Council of Governors. Board Room, The Royal Marsden, London. 26 th September 2017, 11am 1pm, Board Room, Chelsea.

Transcription

1 Council of Governors Board Room, The Royal Marsden, London 26 th September 2017, 11am 1pm, Board Room, Chelsea. 1. Declarations of Interest Governors to declare any relevant interests in light of the meeting agenda 2. Minutes of the meeting held on 21 st June 2017 (Chairman) 3. Matters Arising 3.1. Care Quality Commission Update (Chief Nurse) Enclosed Enclosed 4. Chief Executive s Report Enclosed 5. Patient Experience Report (Governor Co-Chair Duncan Campbell) 6. Quality and Performance 6.1. Quality Account August Patient Experience Surveys (Chief Nurse) 6.3. Financial Performance Report for August 2017 (Chief Financial Officer) 6.4. Key Performance Indicators Q1 (Director of Performance and Information) 7. Board Sub-Committees Report (Ian Farmer and Janet Husband, Chairs of the Committees) 8. Auditor s Report on the Annual Report and Accounts (Jonathan Gooding, Deloitte LLP) Enclosed Enclosed Enclosed Enclosed Enclosed Enclosed Enclosed 9. Any Other Business Date of next meeting: 13 th December 2017, 11am 1pm, Board Room Chelsea.

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3 Council of Governors Boardroom, The Royal Marsden Hospital, Chelsea Wednesday 21 st June am 1pm Minutes Present:- Charles Alexander (Chairman) Governors as per attached attendance list In attendance Cally Palmer (Chief Executive) Ian Farmer (Non-Executive Director) Professor Dame Janet Husband (Non-Executive Director) Dr. Liz Bishop (Chief Operating Officer) Marcus Thorman (Chief Financial Officer) Eamonn Sullivan (Chief Nurse) Dr. Nick van As (Medical Director) Steven Francis (Director of Performance & Information) Samantha Ball (Director of IT) item 4.2 only Shams Maladwala (Managing Director, Private Care) item 5 only Jonathan Gooding (Partner, Deloitte LLP) item 7 only Syma Dawson (Trust Secretary) (minutes) MEETING BUSINESS Apologies as noted in the attached attendance list Dame Nancy Hallett 1. Declarations of Interest Governor Robert Freeman declared a conflict of interest with regard to the Private Care Cavendish Square Development item due to a personal connection with a partner at Harcourt House. 2. Minutes of meeting held on the 22 nd March 2017 The minutes of the meeting held on the 22 nd March 2017 were approved subject to the following amendments: i) section 7.2. should note that the Trust recruited 262 members (not 162) and ii) date of Nancy Hallett s term to be amended as 1 April 2016 (not 2018). 3. Matters Arising 3.1. Nominations Committee Report The Chairman thanked the Governors who attended the Council of Governor extraordinary meeting on the 15 th June 2017 to ratify the Non-Executive Director (NED) appointments. He reported on the search and selection process undertaken by the Nominations Committee and the unanimous decision taken by the Council of Governors to appoint two NEDs for a three year term; Heather Lawrence s term to commence on the 3 rd July 2017 and Martin Elliott s term to commence on the 1 st November The Chairman summarised the experience of the two NEDs, both of whom he noted will make a valuable contribution to the Trust Board. It was confirmed that Heather Lawrence will provide Vice-Chair support to Professor Dame Janet Husband in her capacity as Chairman of the Quality, Assurance and Risk Committee. The Chairman informed the Council that NED Richard Turnor will have served three terms on the Board in December 2017 and therefore, the appointment of Martin Elliott in Page 1 of 6

4 November 2017 provides continuity and stability for the Board prior to Richard Turnor s departure. After due discussion, the Council of Governors unanimously supported the appointments of the two Non-Executive Directors. Heather Lawrence from the 3 rd July 2017 for a three year term, and Professor Martin Elliott to commence his three year term from the 1 st November CQC action plan The Chief Nurse reported that the CQC Quality Summit which took place on the 6 th April 2017, led by the CQC with key stakeholders present, was a positive and constructive meeting which highlighted the following; CQC confirmed that the Trust s cancer services are outstanding ; CQC have agreed to re-inspect the End of Life Care Service and Sutton Outpatients. The Trust welcomes this decision and has made every effort to facilitate this as soon as possible but awaits a response from the CQC. The Chief Nurse noted that the future CQC inspection regime is currently out to consultation. Proposed changes indicate that they will conduct leadership inspections as well as adopt a more targeted approach with regular requests for information to providers. The Trust has produced two action plans in response to the CQC inspection and report. The enclosed action plan was submitted to the CQC following the Quality Summit and focuses on the must-do areas. The other action plan is a detailed internal action plan addressing all of the CQC points and findings in their report. The Chief Executive informed the Council of Governors that Professor Ted Baker has been appointed as the new Chief Inspector of Hospitals to replace Sir Mike Richards. She also noted that the Trust s Deputy Chief Nurse, Sarah Rushbrooke, is leaving the Trust in 3 weeks time and expressed her thanks to Sarah for her hard work and contribution particularly with regard to her work on CQC actions and recommendations. The Chief Nurse noted that Helene Anderson, currently Divisional Nurse Director at St.George s Hospital, has been appointed as the new Deputy Chief Nurse. It was also noted that the Trust Director of Children s Services for Community Services, Anne Howers has been appointed as Divisional Director of Community Services. Professor Dame Janet Husband informed the Council that Community Services staff presented at the Quality, Assurance and Risk Committee on the 19 th June. She highlighted how impressed the Committee were by the variation and breadth of their work but also the dedication of staff to delivering an excellent service to patients. However a key consideration for the organisation is the extent of its responsibilities and liabilities when working closely with other organisations such as local authorities. Professor Dame Janet Husband reported that she would be visiting areas in the Community with the Chief Nurse to develop her understanding of the Service issues. The Chief Executive added that the Sustainability and Transformation Planning process, which was introduced to deliver financial sustainability to the NHS, is currently focussing on out of hospital care and future arrangements for the delivery of Community Services. The Council noted the CQC action plan and relevant updates regarding Sutton Community Services. 4. Governor requested items 4.1. Membership and Communications Report Governor Fiona Stewart presented the enclosed report and highlighted the key initiatives the Membership and Communications Group have implemented to increase membership such as making better use of the Trust website. With regard to future reporting, the Group will look at a comparative analysis of membership figures to monitor progress. Governor Ann Curtis suggested the number of members cancelling their membership should also be considered which the Trust Secretary agreed to include. All Governors were encouraged to attend the open meeting in December (date to be confirmed) to contribute to this important agenda and enhance compliance with their responsibility to represent Trust members. Page 2 of 6

5 The Council of Governors noted the Membership and Communications Group Report and in particular the invitation to attend the annual open meeting in December IT Security Briefing Samantha Ball, Director of IT, joined the meeting for this item. She reported on the IT Strategy which aims to have the Trust fully digitised by 2020/21. She noted that the IT replacement for the Electronic Patient Record (EPR) is a work in progress as the Trust is currently exploring its options including the possibility of collaborating with other NHS providers. Another key aspect of the IT Strategy is the data warehouse project which will bring together information from different Trust systems into one central place, including research data. External IT access for patients was also noted as a key area of focus for the IT Strategy. The Governors were informed that Sphere is the joint venture wholly owned by RM and Chelsea and Westminster Hospital (C&W) to provide a joint IT service in order to minimise costs and maximise IT expertise, including IT Security expertise. It was reported that following the recent cyber-attack to the NHS, the Trust was affected but not infected. Governor Duncan Campbell asked for an update on the type of EPR the Trust is looking at, i.e. is this an off the shelf package or will it be a commercial bespoke system. Sam Ball explained that the Trust currently has a bespoke system which is not sustainable due to the growing demand on IT services and their complex nature. As a result, the Trust is exploring its options and looking into a collaborative commercial EPR system. Governor Duncan Campbell also queried whether the Trust is using Windows XP which was connected to the cyber-attack. Samantha Ball responded that the Trust has carried out its upgrade to Windows 7 however, some computers remain on Windows XP because of their link to medical equipment which is managed by a third party. It was reported that these computers have been isolated on the network for security reasons. Governor Andrew Pearson asked whether there are plans for real time access for prescribing. Samantha Ball confirmed that the specification for the new EPR is currently being worked on with input from clinical and service leads. Following a query from Governor Robert Freeman, it was confirmed that no patient data was lost as a result of the cyber-attack. The Chief Nurse commended the IT team for their response and management of the cyberattack. The Chief Executive suggested that the Trust review its emergency plans in any event to ensure that this is fit-for-purpose and considers the scale of uncertainty across the NHS. The Council of Governors noted the IT Security Briefing update Shared Facilities Management The Chief Operating Officer reported that the Trust is currently running a tender process in collaboration with partners on the Fulham Road for the Shared Facilities Management services. However, Trust catering and portering services have been excluded from the process given that the Trust scores high in these areas compared with the service provided by relevant bidders. The contract value is 3.7m per annum and will therefore go to the Board for sign-off in September The Council of Governors noted the update with regard to the Shared Facilities Management tender. 5. Private Care Cavendish Square Development Governor Robert Freeman abstained from the meeting for this item due to a conflict of interest. Shams Maladwala, Managing Director for Private Care, attended the meeting for this item. Page 3 of 6

6 He explained the reasons for the Cavendish Square Development which he noted are due to a current shortage in capacity thereby limiting Trust growth and sustainability, as well as a growing competitive private healthcare market in London. For these reasons, the Trust has had to consider an off-site model which has the following benefits: Patient experience will improve due to the new Diagnostic and Day Care Facility; Additional capacity available to meet patient and consultant demand; Access to a new Central London market which the Trust has valued at 250m as well as working more closely with primary care providers; and An ability to further support aspiring consultants looking to develop their Private Care portfolio. The Council of Governors discussed whether this development affected the cap on non- NHS income. The Chairman confirmed that the Board had looked at this in detail and was assured that the Trust position, approximately at 25% for Private Care activity, is far from the 49% cap. The Governors discussed the nature and type of services that would be provided and it was also noted that there would be disabled access to the building. Governor Fiona Stewart asked whether this qualified as a significant transaction which Governors ought to approve in line with their legal duties. The Chief Financial Officer (CFO) explained that the financial position and trajectory of the Cavendish Square Development did not meet the regulator s financial definition of a significant transaction (more than 10% of turnover or asset base / material transaction more than 25% of turnover). The Chief Executive added that Governors have previously approved the Private Care Strategy recommending growth in Private Care activity and income. The Council of Governors noted the update with regard to the Private Care Cavendish Square Development. 7. Quality and Performance 7.1. Quality Account April 2017 The Chief Nurse presented the Quality Account for April 2017 and reported that this had been recently refreshed and updated in terms of its formatting and layout. He reported on the positive results regarding patient experience with a low level of complaints received, pressure ulcers in the community are reducing and positive results had been received from the Friends and Family Test. Areas of improvement include pressure ulcers in the Hospital as well as nurse staffing levels, although the Chief Nurse was pleased to report that a number of new nurses are due to start in September 2017 in addition to an international recruitment drive currently underway. Governor Duncan Campbell queried the 20% nurse turnover levels in the Community and whether this has any relation to the CQC findings. The Chief Nurse responded that this is a cumulative figure and it is best to consider the overall community nursing figures in light of the fact the average turnover in London is 24%. However the Chief Nurse assured the Council that nurse staffing levels is a top priority for him and noted that the Board have been very receptive and focused on this issue. The Council of Governors noted the Quality Accounts for April Financial Performance Report The CFO presented the enclosed Finance Report and highlighted the following: Month 1 performance is broadly on plan, income down slightly due to Easter break and less working days; The pay position varied in February and March 2017 however this is now back on plan; NHS payment process has been slow which has affected the Trust cash position. This issue has been escalated via the NHS reporting process to the regulator; The 10m debt position is a combination of NHS tariff debt and Private Care debt. The Council discussed the Private Care debt issue and it was noted that as Private Care income and activity grows, it is anticipated that debt levels will also grow as a result however, the Board and in particular the Audit and Finance Committee are closely monitoring this. The Managing Director for Private Care added that the Trust systems and Page 4 of 6

7 processes for recovering this debt have improved. NED Ian Farmer informed the Council that in the last financial year there had been an increase in the amount of bad debt written off which has been a key areas of focus for the Committee Key Performance Indicators Q4 The Director of Performance and Information presented the enclosed Key Performance Indicators (KPIs) and reported that the Trust has been rated in segment 1 of the Single Oversight Framework which is for the highest performing Trusts. He brought the 7 red ratings to the Council s attention (compared to 8 red ratings in Q3) and 7 amber ratings (compared to 13 in Q3). The Council of Governors noted the KPIs for Quarter Auditor s Report on the Annual Quality Account Jonathan Gooding, Partner at Deloitte LLP, joined the meeting for this item. Jonathan explained his responsibilities regarding the Annual Quality Account as the external auditor for the Trust, including providing limited assurance in reviewing the content to ensure the Trust has complied with its previously set priorities, as well as conducting a data quality audit on the following areas: 18 week RTT: the auditor reported an unqualified opinion and added there had been a significant improvement compared with the previous year; 62 day wait: an unqualified opinion was reported, Outpatient waiting times: there were no major issues to report to the Governors. It was noted that some areas of improvement have been identified as a result of the audits however there are no material issues to report. He further explained that the audits were carried out on a sample basis which was broadened for the 18 week RTT and 62 day wait indicators following some non-material errors that were identified in the initial sample. NED Ian Farmer confirmed the Audit and Finance Committee were satisfied with the report and pointed out that the document flow chart is a useful tool in the report. He added that this is the first year the Trust has received a clean opinion on the 18 week RTT pathway. Governor Duncan Campbell noted that he previously attended a Deloitte Seminar where there was discussion on whether the requirements on the Quality Account content may change. Jonathan responded that there has been some discussion on changing the guidance to make this Report more user friendly however the guidance is not released until February The Chief Nurse added that a majority of the content is mandatory however the Trust will continue to make every effort to simplify and streamline content wherever possible. The Council of Governors noted the auditor s report on the Annual Quality Account 2016/17 and thanked Jonathan Gooding, Partner at Deloitte LLP, for presenting the item. 9. Any Other Business No other business was raised. Date of next meeting: 26 th September 2017, 11am 1pm, Boardroom, Chelsea Signature:... Date:... Page 5 of 6

8 Council of Governors, Attendance List 21June 2017 Elected Governors Constituency Signature Maggie Harkness Kensington & Chelsea and Sutton & Merton Apologies Armine Afrikian Kensington & Chelsea and Sutton & Merton Apologies Colin Peel Kensington & Chelsea and Sutton & Merton Fiona Stewart Elsewhere in London Dr Peter Lewins Elsewhere in London Dr Andrew Pearson Elsewhere in England Simon Spevack Elsewhere in England Lesley-Ann Gooden Carer Apologies Duncan Campbell Carer Public Governors Dr Carol Joseph Kensington and Chelsea Tim Howlett Sutton & Merton Ann Curtis Elsewhere in England Bernadette Knight Elsewhere in England Apologies Staff Governors Hardev Sagoo Corporate and Support Services Rachel Nabawanuka Clinical Professionals Dr Jayne Wood Doctor Maureen Carruthers Nurse Nominated Governors Dr Charmaine Griffiths Institute of Cancer Research Robert Freeman Local Authority: Borough of Kensington & Chelsea Anne Croudass Cancer Research UK (Charity) Cllr Stephen Alambritis Local Authority: Boroughs of Sutton & Merton Apologies Dr Chris Elliot Clinical Commissioning Group Dr Philip Mackney Clinical Commissioning Group Apologies Page 6 of 6

9 COUNCIL OF GOVERNOR PAPER SUMMARY SHEET Date of Meeting: 26 September 2017 Title of Document: CQC Update Agenda item 3.1. To be presented by Chief Nurse Executive Summary Following the Care Quality Commission (CQC) inspection of the Trust in April 2016 The Royal Marsden received the CQC inspection reports in January This paper provides the Council of Governors with an update on the CQC s findings. Recommendations The Council of Governors is asked to note that the must do action plan is almost complete. Evidence has been submitted to the CQC inspector and the Chief Nurse and Medical Director will meet with CQC in mid-september. The Council of Governors is asked to note that work being taken by Trust staff which has enabled the majority of actions on the internal action plan to have been completed since February By the end of September 2017 only three actions should remain outstanding. Author: Chief Nurse Contact Number or E- mail: 2121 Date: 1 st September 2017

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11 Care Quality Commission Update 1.0. Background Following the Care Quality Commission (CQC) inspection of the Trust in April 2016 The Royal Marsden received the CQC inspection reports in January CQC requirements must do action plan 2.1 The CQC inspection reports highlighted five areas, covering three regulations that CQC required the Trust to make improvements on. After the CQC summit in April an action plan was agreed. 2.2 The must do action plan has been monitored and progress reviewed at the Integrated Governance and Risk Management (IGRM) committee. 2.3 First regulation that was not being met. Self care and treatment (WHO five steps to safer surgery checklist was not being used in the outpatients department). The following actions have been completed; Local Safety Standards for Invasive Procedures (LocSSIPs) Policy published; WHO Surgical Safety Checklist (s) for Outpatients approved and implemented; The four primary relevant OPD LocSSIPs completed (Out Patient Department (OPD) Minor Plastics, OPD Nasoendoscopes, Clinical Assessment Unit (CAU) Ascitic Drain Insertion, Chest Drain Insertion Clinic); Monthly audits into the 5 Steps to Safer Surgery Checklist in Outpatients with the data presented at the monthly Theatre Quality and Safety (TQS) Meeting. Results to be reported every six months to the IGRM committee. 2.4 Outstanding action: monthly audit report of all areas using the WHO surgical safety checklist in outpatients departments. Partial collated to date. 2.5 Second regulation not being met. Need for consent. The following actions have been completed; New Safeguarding Operational Group established; Community specific adult safeguarding action plan, including a review of staff training in MCA and DOLs; Review of specialist safeguarding staffing levels in the Community; Conduct baseline case record audit of compliance with the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DOLS) across Community Services; Hold Master class for community team leaders. 2.6 Outstanding action: Case record audit of compliance with the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DOLS) across Community Services following training to staff. 2.7 Third regulation not being met. Good governance. The following actions have been completed; Reviewed and strengthened of Community Services leadership, including Governance Structures; New weekly team meetings, chaired by a Clinical Director, agenda includes key governance issues, such as reviewing of serious incidents, risk register, complaints and safeguarding issues (adult and child); Established Director-led, Recruitment and Retention meetings, including developing a Community Services Recruitment Plan; Reviewed and strengthened the Community Services Clinical Audit Programme, including increasing the sample size and frequency of the case-record and risk assessment audits to monthly; The Community Services Division to report to IGRM 1

12 on a quarterly basis; Chief Nurse chairs community services serious incident review panels. 2.3 Outstanding action: Monthly audits to be completed for nursing documentation. Baseline audits completed. 2.4 Following the change in the CQCs inspection process from August 2017 the CQC inspector meets each quarter with the Chief Nurse and Medical Director. Progress against the must do action plan will be included. 2.5 In addition the CQC inspector has requested and received evidence of completion of actions e.g. minutes of meetings, policy and audit results Internal action plan 3.1 Despite the overall good rating from CQC in order to maximise quality improvement for patients the Trust devised an action plan based upon the findings in the CQC inspection report in February This action plan has been monitored through the IGRM committee and divisional leads have met with the Chief Nurse and updated the action plan with progress. 3.3 The action plan had 100 items across all divisions where action could be taken. There were 21 items or Chelsea, 27 items for Sutton, 13 items for Sutton and Chelsea, 35 items for Community Services and 4 items for the Trust overall. 3.4 All of the actions have been started and the majority completed, many of which are being monitored by other trust committees. After the latest review on 25 August the action plan had 24 items left to be completed by January By the end of September 2017 only three items would remain open. 3.5 Some examples of actions taken include the following; re-launch of the chemotherapy waiting times group; an audit of non-elective admissions at the weekend showed low numbers; stock room rotation of single use disposables; new monitoring schedule of high/low dusting; Health Care Assistants in OPD have completed their level 1 & level 2 safeguarding training for both adults and children; the outpatient nursing team have an established daily team meeting which is documented in a communication book; Incident reports to be discussed at the monthly Divisional Management Team then cascaded to local team meetings by DND's. Development of Incident action log; regular meetings between director of care and matron in the hospice and community teams Conclusion 4.1 The Council of Governors is asked to note that the must do action plan is almost complete. Evidence has been submitted to the CQC inspector and the Chief Nurse and Medical Director will meet with CQC in mid-september. 4.2 The Council of Governors is asked to note that work being taken by Trust staff which has enabled the majority of actions on the internal action plan to have been completed since February By the end of September 2017 only three actions should remain outstanding. 2

13 COUNCIL OF GOVERNOR PAPER SUMMARY SHEET Date of Meeting: 26 th September 2017 Title of Document: Chief Executive s Report Agenda item 4 To be presented by Chief Executive Executive Summary The Chief Executive will present her report to the Council of Governors with regard to the relevant matters. Recommendations The Council of Governors is asked to note and discuss the Chief Executive s Report. Author: Chief Executive Contact Number or E- mail: Ext2101 Date: 18 th September 2017

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15 COUNCIL OF GOVERNORS Regulatory 1. CQC new inspection process Chief Executive s Report The Care Quality Commission (CQC) announced at the end of July 2017 changes to the inspection process. Their programme of comprehensive inspections of all NHS acute and specialist trusts has now been completed. CQC announced a move towards targeted inspections focused on individual services offered by providers, as well as their leadership. The inspections will usually be unannounced. New Provider Information Requests (PIRs) are being sent from June 2017, the first regulatory planning meetings taking place in August, the first next phase of inspections will take place between September and November 2017, and the first next phase ratings and inspection reports will be published in early Trusts will be inspected once a year on a risk based approach. Service Planning 2. Sutton Site Plans 2.1 Epsom and St. Helier public engagement Epsom & St Helier University Hospitals Trust (ESH) is developing a Strategic Outline Case (SOC) for the modernisation of their estate which includes an option for a new development on the Sutton site, with some services shared with RMH. The precise service and clinical models are yet to be established and we are re-engaging with both Sutton Council and ESH to facilitate the development of the SOC. The benefit of a co-located hospital to RMH is the on-site access to surgical and Critical Care Unit facilities including interventional radiology and endoscopy, which could support a growth in our activity. At present, ESH have entered a public engagement phase setting out the options for the development which the Trust Board has provided a letter of support for London Cancer Hub The London Cancer Hub has a long-term vision to transform the land adjacent to the ICR and RMH into a bio-medical and health research campus, specialising in the diagnosis, research and treatment of cancer. As a supporting partner of this development, we recognise that this expansion and development will be essential to retain the long-term global competitiveness of our integrated research activities in the face of increasing UK and international competition. The Development Framework, which was jointly funded by Sutton Council and the ICR, is a strategic spatial plan covering the Sutton estate, the old Sutton Hospital site and adjacent Belmont Allotment, which are collectively designated as the London Cancer Hub. It is a flexible, strategic planning document that sets a vision and 1

16 principles to guide the physical development of the Sutton site. This is being worked in conjunction with ESH plans. 3. Private Care Cavendish Square Diagnostic and Day Care Centre At the last meeting the Trust shared the plans to develop a Private Care Diagnostic and Day Care Centre in the Harley Street area. The report noted that through extending capacity, brand footprint and a superior clinical model to a broader London catchment, a new treatment and diagnostic centre has the potential to unlock significant benefits for the Trust. The Trust has now signed the lease for the development with a launch date of August However, given the delay with the start date, the Trust is exploring other ways in which it can create additional Private Care capacity in the interim. Such an approach will ensure the Private Care Service maintains a competitive position in this highly competitive market. 4. Maggie s Centre We are delighted that planning has been approved for the Maggie s Centre at Sutton and enabling works will commence November This is a 6m scheme funded by Maggie s Charity with support from RMCC and RM. We expect the Maggie s Centre to be completed by December Clinical Care and Research Centre The development of the new Clinical Care and Research Centre (CCRC) is progressing well with agreement of the 1:100 drawings. The Trust team are currently working with the architects to develop the detailed 1:50 plans for all areas in the new building which involves agreement of the contents and layout of each room and will enable the development of 2D images for all areas. In addition the architects will be using virtual reality technology to develop a 3D vision of the key areas, such as the consulting rooms and chemotherapy pods, enabling the clinical staff to visualise the proposed facility. An informal early planning meeting has been agreed with Sutton Council for September. The scheduled opening of the Centre is as previously reported in The fundraising appeal is going well and the Appeal Board Members, led by Chairman Mike Slade, have identified a long list of potential supporters from their own networks who they have begun to approach. They will meet again for the third CCRC Appeal Board meeting on 28th September. Service Review 6. Soft Facilities Management update In April 2012, following an extensive market testing process, the Fulham Road Collaborative (FRC) commenced a joint Soft FM Framework Agreement with ISS. The constituent parts of the FRC are the RMH, The Royal Brompton & Harefield NHS Foundation Trust (RBH) and Chelsea & Westminster Hospital NHS Foundation Trust (C&W). The Institute of Cancer Research (ICR) participated in the market testing exercise but chose not to enter into the final agreement. The contract is due to expire and therefore repeating this procurement the FRC had reached a final shortlist of two potential providers of Soft FM services: ISS and OCS. RMH has 2

17 included the same list of services as before; cleaning; linen; car park management; and pest control; however have added waste management in this contract. RMH did consider expanding this list of services further, however the conclusion of the internal evaluation was that the bidders proposals did not satisfy the quality thresholds required by the RMH for patient/retail catering or for portering (including security). Nor did the initial cost proposals demonstrate any significant financial incentive to outsource these services. Based on the current project timeline, it is expected that the FRC Project Board will be in a position to notify individual organisations on their recommendation for a preferred bidder in September 2017, after which there will be a period of standstill and mobilisation prior to contract commencement on January Research 7. Imperial College Academic Health Science Centre (AHSC) Imperial College is one of six AHSCs designated for The NHS criteria for AHSC designation include volume, critical mass and world class excellence in basic medical research and the ability to translate findings into the excellent translational, clinical and applied research. The Royal Brompton and The Royal Marsden Hospitals joined the Imperial AHSC in June The Trust has run a series of Seminars about the work of the AHSC which were well attended. The audience comprised mostly of patients, clinical staff, and public. The vision for the AHSC from is to utilise its strengths from discovery science with the critical mass and clinical expertise of the NHS partners to: establish an AHSC Informatics resource develop new diagnostics - digital pathology, remote sensing and point of care products develop new interventions - vaccines, devices, therapies, stratified approaches evaluate and influence policy and practice RCTs, Institute of Global Health Innovation, Imperial Business School. Cally Palmer September

18 COUNCIL OF GOVERNOR PAPER SUMMARY SHEET Date of Meeting: 26 September 2017 Title of Document: Patient Experience and Quality Account Group Report Agenda item 5. To be presented by Duncan Campbell, Governor co- Chair Executive Summary The purpose of this Report is to provide the Council of Governors with an update on the work of the Patient Experience & Quality Account Group (PEQA) for the period Sept 2016 Sept The Group met six times in the year at Chelsea with a video link to Sutton. Recommendations The Council of Governors is asked to note the progress of work undertaken by the Patient Experience & Quality Account Group. Author: Trust Secretary / Duncan Campbell Contact Number or E- mail: 2826 Date: 4 th September 2017

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20 Patient Experience & Quality Account Group Report 1. Purpose The purpose of this Report is to provide the Council of Governors with an update on the work of the Patient Experience & Quality Account Group (PEQA) for the period Sept 2016 Sept The Group met six times in the year at Chelsea with a video link to Sutton. The main aims of PEQA are: To provide the Trust with objective support and recommendations for sustaining and improving the patient experience, quality and contribution to the annual Quality Account. To support the Trust Board and the Council of Governors in continuing to ensure that the safety, effectiveness and quality experience of patient care is always front and central to all RM strategy. 2. Structure The membership of the Group is a combination of Governors, Trust Staff and external partners as listed below: Deputy Chief Nurse (Co-Chair) Governor (Co-Chair) Governors up to eight, including at least three patient/carer Governors Patient and Carer Advisory Group (PCAG) members up to four Head of Quality Assurance Head of School Healthwatch Sutton and Kensington & Chelsea Divisional Nurse Director representation Matron representation Community Services Division representation Member and Governor Lead (minutes) 3. Summary 3.1 Patient Experience During the year Members received presentations and updates from the following services: Community Services Vanguard: Patient & Family Leadership and Engagement work stream Always Events At each meeting members received an update from the Patient Experience Steering Group. Eamonn Sullivan, Chief Nurse, attended the meeting in June to outline the plans for the Group going forward. The Group discussed the various different ways in which the Trust considers the Patient Experience. It was noted that this work is greatly appreciated including the mock inspections prior to the CQC visit. It was agreed that all the Patient Experience Groups should be reviewed to avoid duplication of work and ensure clear lines of reporting.

21 3.2 Quality Account 2016/17 The Group reviewed, commented and contributed to the development of the Quality Accounts at each meeting. The final Quality Account report had been awarded the Plain English Crystal Clear Campaign Mark and members of the Group congratulated the Trust on the detail and presentation of the Accounts. 3.3 Reports & Surveys Members reviewed and advised action on reports and surveys relating to the patient experience including the following: CQC Reports National Inpatient and Outpatient surveys (Picker) Private Care Patient Experience survey Friends and Family test Integrated Risk and Governance Monitoring Report Listening Post View Point Quarterly Complaints Report 3.4 Members Event The Group suggested format and presentation ideas, for the annual Quality Account Members Event in November 2016 which focused on gathering member s views on the quality improvement priorities for 2017/2018 using interactive voting pads. Those who attended the event fed back how pleased they were to be given the opportunity to take part in the voting, particularly after being shown the historical data about how the Trust performed in certain areas. 4. Recommendations The Council of Governors is asked to note the progress of work undertaken by the Patient Experience & Quality Account Group.

22 COUNCIL OF GOVERNOR PAPER SUMMARY SHEET Date of Meeting: 26 September 2017 Title of Document: Quality Account June & July 2017 Agenda item 6.1 To be presented by Chief Nurse Executive Summary: The Council of Governors is asked to note: 1. There has been one grade 4 pressure ulcer in the hospital this period. 2. Complaints have fallen in July, following a higher than normal number in June. Clinical complaints remain low. 3. There has been a sustained reduction in falls with harm across the Trust. 4. There are over 70 Registered Nurses in the pipeline with start dates, which will see vacancy rates fall to a year-low in October. Recommendations The Council of Governors is asked to review and comment on this report. Author: Eamonn Sullivan Contact Number or E- mail: 2121 Date: 25 August 2017

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24 1 The Royal Marsden NHS Foundation Trust Quality Account June & July 2017 for September Board, QAR & Council of Governors A report by the Chief Nurse: Eamonn Sullivan eamonsullivan@rmh.nhs.uk

25 Monthly Quality Account Table of Contents Summary Dashboard P3 Infection P4 Falls P5 Medication Incidents P6 Hospital Pressure Ulcers P7 Community Pressure Ulcers P8 Readmissions & VTE P9 Chemotherapy Waits P10 Patient Experience P11-13 Safer Staffing P

26 Summary Dashboard (detail/narrative in main paper) Indicator Safe care SIs: Number of SIs Number of diagnoses of Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia Number of diagnoses of Clostridium difficile (C.Diff) (Attributable)** Number of C-Diff lapses of care (quarterly)** Number of diagnoses of Methicillin-sensitive Staphylococcus aureus (MSSA) (Attributable) % Harm free care (RMH) % Harm free care (RMCS) % New harm free care (RMH) % New harm free care (RMCS) Falls: Attributable Moderate Harm Incidents while patient under RMH care Falls: Attributable Major Harm Incidents while patient under RMH care Falls: Attributable Death Incidents Number of attributable medication incidents with moderate harm and above Number of cardiac arrests Failure to recognise deterioration in a patient leading to death VTE risk assessment Effective Care Number of patients with attributable pressure ulcers (RMH) Number of patients with attributable pressure ulcers (RMCS) Patient Experience RMH Inpatient Friends and Family Test: % Recommended RMH Inpatient Friends and Family Test: Number of responses Community Friends and Family Test: % Recommended Community Friends and Family Test: Number of responses Chemotherapy waiting times (Chelsea): % waiting an hour or less Chemotherapy waiting times (Sutton): % waiting an hour or less Chemotherapy waiting times (Kingston): % waiting an hour or less Number of PALS contacts Complaints: Number of complaints (RMH) Complaints: Number of complaints (RMCS) Vacancy/Sickness Rates Trust vacancy rate Trust sickness rate Nurse vacancy rate Nurse sickness rate Nurse turnover rate HSMR Quarterly Figures Indicator Hospital Standardised Mortality Rate (rolling 12 months, NHS only) Annual Target Aim Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2017/ /17 YTD 4 Below Below No target Below Below % Above 92.5% 94.7% 92.7% 94.6% 93.6% 94.3% 92.0% Above 95.2% 94.9% 90.7% 92.1% 93.1% 92.0% 96.4% Above 94.8% 96.2% 92.7% 96.0% 94.9% 96.4% 97.3% Above 98.6% 98.0% 96.3% 96.7% 97.3% 97.3% 3 Below Below Below Below Below Below % Above 96.2% 96.9% 94.3% 96.7% 96.0% 96.9% Number of patients 136 Below Category Below Category 3 9 Below Category 4 0 Below Number of patients 160 Below Category Below Category 3 50 Below Category 4 4 Below % Above 97.5% 98.0% 95.5% 97.3% 97.2% 97.8% No target % Above 97.8% 95.9% 96.3% 98.3% 96.8% 97.4% No target % (target under Above 76.1% 76.7% 77.7% 78.8% 77.3% 74.2% Above 89.8% 88.5% 86.4% 90.4% 88.7% 88.6% Above 81.9% 74.2% 83.6% 80.5% 80.0% 62.2% review) No target ,246 5, Below Below % Below 11.2% 11.7% 10.8% 11.7% 45.5% 9.4% 3% Below 2.9% 2.5% 2.7% 2.7% 10.8% 3.0% 5% Below 15.1% 14.3% 13.3% 14.2% 56.9% 13.8% 3% Below 3.3% 3.5% 3.7% 3.3% 13.8% 3.7% 12% Below 17.4% 17.0% 18.1% 18.4% 70.8% 17.5% Quarterly Aim Qtr3 Target 16/17 75 Below Qtr4 16/17 Qtr1 17/18 Qtr2 17/18

27 Healthcare Associated Infections & Hand Hygiene Target: <31 C-Difficile lapse in care and <Zero MRSA bacteraemia Data Owner: Pat Cattini Deputy Director of Infection Prevention & Control. There have been no infection transmissions or outbreaks reported in this period & we remain below our infection control tolerances. In this period there were are 8 CDIFF cases identified 72 hours after admission. These will be jointly reviewed with CCG colleagues to ascertain if there were any lapses in care. There have been no MRSA or MSSA cases for June. Over this period we have had five patients identified with Ecoli, one of which was attributable to the Trust. There continue to be a number of complex patients admitted with high risk infections such as Carbapenemase- Producing-Enterbacteriaceae (CPE), in this period we have had 4 patients admitted with CPE, all four patients were isolated promptly and treated without issue. Finally, of particular note this period is that our Deputy DIPC (Pat Cattini) has been appointed as President of the UK Infection Prevention Society, taking up the parttime position in October This is a prestigious role, which will further enhance the reputation of The Royal Marsden Infection Prevention Team. Table 1.0 May MRSA & Cdiff Monthly Performance Organism Feb 2017 Mar 2017 Apr 2017 May 2017 June 2017 July 2017 YTD Trajectory/Comments MRSA Bacteremia Last MRSA Bacteremia: July (All) C.Difficile cases identified at RMH NA C.Diff cases post 3 days * C.Diff Cases attributed to RMH through a lapse in care * * 2* 5* 8* *These figures are provisional and awaiting CCG sign off. Target no more than 31 cases in year. Table 2.0 May 2017 Hand Hygiene Compliance by Site Hand Hygiene Compliance May June July Chelsea Site 91% 91% 95% Sutton Site 96% 96% 96% Kingston MDU 85% 90% 90% Monthly Total Score 91% 92% 94% Reviewing Infection Control Compliance Hand hygiene audit., overall results >90% with an improvement across all areas this period. These results, as well as other key monthly infection control audits, such as Commode cleanliness results are fed back for action to Sisters and Matrons. Other audits of note: a revised community focused infection audit tool is being piloted and will be rolled out across community areas in September. 4

28 Patient Fall Incidents Target: <0.7 falls with moderate or above harm Data Owner: Richard Schorstein, DND. Trust Falls Lead. To date, Trust falls rates are falls per 1000 bed days, below the Quality Account target. The majority of falls resulted in no or low harm and there have been no moderate harm or above falls since April A newly revised Falls Prevention Committee has been established that group is very active in scoping the latest falls-reduction techniques and technologies, such as integrated anti-slip embolism stockings and a electronic alerting system called Wanderguard. Table 3.0 5

29 Medication Incidents Target: Increase the reporting of near misses and decrease incidents that cause harm (low harm <2 per 1000 bed days and moderate <0.17 per 1000 bed days) Data Owner: Fleur Harvey Associate Chief Pharmacist. The current 12 months sees the majority of all medication incidents resulting in no or low harm within the Trust. The number of moderate or above harm events remains extremely low for a Trust of our complexity (moderate incident n =3, severe & catastrophic n=0). The increasing number of Near Miss reports shows a good reporting culture within the Trust. July data trends show that reports involving Controlled drugs (CDs) remains a current theme, and a total of 15 incidents were reported, these are no harm incidents. The executive medicines safety group are working to provide context to the figures regarding CDs to understand if this is due to the high rates of prescribing and administration of CDs as expected in a cancer specialist Trust. Table 4.0 6

30 Hospital Pressure Ulcers Category 2,3,4 Target: Zero grade 4 pressure ulcers Data Owner: Andrew Dimech DND. We have seen a small increase in reporting of Category 2 pressure ulcers in the Hospital and a reduction in Category 3. The Trust has seen one Grade 4 pressure ulcer reported in June 2017, this was a unique incident, and the first of kind in over 24 months. The incident which was independently reviewed and despite the patient being non-compliant, the assessment was that there were learning issues which concluded that this should be categorised as attributable. The Tissue viability service has been significantly enhanced in this period. The Trust has substantively funded a Band 7 TVN and we have appointed a 8a Darzi Fellow (TVN) to undertake a quality improvement project specifically looking at reducing pressure damage in complex cancer patients. This new post holder has been recruited from UCLH and starts in post in September Table 5.0 7

31 Community Pressure Ulcers Category 2,3,4 Target: Zero grade 4 pressure ulcers Data Owner: Debbie Linton-Taylor Community DND. There continues to be a positive reduction in the number and severity of acquired pressure ulcers in Community services. The previous detailed analysis of the two Grade 4 pressure ulcers (acquired this calendar year) has led to a number of significant changes in clinical practice including the development of a new Pressure Ulcer Care Bundle to which will be deployed in August 2017 following a two month training programme for all nursing staff. The Nursing service has also implemented a rolling monthly Audit programme, which includes reviewing compliance with the content of the Pressure Ulcer Care Bundle. The Chief Nurse continues to chair all Category 3 and 4 4 panels both in the Community & Hospital. Table 6.0 8

32 Hospital Readmissions Performance (June Data) Hospital VTE Screening Performance (June Data) Table 7.0 Hospital Readmissions Summary % of eligible admissions resulting in an eligible re-admission 1.00% 0.80% 0.60% 0.40% 0.20% 0.00% Reported % of Emergency Readmissions Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Month June 2017 Readmissions Summary: Readmissions remain below 0.3%. There are no anomalies to report this period with any speciality or CBU. VTE Data Owner: Richard Schorstein June data 94.4% compliance with inpatient VTE assessments. July data 96.7% Despite one dip in June 2017, the Trust consistently achieves >95% compliance with VTE risk assessment (the CQUIN target previous sat at 90%). All patients with confirmed VTE as reported by radiology undergo a Root Cause Analysis (RCA) The VTE steering board monitor all confirmed VTE and take action as required. The VTE steering board is currently being refreshed and relaunched in September

33 Chemotherapy Waiting Times & Prescribing (July data) Table 8.0 Sutton Site Data Owner: Jat Harchowal, Chief Pharmacist The Trust continues to monitor chemotherapy waiting times at each site. This metric is unique to RMH & not easily benchmarked. The data is triangulated with patient feedback (complaints, PALs queries) Table 9.0 Chelsea Site The results for Sutton (table 8) show that consistently 10% of patients wait over an hour between treatment appointment time and treatment start time, with approx 50% waiting 30 minutes or less. Table 9, shows the waiting times for the Chelsea site. These results show that over 20% of patients wait over an hour. Two key actions this period: New Chief Pharmacist led Quality Improvement project. The aim will be to make improvements at each stage from preparation, manufacturing and release of the final chemotherapy product. The Chemotherapy waiting time group will focus on the factors outside of the pharmacy department - the scheduling, prescribing, ordering, prep of the patient and administration. 10

34 Our Patient Experience Family & Friends Test (FFT) Table National Family & Friends Data (as of 10 August 2017 June National data available) Inpatient data was collected for 177 Acute NHS trusts and independent sector providers. Nationally, the overall average percentage for those who would recommend the service to friends and family was 96% in June. The Trust is below this with a score of 95%. Outpatient data was collected for 238 Acute NHS trusts and independent sector providers. Nationally the overall average percentage for those who would recommend outpatients to friends and family was 94% in June. The trust was above this with a score of 98%. Community Health Services data was collected from 140 NHS organisations and independent sector providers who provide community health services. Nationally the overall average percentage for those who would recommend community services to friends and family was 96% in June. The trust was the same with a score of 96%. INPATIENTS FFT Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 April 2017 May 2017 June 2017 The Royal Marsden 97% 98% 98% 98% 97% 97% 98% 95% inpatients who would recommend National average 96% 96% 96% 95% 96% 96% 96% 96% Response number OUTPATIENTS FFT Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 April 2017 May 2017 June 2017 The Royal Marsden 96% 98% 98% 98% 98% 99% 97% 98% outpatients who would recommend National average 93% 93% 93% 93% 93% 94% 94% 94% Response number COMMUNITY Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Apr 2017 May 2017 June 2017 SERVICES FFT The Royal Marsden 98% 98% 100% 97% 97% 98% 96% 96% community services clients who would recommend National average 95% 95% 95% 95% 96% 96% 96% 96% Response number

35 Our Patient Experience Monthly Survey Results (score out of 5.0) In-Patients Were you treated with dignity and respect? Did you feel involved enough in decisions made about you? Did you receive timely information about your care and treatment? Was the location clean? Out-Patients Were you treated with dignity and respect? Did you feel involved enough in decisions made about you? Did you receive timely information about your care and treatment? Was the location clean? Community services (nursing) Were you treated with dignity and respect? Did you feel involved enough in decisions made about you? Were you treated well by the staff looking after you? Jan 2017 Feb Mar April May June July Jan 2017 Feb Mar April May June July Jan Feb Mar April May June July Table 14-18: The patient comments below are captured via our paper comments cards. Ward Sisters and Matrons review the data at minimum monthly, and it is also reviewed at the CBU Performance Review meetings. I found the radiotherapy department very caring and professional in every way, and always made you feel at ease in the treatment room, plus away so accommodating if you needed to change a future appointment. I have been attending the Royal Marsden for many years. I could not fault it in any way. Great care and warm and friendly staff I could not rate this hospital highly enough. I am very grateful for all the good care I get. I would never want to go anywhere else. Excellent staff and so caring. Could not ask for better care. Every aspect of the stay was 100% Perfect. Wouldn't change a thing. (CCU) The spirit of the staff is superb, they are enthusiastic about their work and very respectful and helpful to their colleagues, which is quite uplifting for patients. The noise at night is a real nuisance, particularly the chattering by patients on late as 3 am, which time someone switched on the lights. (General) Care and attention is superb. Thoroughness is admirable. Excellent Staff are professional. Setting up clinic appointments could be easier. Getting a bed feels like a lottery, but I appreciate the stress of too much demand. (Pharmacy) Waiting for medication to take home 2 hours? - not very happy stress I could do with out at moment. 12

36 Patient Feedback PALs Queries and Complaints Data Owner: Helen Mills, Head of Assurance. PALs and Complaints summary. July 2017 PALS Summary: 222 patient contacts this month - within expected numbers (cross site). Top three contact subjects were Advice and Information (147) & Communication - verbal / written / electronic (14). Complaints Summary: After rising to a year high level of 19 in June, complaint levels fell slightly in July. 13 new complaints were opened in July, with 14 open in total at the end of July. Delays, communication and eligibility has been noted as a theme across all of the Divisions. We received no reports from the PHSO this month. Queries related to clinical care have fallen to two complaints this period. Table 19.0 Formal Complaints Trend Complaints Oct Nov Dec Jan Feb Mar Apr May Jun Jul Number per month (aim <12) PHSO - Upheld PHSO Not upheld Table 20.0 Formal Complaints Detailed information by Division Changes to appointment scheduling Table 18.0 Complaints Narrative: Of the 13 complaints, specific issues/themes raised this month were: - Transferring from private status to NHS status - Staff communication when booking appointments - Time taken to schedule appointments - Delays in receiving test results 13

37 Safer Staffing: Nurse Retention Turnover/Retention The overall (all staff) turnover rate for the Trust has increase in month to 15.62%. When split by the hospital and community services it is 14.81% and 22.22% respectively. Nursing specific turnover currently sits at 18.38% however the overall Trust turnover rate is average for London, and the nurse specific turnover is below the London average of 16%. Retention & Recruitment continues to the key focus of the new incoming Chief Nurse and HR Director, working together they now chair weekly Retention & Recruitment Meetings. This has significantly increased the Retention & Recruitment Activity across the Trust. The Trust has engaged a firm called April who identified five key priorities from the feedback gathered. An action plan has put together to implement both locally and corporately. As of August there have been no adult community nurse leavers for over two months. Table 21.0 Nurse Joiners and Leavers cumulative position Nursing Joiners & Leavers - Band 5-6 Month Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Total Starters (wte) Leavers (wte) Variance Table 22.0 Nurse Leavers reasons for leaving June 2017 Nursing Leavers Bands 5-6 July 2017 Area Job Title Leaving date LOS Band FTE Reason for leaving Cancer Services Division Medical Day Unit (S) Staff Nurse 28/07/ y 3 m Retirement - Age Clinical Services Division Critical Care Unit (L) Staff Nurse 03/07/ y 5 m Voluntary Resignation - Promotion Theatres (L) Staff Nurse 11/07/ y 0 m Voluntary Resignation - Relocation Outpatients (L) Senior Staff Nurse 21/07/ y 1 m Voluntary Resignation - Promotion Horder Ward Staff Nurse 04/07/ y 9 m Voluntary Resignation - Relocation Private Care Division GH Ward Staff Nurse 09/07/ y 1 m Voluntary Resignation - Relocation GH Ward Staff Nurse 31/07/ y 10 m Voluntary Resignation - Relocation Voluntary Resignation Work Life Robert Tiffany Unit (S) Staff Nurse 13/07/ y 3 m Balance - Cost of Living (Travel Community Services HV Sutton Health Visitor 07/07/ y 9 m Retirement - Age HV Sutton Health Visitor 09/07/ y 8 m Voluntary Resignation - Relocation Total Leavers FTE 14

38 Safer Staffing: Nurse Recruitment Nurse Recruitment. Nurse recruitment remains a Trust priority. The nurse recruitment and retention group continue to meet weekly. The Nursing vacancy rate is % which is an increase in month. The Hospital nursing vacancy rate has increased to 12.50% and the Community nursing vacancy rate has decreased to 24.72%. We have an unprecedented There are 110 wte registered nurses in the recruitment pipeline of which 70.8 wte have start date confirmed, predictions are that vacancies will fall to a year-low in October when the new starters commence, Summary of July/August 2017 Nurse Recruitment Activity: The annual recruitment activity plan for nurses remains on track, with monthly substantive and bank events, Sutton and Chelsea Open days planned in September. Based on Sisters feedback - launched new fast track vacancy control process for nurses band 5 & 6. International recruitment 7 nurses (out of 30 recruited) on track to be deployed in November. Dublin job fair in October promoting education opportunities and targeting senior/experienced oncology nurses. Newly qualified nurse on boarding review - Regular liaison before start date and encourage to start pending NMC pin Increase notice periods for band 5 nurses to 8 weeks after discussion TCC in September Programme to Identify nurses already at the Trust working as HCA s and support them to undertake OSCE and obtain NMC Pin Table 23.0 Nurse Vacancy Rates 15

39 Safer Staffing: Planned Vs Actual Staffing July 2017 Safer Nurse Staffing Summary: The planned staffing level versus the actual staffing level for June 17 remains greater than 95% for RN this is higher from previous months due to a need for Registered Mental Health Nurses specials in Chelsea. A greater 100% for Healthcare Assistants this can largely be explained through the use of specials (one to one care) and high acuity. Keeping our wards safely staffed launch of Safe Care module March/April The Trust launched a daily census and staffing siterep which Clinical Site Managers & Matrons use as a decision aid to deploy and move staff safely across our wards and departments. Data is collected three times per day and used by the senior team at their daily staffing and quality huddles. Table 24.0 July 2017 Planned vs Actual RN & HCA fill rate Date 2017/2018 RN fill % HCA fill % Chelsea Sutton Combined Chelsea Sutton combined April % 96.10% 97.10% % % % May 98.50% 97.30% 98.00% % % % June 98.80% 98.20% 98.50% % % % July 99.90% 97.80% 99.10% % % % Quality Account Summary The Council of Governors is asked to note and comment on this report. Eamonn Sullivan Chief Nurse September

40 COUNCIL OF GOVERNOR PAPER SUMMARY SHEET Date of Meeting: 26 th September 2017 Title of Document: Patient Experience Surveys (x3) Agenda item: 6.2. To be presented by: Chief Nurse Executive Summary: The Royal Marsden has taken part in national surveys for many years. Some surveys, like the adult inpatient and cancer patient experience are mandatory and others the trust participates in. For the Children s and Young Peoples survey as the numbers participating are low they are not able to be benchmarked against national figures as the responses may be identifiable to participants. It provides an excellent forum to collate patient experience feedback and there are worthwhile learning opportunities. Recommendations: The Council of Governors are asked to note the findings in this paper. Author: Chief Nurse Contact Number or E- mail: x2121 Date: 1 st September 2017

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42 National Adult Inpatient Survey, Children & Young People s Inpatient & Day Case Survey 2016, and the National Cancer Patient Experience Survey Introduction to the National surveys The Royal Marsden (the Trust) has taken part in national surveys for many years. Some surveys, like the adult inpatient and cancer patient experience are mandatory and others the trust participates in. For the Children s and Young Peoples survey as the numbers participating are low they are not able to be benchmarked against national figures as the responses may be identifiable to participants. It provides an excellent forum to collate patient experience feedback and there are worthwhile learning opportunities National Adult Inpatient Survey This is the fourteenth survey of adult inpatients. The survey included all adult patients (aged 16 and over) who had spent at least one night in hospital in July The results were published 31 May The trust achieved a response rate of 58% (n=686) which was higher than the national response rate of 44%. 2.2 Patient responses placed the trust in the best performing trusts for the ten relevant sections (waiting list and planned admissions, waiting to get a bed on a ward, hospital and ward, doctors, nurses, care and treatment, operations and procedures, leaving hospital, overall views of care and services, overall experience). 2.3 The responses showed that for overall experience the trust was rated very highly by patients with a score of 9.0/10, just below the highest trust score of 9.2/ Patient responses also placed the trust scores in the best performing trusts for 53 out of 63 questions. For example, were you involved as much as you wanted to be in decisions about your care and treatment 8.8/10 (highest national score 8.8) did you get answers from doctors that you could understand 9.3/10 (highest national score 9.3) someone to talk to about your worries and fears 8.0 (highest trust score 8.0) 3.0. National Cancer Patient Experience Survey adult patients who had a confirmed diagnosis of cancer and had received care as an inpatient or a day case between April 2016 June 2016 were sent a survey. The results were published on 21 July The trust achieved a response rate of 63%, slightly lower than the national response rate of 67%. 3.2 The types of cancer that patients had included significant numbers with rarer cancers as well as those patients from the common cancer groups i.e. breast, prostate, lung, and colorectal cancer. Patients from thirteen tumour groups returned questionnaires. The responses are available for each tumour group also to allow for benchmarking internally across the tumour groups. 3.3 Some overall responses show the following. Overall the Royal Marsden cancer patient experience was rated very highly above the national average at 8.9/10 for Q59 Patients average rating of care scored from very poor to very good. (National average 8.7) 1

43 93% of patients started they had been given the name of the CNS who would support them through their treatment. (National average 90%) 93% of patients started they were always treated with respect and dignity by staff. (National average 88%) 73% of patients stated they were given understandable information about whether chemotherapy was working. (National average 67%) 4.0 Children s & Young People s Inpatient & Day Case survey eligible patients, aged 0-16 years, from the Royal Marsden NHS Foundation Trust were sent a survey with 84 questionnaires returned. This represents a response rate of 33% once deceased patients and questionnaires returned undelivered had been accounted for. The average response rate nationally was 26% % of returned questionnaires were the parent/carer version (0-7 years), 20% were the children s survey (8-11 years), and 20% were the young person s questionnaire (12-15 years). Overall: 96% of parents rated care 7 or more out of 10. Hospital staff: 85% of parents always had confidence and trust in the members of staff treating their child (0-15 years). Overall: 94% of parents stated they were always treated with dignity and respect by the people looking after their child (0-7 years). Overall: 97% of children (0-15 years) said they were looked after very well or quite well in hospital? 46% of parents said that their child had stayed in a hospital ward more than four times in the past six months (nationally 6% of parents reported this) 25% of parents said their child had stayed two or three times (nationally 21% of parents) 5.0 Inclusive Action Plan 5.1 An action plan is being developed which will incorporate learning from all three national surveys and this will be monitored through the Patient Experience Steering Committee and the Integrated Governance and Risk Management committee. 5.2 The results of the surveys have been disseminated to staff through relevant committees and are all available on the intranet Conclusion The national surveys that the Trust participates in provides a wealth of information about patient experience with which the trust is able to scrutinise and make improvements to the patient experience. The Royal Marsden has demonstrated that it can improve in this year s survey but now needs to plan for improvement next year. The Trust is very grateful to all of its patients who took the time to complete the survey. The Council of Governors are invited to note the findings in this paper. 2

44 BOARD PAPER SUMMARY SHEET Date of Meeting: 26 th September 2017 Title of Document: Financial Performance Report for August 2017 Agenda item: 6.3. To be presented by: Chief Financial Officer Executive Summary: The paper provides a summary of the financial position. Recommendations: The Council of Governors is requested to note the Financial Performance Report. Author: Chief Financial Officer Contact Number or x2646 Date: 1 st September 2017

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46 Summary Financial Performance Report for August Introduction The paper provides a summary of the financial position for the month of August 2017 in FY 2017/18. The reporting format within this paper provides consistent reporting to all Trust Committees. The Board is requested to note the contents of this report. 2. Summary Financial Position Key headlines For the month of August the key headlines are as follows: Operating surplus in month of 1.9m, a favourable variance of 0.3m Retained surplus in month of 0.6m, a favourable variance of 0.4m Agency expenditure of 0.6m, a favourable variance against the cap of 0.2m Capital expenditure of 0.5m, a favourable variance of 0.3m Cash in bank of 27.6m, a favourable variance of 10.5m The Trust was notified of additional STF funding of 417k for 2016/17 and this has all been included within the position in year as required by NHSI. The retained surplus was broadly on plan in month and year-to-date with higher operating surpluses offset by lower donated asset income. The plan expected the new medical equipment would be delivered in June whereas it is now expected to be delivered later in the year. The forecast takes this into account, targeting a 3m favourable position by year-end ( 2.5m against the control total). The year-to-date position at month 5 is in the table below: Income Year to Date - August 2017 Budget Actual Var '000 '000 '000 NHS Clinical Income (86,412) (84,351) 2,061 Non NHS Clinical Income (39,960) (41,572) (1,611) NHS Non Clinical Income (20,174) (23,137) (2,962) Non NHS Non Clinical Income (8,966) (8,927) 39 Expenditure (155,512) (157,986) (2,474) Pay 89,303 87,464 (1,839) Non Pay 59,008 61,499 2, , , Operating Surplus (7,201) (9,023) (1,822) PDC, Interest, JV 1,675 1,667 (8) Development Reserve for Inv (5,526) (7,356) (1,830) Donated Asset Income (2,904) (757) 2,147 Depreciation 6,323 6,144 (179) Retained (Surplus)/Deficit (2,107) (1,969) 139 Control total excl STF (640) (2,145) (1,505) % of NHS income/total income 69% 68% (1%) 1 P a g e

47 Summary Financial Performance Report for August 2017 As shown in the table above, the Trust was ahead of plan in month on a control total basis and as such the full STF year-to-date has been accrued. The operating surplus at month 5 of 9.0m is 4.3m better than the same period last year. This is predominantly driven by additional income, including the additional STF. Under the new Single Oversight Framework, the Trust delivered a Use of Resources rating of 1, against a plan of 1. The Trust reports the percentage of income for the provision of goods and services for the purpose of the health service as set out within the NHS Act 2006 and amended by the Health and Social Care Act This is completed annually and a statement included within the Annual Report, which the auditors review. However, it is also reported to the Board and Council of Governors in each finance report. The income is split into four overall categories with examples of the types of income included: NHS clinical income income from NHS England and CCGs for clinical activities; Non-NHS clinical income private care income for clinical activities; NHS non clinical income NHS R&D; salary support for staff in training eg junior doctors; Non-NHS non clinical income commercial R&D; car-parking; catering income. As a ratio the Trust is required to have more income as NHS than non-nhs and as at month 5 the position was 68% of income from NHS sources. 3. Income and Expenditure Income The income position in month 5 was an adverse variance of 0.7m. NHS Clinical Income was adverse to plan in month by 1.4m. Although most activity areas were broadly on plan in month, there were two particular areas that had significant adverse variances. The first was BMTs due to the planned closure of the Bud Flanagan ward for refurbishment works required for JACIE accreditation, and the second was in critical care due to the revised pricing agreement with the CCGs which was implemented this month but included backdating to the beginning of the financial year NHS Clinical Income Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Acutal 15/16 Actual 16/17 Actual 17/18 Plan 17/18 Forecast 17/18 Private Care income was 0.5m ahead of plan in month due to continued strong underlying activity, although slightly offset by the growth areas not delivering as well as planned. A review of the business cases is planned to ensure these areas deliver as per the original case. Income overall is now 14.3% higher when comparing the same period with the previous year. 2 P a g e

48 Summary Financial Performance Report for August Private Patient Clinical Income Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Acutal 15/16 Actual 16/17 Actual 17/18 Plan 17/18 Forecast 17/18 Pay expenditure was a favourable variance of 0.6m in month compared to the plan and is now 1.8m favourable variance year-to-date. Due to a reduction in activity in some key areas like critical care the agency costs were lower in month compared to July. There has been a 5% increase in pay compared to the same period last year. Some of this will be the pay award and incremental increases, however there has also been investment in additional posts in growth areas Pay Cost Trend Substantive Bank Agency Pay Budget Agency expenditure decreased in month and for the first time the Trust underspent against the medical staffing cap set by NHSI. Overall the Trust is below the NHSI spend cap by 0.2m in month and is now 0.7m under the cap year-to-date. There is still a focus on converting from agencies to the bank, as with the IR35 changes and NHSI pressure on agency rates, pay has become more comparable, however the agency premium is saved. 3 P a g e

49 Summary Financial Performance Report for August Bank and Agency Spend Trend Bank Agency Linear (Bank ) Linear (Agency) Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Non-pay expenditure was a favourable variance of 0.4m to plan in month and has reduced the adverse variance year-to-date to 2.4m. The key variance was drugs which underspent in month due to the low activity on the Cancer Drug Fund; the drug position is now 1.1m underspent despite significant increases in private activity. Unspent reserves contributed to this favourable position in month and helped to offset higher RM Partners costs (which are funded through additional income). Higher costs are also being seen in clinical supplies on pathology reagents, molecular tests, Hospira charges and theatre consumables. These are being analysed to understand whether the increases are volume or price driven or linked to an increase in stock which will then unwind over time. 4. Capital Expenditure Capital expenditure totals 0.5m in month, 3.1m year-to-date, which is a favourable variance of 3.9m. The key difference is the timing of donated equipment, a variance of 2.2m, which in the original plan was due to be received in June and now will not be delivered until later in the year. The other key timing difference is in IT schemes driving the favourable variance. 5. Cash and Debt Cash The Trust had 27.6m in cash at the end of August, 10.5m more than planned. Working capital movements drove this, in particular NHSE cleared some of the previous year s invoices and a number of historic debt issues with other NHS organisations were cleared in month. Chart 2.3 in Appendix 2 shows the trend of cash balances in the last three months and the forecast and plan for the full year. Cash will need to be monitored closely in 2017/18 as NHS organisations are paying much slower and the private care debt continues to rise. In July the Trust received the cash from the remaining STF funds from 2016/17, a total of 4.8m and in September NHSE has paid the remaining overperformance from 2016/17, a total of 3.9m. Debt Invoices raised but not yet paid have decreased in month by 3.6m to 57.6m at the end of August. NHS debt reduced by 3.2m and non-nhs debt fell by 1.8m. Despite this improvement it continues to be offset by the Embassies where the position has increased in month once again, although Kuwait Military paid off over 50% of their debt in month, most of which was very aged. Chart 2.4 in Appendix 2 provides a trend of debtor balances for the last twelve months by age of debt, which shows the increase in debt over 90 days, the majority of which is with embassies and a small number of commissioners. 6. Conclusion and Recommendation The performance in month 5 was broadly as expected due to sustained growth in private care income yet continued controls on pay expenditure. This meant the Trust has again delivered the control total set by NHSI in month. The Board is requested to note the continued financial performance as at month 5. 4 P a g e

50 Appendix 1: Income and Expenditure Budget Actual Var Budget Actual Var Actual Var Budget Forecast Var 1617 Q Q Q Q2 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 Income Actual Actual Actual Actual NHS Clinical Income (18,125) (16,727) 1,397 (86,412) (84,351) 2,061 (80,513) (3,838) (208,554) 1,191 (15,919) (18,675) (17,084) (16,577) Non NHS Clinical Income (7,870) (8,316) (445) (39,960) (41,572) (1,611) (36,358) (5,214) (97,587) 410 (7,772) (8,214) (8,386) (8,207) NHS Non Clinical Income (4,059) (4,815) (757) (20,174) (23,137) (2,962) (17,875) (5,262) (48,911) (4,609) (3,940) (4,447) (4,464) (4,842) Non NHS Non Clinical Income (1,785) (1,244) 542 (8,966) (8,927) 39 (10,442) 1,515 (21,523) 274 (2,333) (1,612) (2,088) - Expenditure In Month Year to Date Prior Year to Date Year /18 Average Monthly Run Rates (31,839) (31,102) 737 (155,512) (157,986) (2,474) (145,187) (12,799) (376,575) (2,733) (29,964) (32,947) (32,021) (29,627) Pay 17,981 17,431 (550) 89,303 87,464 (1,839) 82,802 4, ,235 (604) 16,904 17,685 17,437 17,627 Non Pay 12,219 11,786 (433) 59,008 61,499 2,491 57,695 3, , ,132 11,730 12,550 11,924 30,200 29,217 (983) 148, , ,497 8, ,358 (218) 29,036 29,415 29,987 29,551 Operating Surplus (1,640) (1,886) (246) (7,201) (9,023) (1,822) (4,690) (4,333) (18,217) (2,952) (928) (3,532) (2,034) (76) PDC, Interest, JV (1) 1,675 1,667 (8) 2,332 (665) 4,058 (36) Development Reserve for Inv (1,305) (1,552) (247) (5,526) (7,356) (1,830) (2,358) (4,998) (14,159) (2,988) (437) (3,485) (1,701) Donated Asset Income (140) (264) (125) (2,904) (757) 2,147 (4,333) 3,576 (6,600) - (31) (237) (66) (279) Depreciation 1,278 1,244 (34) 6,323 6,144 (179) 5, ,508-1,101 1,273 1,222 1,239 Loss Disposal Fixed Assets (1) Impairment , Retained Surplus (166) (572) (406) (2,107) (1,969) 139 (1,327) (641) (5,251) (2,988) 632 7,111 (546) 1,218 Control Total (excl. STF) (305) (558) (253) (640) (2,145) (1,505) 1,826 (3,971) (1,585) (2,571) 476 (1,150) (625) (136) Use of Resources Rating Plan Y TD Actual Y TD Liquidity 1 1 (1) - Liquidity = Cash for liquidity purposes (net current assets excluding inventories) divided by opex expressed in days Capital Debt Cover Ratio 1 1 (2) - Capital Debt Cover Ratio = revenue available for debt servicing (EBITDA plus interest receivable) divided by annual debt (PDC I&E Margin 2 1 Dividends, Loan repayments, Loan interest) Variance From Plan 1 1 (3) - I&E Margin - degree to which the Trust is operating at a surplus / deficit Agency Spend 1 1 (4) - Variance between the Trust's planned I&E Margin and its actual I&E Margin year to date Use of Resources Rating 1 1 (5) - Distance from the Trust's agency spend cap N.B. In Budget and Actual Columns, Income is shown in brackets, Costs are without brackets. In Variance Columns, Red is an Adverse Variance and Black a Favourable Variance Liquidity Ratio 2015/16 (1) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 1.2 Capital Debt Cover 2015/16 (2) 1.3 I&E Margin 2015/16 (3) 1.4 Variance from plan (4) 1.5 Agency Spend Variance to cap 2016/17 (5) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 3% 2% 1% 0% -1% -2% -3% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2% 1% 0% -1% -2% -3% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 50% 30% 10% -10% -30% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Actual 5 P a g e

51 Appendix 2: CIPs, Agency, Cash and Debt Cash Balance Debtors - Aging over time Actual Forecast Plan > CIPs - The Trust has delivered 3.2m of savings at July 17, 1.2m behind the total list of schemes identified but only 0.7m behind the YTD NHSI plan. The forecast is 0.5m behind plan so is being reviewed so the gap can be closed. Agency - the Trust was 199k under the 756k NHSI monthly cap in month and 92k under the new Medical Agency spend cap. Spend across the board remained stable in month (areas of high spend continue in Community and Clinical Services) but fell with Junior Doctors as the new summer rotas have been filled. Biweekly meetings rotating around areas of high spend help to control and monitor this position, bringing spend down. Cash - Cash was 27.6m at month-end, 10.5m ahead of plan. Strong performance, working capital and a favourable opening position drove this variance. Debt - invoices raised to customers not yet paid has decreased by 3.6m in August to 57.6m. NHS debt decreased by 3.2m, as aged CDF invoices were paid as well as some contract SLA invoices. Non-NHS debt also dropped in month as numerous debts were paid. Embassy debt however continues to rise, primarily due to a lack of payments from Kuwait Health Office. Although the total quantum of debt has increased, the debt ratios have improved slightly in PP as Kuwait Military settled some very aged debt in month: 50% of PP debt > 90 days and 61% of non-pp debt > 90 days. 6 P a g e

52 COUNCIL OF GOVERNOR PAPER SUMMARY SHEET Date of Meeting: 26 September 2017 Title of Document: Key Performance Indicators Q1 Agenda item 6.4. To be presented by Chief Operating Officer Executive Summary This paper provides a report on the Trust s performance for quarter /18 including the balanced scorecard for the Trust and a commentary on the red rated indicators and actions underway to improve performance. Recommendations The Council of Governors is asked to discuss and note the Trust s performance against the balanced scorecard indicators for quarter Author: Director of Performance and Information Contact Number or x 2150 Date: 5 th September 2017

53

54 KEY PERFORMANCE INDICATORS QUARTER /18 1. PURPOSE This paper provides the Council of Governors with an update on the Trust s performance for quarter /18. The scorecard and narrative is also submitted to the Board. The report includes the balanced scorecard for the Trust and a commentary on the red-rated indicators in the quarter 1 report including actions underway to improve performance. 2. NEW MEASURES AND CHANGES TO DEFINTIONS As part of the annual review for the board dashboard the following changes have been made to existing KPIs: Serious incidents Complaints Total NHS referrals Total PP referrals Research Trials led by RMH MDU patients per Chair updated thresholds in line with 2016/17 outturn refined definition to commercial trials only to commence from Q1 reporting updated threshold based on new data In consultation with clinical and operational colleagues, the following were introduced: + Number of patients with attributable pressure ulcers relating to RMCS + Community staff vacancy rate + Friends and family test relating to RMCS + Care Hours per Patient Day total ratio in line with Carter recommendations + No of 1st UK patients in a clinical trial (rolling 12 months) + Quality account indicators have been split into its composite parts + PP Aged Debt at >6months has replaced the previous PP debt indicator 3. PERFORMANCE FOR QUARTER % of metrics were green in Q1, with 12.5% (10) metrics being red. 1

55 Of these, five indicators have been identified as longer-term issues. These include: 62 day standard, Community Nurse vacancy rate, non-pp debtors, research (accrual to target) and staff turnover. Appendix A shows the balanced scorecard report for quarter 1 for 2017/ Patient Safety, Quality and Experience Q1 17/18 62 day wait for first treatment GP referral to treatment (before reallocation) Actual: 76.2% Target: 85% Forecast: Met target using national reallocation methodology The Trust did not meet the 62 day urgent GP referral standard (before reallocations) with performance at 76.2%. However, the trust exceeded the target following reallocation with performance at 85.6%. During Q1 there were 44 accountable breaches prior to reallocation. Of those, 31 accountable breaches were received late in the pathway (defined as after day 38). The remaining breaches are categorised as follows:- Out of the Trust s control (4.0 breaches) Complex diagnostic pathway (2.5) Patient unfit (1.5) Within the Trust s control (9.0 breaches) Administrative (5.0) Capacity (2.0) Delay in work up/poor pathway management (2.o) The Trust continues to receive a high number of late referrals, as shown in the graph in Appendix B. The full breakdown of performance by tumour site prior to reallocation can be found in the table at Appendix C. On 30 th March 2017, the Trust submitted a trajectory to NHSI for compliance with the 62- day standard in 2017/18. This trajectory incorporates plans submitted by referring trusts within SW London to ensure referrals are made to RM by day 38 wherever appropriate. The 2017/18 trajectory indicates that a compliant position on reallocation from April 2017 should be achieved, dependent on referring organisations achieving their own trajectories. In May and June the Trust achieved 100% of internal pathways being treated in 62 days and this lead to the Trust achieving its trajectory based on the reallocated position despite referring trusts failing to meet theirs. The Trust Performance Group has developed of an internal action plan to manage the service improvements needed to meet the 2017/18 trajectory. 2

56 Q1 17/18 62 day wait for first treatment Screening referral to treatment (prior to reallocation) Actual: 89.6% Target: 90% Forecast: Meet the standard in Q2 2017/18 The Trust did not meet the 62 day urgent GP referral from screening standard prior to reallocation, based on the national reallocation policy in Q1. However, it did meet the standard following reallocations. During Q1, there were 3.5 accountable breaches before reallocation. Of these breaches, 2 accountable breaches were received late in the pathway. The remaining 1.5 breaches all were categorised as out of the Trust s control due to patient choice (1.0 breach) and complex diagnostic pathway (0.5 breach). 2.2 Community measures Q1 17/18 Community Nurse vacancy rate Actual: 26.8% Target: <5% Forecast: Red There is a significant programme of work in place to reduce the community nurse vacancy rate including incentive schemes for refer a friend and golden hello, continuous recruitment campaigns and open days as well as increased social media presence. This is having a positive impact the recruitment pipeline of staff waiting to start and will have a significant impact on the nursing vacancy rates. 2.3 Finance, Productivity and Efficiency Q1 17/18 PP Aged Debt at >6months Actual: 29% Target: <27% Forecast: Amber The PP Aged Debt at >6 months is a new metric to the scorecard in Q The total PP debt over 6 months at the end of Q was above target at 29% of the total debt. Challenges of recovering income from Embassy sponsors is driving the aged debt. The finance team are continuing to work on customising the Trust s billing to the Embassies and re-invoicing old debt which will help facilitate easier payments of the old debts. The target by the end of Q4 is set at 19% (25% end of Q2, and 23% end of Q3). Q1 17/18 Non-PP Debtors over 90 days (% of total PP-debtors) Actual: 57% Target: <25% Forecast: Amber Non-PP debtors over 90 days increased in Q1. This was due to the total quantum of debt decreasing more than the quantum of aged debt decreasing. Cash settlements in the NHS have slowed in the last year which is driving this metric deterioration, with specific accounts being escalated to NHSI to assist with settlement. A long term recovery plan is being targeted for Q4. Q1 17/18 Capital Expenditure Variance YTD ( 000) Actual: -3,261 Target: <25% Forecast: Green in Q3 Capital expenditure is behind plan primarily due to the delayed arrival of some large medical equipment items, which were planned to arrive in June but are now scheduled to arrive in September. There is no clinical risk impact with the slippage of any capital schemes. The forecast is expected to return to green by Q3. 3

57 2.4 Clinical and Research Strategy Q4 16/17 (1 quarter in arrears) 70 day target (for externally sponsored trials, NIHR adjusted figure) Actual: 63.6% Target: 85% Forecast: Red NIHR issued new guidance on 21 st March The new guidance was retrospectively applied on quarter 4 data by NIHR, which meant 5 studies which previously would have been removed from the denominator were not excluded. This lead to a performance figure significantly lower than expected. RMH has now applied the NIHR guidance to its data validation process and as such expect performance to recover by Q Q4 16/17 (1 quarter in arrears) Accrual to target, % of closed commercial trials meeting contracted recruitment target (national definition) Actual: 47.8% Target: 85% Forecast: Red As described in previous reports, the NIHR made changes to its Delivery metric (from quarter /16), which now focuses on recruitment to target, by target date recorded in each trial s contract. The recruitment target is set following discussion between the Principal Investigator and the Sponsor and is a best estimate of recruitment at the site recruitment to time and target. Recruitment to target is affected by many factors. Recruitment may be more challenging than anticipated; the Sponsor can often choose to close the trial earlier than anticipated and the trial is sometimes withdrawn by the Sponsor. In some instances, the recruitment window may be extended in agreement with the Sponsor, with no change to the date held the trial Contract (and hence the metric does not reflect the agreed extension). The NIHR collects reasons for recruitment targets not having been met but, unlike the NIHR Initiation metric, no adjustment is made to account for these reasons. 50 studies closed to recruitment in the last 12 months (for comparison, 49 were uploaded for Q3). 4 studies had no target recruitment date and were therefore removed from the analysis. Of the 24 studies that did not meet their target recruitment, 13 studies were withdrawn by the sponsor and no adjustment is made by the NIHR. To consider the adjusted denominator excluding the 13 studies (46 to 33 studies) the performance achieved is 63.6% In order to improve performance against the NIHR metric, researchers are negotiating recruitment ranges, rather than a single definitive number of patients, and will request amendments to contracts where recruitment is not happening at the anticipated rate. Recruitment data are reviewed regularly at Clinical Research Team meetings, and are reported at quarterly performance meetings held with the teams. 2.5 Workforce Q1 17/18 Vacancy rate Actual: 11.30% Target: <5% Forecast: Amber The Trust vacancy rate has increased during Quarter One. The Community Services vacancy rate remains high 17.8% but the recruitment pipeline is healthy and a significant reduction in the vacancy rate is predicted in September and October. The vacancy rate across the hospital has seen an increase and this largely because of a significant number of new posts being created as a result of approved business cases including private care growth and other service developments. The establishment is being reviewed and cleansed during Quarter Two to ensure there is active recruitment for all vacant positions. The overall nurse vacancy rate 4

58 for the Trust at the end of Quarter 1 was 13.3%. The Trust has a targeted campaign to recruit 225 new nurses during 2017/18. This will involve local, national and international activity and is in track to meet the target. Q1 17/18 Staff turnover rate Actual: 15.10% Target: <12.0% Forecast: Amber The overall turnover for the Trust is 15.1% which is relatively stable in comparison to Quarter Four. The overall Trust rate is average for London but remains above the Trust target. The workforce data indicates there is a peak in turnover at one and three years service. In response to this the Trust has reviewed the pre-appointment, induction and on-boarding processes to ensure they are robust and support the retention of an engaged new workforce. Analysis of the information from the new joiners and leavers surveys on a quarterly basis has helped to inform this work as well as engagement with all levels of staff across the Trust. There are a number of educational programmes to support improved retention including Nurses New to Community and an Apprenticeship Scheme. In addition, there are wider NHS workforce development initiatives, including Capital Nurse, Pharmacy Rotation and Nurse Associate programmes, which the Trust is actively involved in. 3.0 Conclusion The Council of Governors is asked to note the Trust balanced scorecard and commentary for quarter /18 and is invited to discuss the position. 5

59 The Royal Marsden NHS Foundation Trust Balanced Scorecard 2017/18 APPENDIX A NHSi denotes NHS Improvement standard 1. To achieve the highest possible quality standards for our patients, exceeding their expectations, in terms of outcome, safety and experience Patient Safety, Quality & Experience Q1 (Apr-Jun 17/18) Q4 (Jan-Mar 16/17) Q3 (Oct-Dec 16/17) Q2 (Jul-Sep 16/17) NHSi Single Oversight Framework: level of support segment New in Q3 Quality Account indicators MRSA positive cultures (cumulative) C Diff lapses of care (1 quarter in arrears) Q1 (Apr-Jun 16/17) VTE risk assessment 95.8% 97.3% 96.7% 96.6% 96.9% Certification against compliance : access to health care for people with a learning disability NHSi G G G G G Serious incidents (excl pressure sores) Complaints - % upheld 16.22% 19.00% 24.00% 21.00% 29.00% Mortality Hospital Standardised Mortality Ratio (rolling 12 month - qtr in arrears - NHS & Private patients) Mortality audit (based on qtr data in arrears) G G A A A 30 day mortality post surgery 0.29% 0.66% 0.36% 0.58% 0.59% 30 day mortality post chemotherapy 1.62% 2.09% 2.27% 1.99% 2.18% 100 day HSCT mortality in previous 6 months (Deaths related to SCT) 4% 0.00% 5.40% 1.90% 4.30% 100 day HSCT mortality in previous 6 months (All deaths) 6% 0.00% 5.40% 1.90% 5.80% Medicines Management % Medicines reconciliation on admission 95% 100% 98% 99% 96% Unintended omitted critical medicines Cancer staging Staging data completeness sent to Thames Cancer Registry (1 qtr in arrears) 70.90% 72.41% 72.62% 68% 72% Patient satisfaction Friends and Family Test (inpatient and day care) 97.13% 97.20% 97.90% 97.60% 98.40% Friends and Family Test (outpatients) 97.99% 98.30% 98.20% 97.50% 97.90% Waiting times for day chemotherapy (over 3 hrs) 12.10% 11.56% 12.69% 12.54% 13.15% Mixed sex accommodation breaches PP access to single rooms - Chelsea % % 99.90% % 99.92% % PP access to single rooms - Sutton % % 99.70% % % 95.03% National waiting times targets NHSi 2 wk wait from referral to date first seen: all cancers 97.40% 97.73% 98.70% 97.40% 93.90% NHSi symptomatic breast patients 93.60% 95.91% 96.70% 95.50% 93.30% NHSi 31 day wait from diagnosis to first treatment 98.10% 97.39% 98.30% 98.10% 99.30% NHSi 31 day wait for subsequent treatment: surgery 97.00% 95.15% 94.00% 94.50% 95.20% NHSi drug treatment 99.00% 98.80% 99.40% 99.70% 99.80% NHSi radiotherapy 94.60% 96.56% 98.10% 97.10% 98.30% NHSi 62 day wait for first treatment: GP referral to treatment (reallocated) 85.60% 85.31% 87.00% 82.40% 85.40% NHSi GP referral to treatment (pre-reallocations) 76.20% 77.94% 77.90% 75.20% 77.10% NHSi Screening referral (reallocated) 91.30% 89.57% 93.30% 90.00% 78.30% NHSi Screening referral (pre-reallocations) 89.60% 90.82% 92.60% 90.50% 84.30% NHSi 18 wks from Referral to Treatment still waiting (incomplete) 95.70% 95.90% 94.70% 95.90% 94.30% NHSi 18 wks pathways - patients waiting > 52 wks. (distinct patients across the quarter) Staff Friends and Family Test - How likely are you to recommend this organisation to friends and family as a place to receive care or treatment Staff Friends and Family Test Q1 (Apr-Jun 17/18) Q4 (Jan-Mar 16/17) Q3 (Oct-Dec 16/17) Q2 (Jul-Sep 16/17) Q1 (Apr-Jun 16/17) Recommend Care 95.90% 95.40% N/A % 95.50% Not recommend Care 0.60% 0.70% N/A 0.00% 0.90% 3. Community Measures NHSi Community Measures Q1 (Apr-Jun 17/18) Q4 (Jan-Mar 16/17) Q3 (Oct-Dec 16/17) Q2 (Jul-Sep 16/17) Q1 (Apr-Jun 16/17) NHSi Community care data completeness referral to treatment information 75.00% 75.00% 75.00% 75.00% 75.00% NHSi referral information 75.00% 75.00% 75.00% 75.00% 75.00% NHSi activity information 76.20% 76.20% 76.20% 76.20% 76.20% Patient satisfaction Friends and Family Test 96.7% 97.0% 96.9% 99.9% 98.1% Effective care Number of patients with attributable pressure ulcers (RMCS) Total 44 New in Q1 Category 4 0 New in Q1 Community staff vacancy rate Nurse vacancy rate 26.75% 24.14% 24.69% 20.17% 17.49% Page 1 of 2

60 The Royal Marsden NHS Foundation Trust Balanced Scorecard 2017/18 APPENDIX A NHSi denotes NHS Improvement standard 4. To improve the productivity and efficiency of the Trust in a financially sustainable manner, within an effective governance framework Finance, Productivity & Efficiency Q1 (Apr-Jun 17/18) Q4 (Jan-Mar 16/17) Q3 (Oct-Dec 16/17) Q2 (Jul-Sep 16/17) NHSi NHSi Use of Resources risk rating New in Q3 NHSi %age variance from Agency Spend Cap -18% -14% -13% -7% 9.30% Cash ( m) NHS activity Income Variance YTD ( 000) PP activity Income Variance YTD ( 000) 1,100 2,868 1,862 1,498 1,349 PP Aged debt at >6months 29% New in Q1 Non-PP Debtors over 90 days (% of total non PP-debtors) 57% 42% 51% 51% 52% Achievement of Efficiency Programme YTD (%) 81% 102% 99% 98% 66% Capital Expenditure Variance YTD ( 000) -3,261-4,579-5,072-2,494-1,781 Q1 (Apr-Jun 16/17) Productivity & Asset Utilisation Bed occupancy - Chelsea 83.01% 85.10% 82.47% 81.92% 83.12% Bed occupancy - Sutton 81.05% 79.40% 79.26% 80.16% 82.95% Care Hours per Patient Day total ratio Theatre utilisation - Chelsea 87.20% 89.90% 92.35% 96.44% 96.71% Theatre utilisation - Sutton 81.20% 82.70% 69.81% 77.57% 76.35% MDU Patients per Chair (Adjusted method and chair numbers) Quarter in arrears Q4 (Jan-Mar 16/17) Q3 (Oct-Dec 16/17) Q2 (Jul-Sep 16/17) Q1 (Apr-Jun 16/17) Q4 (Jan-Mar 15/16) Contractual Sanctions incurred ( 000) New in Q1 CQUIN %age achievement Acute NHSE 100% 100% 100% 100% New in Q1 CQUIN %age achievement Acute CCG 100% 100% 100% 100% New in Q1 CQUIN %age achievement Sutton Community Services 100% 100% 100% 100% New in Q1 5. To deliver the Trust's clinical and research strategy; to better meet the needs of patients and commissioners Clinical and Research Strategy Q1 (Apr-Jun 17/18) Q4 (Jan-Mar 16/17) Q3 (Oct-Dec 16/17) Q2 (Jul-Sep 16/17) Total NHS referrals Total PP referrals RMH Patients recruited to 100K Genome Project Q1 (Apr-Jun 16/17) Efficient clinical models NHS Average (mean) Elective LoS NHS Non-Elective Admissions as %age of all NHS Admissions 29.85% 26.97% 25.01% 25.08% 23.72% Q4 (Jan-Mar 16/17) Q3 (Oct-Dec 16/17) Q3 (Jul-Sep 16/17) Q1 (Apr-Jun 16/17) Q4 (Jan-Mar 15/16) Research (1 QUARTER IN ARREARS) 70 day target (for externally sponsored trials) NIHR Adjusted figure (excl delays attributed to sponsor/neither sponsor or trust) 63.6% 90.5% 94.3% 97.9% 96.4% Accrual to target (1Q arrears) - National definition % of closed commercial interventional trials meeting contracted recruitment target (excluding trials that 47.8% 45.7% 42.6% 43.6% New in Q1 had no set target) No. of 1st UK patients in previous 12 months 1 New in Q4 No. of 1st European patients in previous 12 months New in Q1 Patients on interventional trials as %age of first treatments 8.6% 8.1% 9.3% 9.7% New in Q1 Trials lead by RMH as %age of interventional trials with RMH involvement 57.0% 54.0% 54.0% 42.6% New in Q1 6. To recruit, retain and develop a high performing workforce to deliver high quality care and the wider strategy of the Trust Workforce Q1 (Apr-Jun 17/18) Q4 (Jan-Mar 16/17) Q3 (Oct-Dec 16/17) Q2 (Jul-Sep 16/17) Q1 (Apr-Jun 16/17) Workforce productivity Vacancy rate 11.30% 8.80% 8.60% 9.30% 6.60% Staff turnover rate 15.10% 15.20% 15.10% 14.60% 15.10% Sickness rate 2.70% 3.50% 2.80% 2.60% 2.90% Quality & development Consultant appraisal (number with current appraisal) 98.00% 96.00% 94.00% 92.00% 91.70% Appraisal & PDP rate 85.70% 86.90% 83.00% 80.50% 82.40% Completed induction (new measure) 84.20% 80.80% 72.00% 76.00% 84.50% Statutory and Mandatory Staff Training 89.00% 87.80% 86.40% 91.20% 90.40% Page 2 of 2

61 APPENDIX B 62 Day GP Urgent Referrals by Category 6

62 APPENDIX C 62 Day Wait for First Treatment (GP Urgent). Performance by Tumour Type (prior to reallocation). Please note that the RAG ratings below are designed to be used at Trust level rather than tumour level and are only shown below as a guide. Tumour site Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17 Q1 17/18 Breast 96.7% 89.6% 98.3% 96.5% 96.7% Gynaecological 57.1% 51.7% 66.7% 60.9% 70.0% Haematological (excl. Acute Leukaemia) 85.7% 55.6% 75.0% 42.9% 53.3% Head & Neck 50.0% 45.0% 67.9% 27.8% 33.3% Lower GI 75.7% 83.3% 70.8% 73.7% 85.2% Lung 71.1% 85.3% 71.4% 64.0% 75.0% Other/Unknown 71.4% 66.7% 50% 100% 72.7% Sarcoma 57.6% 66.7% 72.2% 64.0% 66.0% Skin 71.4% 83.3% 88.0% 91.7% 80.0% Testicular N/A 100.0% 100% 100% 100% Upper GI 76.5% 64.3% 54.5% 63.0% 67.7% Urological 45.8% 60.4% 67.7% 66.7% 51.9% 7

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64 COUNCIL OF GOVERNOR PAPER SUMMARY SHEET Date of Meeting: 26 th September 2017 Title of Document: Board Sub-Committees Report Agenda item Item 7. To be presented by Ian Farmer, Chair of Audit and Finance Committee Professor Dame Janet Husband, Chair of Quality, Assurance and Risk Committee Background The NHS Act 2006 as amended by the Health and Social Care Act 2012 specifies that it is the duty of the Council of Governors to hold the Non-Executive Directors (NEDs) to account for the performance of the Board. This requires Governors to scrutinise how well the Board is working, challenge the Board in respect of its effectiveness, and ask the Board to demonstrate that it has sufficient Quality Assurance in respect of the overall performance of the Trust. Executive Summary The performance of the Board sub-committees is an important consideration for Governors to hold the NEDs to account for the performance of the Board. The purpose of this Report is to set out how the Board sub-committees have met their terms of reference while highlighting key issues the Committees have considered for the year of 2016/17. Recommendations The Council is asked to note and discuss the Report. Author: Ian Farmer, Chair of Audit and Finance Committee / Professor Dame Janet Husband, Chair of Quality, Assurance and Risk Committee Contact Number or Date: 31 st August 2017

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66 2016/17 Audit & Finance Committee / Quality, Assurance & Risk Committee Report 1. Introduction The performance of the Board sub-committees is an important consideration for Governors to hold the NEDs to account for the performance of the Board. The purpose of this report is to set out how the Board sub-committees have met their terms of reference while highlighting key issues the Committees have considered for the year of 2016/ Key Issues Key Issues Key Points Audit and Finance Committee 1. Performance of the External Auditor Discussion on the results of the 2015/16 audit and Letter of Representation. The Trust s External Auditors, Deloitte LLP, presented a report on the Trust s Quality Accounts Report 2015/16 at the May 2016 meeting. The Committee members held a closed session with Deloitte in September 2016 following good practice guidelines. The Annual External Audit Plan 2016/17 was presented by the Trust s External Auditors, Deloitte LLP, and approved at the September 2016 meeting. 2. Annual Report and Accounts The Committee considered the Annual Accounts and took specific note on the following areas: o Discussions on levels of income as they relate to patient activity; o Further Income opportunities and the Trust s overall financial position; o The Trust s asset valuation processes and impairment charges; o The significant increase in Private Care income and relevant bad debt provisions; o The Trust s overall operational costs, including staffing costs and charitable expenditure. The Committee also reviewed the Quality Accounts and local quality indicator in conjunction with Quality, Assurance and Risk Committee. 3. Performance of the Internal Auditor The Committee reviewed eight reports during the year relating to 2016/17 audit plan. These included: o Patient safety data; o Radiology; o Managing Partnerships; o Response to Carter; o Clinical Audit; o Financial Management; o Financial Controls; o Information Governance. The Committee received a technical update from 1

67 KPMG at each of its meetings. The Committee held a closed session with KPMG in April 2017 following good practice guidelines. 4. Anti-Fraud A number of investigations took place during the year and the Committee received updates and reports on each area. None of the cases investigated were material in nature. 5. Internal Control and Risk Management The Committee reviewed a number of other areas for assurance purposes. These included: o Efficiency Programme; o Financial Performance; o Losses, Compensation and Waivers; o Cancer Vanguard funding; o AFC Self-Assessment; o Reference Costs; o Internal Audit & Anti-Fraud Tender; o Private Care Strategy Business Case; o o Cyber Security; Review of Business Conduct Policy and Non-Audit Services Policy. 6. Terms of Reference review The AFC Terms of Reference was presented at the September 2016 meeting for the Committee s Annual Review and approved. Quality, Assurance and Risk Committee 1. Terms of Reference review The Terms of Reference is currently under review and due to be discussed at the September 2017 meeting. 2. Quality related mandatory inspections Annual staff survey: The Trust had a positive survey report with staff rating the Trust as a good place to work and receive health care. The national cancer patient experience survey runs annually and covers all acute trusts which provide cancer care. The Trust has identified areas of the survey results for action. 3.Risk register The change in a number of risks highlighted from the risk register were discussed, including those relating to the Cancer Vanguard, the Trust s IT Services, and Research Strategy. Others included the risk associated with future funding of Biomedical Research Centre, and recruitment and retention of specialist nursing and theatre staff. 4. Board Assurance Framework The Committee reviewed the Board Assurance Framework (BAF). It noted that the BAF had been reviewed by the Trust s internal auditors, KPMG LLP, and updated to reflect the Trust s five year Strategic Plan 2014/ /19 which in turn takes into account the NHS Five Year Forward View. Other issues included the strengthening of academic and research work and the on-going efforts to finalise a Joint Working Agreement with the Institute for Cancer Research, and Cyber Security. 5. Face to face frontline staff reports Attendance by frontline staff including Symptom Control and Palliative Care team; Sisters, Matrons, Advanced Nurse Practitioners and Nurse Consultants, Community Services staff, and Academic Biochemistry staff. 6. Monthly and annual quality accounts The quality accounts were reviewed. Areas monitored through the Quality Accounts include rates of healthcare associated infections, rates of incidents resulting in serious harm or death, monitoring of community acquired pressure ulcers, chemotherapy waiting times, nurse staffing levels 2

68 and medication errors. 7. Emergency and fire planning Preparedness for emergencies and fire was scrutinised. 8. Research governance Governance structures between the Trust and the Institute of Cancer Research are now integrated and a new Joint Executive Group has been established bringing together members of the Leadership Teams of both organisations. 9. Annual clinical audit forward plan The Trust s clinical audit programme was reviewed. The trust has undertaken a comprehensive programme of clinical audit across many healthcare discplines. The plan includes all mandatory (e.g. National; CQUINs); internal must do audits or audits related to local interest/priorities or clinical innovation. 10. Complaints monitoring Selected complaints and complaints summaries were monitored as indicators of quality of care. The Committee reviews Serious Incident reports and Complaints reports at each meeting. Sample complaint letters and Trust responses are also reviewed at each meeting. 11. Safeguarding vulnerable adults and children Trust arrangements for protecting vulnerable adults and children were discussed at each meeting. No issues were identified. 12. Integrated Governance Monitoring Report The Integrated Governance Monitoring Report, describing the governance of care, research and infrastructure, assured QAR of the quality of care provided by the Trust. 3. Coordination between Audit & Finance Committee and Quality, Assurance & Risk Committee The Chair of the Audit and Finance Committee (AFC) and Quality, Assurance and Risk Committee (QAR) have discussed priorities for the respective Committees and the use of internal audit resources to provide assurance in key risk areas. In addition, forward Agendas and Minutes are regularly provided to each Committee and key items from both Committees are reported at each meeting as a standing item. 4. Conclusion The Chairs of each Committee confirm the following: The Terms of Reference for the Audit & Finance Committee have been reviewed and approved during 2016/17; the Terms of Reference for the Quality, Assurance and Risk Committee are currently being reviewed by the Chair of the Committee and the Chief Nurse and are due to be discussed at the September 2017 QAR meeting. The Committee has adhered to the terms outlined in its Terms of Reference as well as received good attendance from its members; The performance of the external auditor is deemed satisfactory by the Audit and Finance Committee and Governors are notified of the retirement by rotation of the audit partner and the appointment of a new one; There are no major concerns or issues to raise with the Governors with respect to the performance of the Trust. The Council of Governors is asked to note the report. 3

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70 COUNCIL OF GOVERNOR PAPER SUMMARY SHEET Date of Meeting: Agenda item 26 September 2017 Title of Document: Auditor s Report- Annual Report and Accounts To be presented by Jonathan Gooding, Deloitte LLP Executive Summary Jonathan Gooding from Deloitte LLP, will attend for this item and present the auditor s report on the Trust s Annual Report and Accounts for the year ended 31 st March Governors will have received their copy of the Annual Report and Accounts already. Recommendations Governors are asked to note the auditor s report and discuss accordingly. Author: Deloitte LLP Contact Number or PA 2151 Date: 1 st September

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72 The Royal Marsden NHS Foundation Trust Final report to the Audit Committee on the audit for the year ending 31 March May 2017 Deloitte confidential: Public sector For approved external use

73 Contents Our final report Introduction 3 Audit of the financial statements - Significant risks 4 Use of resources 10 Control observations 12 Purpose of our report and responsibility statement 20 Appendices A. Audit adjustments 22 B. Fraud responsibilities and representations 23 C. Independence and fees 24 D. Draft management representation letter 26 E. Enhanced audit report - draft wording 32 2 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

74 Introduction The key messages in this report Audit quality is our number one priority. We plan our audit to focus on audit quality and have set the following audit quality objectives for this audit: A robust challenge of the key judgements taken in the preparation of the financial statements. A strong understanding of your internal control environment. A well planned and delivered audit that raises findings early with those charged with governance. We have pleasure in presenting our final report to the Audit Committee for the 2016/17 audit. We would like to draw your attention to the key messages of this paper: Status of the audit Audit of the financial statements Use of resources Quality report Other reporting responsibilities Our audit is now complete. We have set out our work on the significant risks and our findings in the next section. Our risk assessment has not changed from our audit plan and the significant risks that we identified and have tested related to revenue recognition, valuation of the Trust s estate and management override. The materiality that we used in the current year was 7.38m which was determined on the basis of approximately 2% of the Trust s total revenue recognised in the year to 2016/17. Materiality has increased from 7.20m, as set out in our audit plan, to 7.38m. Materiality was initially calculated on planned income of 361m for the year ending 31 March The Trust s actual income for the year was 371m. Details of our work and findings in respect of these risks are set out within section 1 of this report. We have issued an unmodified audit opinion, a draft of which is included in Appendix E of this report. We are not reporting any exceptions to our Use of Resources conclusion and did not identify any significant risks in this area. Further details of our work are set out in Section 2. We will issue an unqualified limited assurance opinion in relation to the quality report. The findings from our work are set out in our report to the Council of Governors which will be circulated to you with this report. We have not modified our audit report in relation to other matters we are required to report on. In Appendix A, we have set out a list of adjustments to the accounts that we identified through the audit. None of these adjustments were material. In section 3, we have provided an update on the implementation of prior year recommendations together with a list of our current year recommendations for control improvements. We have completed our assessment of the consistency of the FTC schedules with the audited financial statements. 3 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

75 Section 1 Audit of the financial statements - significant risks 4 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

76 NHS revenue and provisions Income from commissioner requested services: 195.1m (2016: 214.1m) NHS Revenue receivables at 31 March: 21.6m (2016: 16.3m) STF accrued income at 31 March: 5m (2016: 0m) Risk identified Deloitte response The risk of fraud in revenue recognition is a presumed risk under International Standards on Auditing. For our NHS Foundation Trust clients, we typically specify this significant risk as the risk that a Trust has recorded revenue that is not valid, accurate or valued appropriately. As with the majority of our NHS Foundation Trust audit clients, for The Trust we consider this risk to be greater (and therefore identified as a significant risk) for the NHS revenue that has been recognised in the year but that is yet to be settled by Commissioners. This includes accrued income, partially completed spells (patient episodes that are ongoing at year-end), Q4 over-performance (including the estimation of uncoded activity), together with deductions for contract penalties. In 2016/17, this includes Sustainability and Transformation Funding (STF) which is dependent on the Trust meeting certain financial performance and access standard requirements. These elements of unsettled revenue can involve management judgement and estimation, including management consideration of any unresolved commissioner challenges. We have: Carried out tests of the design and implementation of controls over the billing of income under payment by results. Considered the Trust s performance against its control total and the management estimates that impact that control total and therefore the eligibility of the Trust in recognising the STF funding. We have also reviewed the Trust s correspondence with NHSI, regarding the STF, to validate the amounts of STF recognised in the Financial Statements Carried out tests of the design and implementation of controls over the identification of disputes and other differences with the counterparty s position and the assessment of the amount at which income and receivables are recorded in these cases. Selected a sample of unsettled NHS debt (including accrued income) and traced to after date cash. Where cash had not been received, we agreed to documentation which supported that the debt was valid, including contracts and activity reports. There were no exceptions from this testing. Selected a sample and obtained evidence which supports the position taken by management. We also selected a sample of amounts against which a provision had been made and obtained evidence to support that this debt is unlikely to be recovered. 5 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

77 NHS revenue and provisions (continued) Deloitte response continued Inclusion in our report and finding Selected a sample of differences between the amounts that the Trust reports as receivable from commissioners, and the amounts that commissioners report that they owe the Trust, in the agreement of balances ( mismatch ) report. For this sample, we sought explanations from management for the variances together with documentary evidence to corroborate those explanations. It is common to see variances on these reports for Trusts, but we note that the Trust s total net variance is immaterial. Again, this gives some further assurance that income and receivables have been recorded at an appropriate amount. The Trust considered the adequacy of its bad debt provision policy, including consideration of the prior year provision and historical recovery of debt. However, we were not able to wholly test the prior year accuracy of the provision for impairment of NHS receivables, because the Trust is currently not able to provide us with analysis on how much prior year debt was paid, written off and credit noted. The Trust has provided us with analysis in regards to how much prior year debt was paid and written off, and has provided the total amount of credit notes raised during the year but, due to system limitations, is not able to demonstrate how much prior year debt was credit noted. We have therefore raised a recommendation, on page 14, that the Trust introduces a system process to capture this information as it will assist ion the Trust s assessment of the appropriateness of the provision policy. We were able to conclude, based on the other procedures that we performed, that the Trust s provision estimate is within an acceptable range. We have included this risk in our audit report because it had a significant effect upon our overall audit strategy, allocation of resources, and direction of the efforts of the team (which is the criteria we consider when assessing whether a risk should form part of our audit opinion). Our draft audit opinion is set out in Appendix E. We have not identified any material audit adjustments in relation to this significant risk. 6 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

78 m Property valuations Risk identified The Trust is required to hold property assets within Property, Plant and Equipment at valuation, which will usually be on a modern equivalent use basis. As detailed in our Audit Plan, valuations are by nature significant estimates which are based on specialist and management assumptions and which can be subject to material changes in value. The Trust has had an independent valuation carried out by Montagu Evans for the purposes of the 31 March 2017 financial statements. The Trust has made a number of changes to its valuation assumptions this year, including: In conjunction with their Valuer, revisiting the floor areas assumed as required to reprovide an asset with equivalent service potential as a Modern Equivalent Asset; categorisation of assets as specialised or non-specialised ; valuation of non specialised non-medical elements at each site by, reference to Existing Use Value; and reducing the assumed land area by infilling void areas, excluding land relating to assets deemed non specialised and excluding all onsite car parking at the Chelsea site. Key judgements The Trust s revaluation has decreased land values by 15.2m (52.43%), and buildings by 32.9m (21.94%). The impact of this will be to decrease PDC dividends payable in the coming year by 1.6m. Movement in property valuations The chart below shows the movements in the period. There has been a 28.5m impairment charge to the Statement of Comprehensive Income and a 29.3m decrease in the revaluation reserve leaving a revaluation reserve of 8m as at 31 st March m of the Trust s property assets have no associated revaluation reserve, meaning that any impairment to those assets would be recognised directly in the surplus for the year, rather than in comprehensive income March 2016 Depreciation Impairment Revaluation gain 31 March 2017 Source: Management information 7 Deloitte Confidential: Public Sector 2017 Deloitte LLP. All rights reserved.

79 Property valuations (continued) Deloitte response We engaged our property specialists Deloitte Real Estate to review the assumptions and methodology used to value the estate. We have used their findings to challenge management s assumptions. The Depreciated Replacement Cost method, used for valuing most of the Trust s properties in line with other NHS bodies, is particularly judgemental. We presented to the Audit Committee, in our interim paper, the key assumptions used in the valuation and our challenges of those key assumptions. We have concluded that the valuation is towards the prudent (low) end of an acceptable range and we have asked the Trust to provide a representation from management stating that they consider the assumptions made in the valuation to be reasonable, appropriate and to reflect a realistic hypothetical scenario for the purposes of the modern equivalent asset valuation. Please see Appendix D for this representation. Inclusion in our report and finding We have included this risk in our audit report because it had a significant effect upon our overall audit strategy, allocation of resources, and direction of the efforts of the team. As stated above, we have included the comment that we consider the Trust s valuation to be at the more prudent end of the acceptable range. 8 Deloitte Confidential: Public Sector 2017 Deloitte LLP. All rights reserved.

80 Management override of controls We did not identify any evidence of management override Issue Our procedures Inclusion in our report and finding In accordance with ISA 240 (UK and Ireland) management override is a significant risk. This risk area includes the potential for management to use their judgement to influence the financial statements as well as the potential to override the Trust s controls for specific transactions. There continues to be pressure on managers across the NHS to deliver to control totals. Specific areas of work are: Journals - We have made inquiries of individuals involved in the financial reporting process about inappropriate or unusual activity relating to the processing of journal entries and other adjustments. We have used data analytics tools to identify journals for testing based upon their potential audit interest. Investigation of these items did not identify indicators of management override. Accounting estimates - In addition to management estimates made in relation to the recognition of NHS income, discussed above, we have considered the results of our testing across other areas which involve estimates, including provisions for liabilities and charges, bad debt provisions, fixed asset valuation, and accruals, together with judgements made on the capitalisation of expenditure, to tested the basis for other estimates used in the financial statements and findings. We did not identify any significant bias across these estimates or areas of significant changes in the estimation process. Significant transactions - We did not identify any significant transactions outside the normal course of business or transactions where the business rationale was not clear. We have not referred to this risk in our auditor s report because it did not have a significant effect upon our overall audit strategy, allocation of resources, or direction of the efforts of the team. 9 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

81 Section 2 Use of resources 10 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

82 Use of resources Value for Money We are required to satisfy ourselves that the Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. VfM is assessed against the following criterion, and three sub-criteria (informed decision making, sustainable resource deployment, and working with partners and other third parties): In all significant respects, the audited body had proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. Our work takes account of the Annual Governance Statement and the findings of regulators. We are required to perform a risk assessment through the course of our audit to identify whether there are any significant risks to our VfM conclusion, and perform further testing where risks are identified. Overall Financial & Quality Performance As part of our risk assessment, we have considered how the Trust s performance compares to plan and prior year: Actual 2016/17 Plan 2016/17 Variance Prior year 2015/16 Plan 2017/18 Surplus/ (Deficit) ( 21.2m)* 2.4m % ( 0.8m) 5.3m EBITDA margin 5.4% 4.1% % 4.4% 5.1% CIP target and identified to date Achieved Achieved - 9.3m 13.1m Single Oversight Framework segmentation Breaches of NHSI performance targets 62 cancer day waits - None CQC report conclusions Good Good * Note that deficit of ( 21.2m) is after a 28.5m impairment due to a full revaluation being carried out on the Trust s estate, 5.9m of donated capital income, 3.9m depreciation on donated assets and 164k loss on disposal of donated assets. When these items are removed the Trust s surplus for the year would be 5.6m. Risk Assessment work performed As part of our risk assessment, we have considered information from: a combination of: Interviews with the Trust s Chief Executive and Chief Financial Officer and attendance at all Audit Committee meetings where relevant matters have been discussed; review of the Trust s draft Annual Governance Statement; consideration of issues identified through our other audit and assurance work; consideration of the Trust s results, including benchmarking of actual performance (including on CIP delivery as summarised below) and the 2017/18 Annual Plan; review of the Care Quality Commission s report on the Trust; review of NHSI s risk ratings; benchmarking of the Trust s performance of which we provided the Audit Committee with a summary in our interim paper. Conclusion We have not identified any specific risks in respect of Value for Money 11 Deloitte Confidential: Public Sector 2017 Deloitte LLP. All rights reserved.

83 Section 3 Control observations 12 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

84 Recommendations from the audit Current year recommendations We have provided these recommendations to management to review. At the date of this report, no responses have been received, but this reflects the short time period since start of the final audit and the very limited time available for management to respond prior to issuing this report to the committee. We recommend that management prepares a response to these recommendations and presents that to the next audit committee meeting. Management response and action plan Reconciliation of bank accounts Observation: The Trust currently does not include all cash receipted on 31 st March 2017 as additive items in their bank reconciliation as the cash books are closed at 4pm. There were 38k of items that were excluded from the year end bank reconciliation. See comment above. Recommendation: We recommend that the Trust includes these items in their bank reconciliation. Paediatrics Invoices Observation: The Trust has 3.6m of Paediatrics invoices due from NHS England in debtors of which 1.6m were raised during 2015/16. The Trust has accounted for them by debiting debtors and crediting accrued income which has the effect of overstating both balances but total current assets are correct. See comment above. Recommendation: We recommend that the Trust resolves this matter with NHS England and accounts for the resolution accordingly. 13 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

85 Recommendations from the audit (continued) Current year recommendations (continued) Management response and action plan Journals segregation of duties Observation: There is one journal in relation to the posting of the revaluation which was posted and approved by the same user on Oracle. We understand as per the Trust s policy that users are allowed to approve their own journals if the individual postings which total the journal value are below their allocated approval limit. See comment on page 13. Recommendation: We recommend that the Trust revisits their journal approval policy and ensures it has effective segregation of duties controls within Oracle. Historical analysis of the bad debt provision Observation: The Trust considered the adequacy of its bad debt provision policy, including consideration of the prior year provision and historical recovery of debt. However, we were not able to wholly test the prior year accuracy of the provision for impairment of NHS receivables, because the Trust is currently not able to provide us with analysis on how much prior year debt was paid, written off and credit noted. The Trust has provided us with analysis in regards to how much prior year debt was paid and written off, and has provided the total amount of credit notes raised during the year but, due to system limitations, is not able to demonstrate how much prior year debt was credit noted. We have therefore raised a recommendation on page 19 that the Trust introduces a system process to capture this information as it will assist ion the Trust s assessment of the appropriateness of the provision policy. We were able to conclude, based on the other procedures that we performed, that the Trust s provision estimate is within an acceptable range. Recommendation: We recommend that the Trust introduces a system process which enables it to analyse the amount of cash received, credit notes raised and amounts written off of prior year debt to assess whether the prior year provision applied was appropriate. This should also be used to inform the relevant disclosure in the note to the accounts. We recommend that this information is used by the Trust to reassess the adequacy of the provision policy for 2017/18 and that this process is conducted on an annual basis. See comment on page Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

86 Recommendations from the audit (continued) Current year recommendations (continued) Management response and action plan Third Party Assurance Observation: The Trust is not provided with a Service Auditor Report by the third party SPHERE with regard to their involvement with the Trust s IT systems. The failure to gain assurance over IT controls that are the responsibility of the Third Party increases the risk of unauthorised activity or amendments of information by the third party beyond the remit of their agreement. See comment on page 13. Recommendation: We recommend that a formal review of the Third Party s Service Auditor Report is conducted on an annual basis. This review should address any issues raised, ensure the Third Party s operations are satisfactory and they meet Trust/regulatory requirements. User Access Reviews Observation: We understand that there are no periodic reviews of the appropriateness of user access rights on any of the in scope applications (Compucare, HIS, Data Warehouse, ESR, Windows AD and SBS) thereby increasing the risk that Management fail to detect where user access rights are in excess of expected access rights or where a user has access rights that override an effective segregation of duties. In turn, this increases the risk that users are able to create inappropriate transactions or inappropriately amend financial data within the application. Recommendation: We recommend that the Trust establishes a periodic review of the appropriateness of user access across their applications. See comment on page Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

87 Recommendations from the audit Current year recommendations We have provided these recommendations to management and await a response. At the date of this report, no responses have been received, but this reflects the short time period since start of the final audit and the very limited time available for management to respond prior to issuing this report to the committee. We recommend that management prepares a response to these recommendations and presents that to the next audit committee meeting. Management response and action plan Developer Segregation of Duties Observation: We understand that there is a lack of segregation of duties within the development team that manages in-house changes to Windows, HIS and Data Warehouse. This increases the risk that untested and/or unapproved changes are implemented onto the systems which have an unknown impact. Furthermore, this could lead to applications/systems operating in a way not originally intended by management. See comment above. Recommendation: We recommend that system-enforced segregation of duties is implemented to prevent individuals being able to develop and promote changes to the live environment. 16 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

88 Recommendations from the audit Status of prior year recommendations In this section we comment on the status of Trust actions taken in response to observations set out in our reports to the Audit Committee in May Deloitte comments on progress Reconciliation of year end cash balance Recommendation:We note that for your Private Patients bank accounts the year end bank balance is understated by 30k due to an error made in the bank reconciliation. We recommend that accurate bank reconciliations are performed on a monthly basis, reviewed and reconciling items followed up in a timely manner. Bank reconciliations are performed by the Trust, however, we have reviewed the commercial bank accounts as at 31 st March 2017 and have raised a finding regarding cash receipted on 31 st March but not included in the bank reconciliation. Miscalculation of prepayments Recommendation: During our testing of prepayments we found firstly that the Trust had been calculating prepayments using months instead of days and secondly using out of date information to calculate the prepayment. We recommend that the Trust ensure that prepayments are accurately calculated and that they use the most recent supporting documentation to calculate the prepayment. We have reviewed a schedule of prepayments and note that they have been prepared using the most up to date information available at the time. Accrued Income Recommendation: We have noted a 604k classification error in accrued income which are accruals balances. We recommend that accurate reconciliations of ledger balances to the trial balance are performed on a monthly basis and these are reviewed to an appropriate level. At the time of writing this paper we are progressing with our testing of Accrued Income. We will therefore orally update the audit committee as to our progress. 17 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

89 Recommendations from the audit (continued) Status of prior year recommendations (continued) Deloitte comments on progress Capitalisation of Friends of Marsden donated assets Recommendation: Historically the Trust has been recognising donated asset income from the charity Friends of Marsden but not the fixed asset which has been purchased with this income. The Trust has undertaken a review which estimates there have been 300k of non capitalised donated assets in the 2015/16 financial year and 2014/15 financial year. We recommend that the Trust develops a process where these assets are flagged and recognised on the balance sheet. We have not found any instances of this during our testing of donated asset income in the current year. Capital items in expenditure Recommendation: We identified two capital items during our operating expenses testing which amount to 100k which are capital in nature. We recommend that the Trust performs a review of operating expenses for items of a capital nature on a quarterly basis. We have not found any instances of this during our operating expenditure testing in the current year. Delayed capitalisation of additions Recommendation: During our capital expenditure testing we have identified 2.8m additions which were capitalised after their operational date. We recommend that the Trust improves communication between estates and the finance team to ensure that assets are capitalised as soon as they become operational. We have not noted any instances of this during our fixed asset testing. 18 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

90 Recommendations from the audit (continued) Status of prior year recommendations (continued) Deloitte comments on progress GRNI accrual Recommendation:We have performed a review of the aging of the GRNI accrual and have noted that there is 1.6m of items that are older than a year. We note also that the GRNI has doubled in the current year to 8m. We recommend the Trust introduces a month end process which investigates the ageing of the GRNI accrual. We have reviewed the GRNI accrual and note that there are 380k of items that are older than a year which is a 1.3m decrease on prior year. Post revaluation consideration of quarter four capital expenditure Recommendation: During the audit we flagged to the Trust that there were 4.1m of capital additions to post revaluation Land and Buildings and that the Trust would need to engage its Valuer to assess whether these additions did add value or should be subject to an impairment. Going forward we recommend that if the Trust undergoes a valuation at 31 December in future years they should engage in this process as part of their year end procedures The Trust engaged Montagu Evans to confirm that their quarter 4 additions were not material and we have reviewed this correspondence. Private Patient debtors Recommendation: Private Patient debtors have increased to 24m from 16m in the prior year and we note that debtor days have increased across the board especially for Embassy debtors where it has increased from 165 days in the prior year to 245 days in the current year. We recommend that the Trust reassess their cash-flow forecast to take account of the decline in private patient s recoverability and assess the potential impact this will have upon the Trust. The Trust have confirmed that this has been implemented but we are awaiting evidence regarding its implementation. 19 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

91 Purpose of our report and responsibility statement Our report is designed to help you meet your governance duties What we report Our report is designed to help the Audit Committee and the Board discharge their governance duties. It also represents one way in which we fulfil our obligations under ISA 260 (UK and Ireland) to communicate with you regarding your oversight of the financial reporting process and your governance requirements. Our report includes: Results of our work on key audit judgements and our observations on the quality of your Annual Report. Other insights we have identified from our audit and in following our audit planning report. What we don t report As you will be aware, our audit is not designed to identify all matters that may be relevant to the Audit Committee. Also, there will be further information you need to discharge your governance responsibilities, such as matters reported on by management or by other specialist advisers. Finally, the views on internal controls and business risk assessment in our final report should not be taken as comprehensive or as an opinion on effectiveness since they will be based solely on the audit procedures performed in the audit of the financial statements and the other procedures performed in fulfilling our audit plan. The scope of our work Our observations are developed in the context of our audit of the financial statements. We described the scope of our work in our audit plan and the supplementary Briefing on audit matters circulated to you on August The Insight and Additional assurance findings sections of this report provide details of additional work we have performed alongside the audit of the financial statements. We welcome the opportunity to discuss our report with you and receive your feedback. Deloitte LLP Chartered Accountants St Albans 26 May 2017 This report has been prepared for the Audit Committee, as a body, and we therefore accept responsibility to you alone for its contents. We accept no duty, responsibility or liability to any other parties, since this report has not been prepared, and is not intended, for any other purpose. Except where required by law or regulation, it should not be made available to any other parties without our prior written consent. 20 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

92 Appendices 21 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

93 Appendix A - Audit adjustments Unadjusted misstatements The following uncorrected misstatements have been identified up to the date of this report which we request that you ask management to correct as required by International Standards on Auditing (UK and Ireland). Uncorrected misstatements increase/(decrease) the deficit for the year by 000, increase/(decrease) net assets by 000 and increase/(decrease) Tax Payers Equity by 000. Misstatements identified in current year Debit/ (credit) income statement 000 Debit/ (credit) in net assets 000 Paediatrics invoices CR NHS receivables [1] (3,700) Paediatrics invoices DR accrued income [2] 3,700 Debit/ (credit) prior year Tax Payers Equity 000 Debit/ (credit) in revenue 000 If applicable, control deficiency identified Total Disclosures We have identified some omissions and deficiencies in disclosures across the annual report and financial statements through the audit. We have communicated these points to management and the Trust has amended all points of any significance in the final annual report and accounts. 22 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

94 Appendix B - Fraud responsibilities and representations Responsibilities explained Responsibilities: The primary responsibility for the prevention and detection of fraud rests with management and those charged with governance, including establishing and maintaining internal controls over the reliability of financial reporting, effectiveness and efficiency of operations and compliance with applicable laws and regulations. As auditors, we obtain reasonable, but not absolute, assurance that the financial statements as a whole are free from material misstatement, whether caused by fraud or error. Audit work performed: In our planning we identified the risk of fraud in NHS revenue recognition and management override of controls as a key audit risk for your organisation. During course of our audit, we have had discussions with management and those charged with governance. In addition, we have reviewed management s own documented procedures regarding fraud and error in the financial statements Required representations: We have asked the Board to confirm in writing that you have disclosed to us the results of your own assessment of the risk that the financial statements may be materially misstated as a result of fraud and that you are not aware of any fraud or suspected that affects the entity. We have also asked the Board to confirm in writing their responsibility for the design, implementation and maintenance of internal control to prevent and detect fraud and error. 23 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

95 Appendix C - Independence and fees Independence confirmation Fees Non-audit services Relationships We confirm that we comply with APB Ethical Standards for Auditors and that, in our professional judgement and our objectivity is not compromised. No non-audit fees, with the exception of our fees for our related services in respect of the Trust s quality accounts, were charged by Deloitte during 2016/17. We continue to review our independence and ensure that appropriate safeguards are in place including, but not limited to, the rotation of senior partners and professional staff and the involvement of additional partners and professional staff to carry out reviews of the work performed and to otherwise advise as necessary. There are no relationships (other than the provision of non-audit services which are covered above) that we consider may reasonably be thought to bear on our objectivity and independence, together with the related safeguards that are in place. 24 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

96 Appendix C - Independence and fees The professional fees expected to be charged by Deloitte in the period from 1 April 2016 to date are as follows: Audit of Trust: Annual report and financial statements, VFM procedures and reporting to NAO on the FTCs Current year 55,900 Total audit fees 55,900 Procedures in respect of the Trust s quality report 20,400 Total non-audit services 20,400 Total fees 76, Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

97 Appendix D Draft management representation letter Representations requested from management Dear Sirs, This representation letter is provided in connection with your audit of the annual financial statements and consolidation schedules (together the financial statements ) of The Royal Marsden NHS Foundation Trust for the year ended 31 March 2017 for the purpose of expressing an opinion as to whether the financial statements give a true and fair view of the financial position of The Royal Marsden NHS Foundation Trust as of 31 March 2017 and of the results of its operations, other recognised gains and losses and its cash flows for the year then ended in accordance with the directions given by NHSI - Independent Regulator of NHS Foundation Trusts in accordance with paragraph 25 of Schedule 7 of the National Health Service Act It is also provided in connection with your limited assurance report on the quality report for the year ended 31 March As Accounting Officer and on behalf of the board of directors, I confirm, to the best of my knowledge and belief, the following representations: Financial statements 1. I understand and have fulfilled my responsibilities for the preparation of the financial statements in accordance with the directions given by Monitor - Independent Regulator of NHS Foundation Trusts in accordance with paragraph 25 of Schedule 7 of the National Health Service Act 2006 which give a true and fair view, as set out in the terms of the audit engagement letter. 2. Significant assumptions used by us in making accounting estimates, including those measured at fair value, are reasonable. 3. Related party relationships and transactions have been appropriately accounted for and disclosed in accordance with the requirements of IAS24 Related party disclosures 4. All events subsequent to the date of the financial statements and for which the applicable financial reporting framework requires adjustment of or disclosure have been adjusted or disclosed. 5. The effects of uncorrected misstatements and disclosure deficiencies are immaterial, both individually and in aggregate, to the financial statements as a whole. A list of the uncorrected misstatements and disclosure deficiencies is detailed in the appendix to this letter. 6. We confirm that the financial statements have been prepared on the going concern basis. We do not intend to liquidate the Trust or cease trading as we consider we have realistic alternatives to doing so. We consider there to be a material uncertainty which may cast significant doubt as to the Trust's ability to continue as a going concern and therefore it may be unable to realise its assets and discharge its liabilities in the normal course of business. We confirm the completeness of the information provided regarding events and conditions relating to going concern at the date of approval of the financial statements, including our plans for future actions. 26 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

98 Appendix D Draft management representation letter 7. We confirm that, in respect of going concern, we have disclosed in Note 1 Section 1 to the financial statements the following: the nature of the concerns; all pertinent facts; all assumptions we have adopted; and our plans for resolving the matter and the feasibility of those plans. 8. We confirm that no significant property, plant or equipment have been sold or disposed of during the year other than those listed in the fixed asset register. 9. We acknowledge our responsibility for ensuring the Trust has put in place arrangements for securing economy, efficiency and effectiveness in its use of resources. 10. With the exception of matters disclosed in our annual governance statement, we are not aware of any other deficiencies in the Trust s arrangements to secure economy, efficiency and effectiveness in its use of resources. 11. With respect to the revaluation of properties in accordance with the DH Group Accounting Manual: measurement processes used are in accordance with the required standards and have been applied consistently, including related assumptions and models; the assumptions appropriately reflect our intent and ability to carry out specific course of action on behalf of the entity where relevant to the accounting estimates and disclosures; the disclosures are complete and appropriate; and there have been no subsequent events that require adjustment to the valuations and disclosures in the financial statements. 27 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

99 Appendix D Draft management representation letter 12. Significant assumptions made by us in regards to the revaluation of the Trust s estate are reasonable, appropriate, and reflect a realistic hypothetical scenario for the purposes of the modern equivalent asset valuation, including: in the modern equivalent asset valuation of the Chelsea land: the exclusion of redundant accommodation, movement of Institute of Cancer Research staff from Chelsea to Sutton, exclusion of car parking, infilling between the buildings and the hypothetical relocation of the site to the London Borough of Hammersmith and Fulham. in the modern equivalent asset valuation of the Sutton land: the reduction of the land area, assumption of replacement with buildings of up to 5 storeys, reduction in surface car parking and replacement with under-croft/multi storey car parking and creation of a single more efficient structure; in the valuation of the Chelsea hospital site: the reduction of plant space due to building efficiencies; the identification of buildings deemed as non-operational; and the amended useful economic lives of each building. Information provided 13. We have provided you with all relevant information and access as agreed in the terms of the audit engagement letter. 14. All transactions have been recorded and are reflected in the financial statements and the underlying accounting records. 15. We acknowledge our responsibilities for the design, implementation and maintenance of internal control to prevent and detect fraud and error. 16. We have disclosed to you the results of our assessment of the risk that the financial statements may be materially misstated as a result of fraud. 17. We are not aware of any fraud or suspected fraud that affects the Trust and involves: management; employees who have significant roles in internal control; or others where the fraud could have a material effect on the financial statements. 28 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

100 Appendix D Draft management representation letter 18. We have disclosed to you all information in relation to allegations of fraud, or suspected fraud, affecting the Trust s financial statements communicated by employees, former employees, analysts, regulators or others. 19. We are not aware of any instances of non-compliance, or suspected non-compliance, with laws, regulations, and contractual agreements whose effects should be considered when preparing financial statements. 20. We have disclosed to you the identity of the Trust s related parties and all the related party relationships and transactions of which we are aware. 21. All minutes of directors, management and governors meetings during and since the financial year have been made available to you. 22. All known actual or possible litigation and claims whose effects should be considered when preparing the financial statements have been disclosed to you and accounted for and disclosed in accordance with the applicable financial reporting framework. No other claims in connection with litigation have been or are expected to be received. 23. We have no plans or intentions that may materially affect the carrying value or classification of assets and liabilities reflected in the financial statements. 24. We are not aware of any deficiencies in internal control. 25. We acknowledge our responsibility for ensuring the Trust has put in place arrangements for securing economy, efficiency and effectiveness in its use of resources. 26. We have disclosed to you all deficiencies of which we are aware in the Trust s arrangements to secure economy, efficiency and effectiveness in its use of resources. 27. We have recorded or disclosed, as appropriate, all liabilities, both actual and contingent. 28. As disclosed in Note 17 to the financial statements, as at 31 March 2017, there were no significant capital commitments contracted by the Trust. 29. All grants or donations, the receipt of which is subject to specific restrictions, terms or conditions, have been notified to you. We have evaluated whether the restrictions, terms or conditions on grants or donations have been fulfilled with and deferred income to the extent that they have not. 30. Based on discussions with other NHS bodies, we consider that the resolution of disputed balances and accrued over performance will not result in a material adverse effect on the reported financial position. 29 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

101 Appendix D Draft management representation letter 31. The measurement processes, including related assumptions and models used to determine accounting estimates in the context of the DH Group Accounting Manual and IFRS are appropriate and have been applied consistently. 32. The assumptions appropriately reflect our intent and ability to carry out specific courses of action on behalf of the Trust where relevant to the accounting estimates and disclosures. 33. The disclosures related to accounting estimates under the DH Group Accounting Manual and IFRS are complete and appropriate. 34. There have been no subsequent events that require adjustment to the accounting estimates and disclosures included in the financial statements. 35. We have drawn to your attention all correspondence and notes of meetings with regulators. 36. We are not aware of events or changes in circumstances occurring during the period which indicate that the carrying amount of fixed assets or goodwill may not be recoverable. 37. We have reviewed the operating segments reported internally to the Board and we are satisfied that it is appropriate to aggregate these as, in accordance with IFRS 8: Operating Segments, they are similar in each of the following respects: the nature of the products and services; the nature of the production processes; the type or class of customer for their products and services; the methods used to distribute their products or provide their services; and the nature of the regulatory environment. Quality Report 38. We understand and have fulfilled our responsibilities for the preparation of the quality report in accordance with the NHS Foundation Trust Annual Reporting Manual. 30 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

102 Appendix D Draft management representation letter 39. We have made available to you all records, correspondence, information and explanations necessary for you to perform your work. All the records have been made available to you for the purpose of your work and all the data collected by the Foundation Trust has been properly reflected and recorded. 40. Significant assumptions that have been made by us in determining the indicators are reasonable. 41. All events subsequent to the date of the quality report and for which the NHS Foundation Trust Annual Reporting Manual requires adjustment of or disclosure have been adjusted or disclosed. 42. We acknowledge our responsibilities for the design, implementation and maintenance of internal control to prevent and detect fraud and error when preparing the quality report. 43. We are not aware of any instances of non-compliance, or suspected non-compliance, with laws and regulations whose effects should be considered when preparing the quality report. 44. With the exception of those matters set out in the quality report, we are not aware of any other deficiencies in internal control over the collection and reporting of the measures of performance included in the quality report. We confirm that the above representations are made on the basis of adequate enquiries of management and staff (and where appropriate, inspection of evidence) sufficient to satisfy ourselves that we can properly make each of the above representations to you. Yours faithfully Signed as Accounting Officer, and on behalf of the Board of Directors 31 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

103 Appendix E Enhanced audit report draft wording The following report is a draft indicative version of our enhanced audit report. This may be subject to change following completion of our audit. 32 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

104 Appendix E Enhanced audit report draft wording 33 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

105 Appendix E Enhanced audit report draft wording 34 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.

106 Appendix E Enhanced audit report draft wording 35 Deloitte confidential: Public sector For approved external use 2017 Deloitte LLP. All rights reserved.