Discosure 55 Remuneration and Entitement of Senior Managers 56 Compensation - Eary Retirement/Loss of Office 58 Payments to Past Directors 58 Staff Report 58 Number of Senior Managers 58 Staff Numbers Anaysis 58 Staff Composition 59 Sickness Absence 59 Staff Poicies 60 Consutancy Costs 60 Off Payro Arrangements 60 Exit Packages 61 Anaysis - Other Departures Financia Statements and Notes 63 2

3 Wasa Heathcare NHS Trust Annua Report 2016/17 WELCOME 3

4 WELCOME Wasa Heathcare NHS Trust Annua Report 2016/17 Wecome to Wasa Heathcare NHS Trust s Annua Report and Accounts. The ast 12 months have been a pivota year for Wasa Heathcare NHS Trust, our patients and our staff. Right at the start of this Annua Report we woud ike to say a sincere and heartfet thank you to a 4,500 coeagues at the Trust as we as a of our friends and supporters in the communities we serve for your continued commitment and dedication it makes a rea difference! We began the year having been paced in Specia Measures foowing our CQC inspection in September The report made cear the scae of the chaenges, incuding those reating to quaity and safety of care, to operationa performance, to our financia position and to the cuture of the organisation. At the start of the 12 months covered by this Annua Report we committed ourseves to five year improvement journey to tacke the issues that we faced. As with any journey it is important to be cear about the destination. During the year we have set a new vision and service strategy for the Trust. Our vision for 2020 is to become your partners for first cass integrated care. To do this successfuy wi need us to achieve five strategic objectives: 1. Provide Safe, High Quaity Care. We wi provide care that we woud want for our famiy and friends. 2. Care for Patients at Home. We wi keep peope we at home, provide aternatives to acute care and return peope home safey and quicky after admission. 3. Work Cosey with Partners. We cannot do this aone and wi work with our partners in Wasa and the Back Country. 4. Vaue Coeagues. We wi be a cinicay-ed, engaged and empowered organisation. 5. Use Resources We. We wi ensure future sustainabiity by iving within our means. This vision and accompanying service strategy was deveoped with input from many of our coeagues and has been shared widey across the organisation. It sets out ceary for our patients, our staff and stakehoders how we beieve our services shoud deveop over the next three to five years. As this Annua Report shows, we have got off to a good start in the first year of our journey towards our 2020 vision. Thanks to the hard work of coeagues across the trust we have been abe to: Improve the quaity and safety of the care we provide especiay in our Emergency Department where we have appointed extra staff, improved pain reief and the care we provide to chidren and in maternity where we have improved access to one to one care in abour and improved staffing eves; Improved our trust governance and risk management so we are better abe to earn when things go wrong and act to ensure we improve; Reduced significanty the backog of patients waiting for eective treatment increasing the percentage seen within 18 weeks from 75% to 85% and consistenty deivering the nationa cancer standards and diagnostic waiting time standards; Continued to progress the deveopment of seven integrated ocaity teams bringing our community nursing teams together with socia care, menta heath and primary care coeagues across the borough; Launched Listening into Action to hep us embed a cinicay-ed, engaged and empowered organisation. There is, of course, sti a ong way to go to reach our vision but in the ast 12 months we have made important progress and aid the foundations for continued future improvement. In this report, we are aso open about the areas in which we sti to need improve. In spite of the progress we have made in 2016/17 we have sti much to do. Our 2016 inpatient survey resuts and our 2016 nationa staff survey resuts were in the bottom 20% of trusts in the country not where we want to be and we are focused on continuing to improve patient experience. We aso ended 2016/17 with a significant financia deficit argey as a resut of needing to spend more money than panned to deiver safe staffing eves as we as difficuties in deivering our savings pans. 4

5 Wasa Heathcare NHS Trust Annua Report 2016/17 Athough this report mainy ooks back over 2016/17, it is worth ending this message by saying something about our pans for the next stage of the journey. The Trust Board has approved our pans for 2017/18 and 2018/19 and we wi focus on: WELCOME Continuing the safety, quaity and performance improvements that we have begun in the ast tweve months especiay improving the care of deteriorating patients, promoting our normaity strategy in maternity and tacking our outpatient foow-up deays; Embedding the cuture change that we have begun by deveoping a cinicay-ed, engaged and empowered organisation; Tacking our deficit by deivering 24m of savings over two years, reducing our deficit to 20.5m in 2017/18 and 12.5m in 2018/19 as part of our five year improvement journey to break even. Work with our partners in Wasa Together to reduce the year on year growth in demand for hospita care by supporting more patients to stay we at home; Competing our pans for the hospita estate by redeveoping the intensive care unit, adding a second maternity theatre and a new neonata unit and a new Emergency Department and assessment unit. So, thank you again to a of our coeagues for your hard work and commitment on behaf of our patients. As we hope this report wi show, we have got off to a good start in the first year of our improvement journey but there remains much to do in the next two years. We have a cear vision to guide us and we trust that with continued support from coeagues, patients and stakehoders we wi be abe to continue to improve successfuy. Daniee Oum, Chair. Richard Kirby, Chief Executive. 5

6 Wasa Heathcare NHS Trust Annua Report 2016/17 SECTION 1: PERFORMANCE REPORT 6

7 OVERVIEW Wasa Heathcare NHS Trust Annua Report 2016/17 Chief Executive s Statement on Performance Wasa Heathcare NHS Trust faced 2016/17 with a need to get the organisation back on track towards deivering safe, high quaity, integrated care in a sustainabe way within the resources avaiabe to us. This was in the aftermath of the pressures faced in previous years and during the year the Trust has had some significant successes through the hard work of our teams and partners. PERFORMANCE REPORT Our improvement journey started with a refresh of the Trust s 2020 vision and service strategy. We recognise we have significant chaenges to address and 2016/17 was the first year of our five year journey to deiver our vision to become your partners for first cass integrated care. The new vision was deveoped with input from the Trust Board and from coeagues across the Trust and is set out in the diagram beow. Care for patients at home whenever we can Provide safe, high quaity care across a our services Becoming your partners for first cass integrated care Work cosey with partners in Wasa and surrounding areas Use resources we to ensure e we are sustainabe Vaue our coeagues so they recommend us as a pace to work 1. Provide Safe, High Quaity Care. We wi provide care that we woud want for our famiy and friends. 2. Care for Patients at Home. We wi keep peope we at home, provide aternatives to acute care and return peope home safey and quicky after admission. 3. Work Cosey with Partners. We cannot do this aone and wi work with our partners in Wasa and the Back Country. 4. Vaue Coeagues. We wi be a cinicay-ed, engaged and empowered organisation. 5. Use Resources We. We wi ensure future sustainabiity by iving within our means. 7

8 PERFORMANCE REPORT Wasa Heathcare NHS Trust Annua Report 2016/17 We have made a good start to this journey and over the ast 12 months we have seen improvements in eective care, maternity services, depoyment of community based ocaity teams and staff engagement. But, in common with many other Trusts across the country, we have faced a number of winter pressure chaenges; particuary around four hour waits in the Emergency Department, managing ambuance activity and increased engths of stay for patients. We know from speaking to our patients and their famiies, as we as feedback from our own staff, that this impacted poory on both patient experience and staff morae. "Our arger discharge ounge achieved reay positive resuts" As we as working with partners to try and avoid hospita admissions, we opened up a arger Discharge Lounge to try and improve patient fow, ensure eary discharges from a wards and free up our Emergency Department. We aimed to compete at east a third of a discharges by midday and this achieved reay positive resuts, with around 30 peope a day being moved quicky out of the Emergency Department to the bed they needed. Extra community nursing support was aso put in pace at targeted parts of the week (Sundays) to proactivey avoid admissions from this care group and ease another pressure point for the Emergency Department. Our staff frequenty went the extra mie for our patients, in sometimes difficut circumstances, and their efforts are very much appreciated. We do, however, need to ook at how to better manage these chaenges moving forward. Our vision is supported by five strategic objectives and the promises we have made for our patients and our coeagues form the basis for our operationa pans for 2017/18 and 2018/19 years two and three of the pan. By 2021 we wi be an organisation that is community focused, with a workforce that is engaged and empowered and working with partners to ensure financia sustainabiity. Our fu CQC re-inspection wi be an important miestone for us on our journey and we ook forward to showing the progress we are making to ensure our services are Safe, Effective, Caring, Responsive and We Led. Purpose and Activities of Wasa Heathcare NHS Trust Wasa Heathcare NHS Trust is an integrated Trust. The Manor Hospita provides the fu range of district genera hospita services and community heath services for aduts and chidren are run from more than 60 settings across the borough, incuding heath centres and GP surgeries, as we as peope s own homes. Wasa borough is made up of a diverse muti-cutura popuation of more than 270,000. In some areas there is a high incidence of ong term conditions, ower than nationa average ife expectancy and high usage of hospita services. In more affuent areas there is a onger ife expectancy and a growth in dependency from frai edery patients. Within the ast two years there has been a positive shift towards integrated heath and socia care with the deveopment of seven of the Integrated Locaity Teams. The teams are co-ocated Community, Socia Care staff and Menta Heath staff who provide a wrap-around service to GP Practices. 8

9 Wasa Heathcare NHS Trust Annua Report 2016/17 The seven teams are spit into four areas North Pinfod Heath Centre West 1 & 2 Daraston Heath Centre East 1 Parkview Heath Centre East 2 Anchor Meadow Heath Centre South 1 Beechdae Heath Centre South 2 Broadway Heath Centre PERFORMANCE REPORT "Within the ast two years there has been a positive shift towards integrated heath and socia care." Members of Broadway Heath Centre s community nursing team. The Trust has, in genera, made good progress towards the majority of the 18 main objectives set out in its Annua Pan for 2016/17 - particuary in areas of quaity and safety, organisationa deveopment, governance, estate deveopment and community/partnership enabers and integration. Further work is needed around the Cost Improvement Pan, finances and the objective to impement a discharge to assess mode to reduce the numbers of patients that are medicay fit for discharge. Detaied beow is information reating to the progress made against our six key annua pan objectives for 2016/2017: 1. Improve the Quaity and Safety of our Care We set out to deiver a programme of quaity improvement in response to the CQC inspection report after the Urgent and Emergency Services and Maternity and Gynaecoogy Services were rated Inadequate by the CQC. We were aso rated Inadequate for the Safe, Effective and We Led CQC domains. We aso set out to improve the percentage of staff ikey to recommend us for treatment in our staff survey and improve the overa score in the nationa inpatient survey. We estabished a Patient Care Improvement Pan which is reported in detai monthy. Considerabe work has been done around Sepsis and Deteriorating Patients and this remains a top priority. We now have Nursing and Consutant Sepsis Champions across our wards at the Manor Hospita. Sepsis champion Annette Turey. Dr Ron Danies BEM, CEO of UK Sepsis Trust ed a seminar at the Trust. 9

10 PERFORMANCE REPORT Wasa Heathcare NHS Trust Annua Report 2016/17 Our focus aso remains on Infection Prevention and Contro and Medicines Management. We have seen improved standards in the Menta Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) and have raised greater awareness of the use of our butterfy symbos to denote patients who are iving with dementia. We started Listening into Action, a fundamenta shift in the way we work and ead. Further detais of this approach can be found ater in this section of the Annua Report. Compaints in ED and Maternity Services have decreased and the Trust aso aunched its Quaity Commitment. The Quaity Commitment to provide safe, high quaity care across a our services inks to our six promises shown beow: Promises: Part of one team working together with we-informed coeagues who understand each other s roes to deiver and improve services. Supported to meet our high standards in a team that sets cear expectations, supports and chaenges you to ive up to them, is open and honest about what s going we and what s not and takes time to refect and improve. Appreciated by coeagues who vaue and respect them as individuas and recognise their efforts and achievements. Provide safe, high quaity care across a our services Use resources we to ensure e we are sustainabe Care for patients at home whenever we can Becoming your partners for first cass integrated care Work cosey with partners in Wasa and surrounding areas Vaue our coeagues so they recommend us as a pace to work In safe hands of highy skied, efficient, reassuringy professiona teams providing first cass joined-up care. Cared for as an individua by kind and considerate peope who invove you and your famiy in your care. Wecomed by friendy, hepfu and attentive staff who vaue your time. Improve the Quaity and Sustainabiity of Maternity and Neonata Care We set out to improve our Midwife to birth ratio and improve resuts in the maternity patient survey. Working with Wasa Cinica Commissioning Group we put a cap on the number of births at the Manor Hospita to stabiise the maternity service and ensure effective, high quaity care. Births have been capped at 4,200 and are expected to remain in pace for 2017/2018 athough we wi keep this under reguar review. "Our Transitiona Care Unit opened in February this year." Transitiona Care Unit Midwives. The Midwife to birth ratio is now around 1:30 and 1:1 care in abour is being maintained. A recruitment drive has attracted 10 additiona midwives and in February this year our Transitiona Care Unit opened for babies who need some extra care. We have a new Head of Midwifery and have been appointing to speciaist midwifery roes. Improve the Quaity and Safety of the Emergency Department We set out to reduce ong waits in ED and improve our four hour performance whie reducing medica and nursing vacancies and improving patient survey resuts. We now have speciaist paediatric nurse cover in ED and have re-designed and re-defined our waiting area, introducing a separate, chid-friendy triage room. This has heped reduce incidents and compaints. 10

11 Wasa Heathcare NHS Trust Annua Report 2016/17 "We need to ensure our environment is fit for purpose for chidren." PERFORMANCE REPORT Paediatric Sister Dawn Luke. Senior Consutant cover has been increased from 6pm to midnight and the number of consutants in our estabishment has increased from six to 10. We are working on a business case to enabe the Trust to expand its Emergency Department to create a better environment for both patients and our staff. We need to ensure our environment is fit for purpose for chidren and is abe to cope with additiona demand we expect when the Midand Metropoitan Hospita opens its doors in Smethwick. Improve the Quaity and Sustainabiity of our Cancer Services We set out to sustain deivery of the two week wait standard throughout the year and deiver the 62 day standard from August A measures achieved the performance target across the year, which compares very favouraby to 2015/16 resuts when three measures faied to achieve. Furthermore, a but one of the measures (62 day wait for first treatment from Screening Service) showed an improvement in the overa percentage achievement across the fu year in comparison to ast year. Estabish a Sustainabe Future for Stroke Services We set out to agree a sustainabe future mode for the Trust s stroke service with commissioners and stakehoders. Work has been done to deveop rehabiitation pathway modes with cinica teams and commissioners in Wasa and to deveop a onger term pan for the service which wi be competed during Improve the quaity of the care we provide to patients at the end of their ife. We set out to embed individuaised management pans across a areas. Improvements have been seen in a standards for End of Life Care. Pans have been deveoped and training deivered to ward and community staff to embed individuaised management pans. A ward and community staff have access to the pan. Individuaised care pans are beginning to embed with improved monthy performance. Ward 3 has particuary focused on End of Life Care as part of Listening into Action, sharing positive improvements and good practice ideas. End of Life care staff are aso invoved in ward rounds where possibe. Speciaist Paiative Care Team promoting Advance Care Panning. 11

12 PERFORMANCE REPORT Wasa Heathcare NHS Trust Annua Report 2016/17 Our Speciaist Paiative Care Team s work with focus groups made up of carers, vounteers and Trust Members to deveop an Individuaised End of Life Care Pan has been recognised nationay. In addition, we are further supporting our patients care and treatment choices by raising awareness of Advance Care Panning which is a communication channe for peope to document choices about their care and treatment. 2. Community Services Deveopment We set out to compete the depoyment of integrated ocaity teams with partners in Menta Heath, Socia Care and Primary Care. Our Community Nursing Teams are now in pace. Socia care is aso now aigned abeit some estate issues remain and wi be resoved in the coming months. We set out to depoy mobie technoogy for community teams. The Trust has invested 800,000 in mobie technoogy for community services staff to change from a paper-based patient assessment and service management system which wi improve the service to patients as we as offer staff greater security whie one working. "The change from a paper-based system wi improve the service to patients." Staff from the West 1 Pace Based Community Team wi be triaing mobie technoogy. We set out to buid a directory of services and a singe point of access to ensure efficient use of resources. A work stream through Wasa Together is undertaking a review of potentia technoogy patforms to house a system-wide directory. We set out to continue the deveopment of integrated care pathways that ink key services together seamessy. Our Chronic Obstructive Pumonary Disease pathway redesign got underway first with Respiratory, Uroogy and Muscuoskeeta (MSK) re-designs in progress. We are working on a coaborative approach to End of Life Care with St Gies. Respiratory, Uroogy and Muscuoskeeta (MSK) redesigns are aso progressing. 3. Improve our Emergency Care Pathway We set out to impement a discharge to assess mode to sustainaby reduce medicay fit for discharge patients unabe to eave acute care. We are continuing to work with partners to finaise the mode to reduce medicay fit for discharge numbers whie exporing community based heath modes. We aim to achieve our target of 50 medicay fit for discharge patients. We set out to deiver nationa seven day services standards for emergency care and continue to work toward deivering these standards in ine with our pans. We have begun to introduce the SAFER bunde across a medica wards and wi continue this work during 2017/2018. We set out to deiver a sustained reduction in unpanned emergency re-admissions to hospita. Each speciaty now has an action pan to review its own re-admissions on a monthy basis foowing anaysis of re-admission profiing. As a resut we have seen a reduction in the percentage of emergency readmissions within 30 days of discharge from 9.12% in October 2016 to 8.56% at the end of March

13 Wasa Heathcare NHS Trust Annua Report 2016/17 4. Improve our Eective Care Pathway In order to improve our eective care pathway we engaged an externa company to technicay vaidate the compete patient waiting ist which was in excess of 22,000 records. An interna data quaity process aso started at the same time. In addition, the Intensive Support Team conducted a review of our data quaity and associated processes in September Through this externa review and the impementation of their recommendations, in October the Trust Board was abe to approve a return to forma nationa reporting for the 18 Week Referra to Treatment Time (RTT). PERFORMANCE REPORT As a resut of this work we have more than haved the number of patients waiting more than 18 weeks, reducing from 4,733 patients to 2,350 patients. However, the onset of winter pressures and the extension of the winter contingency pan has affected our abiity to maintain performance. "We have haved the number of patients waiting more than 18 weeks for treatment." We set out to ensure effective operation of our outpatient services and in order to approve our Did Not Attend rates we set up an SMS messaging system which is resuting in a 4-5% reduction in non-attenders. In addition, we worked with NHS Eect to review booking processes across the Trust and set about impementing recommendations. 5. Improving for Coeagues We set out to estabish a substantive workforce to reduce our expenditure on agency staff. Our tota agency expenditure in 2016/2017 was 10.9m with the highest expenditure in October 2016 at 1.2m. Due to concerted efforts incuding the estabishment of a Workforce Steering Group, we significanty reduced agency expenditure in the second haf of the year, with the March 2017 expenditure reduced to a figure of 548,000. We are working on a number of options to further reduce our reiance on agency staff incuding an increase in bank rates. We continue to work to recruit to posts, reduce turnover and cose additiona capacity to further reduce agency expenditure. We have signed a Memorandum of Understanding with the Coege of Surgeons, Pakistan, for trainees to fi rotas. We set out to improve staff attendance through a number of measures incuding improving occupationa support. A Lead Nurse phone ine was estabished for coeagues to contact and this has seen a reduction in sickness by 0.5% for the year this equates to 50,000 more hours returned to care. We are working with the most chaenged wards in each division in reation to their attendance rates to deiver improvements. Work is aso continuing on deveoping our Occupationa Heath service. We set out to estabish a cinicay-ed mode of service eadership at Care Group and Division eve. The aim is to become cinicay-ed, engaged and empowered by putting our frontine medica coeagues in the driving seat for future improvements and change. This means that each of the cinica divisions is now ed by a Divisiona Director who is a cinician. The Divisiona Director is supported by a Divisiona Director of Nursing and a Divisiona Operations Director. 13

14 PERFORMANCE REPORT Wasa Heathcare NHS Trust Annua Report 2016/17 We set out to deiver a step-change in staff engagement in the Trust using the Listening into Action programme to deiver this. Just under a year ago, we started Listening into Action, a fundamenta shift in the way we work and ead. Listening into Action is at the core of our strategic approach to improving services through engaging coeagues, unocking their potentia and empowering action in order to contribute to our Vision. A repeat puse check was conducted during December and has shown an improvement in positive responses across a questions of the survey when compared to responses obtained in May This is best represented graphicay beow: There has been an improvement of at east 5% points in each question, with the greatest rise for question 5: I fee that our organisation communicates ceary with staff about its priorities and goas. The resuts show a positive trend and highights areas which can be improved further. The LiA Sponsor group wi refect on the newy obtained resuts and make pans for further improvements in puse check resuts in the future. Our Wave 1 teams, which were the first to set the Listening into Action whees in motion, have made a rea impact with Heath Records, Emergency Department, Wards 3, 11 and 16, the Arrivas Lounge and Maternity and neonates among the areas getting us off to a fying start. We aso hed a Listening into Action event excusivey for the Trust s doctors. Projects for Wave 3 of Listening into Action are being recruited. The Nationa Staff survey response rates for 2016 increased by 20% but the overa findings were disappointing. Work has aready commenced on actions and to synchronise this with work reating to the findings of the Nationa Inpatient Survey for We set out to improve the eadership and management cuture of the Trust through a focused programme of deveopment for senior and midde managers. We are making improvements to our to our we-ed and accountabiity cuture with mandatory effective management programmes for a of our coeagues in management positions. The Kings Fund programme for Matrons and Managers has been aunched and more than 330 managers have attended the Effective Managers Programme for eight or more modues. 6. Improving for the Longer Term In 2016/2017 the Trust deivered a forecast deficit of 21.4m against an origina pan of a 6.2m deficit. The deficit position was caused by the foowing factors: Low Cost Improvement Pan deivery. We set out to deiver 9.3m of savings and deivered ony 6.617k resuting in under deivery of 2.683k. Investment in staffing. Temporary staff expenditure to cover vacancies and extra capacity. Extra sessions to reduce waiting times. We set out to estabish a cear Trust Capacity Pan to ensure future sustainabiity and a Trust-wide demand and capacity pan is underway and training for care group managers has started. 14

15 Wasa Heathcare NHS Trust Annua Report 2016/17 To address the inadequate CQC rating for the We Led Domain, a number of actions have been put in pace during the year to improve the governance structures and processes within the Trust. This has incuded a comprehensive review of risk registers and an improved root cause anaysis process. Work wi be ongoing during 2017/2018 to embed the improved arrangements. More information on this can be found in the Annua Governance Statement within this Annua Report. We set out to design and deiver a data quaity improvement pan to ensure that our cinica teams have access to and use data to drive service improvement. A new ED and bed board is now in use as is a new Information Hub. A Data Quaity Group meets monthy to improve data quaity, with a focus on: PERFORMANCE REPORT Utiising nationa/regiona benchmark data Other findings incuding audits & risk reports Finance & coding We set out to deiver a transformationa strategy that draws on the benefits from our partnerships with the Back Country Aiance and Wasa Together. We have set up a Service Improvement Team. Our Service Improvement Strategy was approved by the Trust Board in March 2017 and we continue working with partners in the Back Country Aiance and Wasa Together. We set out to improve our estate through our new Integrated Critica Care Unit (ICCU) and Maternity and Neonata faciities. We have received approva for the ICCU enabing works are now under way. We are currenty waiting for fina approva from NHS Improvement for our Maternity and Neonata business case. We are aso in the process of deveoping the outine business case for the Emergency Department. Artist s impression of ICCU exterior. We set out to estabish a robust approach to workforce panning incuding the deveopment of new roes inked to modes of care especiay for emergency and acute care and maternity services. Foowing the appointment of a Workforce Panning Manager, workforce panning with divisions and care groups has begun to ink with the Trust s strategy to transform the workforce and make it sustainabe. "Wasa was chosen as one of 11 ead provider Trusts for Nursing Associates initiative." Trainee Nursing Associate Sian Cadman. 15

16 PERFORMANCE REPORT Wasa Heathcare NHS Trust Annua Report 2016/17 We have introduced some new roes at the Trust incuding Nursing Associates who work aongside Care Assistants and Registered Nurses to deiver hands-on care. Wasa was chosen as one of 11 ead provider Trusts and ed a Back Country-wide bid, working with a range of organisations representing the variety of paces where Nursing Associates wi provide care for patients. We set out to improve the access and quaity of education and training for medica staff and our Deanery review in Juy 2016 demonstrated improvements in both Medicine and Paediatrics. Work remains ongoing to continue the good progress made. Working with Our Partners and Patients Our We Wishers charity has enjoyed another busy year with a host of fundraising events ranging from a Word Record-breaking pinba marathon to a boxing match, Trust s Got Taent contest, fun run and fashion show. More than 39,000 has been raised by We Wishers over the ast 12 months for items above and beyond what the NHS can provide and activities and events have been we supported by a of Wasa s communities. Notabe achievements incude the refurbishment of the sensory room on Ward 21 Paediatric Assessment Unit which was party funded through the Prince's Trust and donations from the Sikh and Hindu communities. Penty of fundraising events through the year. The room was in desperate need of new equipment to be used by chidren with a range of needs incuding sensory impairments, cerebra pasy, physica disabiities and earning disabiities. It was officiay opened by Wasa s Deputy Mayor Councior Marco Longhi and young britte asthma patient Megan Pritchard. We Wishers has its own Twitter and Facebook accounts and engagement is steadiy growing. Teamwork to reduce avoidabe harm A joint project to reduce avoidabe harm in Wasa s nursing homes and cut down on unnecessary hospita admissions is aso showing positive resuts. The SPACE Safer Provision and Caring Exceence initiative is being pioneered by the Wasa Quaity Improvement Project, a partnership between Wasa Heathcare NHS Trust and NHS Wasa Cinica Commissioning Group. Its focus is on supporting nursing home staff to reduce avoidabe harm such as pressure ucers, fas and community acquired infections. There is aso an emphasis on improving communication and handover processes and providing a range of free training opportunities for staff. 16

17 Wasa Heathcare NHS Trust Annua Report 2016/17 Progress is encouraging and since the SPACE project started ast December nine of the tweve homes have impemented daiy safety crosses to monitor avoidabe harm and another four have introduced staff champions to concentrate on ensuring residents are we hydrated. PERFORMANCE REPORT "The SPACE project has reduced avoidabe pressure injuries." Harrison Unit at Parkands Court has reduced avoidabe harm from pressure injury. Before the project started approximatey one resident per month deveoped a pressure injury in the unit of one of the nursing homes invoved. Since the Quaity Improvement project started on 1 January 2017 none of the residents have deveoped avoidabe pressure injury. This is a good improvement given the severe fraity of the residents in its care. Improving our patients' experience Working with patients, their carers and famiies we have deveoped a new Patient Experience Strategy which wi ensure that the Trust has a co-ordinated approach to istening to, and earning from, patient feedback. We have deveoped four ambitions which are: Ambition 1: We want to improve the experience of our patients and carers from their first contact with the Trust, through to their safe discharge from our care. Ambition 2: We want to improve the information we provide to enhance communication between our staff, patients and carers. Ambition 3: We want to meet our patients physica, emotiona and spiritua needs whie they are using our services, recognising that every patient is unique. Ambition 4: We want to demonstrate that there has been rea earning and change in practice where necessary from what patients have tod us about the care we have deivered as a Trust. Friends and Famiy Test surveys have now moved away from a purey paper-based system to embrace other communication methods incuding SMS texts in response to patients requests. This has brought about an increased response rate. Our new interpreting service has aso been aunched and we are sharpening our focus on Equaity and Diversity for coeagues and patients aike. A review of our Compaints process has resuted in a new process being put in pace that has seen a reduction in faiure to respond within timescae and considerabe work has been done around Duty of Candour showing improved quaity and performance. 17

18 PERFORMANCE REPORT The key issues and risks that coud affect the Trust in deivering its objectives During 2016/17, the Trust identified the foowing key risks to the deivery of its strategic objectives: Wasa Heathcare NHS Trust Annua Report 2016/17 Faiure to improve the quaity and safety of care we provide across the Trust in ine with our commitment in the Patient Care Improvement Pan. Faiure to make progress in improving care for patients attending our Emergency Department. Faiure to make progress in improving care for patients using our maternity and neonata services. Improvements in community services do not deiver a reduction in demand for acute hospita care. The emergency care pathway does not improve resuting in continued deays for patients and poor fow through the hospita. Inabiity to recover performance on the nationa eective standards incuding referra to treatment and cancer as panned. Inabiity to deiver safe sustainabe staffing eves reducing our reiance on expensive agency staff. That we are not successfu in our work to estabish a cinicay-ed engaged and empowered cuture. Inabiity to deiver our pan within the resources avaiabe and keeping expenditure within budget. That we cannot deiver our panned programme of hospita estate improvement incuding ICCU, Neonata Unit, second Maternity Theatre and a pan for the Emergency Department. That our governance remains inadequate as assessed under the CQC We-Led standard. That we do not deveop a cear five year strategic pan to support our 2020 service vision. Mitigating action pans were deveoped to address these wherever possibe and progress against the action pans was monitored by the Trust Board through the Board Assurance Framework. This process is described in more detai in the governance statement section of this annua report. In reation to performance issues, the Trust identified the main issues during 2015/16 as foows: Accident and Emergency four hour waits. Referra to treatment waiting times. Statement of Going Concern The Trust has recorded revenue deficits in the two financia years prior to 2016/17. The Board is committed to addressing the current deficit position and the Trust s five year mode shows a panned breakeven in 2020/21. This financia recovery is dependent upon the achievement of cost improvement programmes over the period during which the Trust wi aso be reiant on financia support from the Department of Heath to continue the provision of services. The Trust recognises there is significant risk associated with the achievement of cost improvements targets incuded the forthcoming financia years. The Trust has agreed a cost improvement target of 11m for 2017/18 and is continuing to deveop initiatives to deiver future savings beyond this financia year. The Trust s financia position is a materia uncertainty that casts significant doubt upon its abiity to continue as a going concern and, that therefore, the Trust may be unabe to reaise its assets and discharge its iabiities in the norma course of business. The Board of Directors has therefore given carefu consideration to the Going Concern principe when preparing these accounts. In respect of the 20.5m panned revenue deficit for 2017/18, the Trust has access to the Uncommitted Interim Revenue Support Faciity and cash supporting oans are agreed monthy with Department of Heath dependent on cash requirement. The Board has concuded that athough the financia circumstances represents a materia uncertainty, the Directors have a reasonabe expectation that the Trust wi have access to sufficient resources, incuding revenue and capita oan funding, to continue to provide services to patients for the foreseeabe future. For this reason the Board has adopted the going concern basis when preparing these accounts. 18

19 Performance Summary: Wasa Heathcare NHS Trust Annua Report 2016/17 PERFORMANCE REPORT 19

20 PERFORMANCE REPORT Nationa Benchmarking Wasa Heathcare NHS Trust Annua Report 2016/17 It is possibe to benchmark our performance with other Acute Trusts. The benchmarking is produced either monthy or quartery providing a snapshot of our position at that point in time. Benchmarking for annua performance is not pubished. Shown beow are monthy/quartery positions for: 18 Weeks RTT Incompete For March 2017 the Trust was ranked 118 th nationay out of a tota of 133 Trusts. Tota Time in A&E 4 hour wait For March 2017 the Trust was ranked 123 rd nationay out of a tota of 136 Trusts compared to 71 st nationay out of a tota of 135 Trusts in March C Difficie For March 2017 the Trust was ranked 30 th (aong with 28 other Trusts) nationay out of a tota 136 Trusts compared to March 2016 when the Trust was ranked 54 th (aong with 30 other Trusts) nationay out of a tota of 137 Trusts. MRSA For March 2017 the Trust was ranked 1 st (aong with 109 other Trusts who aso reported no cases) nationay out of a tota 136 Trusts. This is the same ranking we achieved in March Cancer 2 Week Wait - For Quarter Four 2016/2017 the Trust was ranked 96 th nationay out of a tota 136 Trusts compared to Quarter Four 2015/2016 when the Trust was ranked 90 th nationay out of a tota of 137 Trusts. Cancer 62 Day Referra To Treatment - For Quarter Four 2016/2017 the Trust was ranked 34th nationay out of a tota 136 Trusts compared to Quarter Four 2015/2016 when the Trust was ranked 112 th nationay out of a tota of 137 Trusts. The Trust continued to endeavour to meet the requirements paced on it by its reguators and the Government. The figures show how it is performing against these key requirements. The extremey busy winter period paced pressure on heathcare services across the country and Wasa was no exception. The Trust faied to meet the nationa Emergency Department 4 Hour Wait Overa target and the nationa 18 week Referra to Treatment Time target for Incompete Pathways. The Trust has performed we against cancer measures with a performance targets achieving at an annua eve. Within Infection contro the Trust reported 21 cases for C.Difficie which exceeded the fu year trajectory of 18, however 11 of these cases were deemed to be unavoidabe. There were no cases of MRSA reported during the year. 20

21 Performance Anaysis Wasa Heathcare NHS Trust Annua Report 2016/17 The Trust experienced significant performance pressures in year that resuted in utiisation of additiona capacity to service increased emergency activity and additiona sessiona work needed to support referra to treatment. The Trust invested within staffing baseines foowing the Care Quaity Commission visit to enhance quaity of services and the combined effect of the quaity and performance measures resuted in the Trust deivering a 21.4m deficit as opposed to the panned deficit of 6.2m. PERFORMANCE REPORT The Trust has adopted a financia pan for 2017/18 that targets deivery of a 20.5m deficit and ensures the quaity and performance improvements attained during the 2016/17 financia year are maintained, whist tacking the increasing need to deiver a sustainabe mode of future heathcare. The Trust reviews and monitors performance against key performance indicators (KPIs) via a number of forums as part of its governance processes. Dependent on the nature of the KPIs, performance is monitored, daiy, weeky and monthy using a number of reporting toos and onine dashboards. The KPIs are made up of nationa, oca and internay agreed standards. Performance is reviewed weeky by the operationa eads, incuding executive oversight. Escaation processes are put into pace regarding any concerns incuding actions required to remediate performance and to assess any impact on the deivery of actions pans. Performance is aso benchmarked against peer providers to show how the Trust compares to simiar sized organisations and aso against organisations within the oca heath economy. Monthy reported performance is signed-off by both operationa and executive eads. It is then reported to the appropriate sub-committees of the Trust Board and to the Trust Board for scrutiny. In addition to the interna processes, performance against key nationa indicators is reviewed and scrutinised externay by commissioners via a number of externa meetings associated with system resiience. The Trust then works coaborativey with commissioners in agreeing remedia action pans for any recovery required and associated trajectories. Cancer Services Meeting the standards for cancer waiting times has been an historic chaenge for our organisation. The Trust set a trajectory to achieve a of the nationa cancer standards and deivered ahead of the recovery trajectory. The organisation is benchmarked as one of the highest achievers in the country for the breast symptomatic two week waiting time target. Working as part of the Nationa Institute of Heath Research West Midands, the team works tireessy to encourage patient invovement in trias and to support coeagues in their own studies. Nominated in the Research Team Recognition Award category, the team attended the NIHR Cinica Research Network Division 1 - Cancer AGM in Stoke on Trent on 26 Apri 2017, picking up the Team of the Year accoade for the West Midands. 21

22 PERFORMANCE REPORT Emergency and Capacity Pan Wasa Heathcare NHS Trust Annua Report 2016/17 Whist we did not achieve the four hour standard of treating patients in the Emergency Department; we have focused on improving the patients journey and avoiding unnecessary admissions. The ambuatory care service has been extended to seven day working and has increased the operating hours to support the Emergency Department. The Frai Edery service has aso been extended to seven day working. The team identifies patients in the Emergency Department to assess them with a view to being abe to discharge the patients back home rather than being admitted into an inpatient ward. Patients that cannot be discharged the same day are admitted to the Frai Edery ward where the number of short stay beds has been increased. The Discharge Lounge has been opened to provide patients a pace to wait before being discharged from hospita. This is working we in conjunction with the site management team to improve the fow of avaiabe beds earier in the day. Community services have moved to a ocaity based team mode with a focus on oca based admission avoidance strategies. An in reach services is being deveoped by the Community Matrons to ensure rapid discharge and support at home. Partnership working continues to reduce the number of medicay fit for discharge patients to ensure that patients can be cared for in the right environment and hospita beds are avaiabe for acute patients referred from the emergency department. Due to these measures we have cosed the additiona capacity that was used over the winter period and reduced the number of beds in the hospita. Improving panned care and reducing waiting times Patients who are referred to our hospita for panned care shoud be abe to start their treatment within 18 weeks of their referra but meeting nationa standards for referra to treatment has historicay been difficut for our organisation. Foowing the impementation of Lorenzo in Apri 2014 the Trust stopped reporting the referra to treatment time (RTT) standard due to concerns regarding the accuracy of the data. The compete patient waiting ist was vaidated by an externa company and the NHS Intensive Support Team competed a focused review of the data quaity reating to the patient waiting ists in September Foowing this review it was fet that the data accuracy, systems and processes had improved significanty and the Trust shoud return to reporting its performance against the Nationa Standard. The Trust continues to focus it s efforts on reducing the number of patients awaiting care, in particuar, those patients waiting the ongest. We provided additiona cinics and theatre sessions seven days a week and worked with other providers so that our patients received their treatment faster. We continued to improve underying systems, incuding the information that is avaiabe to service teams, continuous data vaidation and refinements to booking processes, to ensure that patients are seen in a cinicay appropriate and equitabe order. We have more than haved the number of patients waiting more than 18 weeks, reducing from 4,733 patients to 2,350 patients. Due to our focus on those patients waiting the ongest we did not meet the nationa waiting time standards in 2016/17. There is a trajectory in pace to improve this further throughout 2017/18. 22

23 Wasa Heathcare NHS Trust Annua Report 2016/17 SECTION 2: ACCOUNTABILITY REPORT 23

24 ACCOUNTABILITY REPORT CORPORATE GOVERNANCE REPORT The Directors Report Directors of the Trust Wasa Heathcare NHS Trust Annua Report 2016/17 The Chair and Chief Executive Ms Daniee Oum is the Chair of the Trust and took office on the 8 Apri 2016, taking over from Mr Ben Reid OBE who had been Chair since Juy Mr Richard Kirby is the Chief Executive of the Trust (Accountabe Officer) and was appointed in May The tabe beow sets out the names of the Chair, Chief Executive and a individuas who were directors of the Trust from Apri 2016 unti the pubication date of this Annua Report. The individuas in the tabe form the composition of the Trust Board and have authority or responsibiity for directing or controing the major activities of the Trust during the year. TRUST BOARD COMPOSITION Name Designation In Year Start / Leave Dates Ben Reid OBE Chair To 7 Apri 2016 Daniee Oum Chair From 8 Apri 2016 Professor Russe Beae Non-executive Director From 1 June 2016 Andre Burns Non-executive Director To 30 June 2016 John Dunn Non-executive Director - Victoria Harris Non-executive Director - Sukhbinder Heer Non-executive Director From 1 September 2016 Dr Jonathan Shapiro Non-executive Director - Senior Independent Director - John Siverwood Non-executive Director - Deborah Carrington Associate Non-executive Director (non-voting) From 1 Juy 2016 Phiip Gaye Associate Non-executive Director (Non-voting) From 1 August 2016 Richard Kirby Chief Executive - Russe Cadicott Director of Finance & Performance - Daren Fradgey Director of Strategy & Transformation (Non-voting) - Mr Amir Khan Medica Director - Rache Overfied Director of Nursing From 1 June 2016 Mark Sincair Director of Organisationa Deveopment & Human Resources (Non-voting) To 11 May 2017 Steven Vaughan Interim Chief Operating Officer To 30 September 2016 Phiip Thomas-Hands Chief Operating Officer From 3 October

25 Trust Board Member Profies Daniee Oum Wasa Heathcare NHS Trust Annua Report 2016/17 Chair of the Trust Board (Voting Position) Appointed Apri 2016 Daniee has more than 10 years' experience of eading pubic service business improvement and programme management, and has aso worked extensivey in the private sector, buiding and eading internationa teams. Daniee's professiona expertise is in stakehoder engagement and transformationa change. Her other professiona interests are socio-economic incusion, cross sector partnerships and regeneration. Daniee was previousy the Chair of Dudey and Wasa Menta Heath Partnership NHS Trust. ACCOUNTABILITY REPORT Professor Russe Beae Non-Executive Director (Voting Position) Chair of Charitabe Funds Committee Champion for Information and Computer Technoogy Appointed June 2016 Professor Russe Beae hods the Chair in Human-Computer Interaction in the Schoo of Computer Science at the University of Birmingham, and is aso the founder and Director of the Human- Computer Interaction Research Centre, a cross-university Research Institute. Russe has a broad range of interests across the fied of HCI, being particuary interested in the use of artificia inteigence to mode and optimise interaction, and in technoogicay-mediated behaviour change. His research and deveopment activities are funded through a mix of Government grants, innovation awards, commercia partnerships, EU funding, and venture capita. Russe has commercia and entrepreneuria experience as we as an academic background. He has founded six high-technoogy companies, and run four of these; one works on inteigent heathcare apps. He has won awards with websites he has been invoved in, and some of the products have an extensive user base. When not researching HCI he can be mosty be found outside with his chidren, dogs and wife, either saiing, mountain biking, or otherwise trying to be active. John Dunn Non-Executive Director (Voting Position) Chair of Performance, Finance and Investment Committee Champion for the Emergency Department Appointed February 2015 John s professiona ife was spent amost excusivey in the Teecoms sector and he has extensive experience in the fied of operations, and customer service. His career incudes 20 years experience at divisiona board eve in a variety of executive and non-executive roes and his ast position with BT was as Managing Director Openreach. As MD, he was responsibe for the deivery and repair of customer service and for the provision and maintenance of the oca access network for the south of the UK. Victoria Harris Non-Executive Director (Voting Position) Champion for Maternity and Neonata Services Appointed Apri 2015 Vicky has strong oca inks, having worked in Wasa for over 12 years and ived most of her ife in the Back Country. An honours graduate in psychoogy, much of her career has been in the pubic sector in menta heathcare, athough it began in the vountary sector. Vicky has deveoped numerous projects and partnerships to support oca peope into empoyment. For amost a decade she was a non-executive director of the Back Country Partnership NHS Foundation Trust, during which time she saw its transition to achieving FT status, and to acquiring new services across the Back Country under the Transforming Community Services agenda. 25

26 ACCOUNTABILITY REPORT Sukhbinder Heer Wasa Heathcare NHS Trust Annua Report 2016/17 Non-Executive Director (Voting Position) Chair of Audit Committee Champion for Improvement Appointed September 2016 Sukhbinder has over 30 years senior management experience in corporate finance and private equity as we as eading one of the UK s top professiona services companies. Over the past few years Sukhbinder has aso undertaken a number of non-executive positions in private, pubic and charity sectors and is currenty aso Non-Executive Director and Chair of Audit at Birmingham Community Heathcare Foundation Trust (BCHCFT). Dr Jonathan Shapiro Non-Executive Director (Voting Position) Senior Independent Director Chair of Quaity and Safety Committee Champion for Safeguarding Appointed October 2013 Jonathan s interests have aways centred on the whoe system of heathcare, and his career refects this. Originay a GP, he then became a medica manager, before working as a senior academic for many years. His most recent research expored organisationa change in the NHS, and he now appies the essons of his work in a variety of ways, carrying out consutancy in this area, as we as in broader poicy anaysis and change; he chairs the charity Education for Heath, and reguary produces journa artices as we as more detaied reports. Other roes have incuded being Chair of a arge Menta Heath Trust and Cinica Director for Humana Europe unti its move back to the USA. John Siverwood Non-Executive Director (Voting Position) Chair of Peope and Organisationa Deveopment Committee Appointed February 2015 A Chartered Feow of The Institute of Personne and Deveopment, John spent most of his career working in the manufacturing sector in texties and ater in soaps and detergents. He was Group HR Director for PZ Cussons pc, working extensivey in Africa, Asia and Europe before retiring in John then became HR Director for the University Hospita of South Manchester NHS Foundation Trust before retiring for a second time in He hais from Nottingham but has ived in Maccesfied and the Staffordshire Moorands and now ives in Stafford. In addition to his new position with the Trust, he is a Non-Executive Director of The High Peak Theatre Trust which is responsibe for the running of Buxton Opera House. Deborah Carrington Associate Non-Executive Director (Non-Voting Position) Champion for Improvement, Staff Experience (incuding Duty of Candour, Freedom to Speak Up, Whistebowing and Junior Doctors). Appointed Juy 2016 Over the past 20 years Deborah has hed a number of senior executive roes in both the pubic and private sector and has a weath of experience eading organisations through periods of transition and chaenge aong with an in-depth knowedge of governance and deveoping strategic partnerships. 26

27 Phiip Gaye Wasa Heathcare NHS Trust Annua Report 2016/17 Associate Non-Executive Director (Non-Voting Position) Champion for Patient Care, Equaity, Diversity and Incusion Appointed August 2016 Phi Gaye is currenty Chief Executive Officer for Connect West Midands, an organisation that supports those affected by substance misuse. Phi has considerabe experience of the heath sector and has aso worked as a Non-executive Director for Sandwe and West Birmingham NHS Trust. Phi is passionate about contributing to improving services for patients in particuar their experience of care at the Trust and has a strong interest in equaity, diversity and ethics. ACCOUNTABILITY REPORT Richard Kirby Chief Executive (Voting Position) Appointed May 2011 Richard is a graduate of the NHS Management Training Scheme. After undertaking roes in commissioning at both heath authority and primary care group eve, he was Head of Performance at Birmingham and Back Country Strategic Heath Authority, where he ensured that the SHA maintained its position as one of the best performing in the country. Richard gained board eve NHS Trust experience by joining Sandwe and West Birmingham Hospitas NHS Trust initiay as Director of Strategy and then as Chief Operating Officer. In these roes he ed the deveopment of new modes of care working with oca partners, deivered service reconfigurations in paediatrics, surgery and pathoogy, maintained the Trust's track record of deivery on access targets and secured significant improvements in performance across the organisation. Richard was aso chosen to take part in the nationa NHS Top Leaders Programme. Russe Cadicott Director of Finance and Performance (Voting Position) Appointed Juy 2015 Russe ives ocay and has in excess of 20 years experience of working within the acute sector of the NHS, formery undertaking roes such as Senior Divisiona Accountant, Associate Director of Finance and Deputy Director of Finance. A Quaified Accountant and advocate of continuing professiona deveopment, Russe occupies the roe of Executive on the Board of the West Midands Heathcare Financia Management Association, providing support and opportunities for deveopment to the finance teams of Centra Engand. Amir Khan Medica Director and Director of Infection Prevention and Contro (Voting Position) Appointed October 2011 Amir is a Genera Surgeon with a speciaist interest in Vascuar and Bariatric Surgery and joined Wasa in 1992 after competing his training. Amir ed on the estabishment of Wasa as a regiona Bariatric Centre and is the ead accountabe Director for the Medica workforce. Amir is aso the Director of Infection Prevention and Contro and the organisations Cadicott Guardian. Patient Safety and quaity of care are key priorities for Amir in ensuring that our cinica outcomes for patients are of a high standard. 27

28 ACCOUNTABILITY REPORT Rache Overfied Wasa Heathcare NHS Trust Annua Report 2016/17 Director of Nursing (Voting Position) Appointed June 2016 Rache joined the Trust in January 2016 as Interim Director of Nursing before becoming Director of Nursing in June Rache trained in Worcester and worked in Worcestershire before eaving to become a Macmian Nurse in Dudey and Woverhampton, speciaising in breast oncoogy. A spe at the Roya Marsden Hospita in London foowed before Rache returned to Worcestershire to take up a Matron roe in head and neck trauma, orthopaedics and outpatients. She went on to the Deputy Director of Nursing roe before rapidy becoming transitiona director for the new Worcestershire Roya Hospita. Around five years ater she moved to Sandwe and West Birmingham Hospitas Trust as Director of Nursing. From there Rache moved to Leicestershire as Chief Nurse. Before coming to Wasa, Rache has aso worked at the Trust Deveopment Authority as Head of Quaity. Phiip Thomas-Hands Chief Operating Officer (Voting Position) Appointed October 2016 Phiip has worked in Heathcare since 1985, working across acute hospitas, Menta Heath, Primary Care, Medicine, Surgery and Speciaised Services across both Goucestershire and the Midands. Phiip has aso worked for GP fund hoders and in the private sector, spending five years as a management consutant to the manufacturing and heathcare industries. For the past four years he has been a Non-executive Director for a housing association. His roe is to deiver systems, and constanty improve them, to ensure that cinicians can ook after as many patients as possibe within the resources avaiabe. Professiona interests incude change management, succession panning, task management and a strong focus on patient experience. Daren Fradgey Director of Strategy and Transformation (Non-Voting Position) Appointed January 2016 Daren joined the Trust after hoding numerous operationa and director posts at West Midands Ambuance Service NHS Foundation Trust (WMAS). A paramedic by background Daren joined WMAS in 1994 on frontine operations initiay in the Back Country and then Birmingham before moving to the Emergency Contro Rooms in He then went on to manage the Trust Performance Improvement team incuding informatics and Business Inteigence team. In 2013 he became the A&E Operations Director before moving to NHS 111. Daren is responsibe for the Trust's transformation and cost improvement programme together with strategic and business deveopment. 28

29 Audit Committee The Trust has an Audit Committee comprised of four Non-executive Director Members, one of which is Chair. The Members of the Audit Committee are: Sukhbinder Heer: Non-executive Director and Committee Chair. John Dunn: Non-executive Director. Wasa Heathcare NHS Trust Annua Report 2016/17 ACCOUNTABILITY REPORT Jonathan Shapiro: Non-executive Director. John Siverwood: Non-executive Director. Further information reating to the Audit Committee, incuding key responsibiities and highights from the year, can be found in the governance statement section of this annua report. Company Directorships and Other Significant Interests hed by Members of the Board The Board of Directors has a ega obigation to act in the best interests of the organisation in accordance with its governing document, and to avoid situations where there may be a potentia confict of interest. As such, there is a requirement for Board Members to register company directorships and other significant interests that they hod that may be perceived as conficting with their overriding duty as a Board Member. The Trust s register of interests is shown beow and is aso avaiabe on our pubic website and can be found by using the foowing ink: The register is updated as interests are decared and at east annuay and is reviewed by the Audit Committee and the Trust Board. 29

30 ACCOUNTABILITY REPORT Register of Interests of Trust Board Members During 2016/2017 Name Position / Roe at Interest Decared Wasa Heathcare NHS Trust Mr Ben Reid Chair (To Apri 2016) Wasa Heathcare NHS Trust Annua Report 2016/17 Chief Executive Mid Counties Co-operative Society Governor Woverhampton University Ms Daniee Oum Chair (From Apri 2016) Chair: Famiy Optima Housing Non-executive Director: West Midands Housing Group Chair Heathwatch Birmingham (from 01/04/2017) Professor Russe Beae Non-executive Director (From June 2016) Director, sharehoder: CoudTomo- security company - pre commercia. Founder & minority sharehoder: BeCrypt - computer security company. Director, owner: Azureindigo heath & behaviour change company, working in the heath (physica & menta) domains; producer of educationa courses for various organisations incuding in the heath domain. Academic, University of Birmingham: research into heath & technoogy non-commercia. Spouse: Dr Tina Newton, is a consutant in Paediatric A&E at Birmingham Chidren s Hospita & co-director of Azureindigo. Journa Editor, Interacting with Computers. Governor, Hodnet Primary Schoo. Honorary Race Coach, Worcester Schoos Saiing Association. Non-executive Director for Birmingham and Soihu Menta Heath Trust with effect from January Ms Deborah Carrington Mr Andre Burns Associate Non-executive Director (From Juy 2017) Non-executive Director (To End June 2016) No interests to decare. Trustee of Woverhampton Circuit of the Methodist Church Treasurer and an Eder at St Andrew s Methodist/ United Reform Church Mr John Dunn Non-executive Director No Interests to decare. Mrs Victoria Harris Non-executive Director Socia Care Manager, Wasa Counci Governor, A Saints CE Primary Schoo Trysu Husband, (Dean Harris) Deputy Director of IT at Sandwe & West Birmingham Hospita from March 2017 Mr Sukhbinder Heer Mr Phiip Gaye Dr Jonathan Shapiro Non-executive Director (from September 2016) Associate Non-executive Director (from August 2016) Non-executive Director Senior Independent Director Non-executive Director of Hadey Industries PLC (Manufacturing) Partner of Quaitas LLP (Property Consutancy). Non-executive Director Birmingham Community NHS Foundation Trust (NHS Entity). Chair of Mayfair Capita (Financia Advisory). Chief Executive Newservo (charitabe organisation services to menta heath provision). Chair Education for Heath Chair Osteopathic Foundation Director Poicy Deveopment Partnership 30

31 Wasa Heathcare NHS Trust Annua Report 2016/17 Name Position / Roe at Interest Decared Wasa Heathcare NHS Trust Mr John Siverwood Non-executive Director Non-executive Director of the High Peak Theatre Trust Mr Richard Kirby Chief Executive Steward (Trustee) Sey Oak Methodist Church ACCOUNTABILITY REPORT Mr Russe Cadicott Director of Finance and Performance Executive Member of the Branch of the West Midands Heathcare Financia Management Association Mr Daren Fradgey Director of Strategy and Transformation Director of Oakands Management Company Cinica Adviser NHS 111/Out of Hours Mr Amir Khan Medica Director Trustee of UK Rehabiitation Trust Internationa Trustee of Dow Graduates Association of Northern Europe Ms Rache Overfied Director of Nursing No interests to decare. Mr Mark Sincair Mr Phiip Thomas-Hands Director of Organisationa Deveopment and Human Resources (to May 2017) Chief Operating Officer (from October 2016) No interests to decare. Non-executive Director, Aspire Housing Association, Stoke-on-Trent. Spouse, Nicoa Woodward is a senior manager in Speciaised Surgery at University Hospita North Midands. Persona Data Reated Incidents Reported to the Information Commissioners Office The Trust had a tota of three reportabe serious information governance incidents during reated to information being stoen or discosed in error. A of these incidents were reported to the Information Commissioner s Office and investigated accordingy. Actions arising from the investigations incuded devising oca standard operating procedures and updates to training. Compiance is monitored through information governance audits. The Trust undertakes a programme of information governance staff training that starts at induction and is offered either onine or as a face to face monthy session. In addition a comprehensive programme of audits is undertaken to test staff understanding and knowedge of information governance. 31

32 ACCOUNTABILITY REPORT Wasa Heathcare NHS Trust Annua Report 2016/17 Summary of serious information governance incidents requiring investigation invoving persona data as reported to the Information Commissioner s Office in : Statement of Discosure to Auditors Each individua who is, or was, a member of the Trust Board in the year covered by this report confirmed that, as far as they are aware, there is no reevant audit information which woud be reevant to the auditors for the purposes of their audit report, and of which the auditors are not aware, and have taken a the steps that they ought to have taken to make themseves aware of any such information and to estabish that the auditors are aware of it. 32

33 Wasa Heathcare NHS Trust Annua Report 2016/17 Statement of Accountabe Officer s Responsibiities ACCOUNTABILITY REPORT 33

34 ACCOUNTABILITY REPORT GOVERNANCE STATEMENT 2016/2017 Scope of Responsibiity Wasa Heathcare NHS Trust Annua Report 2016/17 As Responsibe Officer I have responsibiity for maintaining a sound system of interna contro that supports the achievement of the Trust s poicies, aims and objectives, whist safeguarding the pubic funds and departmenta assets for which I am personay responsibe in accordance with the responsibiities assigned to me. I am aso responsibe for ensuring that the Trust is administered prudenty and economicay and that resources are appied efficienty and effectivey. The Annua Governance Statement acknowedges these responsibiities as set out in the Accounting Officer Memorandum. Introduction The 2015/16 Annua Governance Statement (AGS) identified significant chaenges facing the Trust. These incuded the requirement for the Trust to respond to the faiings identified by the Care Quaity Commission at its September 2015 inspection. The Trust had received a Section 29A Warning Notice highighting areas for immediate action, was rated Inadequate overa and was paced into Quaity Specia Measures in February The 2015/16 AGS outined the focus of activity that had commenced or was panned to address the issues identified. This deveopment has continued in 2016/2017 through a arge number of improvement actions and this AGS incudes the current state of progress on these. The Trust s Patient Care Improvement Pan has deivered successfuy and our next CQC inspection is expected in eary 2017/18. Our improvement journey started with a refresh of the Trust s 2020 vision and service strategy. We recognise we have significant chaenges to address and 2016/17 was the first year of our five year journey to deiver our vision to become your partners for first cass integrated care. The new vision was deveoped with input from the Trust Board and from coeagues across the Trust and is set out in the diagram beow. Provide safe, high quaity care across a our services Use resources we to ensure e we are sustainabe Care for patients at home whenever we can Becoming your partners for first cass integrated care Work cosey with partners in Wasa and surrounding areas Vaue our coeagues so they recommend us as a pace to work 1. Provide Safe, High Quaity Care. We wi provide care that we woud want for our famiy and friends. 2. Care for Patients at Home. We wi keep peope we at home, provide aternatives to acute care and return peope home safey and quicky after admission. 3. Work Cosey with Partners. We cannot do this aone and wi work with our partners in Wasa and the Back Country. 4. Vaue Coeagues. We wi be a cinicay-ed, engaged and empowered organisation. 5. Use Resources We. We wi ensure future sustainabiity by iving within our means. 34

35 Wasa Heathcare NHS Trust Annua Report 2016/17 Further chaenges have faced the Trust in 2016/2017 as a resut of its operating environment which has resuted in a worsening financia position, argey as a resut of expenditure to ensure safe staffing eves and difficuty in deivering savings pans. In March 2017 a meeting was hed with NHS Improvement regarding the Trust s financia performance and the possibiity of the Trust being paced into Financia Specia Measures. As a resut of the meeting, the Trust confirmed a forecast end of year deficit of 21.4m which was deivered successfuy. The Trust aso set out pans to deiver 24m of savings over 2017/18 and 2018/18 supported by an Improvement Programme and reducing our deficit to 20.5m in 2017/18 and 12.5 in 2018/19. These pans are accompanied by a Long Term Financia Mode that aims to deiver breakeven in 2020/21. The Trust was not paced in Financia Specia Measures and is currenty operating with enhanced oversight of our financia position from NHS Improvement. ACCOUNTABILITY REPORT Progress made during 2016/2017 to address the significant issues raised by the Care Quaity Commission Inspection of September 2015 In response to the Section 29A Warning Notice the Trust responded with a Board approved Improvement Pan which during 2016/2017 was deveoped into the Trust s Patient Care Improvement Pan (PCIP). The PCIP covers the Section 29A Warning Notice Actions together with the must do and shoud do specific recommendations from the Inspection Report. The activities within the PCIP have been managed and monitored through a Programme Management approach which is ed by the Director of Nursing. The Board has received an update and overview of the activity undertaken across the PCIP and associated workstreams at each Trust Board meeting during 2016/2017. In addition the outcome from deep dive reviews into specific PCIP actions have aso been reported to the Trust Board during the year. The PCIP contains 110 actions, 72 of these were confirmed cosed at the beginning of May 2017 foowing a robust Quaity Assessment process. Work continues to address a of the remaining actions as identified in the CQC report and it is expected that the arge majority wi be fuy or substantiay competed by the end of Quarter /2017. There remain three red actions remain at the beginning of May 2017: 1. The action reating to Induction of Labour & C-section rates, which remains higher than expected. Whist the foowing actions have been taken it is accepted that it wi take time to see a shift in rates: A Normaity Launch has taken pace and an education programme has commenced. Recruitment to speciaist midwife positions wi now progress as a wider organisationa change process has concuded. From Apri C-section rates wi be separated for first time deiveries as a change in this group woud be expected first. 2. The action reating to the avaiabiity of up to date NICE / evidenced-based guideines and poicies for Midwifery. The Trust knows the extent of this issue and has prioritised the work to be competed engaging externa expertise to assist with this work. A newy-appointed specia projects midwife wi aso be tasked with competing this. We expect significant progress against this action by June The Trust continues to carry a arge number of Registered Nurse vacancies across the Trust, refecting the shortage of Registered Nurses nationay together with gaps in some medica posts. Pans are in pace to mitigate the risks, mainy with regard to temporary staffing soutions. Longer term pans are in pace incuding new roes and service remodeing. The previous year s AGS set out the action aready undertaken in response to the CQC Section 29A Warning Notice. During 2016/2017 work has continued to resove the issues identified and good progress has been made which is detaied beow. Repacement Gamma Camera: The Trust s new Gamma Camera has been deivered and wi be instaed at the end of May/eary June Cessation of Practice of Prescribed Bous Medications in Critica Care: This practice was immediatey ceased and repeat audits confirm that this has been sustained. Audits of the rest of the Trust did not identify simiar practices anywhere ese. 35

36 ACCOUNTABILITY REPORT Improvements in Risk Management Processes: A significant amount of work had been undertaken to improve processes for identifying and managing risk within the Trust. This incudes: A revised Risk Management Strategy approved by the Trust Board in Juy A Risk Management Committee has been estabished. Wasa Heathcare NHS Trust Annua Report 2016/17 Risk management training has been roed out across the organisation and incuded with the Trust s Effective Manager programme. The Trust has moved to the Safeguard eectronic risk management system which is now used to record and manage the escaation and de-escaation of risk. The corporate Risk Register has been fuy revised to refect risks escaated from divisions or identified by Executive Directors. These risks are monitored and reviewed at the reevant Trust Board sub-committees and reported to the Trust Board on a quartery basis. The Board Assurance Framework which refects the risks to the Trust s strategic objectives has been fuy revised and is reported on a quartery basis to the Trust Board. Wards and departments have oca risk registers and key risks are on dispay in staff areas. Divisiona Governance Advisors have been appointed who work to embed oca risk management. The Divisiona Risk Registers are reviewed at monthy Divisiona Quaity Team meetings. Risk Register confirm and chaenge sessions are hed on a quartery basis between Divisions and the Director of Nursing, the Medica Director and the Trust Secretary. Improvements in Use of Menta Capacity Assessments in reation to Do Not Attempt Resuscitation Orders (DNAR): There have been significant improvements since the CQC visit but it is recognised that a decine in performance earier in the year has been sow to recover. The adut safeguarding team is activey encouraging medica staff to compete assessments and weeky monitoring is made avaiabe to wards and teams. Improvements in Deprivation of Liberties Safeguard (DoLs) processes: A number of actions have been competed and are in progress regarding the process of DoLs. This incudes a number of improved processes such as a trigger to staff to compete a cinica incident; improved database checking to ensure oversight of the process and improved communication with the Loca Authority to assist the triage of patients for priority assessment. There is an education programme that incudes ward based sessions and aso mandatory Safeguarding Adut Leve 2 and 3 training and e-earning. Improvements in End of Life Care (acute) especiay in reation to the use of Individuaised Care Pans: There has been a range of mutipe actions to improve End of Life Care. A Bereavement Officer has been appointed and positive impacts of this service are being seen through a reduction in Patient Advice and Liaison/compaints issues and more positive comments via the Trust s VOICES survey. A recent NHS Improvement Cinica Review reported positivey on End of Life Care. Improvement in Midwifery Staffing Leves: The Task Force estabished to monitor a improvement work and ed by the Chief Executive continues to meet on a monthy basis. Improvements have been: As a resut of a cap on births and an increase in registered midwives of around 10 whoe time equivaent staff. We are currenty reporting a birth to midwife ratio of around 1:30. A business case for a second maternity theatre and additiona neonata cots is with NHS Improvement for approva. One to one care in abour has been reported at 100% for many months. A new Transitiona Care Unit opened in February 2017 and eary signs are positive. A new Head of Midwifery commenced in post in February 2017 and a new matron structure has been confirmed. We are progressing to appointment of speciaists. Senior staff from maternity and obstetrics have been engaged in a deveopment programme ed by Heath Education West Midands. 36

37 Improvements in the Emergency Department: Overa oversight of improvement has been ed by the Emergency Department Task Force chaired by the Chief Executive. Improvements have been: Wasa Heathcare NHS Trust Annua Report 2016/17 Improved pain and triage compiance and improved handover documentation. Paediatric support is now provided by a team of newy recruited nurses. We now have seven whoe time equivaent staff with three being dua trained. A tota of 13 Emergency Department nurses have been trained in the Emergency Care of the Chid Modue via the University of Northampton. ACCOUNTABILITY REPORT Emergency Department paediatric pathways have been reviewed and new processes for monitoring chidren and escaating to paediatrics are in pace. The strategic outine case for the Emergency Department capita deveopment has been approved by the Trust Board and pans and work are progressing on the outine business case. New workforce pans with investment for both nursing and medica staff were approved in October The first stage of recruitment has been competed and the second stage is under way. Advanced Care Practitioners have been recruited to assist with the medica mode and aternative pans are being considered for consutant and midde grades. Pre-Inspection Cinica Review Visit On the 15 March 2017 a pre-inspection cinica review visit was carried out by NHS Improvement and the findings were formay presented to the Trust Board at its meeting on the 6 Apri The findings from the cinica review visit are being considered to ensure that earning from this and that improvements are made. The Governance Framework of the Organisation The Trust has an integrated governance approach to ensure decision making is informed by a fu range of corporate, financia, cinica and information governance. The Trust Board is comprised of a Chair, six Non-executive Director Members, a Chief Executive, Medica Director, Director of Nursing, Director of Finance and Performance and Chief Operating Officer a with voting rights. Two additiona executive director members without voting rights attend each Trust Board Meeting: the Director of Organisationa Deveopment and Human Resources and the Director of Strategy and Transformation. In addition, during the course of 2016/2017 the support to the Trust Board has been strengthened by the appointment of two Associate Non-executive Directors who do not have voting rights. The Trust Board is advised and supported by the Trust Secretary. There have been a number of changes to Trust Board membership in the year with the foowing coeagues wecomed to the Board: Rache Overfied as Director of Nursing in June Deborah Carrington as Associate Non-executive in Juy 2016, and Phiip Gaye as Associate Non-executive in August Russe Beae as Non-executive Director and Chair of the Charitabe Funds Committee in June Sukhbinder Heer as Non-executive Director and Audit Committee Chair in September Phiip Thomas-Hands as Chief Operating Officer in October Mark Sincair, Director of Organisationa Deveopment and Human Resources, eft the Trust in May 2017 to take up an appointment overseas and we are now in the process of making arrangements to fi the vacancy. In recognition of the changes across the past two years in the Trust Board, a programme of specific Executive Team Deveopment and aso Trust Board Deveopment was commissioned with Hut Ashridge Business Schoo. The programme competed during the year and the Board is now embarking upon a programme of deveopment for 2017/2018 to buid upon the previous year. 37

38 ACCOUNTABILITY REPORT Wasa Heathcare NHS Trust Annua Report 2016/17 The Board has met monthy throughout the year with the first part of each meeting open to the pubic and cosing as necessary for a part two confidentia session. The Board meeting foows a structured format with each meeting starting with either a patient/carer or staff story to set the tone and focus of the meeting. The incusion of a staff story was introduced during the year in recognition of the need to address cutura and engagement issues identified by the CQC inspection. The format of the business foowing the patient/carer story covers a items of quaity and risk immediatey, foowed by matters of strategy and panning; peope and organisationa deveopment; performance; governance and compiance and questions from members of the pubic. Board sub-committee minutes and highight reports are continue to be reviewed within the reevant topica section of the agenda to provide the appropriate eve of assurance on the key issues as they are discussed during the meeting. The purpose of the format is to structure the business around the buiding bocks of strategy, accountabiity and cuture to ensure we focus on the issues that matter most to our patients and our staff. In addition to the forma Board Meetings the Board hods deveopment sessions which provide an opportunity for the Board to be briefed on a number of issues of interest or to focus on in-depth work required for strategic or other matters. During the year the Board has covered quaity and risk topics incuding risk and the Board Assurance Framework. The Board worked together to popuate a new Board Assurance Framework and has recenty reviewed this in the ight of the Trust s newy articuated strategy. Quaity issues covered in year have incuded reviews of the Care Quaity Commission Key Lines of Enquiry: Safe, Caring, Responsive and Effective. Strategic and panning items have incuded sessions on the deveopment of the Trust s strategy, two year pan, transformation and working with partners. Performance topics have incuded deep dive reviews into the Trust s financia position and nurse staffing eves. A number of externa experts have attended the deveopment sessions incuding Sir Stephen Moss on refections on transparency and openness and Roger Kine on equaity, diversity and incusion. The Board has refected and reviewed its effectiveness in year during its deveopment sessions with Hut Ashridge Business Schoo and as a resut has impemented a number of changes to improve the effectiveness of its ways of working incuding: Deveopment of new report tempates which provide carity on the ink to Trust objectives and the CQC standards. A report writing guide has been produced in recognition of the importance of ensuring that reports presented to the Board and its Committees are of a high quaity so that they act as a catayst for constructive chaenge and discussion resuting in high quaity decisions. A meeting etiquette has been deveoped to which a Board Members have signed up to. The etiquette was written in recognition of the fact that it is essentia that the Board and its committees conduct their meetings with a view to optimising the use of the time and inteectua capita of their members. The etiquette covers a the eements that can contribute to an effective discussion, incuding the way Board and committee members interact and work together to ensure sound decision making. The Board made a decision to change the structure of its Board Meeting day. From June 2017 the monthy Board Meeting wi start at the earier time of 10am in order to hod its discussions and make its important decisions earier in the day when members have more energy. The Board Deveopment Sessions and Board Waks wi move to a different day to the Board Meeting from the beginning of June in order to give more focus and enabe more energy to be given to the sessions. 38

39 Wasa Heathcare NHS Trust Annua Report 2016/17 During the year the Board has refected on the findings of a number of historic reviews and the more recent capabiity review of February 2016 to ensure that actions have been taken to improve the We Led CQC Key Lines of Enquiry. In May 2017 the Board has conducted a sef-assessment review of We Led in preparation for its CQC re-inspection and has concuded that whist a considerabe number of improvements have been made which can be ceary evidenced, more work is required to embed those changes. The Board has overa responsibiity for the effectiveness of the governance framework and is supported by a framework of sub-committees. Each sub-committee is chaired by a Non-executive Director and has Board approved terms of reference which describe their responsibiities, accountabiities and methods of monitoring effectiveness. The Trust Secretary attends each committee and ensures compiance with the terms of reference; provides support to the Committee Chairs and works to deveop the governance arrangements. The committees are supported by executive eve monthy teams focused on the key deivery areas for the Trust and combining the executive team and divisiona eaders. ACCOUNTABILITY REPORT Each of the sub-committees formay reports its highights from its most recent meeting together with approved minutes to the next meeting of the Trust Board the Committee meeting. The six formay designated sub-committees of the Board together with the names of the Chairs are shown in the diagram beow: Board and Committee Structure Trust Board Daniee Oum Audit Committee Quaity & Safety Committee Performance, Finance & Investment Committee Peope & Organisationa Deveopment Committee Charitabe Funds Committee Nominations & Remuneration Committee Sukhbinder Heer Jonathan Shapiro John Dunn John Siverwood Russe Beae Daniee Oum 39

40 ACCOUNTABILITY REPORT Wasa Heathcare NHS Trust Annua Report 2016/17 The tabe beow sets out the attendance of the Trust Board and its six sub-committees for 2016/

41 Wasa Heathcare NHS Trust Annua Report 2016/17 ACCOUNTABILITY REPORT 41

42 ACCOUNTABILITY REPORT Audit Committee Wasa Heathcare NHS Trust Annua Report 2016/17 The Audit Committee is responsibe for supporting the Trust Board by criticay reviewing and reporting on the reevance and robustness of the governance structures and assurance processes on which the Trust Board paces reiance. The committee comprises of four non-executive director members, one of which is the Chair of the committee. The three other committee members are the Chairs of the Quaity and Safety Committee, Performance, Finance and Investment Committee and the Peope and Organisationa Deveopment Committee. The committee meets on a monthy basis. The committee is normay attended by the Director of Finance and Performance and senior managers together with interna auditors, oca counter fraud speciaist and externa auditors (Ernst Young) in support of the committee s business. The key in-year highights and deveopments for the Audit Committee have been: Change in Chair in September 2016 when Sukhbinder Heer joined the Trust. Appointment of a fourth, independent member of the committee: Dr Jonathan Shapiro, Chair of the Quaity and Safety Committee. A move to monthy meetings from bi-monthy meetings. A refocus of committee working to incude reguar invites to executive directors and senior managers to discuss issues of focus incuding the outcome of interna audit reports. Focus on the outcome of the interna audit reports on medica ocum staffing and Venous thromboemboism (VTE) compiance and the actions to address recommendations. The Medica Director and the Director of Organisationa Deveopment and Human Resources have attended the meeting in regard to these audit reports. A successfu drive to reduce the number of outstanding interna audit recommendations. I am peased to report that these had reduced to ony 6 recommendations which had passed their agreed action date of up to 31 March 2017 compared to 17 at the end of March At the time of the Annua Report pubication this figure has reduced to two. Successfuy estabished an Auditor Pane to oversee the appointment of the Trust s externa auditors. This process has been formay handed down to Trusts foowing the dis-estabishment of Pubic Sector Audit Appointments Limited which previousy carried out this roe on behaf of a Trusts. Competed an annua sef-assessment of its effectiveness. The committee has continued to deveop its annua report to the Trust Board, iustrating how it has discharged its responsibiities. The report incudes the committee s priorities for 2017/2018. The committee, through its terms of reference, has paid due regard to the guidance contained within the NHS Audit Committee Handbook, NHS Codes of Conduct and Accountabiity and the Higgs Report. The main work areas of the committee have been: Assurance framework, governance, risk management and contro Interna audit Externa audit Counter fraud Other assurance functions Management processes Financia performance and reporting (incuding QIPP) Service auditor reporting for third party assurances Conficts of interest Hed informa meetings with the interna auditor, the counter fraud ead and the externa auditors to ensure any issues of concern were addressed. 42

43 Wasa Heathcare NHS Trust Annua Report 2016/17 Quaity and Safety Committee and Quaity Governance The Quaity and Safety Committee is responsibe for providing the Board with assurance on the standards of care, quaity and safety provided by the Trust and, in particuar, that adequate and appropriate governance structures, processes and contros are in pace throughout the Trust to promote quaity, safety and exceence in patient care. The Committee comprises of three non-executive directors, one of which is Chair; the Chief Executive; Medica Director, Director of Nursing, the Director of Finance and Performance and the Trust Secretary. The Committee meets on a monthy basis. ACCOUNTABILITY REPORT The governance reporting structure into and from the Committee is shown in the diagram beow: 43

44 ACCOUNTABILITY REPORT Wasa Heathcare NHS Trust Annua Report 2016/17 The committee receives its assurance and information from the Trust Quaity Executive. The Trust s three cinica divisions are organised into Care Groups. Each Division is currenty ed by a Divisiona Director supported by a Divisiona Director of Operations and a Divisiona Director of Nursing. Each division hods monthy Divisiona Quaity Team meetings which report on a monthy basis to the Trust Quaity Executive. In addition, the Patient Experience Group, Risk Management Committee, Cinica Effectiveness Committee and a number of speciaist quaity committees report into the Trust Quaity Executive. The Trust formay investigates a serious cinica incidents, reports their findings to the Risk Management Committee and foows up on a actions agreed as part of the outcome of the reports. The Board receives a report at each meeting on Serious Incidents and high eve compaints. The Trust Quaity Account is reviewed by the Trust Quaity Executive and the Quaity and Safety Committee in advance of its receipt at the Audit Committee. In year the priorities for the 2017/2018 Quaity Account have been agreed by the Quaity and Safety Committee. The key in-year highights and deveopments for the Quaity and Safety Committee have been: A year of embedding, deveoping and evoving the new structures and the reporting reationships estabished in 2015/2016. The monthy Trust Quaity Executive Meeting continues to report to the Committee and has become an effective source of assurance to the Committee. Wecoming Professor Russe Beae, Non-executive Director and Phiip Gaye, Associate Non-executive Director to the Committee. Commencing a schedue of monthy presentations from the Divisiona Teams of Three who attend the meeting to highight key areas of their work in reation to the quaity and safety agenda. Commencing a schedue of monitoring corporate risks aocated to the Committee as part of the Trust s revised risk management processes. Receiving reguar updates from both the Emergency Department and the Maternity Task Force meetings to provide assurance on the progress of work in reation to the issues raised at the 2015 CQC inspection. Review and approva of the Trust s Quaity Commitment. 44

45 Wasa Heathcare NHS Trust Annua Report 2016/17 Performance Finance and Investment Committee The Performance, Finance and Investment Committee is responsibe for providing assurance to the Trust Board on effective operationa and financia performance and for making investment decisions in ine with the Trust s Standing Financia Instructions and Scheme of Deegation. The Committee meets on a monthy basis and comprises of three non-executive director members, one of which is Chair, the Chief Executive, Director of Finance and Performance, Medica Director, Director of Strategy and Transformation, Chief Operating Officer, Director of Organisationa Deveopment and Human Resources and Trust Secretary. ACCOUNTABILITY REPORT The reporting structure into and from the committee is shown in the diagram beow: The key in-year highights and deveopments for the Performance, Finance and Investment Committee have been: Wecoming Sukhbinder Heer, Non-executive Director to the Committee. Considerabe focus on the trajectory and pans to reduce agency expenditure. A focus on the Cost Improvement Programme in year. Review of the Cost Improvement Pans for 2017/2018 CIP with particuar focus on improved phasing to deiver 50% of the pans by the end of Quarter 2 and risk mitigation. Ensuring deivery of year end outturn of 21,392m deficit. Commencing a schedue of monthy presentations from the Divisiona Teams of Three who attend the meeting to highight key areas of their work in reation to finance and performance. Commencing a schedue of monitoring corporate risks aocated to the Committee as part of the Trust s revised risk management processes. 45

46 ACCOUNTABILITY REPORT Wasa Heathcare NHS Trust Annua Report 2016/17 Peope and Organisationa Deveopment Committee The purpose of the committee is to provide assurance to the Board in reation to effectiveness of human resources and organisationa deveopment arrangements. The committee comprises of two non-executive directors, one of which is Chair, the Chief Executive, Director of Organisationa Deveopment and Human Resources, Director of Nursing, Chief Operating Officer, Director of Strategy and Transformation and Trust Secretary. The committee has met on a bi-monthy basis throughout the year. The governance structure reporting into and from the committee is shown in the diagram beow: The key in-year highights and deveopments for the Peope and Organisationa Deveopment Committee have been: Wecoming Deborah Carrington, Associate Non-executive Director to the Committee. A focus on the cutura and staff engagement issues identified within the Care Quaity Commission report. Review and approva of a new Peope and Organisationa Deveopment Strategy which was approved by the Trust Board in May Monitoring the progress of the introduction and deveopment of the Cinicay Led Mode. Receiving the findings of the 2016 Nationa Staff Survey and reviewing pans to address the issues raised. Agreed that a co-ordinated approach shoud be adopted to address the findings aongside those of the 2016 Nationa Inpatient Survey resuts. In ight of the importance of the issues to address in 2017/2018 reating to staff engagement and earning and organisationa deveopment the Committee has recommended to the Board that it shoud meet on a monthy basis from June

47 Charitabe Funds Committee Wasa Heathcare NHS Trust Annua Report 2016/17 Wasa Heathcare NHS Trust is the corporate trustee for charitabe funds hed on Trust. The Trust Board serves as its agent and has deegated authority to the Charitabe Funds Committee to make and monitor arrangements for the contro and management of the Trust s charitabe funds in accordance with any statutory or other ega requirements, or best practice required by the Charity Commission. The committee comprises of three Non-Executive Director members one of which is Chair of the committee, the Director of Finance and Performances, Deputy Director of Finance, Director of Nursing and Trust Secretary. The Committee meets on a quartery basis and on an ad-hoc basis as required to approve charitabe funding expenditure requests. ACCOUNTABILITY REPORT The key in-year highights and deveopments for the Charitabe Funds Committee have been: Wecoming Russe Beae as Non-executive Chair in June Continuing the work commenced in 2015/2016 to strengthen its governance arrangements. This has incuded the deveopment of principes and procedures to authorise charitabe funds requests. The committee has sought to encourage the use of the Charitabe Funds across the Trust in accordance with the principes and procedures. A Fundraising Committee has been estabished and reports into the Charitabe Funds Committee. Work is progressing to finaise a Fundraising Strategy. Nominations and Remuneration Committee The Nominations and Remuneration Committee is responsibe for considering the process for nominations into executive posts and the remuneration of those posts. In addition, it authorises any exit packages, redundancies from management of change exercises and aso requests for Mutuay Agreed Resignation Schemes. The committee comprises of a the Non-Executive Director members of the Trust Board and the Chair of the Trust Board is the Committee Chair. The Committee is normay attended by the Chief Executive, Director of Organisationa Deveopment and Human Resources and Trust Secretary. The committee has met on eight occasions during the year as a resut of the requirement to consider matters reating to the appointment of the Director of Nursing and the Chief Operating Officer. In addition, the committee has considered and approved appications for Mutuay Agreed Resignation Schemes and management of change outcomes. 47

48 ACCOUNTABILITY REPORT The Risk and Contro Framework Risk Assessment Wasa Heathcare NHS Trust Annua Report 2016/17 As Chief Executive I have overa responsibiity and accountabiity for risk management. The eadership and accountabiity arrangements for mysef, as Chief Executive Officer, Trust Board Directors, Divisiona Directors, Professiona Heads of Service and a other staff are set out in the Trust s Risk Management Strategy. The Risk Management Strategy has been competey revised and updated and was approved by the Trust Board in Juy It sets out how the Trust manages and responds to risk and incudes a number of risk management objectives that the Trust has been working to achieve during the year. The Trust works within a framework that devoves responsibiity and accountabiity throughout the organisation via a tiered Risk Register system (Corporate, Divisiona, Care Group, Ward and Department) which enabes risks to be identified, anaysed, prioritised and managed at a eves of the organisation. The method of assessing the severity and ikeihood of risk is by the use of the Nationa Patient Safety Association mode matrix. This is based on scoring the impact to the Trust of not addressing the risk against the ikeihood of its occurrence. Risk management awareness and heath and safety training is deivered to a new members of staff through our induction programme and to existing staff through mandatory training programmes. Additiona risk management training needs of specific staff groups are assessed through the Trust s Training Needs Anaysis. The Trust has undertaken significant work to improve its approach to risk and risk management foowing issues highighted during the Care Quaity Commission Inspection in September 2015 and the subsequent Section 29A Warning Notice which incuded risk management and risk management processes. The improvements made in year and covered in the earier part of this statement and in summary incude: The estabishment of a Risk Management Committee. The migration of risk registers onto the eectronic Safeguard system and the deveopment of reports from the system. The depoyment of Divisiona Governance Advisors to assist divisions in the identification, management and mitigation of risk. Monthy reporting of risk management activity to Trust Quaity Executive. Quartery review of Corporate Risk Register and Board Assurance Framework at Trust Board together with the deveopment of Board Reports to incude heat maps showing the profie of risk, the movement in risk scores and forecast risk scoring across the year. An interna audit was undertaken in the ast Quarter of 2016/2017 to review risk management processes with an outcome of requires improvement. A number of actions have been agreed to address recommendations made from the audit incuding the further deveopment of the Safeguard system to ensure that it more fuy supports the Trust s risk management processes. The progress on the recommendations wi be reviewed reguary during 2017/2018 at the Risk Management Committee. The Trust Board and its committees have taken an active roe in the improvement of risk management processes. This has incuded the aignment of Board Assurance Framework and Corporate Risks to the Board sub-committees and agreed schedues of review of the risks at each. During 2017/2018 the Board pans to work on the deveopment of its risk appetite to further deveop its understanding and appication of risk management. Board Assurance Framework The Board uses a Board Assurance Framework which sets out the key risks to the Trust s strategic objectives together with the contros in pace to mitigate the risks and the assurance that can be evidenced reating to their contro. During 2016/2017 the Board has competey refreshed its Board Assurance Framework and hed a number of seminar sessions to review its format and content. The Trust Board has received and reviewed the Board Assurance Framework on a Quartery basis throughout the year. The major risks identified and monitored through the Board Assurance Framework during the year reated to: Faiure to improve the quaity and safety of care we provide across the Trust in ine with our commitment in the Patient Care Improvement Pan. Faiure to make progress in improving care for patients attending our Emergency Department. 48

49 Wasa Heathcare NHS Trust Annua Report 2016/17 Faiure to make progress in improving care for patients using our maternity and neonata services. Improvements in community services do not deiver a reduction in demand for acute hospita care. The emergency care pathway does not improve resuting in continued deays for patients and poor fow through the hospita. Inabiity to recover performance on the nationa eective standards incuding referra to treatment and cancer as panned. ACCOUNTABILITY REPORT Inabiity to deiver safe sustainabe staffing eves reducing our reiance on expensive agency staff. That we are not successfu in our work to estabish a cinicay-ed engaged and empowered cuture. Inabiity to deiver our pan within the resources avaiabe and keeping expenditure within budget. That we cannot deiver our panned programme of hospita estate improvement incuding ICCU, Neonata Unit, Second Maternity Theatre and a pan for the Emergency Department. That our governance remains inadequate as assessed under the CQC We-Led standard. That we do not deveop a cear five year strategic pan to support our 2020 service vision. As a resut of the Trust s annua panning process four new strategic risks were identified in year. The risks reate to deivery of the overarching strategy, deivery of the cost improvement programme, market share risk and partnership working risk. The new risks are: That the overa strategy does not deiver required changes resuting in services that are not affordabe to the Loca Heath Economy. This risk repaces the origina risk of faiing to deveop a strategy. That the Service Improvement and Cost Improvement Programme does not deiver the financia impact panned resuting in non-deivery of financia pan. The risk originates from the difficuties experienced in 2016/2017 and because the Trust s ong term financia pan incudes significant savings each year. New entrants into the market wi succeed in attracting services resuting in income oss to the Trust. The risk originates from recent experience where competitors had secured tendered services in and around the Trust s footprint. If the Trust does not agree a suitabe aiance approach with Loca Heath Economy partners it wi be unabe to deiver a sustainabe integrated care mode. The risk originates from the requirement to work effectivey in coaboration with partners to deveop a mode to deiver the best outcomes. Foowing the work undertaken during the year to improve the Board Assurance Framework, Interna Audit has undertaken it s annua review and concuded an opinion of substantia assurance for 2016/2017. This is an improvement on the previous year where a Requires Improvement opinion was found. The Board wi act upon the recommendations incuded in the 2016/2017 interna audit to further improve the Board Assurance Framework during the current year. Data Security Breaches The Trust had a tota of three reportabe serious information governance incidents during reated to information being stoen or discosed in error. These were a reported to the Information Commissioners Office and appropriate action taken. The detai of these incidents is incuded in the Accountabiity Section of this Annua Report. Information Governance Tookit The Trust has consistenty sustained Leve 2 compiance with the Information Governance Tookit. The Information Governance Steering Group has met on a reguar basis throughout the year. The committee has reported its activities to the Quaity and Safety Committee. An interna audit review of the systems of interna contro for compying with the Information Governance Tookit in 2016/2017 concuded that there was substantia assurance. 49

50 ACCOUNTABILITY REPORT Cyber and Data Security Wasa Heathcare NHS Trust Annua Report 2016/17 Cyber and data security continues to be an important focus for the Trust. This became evident in ight of the events on the 12 May 2017 when the NHS was subject to a we-pubicised wordwide cyber-attack. As a resut of the co-ordinated emergency response to the threat by the Information Communications Technoogy (ICT) Department, the Trust defended itsef against this particuar attack and there was no operationa impact to the Trust. The Trust Information Governance Steering Group receives reguar reports on pans and actions to maintain and improve cyber-security defences across the Trust. Some of the proactive work undertaken has incuded a cyber-security awareness campaign. Each year the Trust undertakes a cyber penetration test as part of it s interna audit pan. This invoves being subjected to a simuated cyberattack probing both our externa and interna networks. The resuts provide areas for improvement incuding specific recommendations which are impemented to strengthen our cyber-security. The Trust has assessed itsef against NHS Engand s guidance on cyber risk management foowing the pubished 10 steps to cyber security and adopted these principes. In response to NHS Engand s requirement for a system suppiers to be working towards Cabinet Office Government certification for the Cyber Essentias Standard, the Trust is to incude these standards into the procurements of a new ICT systems and is requesting existing suppiers to provide statements of compiance. The Trust has strengthened its abiity to respond to cyber-security inteigence through its subscription to aerts from the NHS Digita Care Computer Emergency Response Team (CARECert). This provides advance aerting, cyber guidance and expertise. The Trust was aso accepted as an eary adopter for the CareCert Assure/React programme which has provided additiona anaysis of our cyber-security protection. Eective Waiting Time Data The Trust impemented a new patient administration system in The introduction of this new system created mutipe probems with patient data and the Trust ceased recording its nationa RTT performance. These probems eft significant data quaity issues regarding the accuracy of patient waiting ists for new and foow up patients. The Trust engaged an externa company to technicay vaidate the compete patient waiting ist which was in excess of 22,000 records. An interna data quaity process was started at the same time which used a daiy cyce of reviewing user/system errors created. A number of data quaity indicators where deveoped through this process and corrected on a daiy basis by the vaidation team. The Intensive Support Team conducted a review of our data quaity and associated processes in September This review focused on a aspects of the patient waiting ists and assurance of data quaity competeness. Through this externa review and the impementation of their recommendations, the Trust Board approved a return to forma nationa reporting in October Review of the Effectiveness of Risk Management and Interna Contro As Accountabe Officer, I have responsibiity for reviewing the effectiveness of the system of interna contro. My review is informed in a number of ways. The Head of Interna Audit provides me with an opinion on the overa arrangements for gaining assurance through the Assurance Framework and on the contros reviewed as part of Interna Audit s work. I am peased to report an improvement in year with the Head of Interna Audit Opinion for 2016/2017 concuding that....significant assurance can be given that there is a generay sound system of interna contro designed to meet the organisation s objectives, and that contros are generay being appied consistenty. However, some weaknesses in the design and /or inconsistent appication of contros coud put the achievement of particuar objectives at risk. The foowing interna audit reports were competed, with the respective eves of assurance: 50

51 Wasa Heathcare NHS Trust Annua Report 2016/17 ACCOUNTABILITY REPORT 51

52 ACCOUNTABILITY REPORT Wasa Heathcare NHS Trust Annua Report 2016/17 In two areas ony insufficient assurance coud be given in reation to the contros: Temporary Staffing Arrangements for Medics and Training Expenditure. The Audit Committee has focused its attention on the Temporary Staffing Arrangements for Medics audit and requested that the Medica Director attend the Audit Committee to expain the current status. The committee was advised that strengthened governance processes had been impemented and a further audit is panned for May 2017 to test the robustness of those processes. The Training Expenditure audit was in draft at the time of writing this report. Pans wi be put in pace to address the recommendations of the audit which wi be monitored during the course of the year by the Audit Committee. At each Audit Committee meeting a report is received highighting the current status of outstanding audit recommendations. This report is circuated to the Executive Team. The committee has put a focused effort into reducing the number of outstanding audit recommendations by the year end and I am peased to report that these had reduced to ony six recommendations which had passed their agreed action date of up to 31 March 2017 compared to 17 at the end of March At the time of the Annua Report pubication this figure has reduced to two. Executive directors and managers within the organisation who have responsibiity for the deveopment and maintenance of the system of interna contro provide me with assurance. My view is aso informed by comments in reports and other feedback from Interna Audit, Externa Audit, the NHS Litigation Authority for NHS Trusts, NHS Litigation Authority for Maternity Services and interna Trust updates on progress against the action pans from various interna and externa reviews by other externa bodies incuding the Wasa Cinica Commissioning Group, Wasa Metropoitan Borough Counci, NHS Improvement and the Department of Heath. I have been advised on the impications of the resut of my review of the effectiveness of the system of interna contro by the Board, Audit Committee, Quaity and Safety Committee, Finance, Performance and Investment Committee, Peope and Organisationa Deveopment Committee, Risk Management Committee and Trust Quaity Executive as part of our approach to integrated governance. I strive to provide the best possibe standards of care at a times to those who use our services. If I fai to meet these standards and something goes wrong, I take this very seriousy. I and the wider organisation are committed to earning from each incident and making changes to ensure that something simiar coud not happen again. As a resut of my review I consider the foowing items to be significant issues and therefore warrant further discosure: Despite a number of improvements made the Trust remains in Quaity Specia Measures foowing the CQC inspection of September 2015 which rated the Trust as inadequate. The Trust is currenty awaiting its re-inspection visit from the CQC. In 2015/2016 the externa auditors gave us a quaified Vaue for Money Concusion based on the overa Inadequate CQC rating and the fact that despite deivering the panned financia deficit in 2015/2016 the Trust had yet to address the underying deficit in its budgets. For 2016/2017 the externa auditors have again issued a quaified Vaue for Money Concusion based on the foowing: The CQC re-inspection has not yet taken pace and the Trust remains in quaity specia measures. Faiure to meet nationa performance targets incuding accident and emergency and 18 weeks referra to treatment incompete. The financia outturn of 21,392m deficit against a panned deficit of 6.2m. Faiure to deiver the Cost Improvement Programme argey as a resut of over expenditure on temporary workforce. Data issues resuting in the Trust not reporting on referra to treatment times for the first haf of the year. Aspects of Venous Thromboemboism (VTE) remaining unresoved. No evidence of substantive improvement reating to workforce indicated by the nationa staff survey resuts for 2016 and expenditure on temporary workforce. 52

53 Wasa Heathcare NHS Trust Annua Report 2016/17 The Nationa Staff Survey resuts for 2016, pubished on 7 March 2017 were disappointing and indicate that despite the work undertaken in year to deveop a cinicay ed mode and to improve staff engagement there is consideraby more work to do to make improvements in this area. The Peope and Organisationa Deveopment Committee has reviewed the findings and an approach and pans have been identified and reported to the Trust Board which aim to address the issues in a dua approach aongside those required to improve the Nationa Inpatient Survey resuts. The Nationa Inpatient resuts for 2016 due for pubication in June 2017 were aso disappointing and showed that there remains significant room for improving inpatient experience in the foowing areas: ACCOUNTABILITY REPORT Waiting Care and treatment (incuding privacy and invovement) Communications and provision of information/expanations Confidence in doctors, nurses and decisions about care Discharge panning and information The actions taken previousy within the Trust, whist showing signs of improvement in some areas, have not yet been sufficient to shift our overa position when compared to the best performing Trusts. It is the Trust s ambition to be amongst the best performing Trusts in the country for patient experience and therefore both continued effort to maintain good practice and aternative approaches are required to drive a shift in how patients experience care at the Trust. An inpatient experience action pan for 2017/18 has been deveoped that outines actions to improve the inpatient experience over the foowing years. 53

54 ACCOUNTABILITY REPORT Discharge of Statutory Functions Wasa Heathcare NHS Trust Annua Report 2016/17 I can confirm that the Trust is cear about the egisative requirements associated with each of the statutory functions for which it is responsibe, incuding any restrictions on deegation of those functions. Responsibiity for each duty and power has been ceary aocated to a ead director. I confirm that the Trust has the necessary capabiity and capacity to undertake a of the Trust s statutory duties. Richard Kirby. Accountabe Officer. Date: 54

55 Remuneration and Staff Report Remuneration Poicy Wasa Heathcare NHS Trust Annua Report 2016/17 The Trust s approach to Remuneration Poicy for Directors is one of median saaries for Trusts of a simiar size and scope in order that directors pay remains both competitive and vaue for money. ACCOUNTABILITY REPORT The Trust has a Nominations and Remuneration Committee that agrees the remuneration packages for executive directors. Further information about the committee can be found in the Corporate Governance Report section of this Annua Report. Fair Pay Discosure Reporting bodies are required to discose the reationship between the remuneration of the highest paid director in their organisation and the median remuneration of the organisation s workforce. In 2016/17, no empoyees received remuneration in excess of the highest-paid Director (there were 0 in 2015/16). Remuneration ranged from 15,251 to 198,000 ( ,100 to 199,463). Tota remuneration incudes saary, non-consoidated performance-reated pay and benefits-in-kind as we as severance payments. It does not incude empoyer pension contributions and the cash equivaent transfer vaue of pensions. The Nominations and Remuneration Committee agrees remuneration packages for Executive Directors. The notice period and termination payments are defined within the NHS Agenda for Change payment mode as for a empoyees. No performance bonus payments were made to directors during the financia year. The information contained within summary financia statements has been subject to externa audit scrutiny. In addition, the directors remuneration tabes have been audited for compiance with Statutory Instrument 2008 No 410. Pay Mutipes Audited Reporting bodies are required to discose the reationship between the remuneration of the highest-paid director in their organisation and the median remuneration of the organisation s workforce. The banded remuneration of the highest paid director in Wasa Heathcare NHS Trust in the financia year was 198,000 ( , 199,000). This was 8.2 times ( , 8.6) the median remuneration of the workforce, which was 24,000 ( , 23,000). In no empoyees received remuneration in excess of the highest-paid director. 55

56 ACCOUNTABILITY REPORT Remuneration entitement of senior managers - Audited Long Term Long Term Performance Performance A Pension Other Performance Pay Performance Pay Expense A Pension Other Pay and Pay and Expense Reated Name and Tite Saary Remunderation and Bonuses and Bonuses Payments Reated Benefits TOTAL Saary Remuneration Bonuses Bonuses Payments Benefits TOTAL (bands of (bands of (bands of (bands of (bands of (bands of (bands of 5000) (bands of 5000) (bands of 5000) (taxabe) to the (bands of 2500) (bands of 5000) (bands of 5000) 5000) 5000) 5000) 5000) (taxabe to the) 2500) 5000) nearest nearest Ms D. OUIM, Chair (from 8 Apri 2016) Mr B.L.E. REID, (Chairman from 1 Ju 04) Wasa Heathcare NHS Trust Annua Report 2016/17 Mr R. KIRBY, Chief Executive (from 9 May 2011) Mr R. CADICOTT, Director of Finance & Performance (from 1 Juy 2015) Mr I. BAINES, Director of Finance (eft 16 May 2015) Mr P. THOMAS-HANDS, Chief Operating Officer (from 10 December 2016) Mr S. VAUGHAN, Interim Chief Operating Officer (eft 30 September 2016) Mr R. CATTELL, Chief Operating Officer (eft 10 January 2016) Mr A. KJHAN, Medica Director (from 1 October 2010) Mrs K. HALFORD, Nurse Director (eft 3 January 2016) Mrs R. OVERFIELD, Director of Nursing (from 1 June 2016) previousy Interim Nurse Director from 1 November Mr D. FRADGLEY, Director of Transformation and Strategy (1 February 2015) Mr M. SINCLAIR, Director of Organisationa Deveopment & Human Resources (7 Sept 2015) Mr D. CLIFF, Director of Corporate Affairs and Trust Secretary (eft 21 June 2015) Dr J. SHAPIRO, Non-Executive Director (from 23 October 2013) Mr J. DUNN, Non-Executive Director (from 1 February 2015) Mr J. SILVERWOOD, Non-Executive Director (from 1 February 2015) Mr V. HARRIS, Non-Executive Director (from 1 Apri 2015) Mr R. BEALE, Non-Executive Director (from 1 June 2016) Mr D. CARRINGTON, Association Non-Executive Director (from 1 Juy 2016) Mr P. GAYLE, Associate Non-Executive Director (from 1 August 2016) Mr S. HEER, Non-Executive Director (from 15 September 2016) Mr A. BURNS, Non-Executive Director (eft 30 June 2016) Mr F. SUMMERS, Non-Executive Director (eft 29 February 2016) **Other Remuneration - This is the saary payment as a Medica Consutant. The bonus payment for Mr A. Khan is in respect of a Nationa Cinica Exceence Award. Mr S. VAUGHAN, Interim Chief Operating Officer (from 10 January 2016) his saary represents agency costs. Mrs R. OVERFIELD, Interim Nurse Director (from 1 November 2015) her saary represents a recharge from the NHS Trust Deveopment Authority (NTDS). The Trust did not agree any exit packages in 2016/17 for Executive Directors. 56

57 Rea Rea Tota Lump Cash Cash Rea Empoyer s Increase Increase accrued sum at Equivaent Equivaent Increase contribution Name and Tite in pension in pension pension pension age Transfer Transfer in Cash to stakehoder at pension Lump at pension age reated to Vaue Vaue Equivaent pension age sum at at 31 March accrued at 31 March at 1 Apri Transfer pension age 2017 pension at Vaue 31 Mar 17 (Bands of (Bands of (Bands of 2,500) 2,500 5,000) Mr R. KIRBY, Chief Executive (from 9 May 2011) Mr P. THOMAS-HANDS, Chief Operating Officer (from 10 December 2016) Mr R. CALDICOTT, Director of Finance & Performance (from 1 Juy 2015) Mr A. KHAN, Medica Director (from 1 October 2010) Miss R. OVERFIELD, Director of Nursing (from 1 June 2016) Wasa Heathcare NHS Trust Annua Report 2016/17 Mr M. SINCLAIR, Director of Organisationa Deveopment & Human Resources (from 7 September 2016) Mr D. FRADGLEY, Director of Transformation & Strategy (from 1 January 2016) 0 (5)-(7.5) (5) 0 Pension Benefits NOTES The accounting poicies set out how our pension iabiities are treated in the accounts. The CETV for 2016/2017 is not quoted for the medica director as he has reached retirement age. The Trust has made a contribution to a stakehoder pension (NEST) in reation to the Director of Nursing. ACCOUNTABILITY REPORT 57

58 ACCOUNTABILITY REPORT Compensation on Eary Retirement or for Loss of Office The Trust did not make any payments in reation to compensation on eary retirement or for oss of office during 2016/17. Payments to Past Directors Wasa Heathcare NHS Trust Annua Report 2016/17 The Trust did not make any payments to past directors during 2016/17. Staff Report The foowing tabe provides a year-end position of the number of senior managers by band: Substantive senior civi service staff (or senior managers) by band Headcount FTE Band 8 - Range B Band 8 - Range C Band 8 - Range D Band Senior Manager Grade (Director etc.) Consutant (Medica & Denta) The average number of staff empoyed during 2016/2017 is set out beow: 16/17 Average SIP FTE Headcount Additiona Cinica Services Additiona Professiona Scientific and Technica Administrative and Cerica Aied Heath Professionas Estates and Anciary Heathcare Scientists Medica and Denta Nursing and Midwifery Registered Students

59 Staff composition: Wasa Heathcare NHS Trust Annua Report 2016/17 The foowing tabe provides a year-end position in reation to the composition of the Trust s empoyees: Femae Mae A Substantive Coeagues % % ACCOUNTABILITY REPORT Of which are: Directors 4 25% 12 75% Senior civi servants 79 34% % Sickness Absence Data: The foowing tabe provides a comparison of sickness absence to the previous year: Staff Sickness Absence 2016/ /16 Tota Days Absent 39,391 41,301 Tota Average Staff 3,796 3,760 Average working Days absent The staff sickness absence figures incuded within the tabe above refect the numbers of days absent based upon the typica number of working days per year (225 days) by each individua working the fu-time standard working hours (FTE). The tota days absent is divided by the tota average number of individuas (FTE) working within the Trust during the year to produce the average working days absent which sighty improved for 2016/17 by one day. Sickness eves have decreased during the past 12 months ( ) to 4.59% which is a decrease year on year of 0.45%. The argest cause of sickness during 2016/17 was stress/anxiety and MSK reated iness. The Trust continues to work towards a monthy target of 3.39% and during 2017/18 is aiming for a further reduction on the year end %. During the past 12 months the Trust has: Invested in a dedicated Sickness Champion roe, based in the Human Resources department, which is a centra co-ordination point of a sickness data, Occupationa Heath Link and Heath and Webeing initiatives providing support and faciitates enhanced sickness management to hep maintain coeagues attendance at work. The Occupationa Heath Service has been reviewed, deivering a stabiised function to further support coeagues in achieving the eariest possibe return to work. A new Attendance Poicy came into effect in February 2017 which has simpified the management process and which is focused around supportive interventions. As part of the Heath and Webeing work the Trust has invested in services that support coeagues, via the newy estabished Heath and Webeing Hub, as we MSK services and menta heath support. 59

60 ACCOUNTABILITY REPORT Staff Poicies Wasa Heathcare NHS Trust Annua Report 2016/17 The Trust has a range of HR poicies that support staff and which are widey avaiabe on the Intranet. In respect of disabiity, the Trust s Recruitment and Seection Poicy and Guideines sets out it s commitment to ensuring that a staff, incuding those who are disabed, are treated fairy and equitaby in reation to the appointment processes. The Trust maintains Two-Ticks accreditation, guaranteeing an interview for disabed appicants who meet the person specification and to ensure reasonabe adjustments are made. The Trust has an Equaity and Diversity Steering group, which amongst others ensures that disabed persons have equa access to deveopment and support. The Attendance Poicy and Occupationa Heath Service ensure that staff who become disabed are given appropriate training, support and redepoyment opportunities. The Trust monitors its empoyment and poicies to ensure actions are taken to avoid unawfu discrimination whether direct or indirect. The Trust has signed up to the Dying Matters pedge as promoted by Unison. The fu range of Human Resources Poicies is avaiabe to a Trust empoyees via the Trust s Intranet. Consutancy Costs The Trust paid 1.4m on consutancy costs during 2016/2017. Off Payro Arrangements For a off payro engagements as of , for more than 220 per day asting onger than 6 months Number Number of existing engagements as of Of which, the number that have existed: ess than 1 year at the time of time of reporting 2 for between 1 and 2 years at the time of reporting 1 for between 2 and 3 years at the time of reporting 0 for between 3 and 4 years at the time of reporting 0 for 4 or more years at the time of reporting * 3 *Cinica appointments are made according to cinica need and owing to imited avaiabiity in the permanent empoyment market temporary soutions are used. Assurance was received for a existing engagements regarding the payment of income tax and Nationa Insurance in 2016/17. For a new off payro engagements between and , for more than 220 per day asting onger than 6 months Number Number of new engagements between and Number which incude contractua causes giving Wasa Heathcare NHS Trust the right to request assurance in reation to income tax and Nationa Insurance obigations 2 Number for whom assurance has been requested 2 Of which: assurance has been received 1 assurance has not been received 1 engagements terminated as a resut of assurance not being received, or ended before assurance received 1 Number of off payro engagements of 'Board members, and/or senior officers with significant financia responsibiity' during the year 0 Number of individuas that have been deemed 'Board members and/or senior officers' with significant financia responsibiity during the year. This figure incudes both off payro and on payro engagements 6 60

61 Exit Packages Exit package cost band (incuding any specia payment eement Number of compusory redundancies Cost of compusory redundancies Wasa Heathcare NHS Trust Annua Report 2016/17 Number of other departures agreed Cost of other departures agreed Tota number of exit packages Tota cost of exit packages Number of departures where specia payments have been made Cost of specia payment eement incuded in exit packages ACCOUNTABILITY REPORT WHOLE NUMBERS ONLY s WHOLE NUMBERS ONLY s WHOLE NUMBERS ONLY s WHOLE NUMBERS ONLY s Less than 10, , ,594 10,000-25, , ,664 25,001-50, , , ,617 50, , , , , , , ,000 > 200,000 Totas 4 87, , ,413 Redundancy and other departure costs have been paid in accordance with the provisions of the NHS Pensions Scheme. Exit costs in this note are accounted for in fu in the year of departure. Where the Wasa Heathcare NHS Trust has agreed eary retirements, the additiona costs are met by the Wasa Heathcare NHS Trust and not by the NHS Pensions Scheme. I-heath retirement costs are met by the NHS Pensions Scheme and are not incuded in the tabe. A Mutuay Agreed Resignation (MARS) Scheme is a scheme whereby organisations may offer a severance payment to an empoyee to eave their empoyment vountariy. The scheme has been deveoped to assist empoyers in addressing some of the financia chaenges facing the NHS and its key purpose is to create job vacancies for coeagues facing redundancy. The scheme is time imited and has HM Treasury approva. This discosure reports the number and vaue of exit packages agreed in the year. Note: the expense associated with these departures may have been recognised in part or in fu in a previous period. 61

62 ACCOUNTABILITY REPORT Anaysis of Other Departures Wasa Heathcare NHS Trust Annua Report 2016/17 Tota vaue of Agreements Agreements Number 000s Vountary redundancies incuding eary retirement contractua costs - - Mutuay agreed resignations (MARS) contractua costs Eary retirements in the efficiency of the service contractua costs - - Contractua payments in ieu of notice* - - Exit payments foowing Empoyment Tribunas or court orders - - Non-contractua payments requiring HMT approva** As a singe exit package can be made up of severa components each of which wi be counted separatey in this Note, the tota number above wi not necessariy match the tota numbers in tabe 1 which wi be the number of individuas. * Any non-contractua payments in ieu of notice are discosed under non-contractua payments requiring HMT approva beow. **incudes any non-contractua severance payment made foowing judicia mediation, and reating to non-contractua payments in ieu of notice. The Trust did not pay any non-contractua payments to individuas where the payment vaue was more than 12 months of their annua saary. 62

63 Wasa Heathcare NHS Trust Annua Report 2016/17 SECTION 3: FINANCIAL STATEMENTS AND NOTES 63

64 FINANCIAL STATEMENTS AND NOTES 2016/17 Financia Position Wasa Heathcare NHS Trust Annua Report 2016/17 The Trust has reported a deficit of 21.39m for the financia year and consequenty the Trust has not achieved its financia pan for a 6.2m deficit in year. The retained deficit figure that is used to evauate financia performance for the year is adjusted for impairments reating to the new buid and renovation, and the change in accounting treatment for recording donated assets within exchequer accounts. The Trust targeted savings of miion (4% of turnover). These savings were needed to meet the required nationa efficiency savings target and aso for reinvestment into service deveopments. The Trust however experienced a very chaenging year in terms of meeting quaity and performance targets and was unabe to deiver the required savings programme. The Trust aso experienced significant vacancies within cinica roes that were fied utiising temporary workforce. The premiums associated with payment for agency staffing further impacted on the abiity of the Trust to remain within panned eves of expenditure. The overspend against the initia panned deficit of 6.2m totaed approximatey 8.9m. The Trust then was not abe to receive income from the centre of 6.3m which has resuted in deterioration from pan of 15.2m. The Trust has had oan support during the year from the Department of Heath to sette creditor accounts within reasonabe time frames, thereby ensuring continuity of services. How is our financia performance assessed? The Department of Heath measures NHS Trust financia performance against the foowing four targets. Definition of Target Target Set Actua Target Met Income and Expenditure Revised Break Even (Managing Services within the income received by the Trust) 000 (6,136) (21,392) NO Externa Financing Limit (Managing Services within the cash imit agreed with the Department of Heath) ,731 22,656 YES Capita Resource Limit (Managing Capita Expenditure within the Capita Resource Limits agreed with the Department of Heath) 000 4,777 4,660 YES Capita Cost Absorption Duty (return on assets empoyed). The Trust was not required to submit a dividend payment % YES Where our money comes from The majority of Trust income comes from the provision of patient care services ( 223 miion), the remainder of income comes from such things as Education, Training and Research, Income Generation (car parking, staff catering and accommodation) and the provision of non-patient reated services to Wasa Commissioning Care Group. What we spend our money on The Trust spent 266miion in the financia year 2016/17. The argest component of this expenditure was saaries and wages where we spent 172miion, with the average number of staff empoyed being 4,194 whoe time equivaents. The Trust spent a further 37.3miion on cinica suppies and services such as drugs and consumabes used in providing heathcare to patients. 64

65 Wasa Heathcare NHS Trust Annua Report 2016/17 The chart beow shows a breakdown of the main categories of expenditure for 2016/17. FINANCIAL STATEMENTS AND NOTES Capita Investment The tota capita expenditure in 2016/17 totaed 4.7miion. The main areas of investment were: Reconfiguration, ifecyce and refurbishment works 2.8 Computer repacement and information systems 0.7 Medica, theatre and pharmacy equipment 1.0 Other 0.2 Tota 4.7 m 65

66 FINANCIAL STATEMENTS AND NOTES Wasa Heathcare NHS Trust Annua Report 2016/17 Income and expenditure account for the year ended 31 March 2017 Baance Sheet at 31 March

67 Wasa Heathcare NHS Trust Annua Report 2016/17 Cash fow statement for the year ended 31 March 2017 FINANCIAL STATEMENTS AND NOTES 67

68 FINANCIAL STATEMENTS AND NOTES Better Payment Practice Code The Trust is a member of the Better Payment Practice Code in deaing with our suppiers. The code sets out the foowing principes: Wasa Heathcare NHS Trust Annua Report 2016/17 Agree payment terms at the outset of a dea and stick to them pay bis in accordance with any contract agreed with the suppier or as agreed by aw i.e. the code requires the Trust to pay a vaid invoices by the due date or within 30 days of receipt. Te suppiers without deay when an invoice is contested and sette disputes quicky. During 2016/17 the percentage of bis paid within target was: number of bis: 18% vaue of bis: 15% Russe Cadicott Director of Finance These financia statements are summaries of the information contained in the Annua Accounts of the Wasa Heathcare NHS Trust. The Trust s auditors have issued an unquaified report on the Annua Accounts. The fu financia statements are avaiabe as a separate document on the Trust's website or on request from: Mr Trevor Baker Chief Financia Accountant Finance Department, Wasa Heathcare NHS Trust, The Manor Hospita, Moat Road, Wasa WS2 9PS. The Trust's poicy for managing risk is set out in the Annua Governance Statement. The Trust's externa auditors are Ernst & Young LLP. The fee for the statutory audit for 2016/17 was 81,000 (incuding VAT) with an additiona 15,600 for audit reated services (the review of the Trust's Quaity Account). 68

69 Wasa Heathcare NHS Trust Annua Report 2016/17 Statement of Directors Responsibiities in respect of the Accounts FINANCIAL STATEMENTS AND NOTES 69