annual report and accounts The Hillingdon Hospitals NHS Foundation Trust

Transcription

1 annual report and accounts The Hillingdon Hospitals NHS Foundation Trust

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3 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006.

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5 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts contents Introduction from the Chair and Chief Executive Strategic Report Directors Report Remuneration Report Quality Report Statement of Accounting Officer s Responsibilities Statement of Directors Responsibilities in Respect of the Accounts Independent Auditor s Report Annual Governance Statement Annual Accounts Including the disclosures required in the NHS Foundation Trust Code of Governance, staff survey, regulatory ratings, and public interest disclosures. 5

6 01 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Introduction from the chair and chief executive Firstly, we would like to take this opportunity to express our sincerest thanks to Mike Robinson who retired as Trust Chair on 31st March Since joining the Trust in 2009 Mike was a real driving force for the organisation and made a huge contribution to not only the successes over the last year that are outlined in this annual report, but also in helping lay the foundations for the Trust to respond to the challenges that lie ahead. Friends and Family Test The results of the Friends and Family Test indicate that we are moving in the right direction. Last year we received over 15,800 responses to the test with the vast majority happy to recommend our wards and emergency department to family and friends. Where problems were highlighted we looked to address these through initiatives like Comfort at Night. This initiative, which has been cited by the Secretary of State for Health, focuses on the needs of patients, the behaviour of staff and the ward environment during night time. COMFORT AT NIGHT The past year has been a defining one for the NHS with the service coming under intense political and public scrutiny in the wake of the Francis Report into the failings at Mid Staffordshire NHS Foundation Trust. Clearly, there are important lessons for all NHS organisations to learn, not least the need to ensure that patients always take priority in the planning and the delivery of care. However, we should also remember that the NHS continues to provide excellent care to patients every day and this Trust is no exception. Writing in last year s annual report we made a commitment to ensuring that clinical safety and quality would not be compromised despite the increasing financial pressures being faced by the NHS. With this in mind, June saw the launch of the Trust s new vision. To put compassionate care, safety and quality at the heart of everything we do. In order to achieve this vision we must listen to what our patients are telling us and respond quickly to address any problems. Care is something that goes to the heart of what we do and is reflected in the Trust s CARES values which celebrated their first anniversary in May. We marked the occasion with the launch of our new CARES Ambassadors who serve as champions and role models for the values. The Board remains committed to CARES and to ensuring that the values become part of the very fabric of the Trust and set standards against which we are happy to be judged. Like all busy acute hospital trusts we operate seven days a week, 365 days of the year and we were delighted that our improvement in performance for weekend emergency HSMR (Hospital Standardised Mortality Ratio) was Highly Commended in the 2013 Dr Foster Hospital Guide awards. This recognises the excellent work that has been done to improve patient care. Changes we have made include having more consultants available at weekends, improving the monitoring of mortality data and implementing early warning systems to identify patients whose health is deteriorating. As a foundation trust it is important that we maintain our performance and ensure that we meet the requirements of Monitor, the independent regulator. Throughout the year we have remained 6

7 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts on track to be green (on target) against Monitor s performance standards, including the four hour A&E waiting time target that has been such a challenge to the NHS this year. In addition, Care Quality Commission (CQC) intelligence reports published in October 2013 and February 2014 placed the Trust in the lowest risk band. An unannounced inspection by the CQC identified areas where we need to improve, which we are addressing through a comprehensive action plan. By maintaining our clinical and financial performance we are well placed to shape the longterm future of the Trust. Our staff worked hard to redesign the way we work to release 8m of savings. These, and a growth in services to a wider catchment area, helped us achieve a small financial surplus which can be used to invest in our hospitals. As the healthcare needs of patients continue to change we are focusing our efforts on modernising and investing in clinical services that meet the needs of our local population. The modernisation works that have taken place across our maternity, emergency care, endoscopy, dementia and cancer services this year show how we are investing to provide a better experience and improved environment for patients and staff. high quality care and services for local people. The Trust is set to play a central role with comprehensive seven day a week acute emergency care and expanded maternity services. Our staff are working to prepare business cases for major investment in the Hillingdon site as part of the SaHF programme. The end of the year also saw a change in our Council of Governors with our first cohort of Governors reaching the end of their term of office. We are grateful to all for their support and look forward to working with our new Governors from 1st April. The future of the Trust remains bright and it is thanks to the hard work and commitment of our staff, Governors, volunteers, and our fellow Board members that we continue to deliver high standards of care to our patients. Looking at the year ahead the challenge of caring for an ageing population living with complex long term conditions will drive changes across the NHS. Locally, the North West London Shaping a Healthier Future (SaHF) programme continues to gain momentum. Led by local clinicians, the programme proposes changes to services designed to safeguard Shane DeGaris Chief Executive The Hillingdon Hospitals NHS Foundation Trust James Reid Interim Chair The Hillingdon Hospitals NHS Foundation Trust 7

8 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Key achievements at a glance NHS National Litigation Authority Improved our accreditation from Level One to Level Two. 2 Care Quality Commission risk rating Achieved Band 6 (lowest level) in two successive assessments. Dr Foster Good Hospital Guide awards 2013 Highly Commended for our work to improve weekend emergency HSMR (Hospital Standardised Mortality Ratio). Monitor The Trust rated green (compliant) against all of Monitor s performance targets for Patient Experience Network awards Our CARES values work was runner-up in this important national award scheme. National Hip Fracture Database (NHFD) Trust ranked amongst best in London with patients being sent for surgery within 48 hours. Annual NHS Staff Survey 2013 The number of staff agreeing that patient care is the Trust s top priority grew by 5% to 71%; above the national average of 67%. NHS Improving Quality Achievement Our Diabetes Team were awarded a silver certificate for ensuring more than 50% of our clinical staff have completed training in this area. Friends and Family Test We received over 15,800 responses to the FFT during 2013 with the overwhelming majority recommending our wards and emergency department to family and friends. Investing in our services Invested 2.6m in new and improved patient facilities for endoscopy, dementia friendly services, cancer information and maternity deliveries, in addition to the ongoing emergency care major redevelopment due to complete in Trusts risk management standards are assessed by the NHSLA against three levels. Level Three is the lowest risk (highest rating of a trust s risk management processes). 8

9 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Strategic report 9

10 02 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts The Hillingdon Hospitals NHS Foundation Trust was established on 1st April 2011 when Monitor authorised the organisation as an NHS Foundation Trust. The Trust provides health services at two hospitals in North West London: Hillingdon and Mount Vernon. Hillingdon Hospital is the only acute hospital in the London Borough of Hillingdon and offers a wide range of services including accident and emergency, inpatient care, day surgery, outpatient clinics and maternity services. The Trust s services at Mount Vernon Hospital include routine day surgery at a modern treatment centre, a minor injuries unit, and outpatient clinics. The Trust also acts as a landlord to a number of other organisations that provide health services at Mount Vernon, including East & North Hertfordshire NHS Trust s Cancer Centre. The Trust s income in was over 200m and we employ over 2,800 staff. The majority of our patients live in the London Borough of Hillingdon but as part of our strategy are seeking to provide healthcare to a wider area. In : 94,154 attendances were made to our accident & emergency department and minor injuries unit. 4,067 babies were born in our maternity unit. 292,411 attendances were made as outpatients. 24,099 admissions were made for emergency treatment across all parts of the Trust. 23,831 admissions were made for planned operations and day surgery. Overview of the Trust s strategy In 2013 the Trust refreshed its vision and mission as follows: To put compassionate care, safety and quality at the heart of everything we do. To be the preferred, integrated provider of healthcare for Hillingdon and the surrounding population, with a major acute hospital as a hub. Strategic Intent Our long term strategy (3-5 years) is for the organisation to be of a sufficient size and scale to provide responsive, high quality clinical care in the most appropriate setting for patients. Our ambition is to continue Our long term strategy to be seen as both a major acute hospital provider and an integral part of a more integrated health and social care system. This can only be achieved through much closer working and alignment with both commissioners and providers. We also need to broaden our service offering, acknowledging that health care is unaffordable based on the current model of care, and recognising that traditional acute trusts are increasingly vulnerable in the NHS environment. We will increasingly see services delivered in community settings, with a much stronger focus on early intervention, either as the prime provider or as part of a network solution. The medium term strategy (next 1-3 years) is to continue to deliver safe, high quality services and be a top quartile performer for small-medium size acute foundation trusts across quality, operational and finance performance indicators. In order to achieve this, we need to transform our current delivery model, ensuring we increase quality and safety and Our medium term strategy 10

11 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts drive down cost wherever possible. We will also support the transition to a more integrated and affordable healthcare system through much closer collaboration with Hillingdon Clinical Commissioning Group (CCG) the main commissioner of our services and through the development of strategic partnership arrangements with other providers. We have identified four strategic priorities for the future to help deliver our strategic intent: 1. To create a patient centred organisation to deliver improvements in patient experience and the quality of care we provide 2. To deliver a clinically led service strategy that responds to the needs of patients and other health and social care partners 3. To deliver high quality care in the most efficient way 4. To develop sufficient sustainable scale to enable us to improve and grow healthcare services for our communities. These priorities are underpinned by more detailed strategic objectives and actions, which are refreshed each year, to ensure we deliver our strategic plan. We need to change the views of patients, commissioners and partner providers that the Trust is not just a high quality provider of hospital services in Hillingdon. Ultimately our objective remains to be the main provider of health services in Hillingdon, but also to grow our presence and service offering in neighbouring boroughs through the development of high quality, value for money, integrated health care services. Shaping a Healthier Future The Shaping a Healthier Future (SaHF) programme aims to improve NHS services for the two million people who live in North West (NW) London. The principal changes aim to: Centralise specialist services which people need when they are seriously ill Localise the most common services people need for everyday illnesses and injuries Integrate all of these services with others such as social care. On 19th February 2013, the North West London Joint Committee of Primary Care Trusts (JCPCT) agreed the following recommendations for service change: To adopt the NW London acute and out of hospital standards, service models and clinical specialty interdependencies for major, local, elective and specialist hospitals. To adopt the model of care based on five major hospitals: Hillingdon, Northwick Park, West Middlesex, St Mary s and Chelsea & Westminster. That Ealing should be a local hospital. To coordinate implementation of out-ofhospital strategies in conjunction with the above changes. We see our future, in the context of this programme, as being a fixed point major acute hospital with 24/7 Accident & Emergency capability, delivering emergency and elective services over a progressively broader catchment area as the changes in the North West London sector take effect. This regional health economy strategy is a primary driver influencing our four key strategic priorities, primarily as a major acute hospital, but also responding to commissioner intentions of providing more healthcare in an outof-hospital setting, and capitalising on changing commissioner and provider configurations by expanding and diversifying our service portfolio. 11

12 02 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts As part of the programme, the Trust is developing an Outline Business Case for major improvements to the estate which include: Expansion of the maternity facilities to allow an increase in births up to 6,000 each year. This will enable the Trust to make improvements in the models of care offered, in particular by providing a dedicated midwifery-led unit to provide additional choice for women. Expansion of existing theatre capacity on the Hillingdon site by providing additional recovery beds, and upgrading one of our theatres. Expansion of the current Intensive Care Unit by four beds, which will meet modern healthcare standards in terms of space. Expansion of the emergency department both in terms of the number and size of cubicles. Addressing some of the high and significant risk backlog maintenance issues across the Hillingdon site. Quality strategy During there has been an increased focus on how we measure and monitor quality and there has been a review of the information that is received both at the Board and at its Quality and Risk Committee (QRC). Whilst undertaking this work the Trust has considered and made reference to key NHS investigations and reviews, and in particular the Francis Report, and the Keogh and Berwick reviews. This in turn has supported the Trust in developing a new clinical quality strategy. The learning and recommendations from these key publications have been used to underpin our key aims and objectives for quality improvement. In addition we have reviewed our current quality performance alongside national and regional quality data and referenced local feedback from both staff and patients. Our new clinical quality strategy will help us to achieve our vision To put compassionate care, safety and quality at the heart of everything we do. It provides a structure for ensuring strong clinical governance and ongoing improvement in the quality and safety of patient care. It outlines the responsibilities of staff and is supported by our culture and values framework, CARES (Communication, Attitude, Responsibility, Equity and Safety) which embraces a culture that empowers staff to report incidents and raise concerns about quality in an open, blame-free working environment. The clinical quality strategy provides a framework to provide assurance that our services are safe and effective. It also builds on the local and national context of service change that so critically affects quality of care for all our patients. The objectives in the strategy are grouped under the three domains of quality: improving clinical effectiveness, improving patient safety, and improving the patient and carer experience. Further information on the quality of the Trust s services and the Board s priorities for improving clinical quality is presented in the quality report. Delivering the strategy Developing our services A number of service developments have taken place over the last year as part of the delivery of the Trust s four strategic objectives. Several of these span multiple years. strategy Musculoskeletal (MSK) services As outlined in last year s annual report, the Trust agreed with commissioners to implement a redesigned orthopaedic, rheumatology and pain service model from April This implemented jointly agreed pathways in primary and secondary care and developed a CATS (Clinical Assessment and Triage Service) model to triage referrals. Changes made this year include new pathways, increased utilisation of the Choose and Book service, and an enhanced number of patients being seen by Extended Scope Practitioners (ESP). This large scale programme of work will continue to develop and evolve throughout Further review of pain and rheumatology pathways is expected, and there will be a review of guidelines for ESPs to refer patients for diagnostic and interventional procedures. Work will take place with Central & North West London (CNWL) NHS Foundation Trust to design improved discharge processes to community services. 12

13 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Support for other trusts Following an external assessment of other trusts preparedness for winter pressures, the organisation was approached to see if support could be provided to patients usually seen at another trust without compromising the provision of care to local Hillingdon residents. In conjunction with local commissioners the Trust agreed to re-commission Edmunds Ward on the Mount Vernon site to provide additional winter capacity for North West London Hospitals NHS Trust (NWLHT). The ward has capacity for 29 patients; 20 beds were commissioned for use by NWLHT with the remaining nine beds used as part of our Trust winter plan. The ward opened in December The Trust is also providing support to NWLHT to deliver the 18 week referral to treatment target in orthopaedics, general surgery and gynaecology, largely from the Treatment Centre at Mount Vernon; and has supported Heatherwood & Wexham Park Hospitals NHS Foundation Trust with their planned surgery. Emergency and urgent care development Following the award of 12.4m of Public Dividend Capital from the Department of Health, the Trust is in the process of a major programme that includes the construction of a new 46-bed Acute Medical Unit (AMU) adjacent to the existing A&E Department at Hillingdon Hospital, a new Rapid Assessment and Triage area to facilitate a quicker clinical assessment, and a new Urgent Care Centre (UCC) to integrate with community, social & mental health service providers. The aim is to provide improved high quality, safe, urgent and emergency care services for the local population. The co-location of this new unit, which will open in January 2015, will facilitate better integration between the hospital s emergency and acute services and create an Emergency Care Department. This co-location also means that Rapid Response and the new Home Safe Community Team can be based in the same area and be able to provide more integrated care pathways. The new AMU will accommodate patients for up to 48 hours under the care of acute physicians with in-reach from specialty teams. There will be a focus on intensive interventions to ensure patients are able to return home as quickly as possible. The Trust has a developed an Ambulatory Emergency Care (AEC) unit, which will be transferred to the new building, co-located with A&E and will become part of the Emergency Department. The AEC unit has significant potential to expand services and help prevent avoidable admissions. The unit will accept direct referrals from GPs and from the Urgent Care Centre which is also co-located to A&E. This model is well developed in medicine and the new building will allow for a significant expansion of this type of care into surgery and gynaecology. Improvements to the birthing room environment The Trust was awarded more than 700,000 of Public Dividend Capital to improve the birthing room environment within the Maternity Unit. This will entail refurbishing all ten rooms on the labour ward and installing en-suite bathroom facilities. This work is being undertaken in phases and is set to complete in summer

14 02 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Development of endoscopy services The Trust is undertaking an extensive programme of redevelopment of its endoscopy services at both Mount Vernon and Hillingdon sites. This includes the relocation in January 2014 of endoscopy services at Mount Vernon Hospital from the listed building to the modern Treatment Centre. Endoscopy services at the Hillingdon site will also be relocated downstairs in the new AMU, with two fully developed endoscopy suites. The redevelopment will support accreditation of both units by the Joint Advisory Group on Gastrointestinal Endoscopy Services. The relocation will also mean that patients will enjoy a significant improvement to the current environment. Dermatology services The Trust has continued to expand its dermatology service including the growth of tertiary level services which has brought in work from a much larger geographic catchment area. The team are currently exploring the development of an integrated skin centre and hope to finalise a business case for investment in summer Seven day working The Trust has made some significant strides in enhancing the coverage of clinical services across all seven days of the week. In the last year the Trust has extended medical cover across the seven days in acute medicine, paediatrics, obstetrics and A&E. Using winter funds made available in December 2013 the Trust funded a number of additional projects to expand services over the weekend. These included expansion of therapy and radiology services, and enhanced medical and pharmacy cover. The success of these projects will be evaluated and will inform the Trust s seven day working strategy, which will be developed by July 2014 and will look to be implemented over three years. It is anticipated that there will be significant workforce implications as the Trust seeks to provide a more uniform service model across the seven days of the week. Specialist rehabilitation at Mount Vernon Hillingdon Hospital currently provides specialist rehabilitation through the 20 bedded Alderbourne Rehabilitation Unit (ARU). The ARU currently has over 200 referrals per year for 20 beds and is able to admit in the region of 115 patients per year, with a bed utilisation rate of 97%. The clinical teams provide multi-disciplinary, goal-orientated rehabilitation for patients with predominantly, though not exclusively, complex neurological conditions. The ARU catchment area is predominantly the Hillingdon borough. As the reputation of the unit has grown over recent years, referrals have been increasing from Harrow, Hounslow, Ealing and Berkshire. In addition, the unit has close links with neurology and neurosurgery services at Charing Cross Hospital which has resulted in an increasing number of referrals from West London, not only for inpatient rehabilitation beds but also for specialist outpatient activity. In order to increase capacity and draw in referrals from outside the immediate catchment area, in August 2014 a new Neurology Rehabilitation Unit will open on the Mount Vernon site. The unit will have 16 beds and will be managed as an extension of the existing service operating at Hillingdon Hospital. Development of networks and partnerships The Trust has over the last year sought to develop its networks and partnerships with other providers. This has been through sector wide programmes such as the London Cancer Alliance (LCA) which is the integrated cancer system and strategic clinical network for cancer for West and South London. The Trust has also developed more bespoke network proposals such as the pathology modernisation programme which is exploring the creation of a hub and spoke model for pathology services across Hillingdon, Imperial, Chelsea and Westminster, and West Middlesex Hospital Trusts. We have also continued to develop much closer links with Central & North West London NHS Foundation Trust as our mental health and community care 14

15 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts provider in Hillingdon. This has been in the form of work such as the Early Supported Discharge programme, as well as exploring joint bidding opportunities outside of Hillingdon. The Trust has also undertaken a number of pieces of work with the Royal Brompton and Harefield NHS Foundation Trust which has seen the signing of an extensive support contract for the Trust to provide a variety of acute hospital services to their Harefield site, and the redesign of cardiology pathways for patients in the Hillingdon borough. The Trust continues to be a member of Imperial College Health Partners (ICHP). ICHP is an Academic Health Science Partnership that includes members from academia, community care, mental health, secondary and specialist care and the clinical commissioning groups that operate in the North West London area. It is also the designated Academic Health Science Network for the area. ICHP s stated strategic objectives are: Enabling discovery of new ideas and innovations, and then facilitating the adoption and diffusion of these across the NHS. Reducing variation and spreading best practice across healthcare. Strengthening synergy between the NHS and industry for the benefit of patients and to create wealth for the local population, the NHS and the UK. Person centred and co-ordinated care Many patients have complex care needs and currently services remain fragmented. This means at times patients and carers can find it difficult to access health and social care services to meet their needs. Services are often provided by different professionals, in a number of settings, and across different providers. Patients are often expected to navigate this system without appropriate signposting which can result in poorer outcomes, with duplication and inefficiencies at various stages of the pathway. A key focus of work for the Trust and partners is the drive to improve the integration of care provided by health and social care organisations. The Trust has been participating in the North West London (NWL) integrated care pilots that have been running for a number of years, and is currently participating in a Whole Systems Integrated Care Programme which is viewed as the next stage in the journey to provide a seamless model of health and social care. The overarching aim of this ambitious and transformative programme is to improve health and social care support for some of our most vulnerable residents. Patient pathways will be redesigned, with an initial focus on care of the elderly (those over 75 years of age) and adults with diabetes. This integrated approach is expected to deliver improved outcomes for patients by averting hospital attendances and admissions; reducing length of stay for those patients who are admitted to hospital; improving patients experience of discharge from hospital; and preventing readmissions. Whilst the effectiveness of the programme relating to elderly and diabetes is still being evaluated, early indications show encouraging results, including very positive patient experience feedback. The integrated care pilot will continue through with a focus on risk profiling. This seeks to identify patients at higher risk and instigate earlier intervention in order to prevent deterioration in health and hospital admission. During last year the Trust has been working with a number of partners as part of the North West London pioneer pilot of Whole Systems Integration of Care (WSIC) which seeks to design an implementation toolkit for integrated care. The Trust is also working with partners to develop a plan for utilising the Better Care Fund that responds to the Government s request for evidence of health and social care organisations working together. 15

16 02 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts The integrated model is expected to include: The GP as the professional with overall responsibility for the patient including approval of multi-disciplinary care plans. A focus on supporting self-care and independence. The use of budgets and contracts that increase incentives for primary and secondary care organisations to work together to prevent the need for intervention. Through the Better Care Fund, pooling commissioning budgets relating to services commissioned for older people. Access to the Better Care Fund in will be dependent on a local two year plan for and The Hillingdon Health & Wellbeing Board set up a sub group to work up schemes, develop a vision, scope changes and outcomes, and to agree and sign off plans. The Trust has been an active participant in both this sub-group and the main Health & Wellbeing Board. DEVELOPING A VISION The plan for the Better Care Fund in Hillingdon is initially aimed at the elderly. The proposed schemes build on current existing early stages of integrated care, examples of which include proactive early identification of people with susceptibility to falls, dementia and social isolation; development of shared care plans; early supported discharge; seven day working; and integrated services for patients receiving end of life care. The Health and Social Care Act 2012 sets out an explicit focus on the importance of integrated care, and integrated care is a condition in Monitor s Licence issued to foundation trusts. The Trust views integrated care as an essential and vital way forward when planning and delivering health care services, and the Trust is committed as part of its long term strategy to be seen as provider and system leader of integrated health and social care services. The drive to integrate care is a key priority for the Government and is likely to be a significant factor in the delivery of the Trust s strategy over the next year. 16

17 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Performance review Our performance against key targets The Trust had another year of strong performance against the targets used by Monitor, the regulator of foundation trusts, to calculate the governance risk rating 3 : Indicator Performance in Target in Performance In Target Achieved Clostridium difficile (maximum) 12 All cancers: 31 days for second or subsequent treatment (surgery) All cancers: 31 days for second or subsequent treatment (anti-cancer drug treatments) All cancers: 62 days for first treatment from urgent GP referral for suspected cancer All cancers: 62 days for first treatment from NHS Cancer Screening Service referral All cancers: 31 days diagnosis to first treatment Cancer: two week wait from referral to date first seen for all urgent referrals (cancer suspected) Cancer: two week wait from referral to date first seen for symptomatic breast patients (cancer not initially suspected) Maximum time of 18 weeks from point of referral to treatment admitted patients Maximum time of 18 weeks from point of referral to treatment non admitted patients Maximum time of 18 weeks from point of referral to treatment patients on an incomplete pathway A&E: Total time in A&E less than 4 hours (Accident & Emergency, Minor Injuries Unit, Urgent Care Centre) 100% 94% 100% 100% 98% 100% 93.3% 85% 90.3% 93.9% 90% 97.8% 99.2% 96% 99.3% 97.9% 93% 97.9% 98.1% 93% 94.7% 97.5% 90% 97.1% 98.8% 95% 98.6% 97.3% 92% 97.4% 96.7% 95% 96.0% Self-certification against compliance with requirements regards access to healthcare for people with a learning disability Fully Compliant Fully Compliant Fully Compliant 3. Definitions for the indicators are included in Monitor s Risk Assessment Framework (available at Information on the risk ratings issued by Monitor is contained on pages of this annual report. 17

18 02 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Clostridium difficile The Trust successfully achieved a significant reduction in Clostridium difficile (C. diff) this year and reported 12 cases, a 48% reduction from the previous year s total of 23. This was achieved through a number of focused activities across the organisation which included: Learning from root cause analysis and sharing best practice across the Trust Developing a new bowel monitoring chart which helps staff make assessments on when it is appropriate to send a sample to the laboratory for testing Undertaking further work on antimicrobial prescribing including an action plan on the Start Smart then Focus Department of Health guidance and a new sticker for patient notes requesting an antibiotic review if necessary. Referral to Treatment waiting times All 18 week targets for both admitted and nonadmitted patients were achieved and exceeded. The Trust consistently achieves this target and has been one of the strongest performers in London for the past three years. The Trust s continued high performance means that other organisations have been in contact requesting support with delivering their elective 18 week activity. As outlined earlier in the report, in the last year the Trust supported two organisations in undertaking elective work. significant positive impact on performance, and the Trust achieved 96.8% in quarter four. The number of acutely unwell patients continued to increase throughout the year. Between April 2013 and March 2014, 1,777 blue light ambulances attended the Trust compared to 1,633 for the same period last year. This represents an 8.8% increase (144 attendances). Blue light ambulances convey the sickest patients to the hospital who require admission to the A&E resuscitation unit and intensive support. It takes on average seven hours to stabilise patients before they can be transferred to another location in the hospital. On average 4.8 patients per day are treated in the resuscitation unit. Despite the increase in the number of blue light conveyances, non-elective (unplanned/emergency) admissions are slightly down on the previous year. During there was an increase in the number of elective admissions compared to the previous year, which equated to an average increase of four admissions per week. Accident and Emergency (A&E) waiting times The Trust achieved the target for 95% (all types) of patients to have a total time in A&E of less than four hours, with a mean performance throughout the year of 96%. Initial performance was affected by a challenging start to the year (April and May) when the Trust did not meet the required standards. An extensive review was undertaken and a number of measures were introduced which improved performance. Additional winter funds were made available to the A&E department for the final quarter of the year. Extra medical, nursing and phlebotomy staff were recruited. In addition, on site senior managerial support was provided over the weekend. This had a 18

19 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Ambulatory emergency care As outlined above, with the support of Hillingdon CCG the Trust continued to invest in the Ambulatory Emergency Care (AEC) programme. Over the summer there was an increase in the number of clinics available to treat patients. Consequently the Acute Medical Clinic (AMC) was able to expand the range of services available and increase the number of conditions that can benefit from ambulatory care. The graph below highlights the expansion of the service. AMC attendances AMC attendances Linear (AMC attendances) 0 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 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 The graph below demonstrates the effectiveness of the ambulatory service at the Trust despite the increase in the number of actual attendances the total number of admissions from the AMC decreased. Admissions are being prevented as it is now possible for patients to receive follow-up care in ambulatory clinics. Number of admissions directly from AMC Number of Admission Directly from AMC Linear (Number of Admission Directly from AMC) Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 19

20 02 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Cancer performance The Trust successfully achieved all of the cancer access targets for the second successive year in a row. Extensive re-modelling has been undertaken with other providers to ensure that the care of patients on complex pathways is co-ordinated between organisations. This means that patients can have their procedure booked at another hospital while they are still undergoing investigations at this trust. Access to healthcare for people with learning disabilities The Trust continues to fully comply with the requirements regarding access to healthcare for people with a learning disability. Financial review Overall performance During the third year as a stand-alone foundation trust regulated by Monitor, the Trust again achieved a financial risk rating of at least three 4 in each quarter. This has meant the Trust has now sustained this level of overall financial performance for 12 consecutive quarters since authorisation as a foundation trust on 1st April Although faced with a challenging set of local and national monetary constraints the Trust was nevertheless able to over-achieve against the plan approved by the Board for the financial year and ended with a revenue account surplus before impairments of plant, property and equipment of 0.3m. With these non-cash accounting charges included, the final position was a revenue deficit for the year of 0.7m. It is important to note this financial position was achieved together with good overall clinical and operational performance, as outlined above and in the quality report. This overall performance was also achieved whilst much-needed capital investments totalling 18.6m were made. 4. See pages for further information on the risk ratings. financial review Trading for the year The Trust achieved a surplus for the financial year of 0.3m before charges for fixed asset impairments of 1.0m mainly in relation to buildings demolished to enable the creation of the Trust s new emergency care facility. Higher clinical activity levels than contracted by healthcare commissioners helped to increase overall trust revenue by 5% for the year. However, in line with the Trust objective to increase activity from outside of its immediate local catchment this growth did not come from its contract with Hillingdon Clinical Commissioning Group (CCG). The local and wider North West London strategy of healthcare commissioners is to move activity out of a hospital setting where this is possible. As a consequence of this the Trust s activity-related revenue from Hillingdon CCG reduced compared to last year. This was more than offset with additional activity delivered for commissioners outside of London; from the contract for the provision of pathology for Hounslow GPs; and from additional non-elective capacity made available for North West London Hospitals NHS Trust to utilise during the winter period. This additional activity increased operating costs for the year by 3.5% but crucially lower than the increase in revenue. The robust management of operating expenses was underpinned by the Trust delivering 8.2m of efficiency savings for the year. This was 4.1% of total operating expenses and represented a level of performance above the average for the foundation trust sector. Cash flow During the operating year the Trust generated 12.9m cash from its predominantly direct healthcare related activities. In addition, 11.2m of Public Dividend Capital was received from the Department of Health (DH) and 3.5m of finance leases were entered into to help fund capital investment. From this 18.6m was utilised to create and purchase new assets and 3.6m cash was used to service the 20

21 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Apart from the physical infrastructure of the organisation the Trust also continued to invest in updating its medical equipment impacting on a wide range of clinical services. This included the purchase and installation of a new MRI scanner incorporating the latest technology and enabling a greater throughput of patients. outstanding debt and interest from loans and leases. A further 3.6m was paid to DH in relation to the Trust s annual public dividend payment. The remaining 1.8m was retained as cash at the year-end. This will be utilised in the financial year on further committed capital investment. Capital investment During the financial year 18.6m was invested in the facilities, equipment and technology used by the Trust to deliver healthcare. The Trust s own resources were supplemented by 11.2m of new Public Dividend Capital received from DH. This was in relation to the major upgrade and new build of emergency care facilities on the Hillingdon Hospital site, to make Beaconsfield East Ward a more dementia friendly environment, and to provide the technology to enable midwives to have remote access to Trust IT systems. The Trust s physical estate infrastructure remained the largest area of investment. This was again concentrated on prioritised investment targeted to keep operational buildings safe, fit for purpose, and compliant with statutory legislation. This was in line with a long-term plan of works focusing investment on the highest risk areas first. Investment in information technology infrastructure and capability also remained a priority. New ward-based technology incorporating electronic white boards which link to the Trust s Patient Administration System was implemented. This helped to improve patient flow throughout Hillingdon Hospital and supported faster discharge. Looking ahead The Trust s forward financial plans will continue to be set in the context of difficult national economic conditions. Although there are real signs of recovery, in the short-term at least, public service budgets will remain constrained at historic low-levels. This will mean the NHS in England will continue to face the most sustained challenging financial environment in its history. NHS England has allocated 2.54% in additional revenue resource to CCGs in and a further 2.09% in However, this will barely meet inflationary pressures let alone fund growth in demand for services which is currently running between 3% and 4%. Following years of restraint there is growing pressure for basic pay increases to restart, and in addition annual incremental uplifts will continue to have to be funded locally. On top of this, employer pension contributions are set to rise from April 2015 and reforms to the state pension will result in a significant additional pay cost pressure from April Other significant estate projects completed during the year included a major upgrade to the endoscopy facility at Mount Vernon Hospital, work to repair roofs, refurbishment of more public toilets and further upgrade and refurbishment of the Maternity Unit. In addition, the Trust utilised funding from Macmillan to create a cancer information centre on the Hillingdon Hospital site. For this reason, all providers of NHS commissionerrequested services will continue to have to manage with a reduced national tariff; -1.5% for both and This will continue to embed a 4% efficiency saving requirement merely to stand still. Clearly, this represents a major challenge to the organisation but it is one the Board has prepared for by strengthening the organisation with an enhanced 21

22 02 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts project management capability, and improving governance by way of a Transformation Committee focused on supporting the Trust to meet the financial challenges ahead. In addition to the challenging national context described above there is further considerable risk posed by the local health financial economy position. Specifically, as it plans to clear a significant underlying deficit, Hillingdon CCG has the most aggressive savings programme of any North West London commissioner over the next four years. This had already started in and continues in with schemes to the value of 12m relating directly to this trust out of a total of 15m. Over the next four years Hillingdon CCG s total planned savings are nearly 40m of which 32m (80%) relate to acute healthcare provision at the Trust. The financial risks this poses to the local health economy are further magnified by the transition path to the Trust s end-state as a major acute hospital under Shaping a Healthier Future (SaHF). The Trust will lose significant activity and associated revenue well in advance of gaining from services transferring from Ealing Hospital in As a direct implication of this, the Trust will require transitional funding from NWL commissioners so it can continue to cover its fixed costs and remain financially viable in the years leading up to This process began in and continues in In December 2013 NHS England approved a new formula for allocating funds to CCGs. The changes followed an extensive review into funding allocations given concerns that the current funding was based on allocations that were at least three years out of date. The NHS England Board agreed that all CCGs would receive funding increases of at least inflation matching 2.14% in , with a higher increase for those CCGs underfunded once the new formula is taken into account. Hillingdon CCG s allocation will therefore increase by 4.36% in and with a further 3.99% year on year increase for Compared to the average this represents additional funding of around 11m. However, the transfer of funds to the Better Care Fund (BCF) to be jointly owned and managed with Social Services presents an additional significant financial risk to the local health economy depending on how it is implemented. This is a risk all health economies in England face under which funding that is currently spent on hospital services could be moved to funding community health and social care services. Nevertheless, it is hoped the additional resources allocated to Hillingdon CCG will allow it to restore underlying financial balance sooner than it would otherwise have done, which would clearly be a positive for the local health economy in the medium to long-term. The Trust s agreed status within SaHF is also important for its forward investment objectives. As a part of the overall reconfiguration programme it has submitted the first stage of a business case for 43.3m of investment in the clinical facilities on the Hillingdon Hospital site. This is critical to developing the capacity required for the Trust to undertake the significant amount of activity and in particular maternity, transferring from Ealing Hospital. Given the nature of the Trust s estate, the investments needed to improve and maintain the highest risk areas will be a long-term process. The SaHF programme does not include the significant investment, approximately 40m, that is required to repair the tower block and podium main hospital building in areas such as the major updating of roofs, windows and other major building and engineering 22

23 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts components. Although there are no immediate safety concerns regarding the tower and podium s facade and windows, the poor thermal efficiency creates an uncomfortable patient environment and the aesthetics of the building are not in keeping with the public s perspective of modern healthcare. One of the key considerations for the Board is how further investment will be sought to ensure the Trust is able to provide high quality modern healthcare in appropriate clinical settings. The Board is seeking to raise this issue through a number of routes including through the SaHF programme and with Monitor. In the meantime, the Trust s annual capital investment is routinely aimed at works that have been assessed as high risk and that for most part are determined by the need for immediate investment that could, if left undone, impact on patient safety. The Trust will also focus on delivering the benefits from its refreshed informatics strategy. These mainly come from risk reduction, quality improvement, more efficient clinical practice and business processes. The strategy recognises patient care can be enhanced by better use of digital and online technology through a series of planned changes to a paper-lite then largely paperless environment. Comparative financial performance Compared to the foundation trust sector as a whole, this is how the Trust performed on a range of key financial performance indicators in The comparative performance table is based on Monitor s most recent available review of the foundation trust sector of 147 trusts, of which 83 were acute, as at quarter To enable a direct comparison, the THH figures reflect performance as at end of quarter Continuity of Services Risk Rating Medium Acute Trusts* Earnings Before Interest, Taxes, Depreciation, and Amortisation (EBITDA) Margin Acute Trusts Operating Cost Reduction from Efficiency Saving The Hillingdon Hospitals NHSFT All NHSFT Average % 5.0% 3.6% 2.9% Capital Spend to Operating Revenue** 5.1% 4.5% Cash Balances*** 6.6m 25.5m Net Borrowing**** 23.0m 39.3m * Monitor defines a medium acute Trust as having total revenue of between 200m and 400m per annum. Ratings are allocated from 1 (highest risk) to 4 (lowest risk). **Due to the planned phasing of major capital works the Trust s capital expenditure increased sharply in quarter 4 and ended the year at 9.1% of operating revenue. *** The majority of the cash balance was required to cover contractually committed capital payments in respect of the emergency care project. **** Net borrowing includes capital investment loans, PFI (LIFT) and finance leases. 23

24 02 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Going concern The financial statements for the year ended 31st March 2014 have been prepared on a going concern basis. After making enquiries, the Directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. In making this declaration, the Board is mindful of the Trust s positive financial performance in including the level of efficiency savings delivered; and that the Trust is a fixed point in the Shaping a Healthier Future reconfiguration of health services in North West London and as such has received transitional funding to ensure the Trust remains financially viable during this transition. The financial statements have been prepared under a direction issued by Monitor under the National Health Service Act Equality, diversity and human rights The Trust as a public health authority is listed under Schedule 19 of the Equality Act 2010 and is therefore required to comply with the equality duties under Section 149 and Regulations This means that when staff are delivering services and carrying out the Trust s functions, they must consciously think about, and pay due regard to, the three aims of the general equality duty as an integral part of the decision making process. Details of the equality duty aims and the Trust s statement, documenting how the Trust is meeting the duty, have been published on the Trust s website. On 31st January 2014, the Trust published its Service Equality Compliance Report and Workforce Equality Compliance Report on the Trust s website. Both reports include actions and initiatives taking place within the Trust to meet the Public Sector Equality Duty and the areas that continue to need addressing are being addressed via the four year objectives set in April The Trust published an update of its objectives in April 2014 and will do so thereafter on an annual basis. The breakdown of the number of male and female Directors, other senior managers and employees at 31st March 2014 is shown below 5. Male Female Directors 10 6 Other senior managers 7 20 Employees 716 2,169 Social, community and environmental issues The Trust is committed to acting as a good corporate citizen. All Trust tenders include a section for prospective suppliers to provide narrative on environmental, sustainability, and ethical issues relating to their offer. This includes information on the suppliers adherence to environmental standards and policies; information on carbon reduction initiatives; and evidence that the supplier s procurement is conducted in an ethical manner that is compliant with current legislation and takes account of relevant environment and sustainability standards. The Trust s contracts with suppliers contain clauses relevant to these issues. The specific duties require public bodies to: Publish relevant, proportionate information demonstrating their compliance with the general equality duty by 31st January each year; Set and publish specific, measurable equality objectives by 6th April 2013 and refresh these annually. The Trust has a Sustainable Development Management Plan that seeks to minimise the organisation s impact on the environment. The plan 5. Directors refers to those listed in the remuneration report as the Directors who regularly attend Board meetings; other senior managers relates to the direct line reports of these Directors; employees includes fixed term and permanent employees. 24

25 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts is overseen by a Sustainability Steering Group that seeks to ensure a whole trust approach to meeting the organisation s sustainability obligations. Reducing our energy use A key element of the Sustainable Development Management Plan is to reduce the Trust s energy use. The Carbon Reduction Commitment Energy Efficiency Scheme (often referred to as the CRC ) is a mandatory scheme aimed at improving energy efficiency and cutting emissions in large public and private sector organisations. The scheme features a range of reputational, behavioural and financial drivers, which aim to encourage organisations to develop energy management strategies that promote a better understanding of energy usage. The total carbon dioxide emissions from gas and electricity at the Hillingdon site in were 6,148 tonnes, and 6,173 tonnes at the Mount Vernon site. The Trust is on track for an absolute carbon reduction target of 10% by 2015 against a 2007 baseline assessment. During the Trust reduced the total energy use by 19,871 Gigajoules (GJ) from the previous year. This was attributed to good incinerator reliability providing steam for the Hillingdon Hospital site, a relatively mild winter and improvements to the operation of the gas boilers for the Hillingdon steam system. Although improvements to the heating system at Hillingdon Hospital have reduced the use of electrical heating, electrical demand has increased slightly linked with increases in clinical activity. The Trust s contract with SRCL to operate the incinerator based on the Hillingdon Hospital site ensures our clinical waste travels a minimum distance before entering the incinerator process; it helps minimise the impact on the environment in that the steam created from burning clinical waste is used to provide 70% of the energy needed to heat the radiators and provide hot water at Hillingdon Hospital, therefore significantly reducing our need for energy sources such as gas and oil. The Estates Capital Programme for has included schemes that have created sustainable improvements and efficiencies in the heating and electrical infrastructure. To ensure further reductions are achieved in respect of electrical consumption during the capital project team have included proximity lighting for all new builds and major refurbishments. This ensures areas such as public toilets and store cupboards are not lit when not in use, with sensors turning lights on and off in response to body movement. Next year further investments are planned in the areas of roof replacement and glazing upgrading, which will help improve the Trust s impact on the environment. Waste reduction and minimisation The Trust s Waste Group has met on a regular basis during the year. Part of its role is to ensure waste is segregated, managed, recycled and disposed of effectively in line with the Department of Health publication Safe Management of Healthcare Waste and the Department for Environment, Food & Rural Affairs Waste Hierarchy. There has been Summary of the Trust s energy use in Gigajoules (GJ) Electricity 61,173 59,851 58,518 56,703 60,209 Gas 89,369 89,327 66,806 87,551 64,164 Steam (incinerator) 79,990 79,991 79,991 69,990 70,000 Total 230, , , , ,373 25

26 02 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts a significant change with the new main waste compound at Hillingdon Hospital that has been designed to handle the volume of recycling and waste materials generated on the site. Training has been extended to the house-keeping teams to enable a higher volume of waste materials to be segregated. The volume and proportion of total waste recycled has increased compared to last year. However the overall volume of waste produced and that sent to landfill both increased. The Trust is progressing with several development and refurbishment projects which has led departments to dispose of items that had become surplus to requirements. An upgrading of the Trust s desktop IT infrastructure also generated significant waste for disposal. Total waste generated at Hillingdon and Mount Vernon Hospitals ,363 tonnes Waste recycled 351 tonnes (26%) Clinical waste incinerated to produce steam that generated heat and hot water at Hillingdon Hospital 545 tonnes (40%) Waste sent to landfill 467 tonnes (34%) 1,476 tonnes 437 tonnes (30%) 537 tonnes (36%) 502 tonnes (34%) Green travel The Trust has continued to promote green travel for staff and service users. Events took place at both hospital sites giving staff the opportunity to learn about changing to greener travel alternatives such as car sharing and cycling to work. The Trust is intending to update its Travel Survey looking at how people travel to hospital. We will also be supporting a wide range of initiatives in the year ahead including Bikewise events and Walk to Work Week, and will work with Transport for London and Hillingdon Council to promote better public transport services to the Trust s hospitals. The Trust has 106 cycle spaces either in bicycle racks or lockable bicycle bins, as part of our encouragement of cycling. Looking ahead: principal risks and uncertainties The preceding pages have highlighted the key issues that have affected the Trust and are likely to shape the delivery of the Trust s strategy over the coming year. In summary, these include the focus on the quality of care provided by the NHS; demographic changes that are increasing the demand for health services; challenges with the Trust s estate; a challenging financial environment; and major policy initiatives such as the Shaping a Healthier Future Programme and the drive for increased integration of health and social care. These factors are reflected in the key risks identified by the Board, which if not managed, will impact on the Trust s ability to deliver its mission and objectives. In the current and forecast operating context these are summarised as follows: Future clinical risks: Through the Shaping a Healthier Future (SaHF) transition of care to Hillingdon Hospital, there is a risk that the Trust is unable to maintain clinical quality as services are transferred, impacting adversely on patients and carers (particularly in relation to maternity and paediatrics). The large emergency care project does not deliver the operational benefits as planned. Failure to meet MRSA or C-diff target. Failure to meet adequate levels of staffing implied in the Francis Report due to financial and trained staff constraints. Failure to reduce weekend Hospital Standardised Mortality Ratio (HSMR). Inability to improve harm free care and variability in ward care. Future financial risks: Commissioning risk that Hillingdon Clinical Commissioning Group s significant out of hospital strategy results in a trust deficit. 26

27 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Commissioning risk if activity is not paid for, potentially leading to clinical and financial viability concerns. Operational and investment cash gets extremely tight and starts to impede on service delivery. Unprecedented size of efficiency savings required in and for the next five years and its impact on quality of care provided. Future estate risks: Access to sufficient resources to keep pace with the scale of short and long term investment that is required to deal with the backlog maintenance. This could exceed the Trust s financial capacity and lead to a failure of the financial plan and interruption of or reduced quality/safety of service delivery. Public access to services and car parking capacity. The Annual Governance Statement contains further information on the risks facing the Trust and the approach to managing these. Shane DeGaris Chief Executive 28th May

28 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Directors report 28

29 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Quality Reporting The Quality Report contains a comprehensive review of the quality of the Trust s services, and the priorities for quality improvement. The following summary outlines some key points of note. Quality Governance arrangements In December 2013 the Trust conducted its selfassessment against the Monitor Quality Governance Framework which highlighted the Trust s position in relation to four key areas: strategy; capabilities and culture; processes and structure; and measurement. This assessment assisted us in identifying the areas where there are robust and effective systems in place and the areas of quality governance that need strengthening. To provide further assurance on our position the Trust commissioned an independent assessment by KPMG to evaluate the Trust s self-assessment and governance arrangements against the Framework; this consisted of 1:1 interviews with key staff, reviewing the evidence collected by the Trust to support its self-assessment, such as our new clinical quality strategy, meeting observations and focus group sessions with staff and patients. KPMG s assessment found agreement with the Trust s self-assessment in most of the domains in Monitor s Quality Governance Framework. KPMG reported that overall the quality governance systems and processes at the Trust appear to be strong, and in particular, the strength of challenge at Trust Board and in sub-committees was robust and appropriate and that this extended into other meetings that are not formally part of the governance structure. In addition, they noted that across all meetings and observations there is a general sense that the culture amongst senior staff and the Board is one of openness, where problems are accepted and the focus is on finding solutions as opposed to a culture of defensiveness and self-protection. KPMG noted that the Board needs to sustain its intentions in maintaining strong governance arrangements in the face of pressures arising from the estate, funding constraints, and Shaping a Healthier Future. The Trust has developed a local action plan in response to the review, which will support delivery of the Trust s overall strategy, the clinical quality strategy action plan, and the quality priorities for outlined in the quality report. The Trust will ensure there is improved alignment in relation to strategic and clinical quality priorities and that measures of success are consistent and clearly communicated, understood and measured from Board to Ward, as recommended by KPMG. LOCAL ACTION PLAN The following information provides an outline of some of the arrangements that are in place in relation to governance and leadership structures that support the Trust in ensuring that the quality of care is being routinely monitored across all services and that poor performance or variation in quality is challenged. There is monthly reporting to the Board via the quality and performance report; this highlights quality issues and improvement through narrative information and performance indicators. Each quarter the Quality and Risk Committee (QRC) receives a much larger quality and patient safety report. This includes mortality indicators that review variance by day of the week and performance in relation to national and regional averages; nursing quality indicators by ward; outcomes of clinical audit; patient feedback from NHS Choices; and external and peer reviews. The Committee also reviews a detailed quarterly overview of complaints in terms of themes and lessons learned and actions taken; claims and litigation data; incidents numbers, severity and themes by clinical division; and medium and high risks on the integrated risk register. Clinical divisions review their quality data in relation to patient safety, patient experience and clinical effectiveness on a monthly basis at their divisional governance boards. A divisional exception report is received by the Clinical Governance Committee and any concerns on quality are escalated to the Quality and Risk Committee. 29

30 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Serious incidents are thoroughly investigated, with panel reports reviewed by the Board. Root cause analysis is used for all serious incident investigations and forms the basis of the report to the Board and the formulation of action plans. There is a programme of regular monthly ward visits, conducted in a structured Observations of Care approach assessing the environment of care, the quality of care being delivered, the nursing documentation, teamwork elements and patient/staff experience. Board members participate in this observation which gives them the opportunity to talk to staff and patients about their experience. The Director of Patient Experience and Nursing has introduced Clinical Fridays which allows the corporate nursing team and divisional senior nurses to work with clinical staff on wards and in departments to experience the environment and delivery of care, and to engage with staff, patients, and their carers. Any issues or concerns raised through this opportunity are escalated accordingly to the Executive Team and Board. There is a robust framework to ensure that all service changes have a Quality Impact Assessment (QIA) which is then reviewed by the Medical Director. Any schemes where there are quality concerns are reviewed at a multiprofessional Clinical Assurance Panel (CAP), with the project leads presenting the scheme and the actions being taken to mitigate any risks to quality associated with the scheme. Listening to Patients and Governors: it is important that there are a range of opportunities to support patients in providing feedback and raising their concerns. This is welcomed by the Trust as a learning organisation which is always striving for quality improvement. Patients can complete local patient experience surveys, provide feedback via the Trust website, via NHS Choices, in person directly to department managers and matrons, or via the PALS/Complaints offices. There is also opportunity for patients and members of the public to attend the Trust s People in Partnership (PiP) meetings and there are also specialty-based focus and support groups, where patient feedback can be obtained. The Board receives patient stories as part of understanding the patient experience; this ensures that the voice of the patient and their families/carers is heard first hand by Board members. Further information on patient and public engagement is contained later in the report. Care Quality Commission (CQC) compliance The Trust is required to register with the Care Quality Commission and is registered without conditions. The CQC paid an unannounced visit in October 2013 as part of their planned review of the Trust. The report issued from this visit stated the Trust is not fully compliant with the essential standards 30

31 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts of quality and safety; one moderate concern was raised (staffing) and there were two minor concerns (cleanliness & infection control, and safety & suitability of premises). The Trust developed an action plan to address the issues raised, and at time of the approval of this annual report (May 2014) awaits further CQC inspection to review its compliance level. The Trust did not declare a risk of non-compliance with the CQC s registration requirements in the Corporate Governance Statement submitted to Monitor in May Information on the actions taken in response to the review is contained in the quality report. The CQC has not taken enforcement action against the Trust during Assurance processes are in place to seek to ensure that the Trust remains compliant with the CQC essential standards of quality and safety. Provider compliance assessments (PCA) are used to ensure the Trust has due processes in place to enable compliance. Reports on the outcome-based review of all the regulated outcomes demonstrate where any concerns with potential non-compliance are arising. These are reported to the Board s Quality & Risk Committee (QRC) and the Audit & Assurance Committee (AAC) which review compliance during the year. Internal Audit undertook their annual CQC compliance audit review in March 2014 and judged the Trust to be at substantial level of assurance. The Trust s Corporate Governance Department examine the CQC s risk profile information and produces a tracker of the Trust s position for review by the Executive Team and senior management. The results are challenged and investigated where required, and discussed with the CQC inspectors as necessary. The CQC changed this system during the year with the intelligence monitoring report replacing the Quality Risk Profile to a new risk banding system. In October 2013 and February 2014 the Trust was rated in the lowest risk band, band 6, under this system. Moving forward, the Trust s processes for CQC compliance will be internally assessed using both the established desk-top review of outcomes, and a revised peer review process which will be based on different levels of review and frequency from daily ward based checks, to monthly Executive/Non-Executive led Observations of Care ward visits and external peer review from another NHS trust. This seeks to reflect the changes the CQC are implementing to the way they regulate and inspect health services. Developments in patient care Further work was undertaken this year to refine our ward level nursing dashboard. This dashboard brings together a number of high level indicators relating to nursing care under the three domains of quality: safety, patient experience and clinical effectiveness. The indicators cover processes and outcomes. Examples of indicators include: Hospital acquired pressure ulcers Patient experience Infection prevention and control audits. patient care The dashboard is updated each month and provides an at a glance view of each ward. The Senior Sister/ Charge Nurse and their Matron meet with the Deputy Director of Patient Experience & Nursing each month at the Nursing Quality Performance Meeting to review their indicators on the dashboard and discuss areas of good performance and areas where improvements are required. The meeting also gives the Sister/ Charge Nurse the opportunity to highlight any specific challenges that they may be facing and seek peer support from their colleagues. Falls This year there has been a particular focus on reducing patient falls. A multidisciplinary falls group has been established. This meets monthly to review incidents of falls and plan actions to reduce the number of inpatient falls. Key actions include: Developing and implementing a Root Cause Analysis (RCA) tool specific to falls. This enables an in-depth investigation and analysis of any fall resulting in harm to the patient to identify care or service delivery problems and any contributory factors. 31

32 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts which strives to provide compassionate patientcentred care. All new staff receive awareness training as part of the Trust s induction programme. In addition this year, more detailed dementia training has been offered to clinical staff, delivered by experienced senior nurses. Over 90% of Registered Nurses and Health Care Assistants on Hayes and Beaconsfield East Wards have attended this training, as well as a number of therapy staff. The programme has started to be rolled out to other wards. Developing and implementing a new falls risk assessment and associated care plans. Introducing non slip socks for patients, now available on all wards. Trialling low rise beds. Work on reducing harm from falls will continue next year with the continued implementation and embedding of Fallsafe recommendations which were developed by the Royal College of Physicians following a two year research project across 17 inpatient wards in the South East. A learning culture The Berwick report published in August 2013 highlighted the need for learning and continuous improvement in patient safety. Following a root cause analysis (RCA) for a fall or any grade 3 or 4 hospital acquired pressure ulcers a sharing the learning memo is circulated to the senior nurses in each clinical division. In addition the Senior Sister/Charge Nurse presents their RCA, including the key learning and actions taken to prevent reoccurrence, at divisional governance forums and the monthly Care Accounts (Senior Sister/Charge Nurse) meeting. Dementia care Much work has taken place this year as the Trust progresses on its journey to become a dementiafriendly organisation. The first step towards achieving this is to have a dementia-aware workforce Early diagnosis of dementia can improve the quality of life for patients and their carers. The national dementia CQUIN (Commissioning for Quality and Innovation) 6 target aims to improve the rate of diagnosis, and where appropriate, referral to specialist services in patients over 75 years of age. Delivering this has been a huge challenge, but thanks to the drive and dedication of both clinical and administrative staff over 70% of relevant patients are receiving a screening assessment. While it is disappointing not to have achieved the target of 90%, this is a huge improvement compared with the previous year. Work continues to ensure even more patients undergo screening next year. The experience of carers has also been considered this year, with an audit being undertaken of their experience whilst their relative was an inpatient. Learning from this has led to the development of dementia information resource folders. The environment of care also influences the quality of patient and care experience. The Trust was notified in June that it had been successful in its bid to the Department of Health to fund dementiafriendly improvements on Beaconsfield East rehabilitation ward, as part of a research project to inform future guidance across the NHS. We received 854,000 to create an environment with both quiet and stimulating areas and a sensory garden. Artwork and colour have been used to create a less clinical environment and aid orientation, which is further enhanced by colour-coded furniture. New 6. Further information on CQUINs is available on page 34 in the quality report. 32

33 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts flooring and dementia-friendly lighting have been installed and each bay has access to a new garden terrace. Patient facilities have been increased by the provision of a day room where patients can take their meals a sensory room, and a therapy kitchen. The ward re-opened at the end of February 2014 and clinical staff are developing new models of care to make full use of the new facilities to maximise the quality of patient experience. Nurses, estates staff, therapists and physicians, in consultation with patients and carers, worked closely to ensure delivery of this exciting scheme within a demanding timescale; it is hoped the ward will provide a template for future refurbishments in other areas across the Trust. The Trust launched its Dementia Strategy in December, which will ensure work continues to deliver objectives that are supportive of local need and in line with the National Dementia Strategy. Patient nutrition The corporate nursing team has continued to work closely with Age UK representatives embedding a programme of monthly mealtime observational assessments. Since 2011, Age UK Hillingdon has conducted unannounced visits to ward areas to provide an informed view of the standards of care, specifically related to nutrition, dignity and compassion towards the elderly. The wards are chosen on the day by Age UK and the assessment incorporates an observation of mealtime practices, review of records related to nutrition and hydration, and feedback from patients, carers and staff. The tool used is aligned to the key elements from the Age UK Hungry to be Heard campaign. Feedback is given on the day of the assessment and this is followed by a written summary that highlights areas of good practice and areas for improvement. The outcomes are reported both to the Board and to the area visited. Staffing In line with the recommendations in the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry the Trust has undertaken a review of the nursing establishment and skill mix. The approach taken was aligned with guidance published by the National Quality Board in 2013, ensuring that evidence-based tools in conjunction with professional judgement and scrutiny were used to inform safe staffing requirements. The review has led to an adjustment to the nursing levels on some 33

34 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts wards. A further review using the same approach will be carried out later in Delivery of quality targets agreed with the Trust s commissioners Commissioning for Quality and Innovation (CQUIN) is a national framework for locally agreed quality improvement schemes. It links a proportion of healthcare income to the achievement of local quality improvement goals. CQUINs are divided between those that are set nationally for all hospitals, those which are set regionally, and those are agreed locally between the Trust and commissioner. In there were ten CQUIN schemes relating to the Trust s acute services, six of which were locally derived by Hillingdon CCG. At the time of writing, there is potential achievement of 80% of the maximum possible CQUIN income, compared to 73% that was achieved in This will equate to around 3m of income in compared with 2.7m in Detail on these schemes and the Trust s performance against these is included in the Quality Report. Patient public and stakeholder engagement Improvements following patient feedback The Trust has a number of approaches to gathering patient feedback. Our real time patient survey system captures the views of our inpatients, outpatients, maternity patients, children and teens. The Friends and Family Test (FFT) for inpatients and patients who are seen, treated and discharged from the Emergency Department was implemented in November 2012, the test was then rolled out to patients using our maternity services in October In over 28,400 people have completed one of our surveys, giving feedback about their experience. Results and comments from the surveys are reviewed alongside other feedback such as complaints, NHS Choices feedback, and national patient survey results. A selection of the measures in place or underway to respond to feedback are presented below. Many others are put into action by individuals and teams at the local level. Call bells In response to patient feedback and a drive to be responsive to the personal needs of patients, the Trust developed and implemented a call bell standard. The standard sets out our aim to answer nurse call bells within two minutes, but never any longer than five minutes. It is pleasing to see that we have seen an improvement in the related question in our national patient survey results since introducing our standard. The inpatient Friends and Family Test comments are reviewed every month to identify good practice and areas for improvement; this enables us to identify any specific wards where patients may report a concern about call bells on an ongoing basis. Comfort at Night Campaign The Trust received patient feedback related to noise and light at night along with some comments related to nurses responsiveness to patients needs at night. As this was across a number of wards, group work was undertaken at our monthly Senior Sisters/Charge Nurse meeting to discuss the concerns and come up with ideas for improvement. A Comfort at Night Campaign was launched supported by our Director of the Patient Experience & Nursing. The aim of the campaign is to: Create the right conditions to reduce sensory overload and enhance comfort at night. The campaign involves a number or activities or interventions related to factors that could have an effect on a patient s comfort at night. Actions underway include: Setting a standard for the main ward lights out or dimmed at night and lights on in the morning. Working towards changing all waste bins in, or close to, sleeping environments to silent closing models. 34

35 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Alerting and explaining to any patients who may be awoken early for medication or any other planned interventions. Support patients to maintain their own normal personal hygiene routines, such as cleaning teeth and soaking dentures before bed. Ensuring that there are sufficient pillows and blankets available. Lowering voices and being aware of the impact of staff conversations and discussions in an environment that is quieter, especially when close to sleeping areas. Ensuring that shoes adhere to uniform policy and do not create noise. The Trust is looking to provide eye masks and earplugs to those patients who would like them. Parkinson s alarm A patient raised a concern on his Friends and Family survey about a delay in receiving his Parkinson s Medication. After reviewing information on the Parkinson s UK website about the Get it on time (a campaign that is a national initiative by Parkinson s UK to ensure that patients get their medication on time, every time) we have taken a number of actions. These include introducing: A Get it on time symbol on our new electronic whiteboards which are used as part of our shift handover. The symbol is used in the clinical indicator column to show that the patient has Parkinson s and requires extra vigilance around the timing of medication. A Parkinson s alarm: this is a simple alarm clock that is used to set a reminder for when medication is next due. The clock is kept in a stand that is handed over between shifts. The stand has information related to get it on time included with it. This is currently being trialled on one ward. Get it on time Wheelchairs A complaint was received that highlighted the distress caused to a gentleman who struggled to find a wheelchair to transport his frail elderly mother from his car into the Emergency Department; a similar concern was also raised through our Patient Advice & Liaison Service (PALS) department. As a result of this feedback the Trust purchased wheelchairs for the use of visitors and the public. These are located at entrances and exits across the site. 35

36 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Complaints Number received Performance % 77.5% 83.5% 76.1% 73.6% Complaints are an important source of patient feedback. In the Trust received 405 complaints, a fall of 19% from the previous year. The response rate was 73.6% which means that 298 of the 405 complaints were answered within the timescale agreed with the complainant. The number of complaints received year by year s shown in the table above, together with our performance in responding within the agreed timescale. The number of complaints registered for response across the year is detailed below and shows a wide variation month by month. the team to maintain output but there was a lack of stability and systems in place. Following a new permanent appointment to the Complaints Manager post in December 2013, enhanced processes were established and new ways of working introduced to align the process to that set out in the Ombudsman s Designing Good Together report. It is useful to analyse the number of complaints received across the various divisions year by year, as this is one way of demonstrating the impact of service improvement measures and learning from past complaints. It is important to note that the Complaints Management Unit went through a period of significant change this year, with the long term Complaints Manager leaving, followed by the two Complaints Administrators. Between May and November 2013 temporary staff were seconded into With the exception of the Division of Cancer and Clinical Support Services (CSS), which saw a 30% increase in the number of complaints received during the current year, all other divisions saw a decrease. It is particularly encouraging to see a reduction of 39% in the Division of Surgery and Complaints 2013 to 2014 Number Performance % Complaints due for response Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 36

37 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Number of complaints registered by Division each year CSS Medicine Other Surgery Womens & Children 35% in Women s and Children s Division. The Division of CSS are investigating the themes behind this increase in order that any appropriate action can be taken. The performance figures by Division are shown below. These are the percentage of complaints that were closed within the timeframe agreed with the complainant. With the Trust target set at 90% there is room for improvement across the board. An analysis of the performance for the first three quarters of the year identified that the complaints team was working on a just in time basis. This meant that there was limited time to get the response letters approved or to collate additional information if the reply was not complete. The new Complaints Manager implemented a number of control measures in order to enhance performance and support the divisions in meeting their deadlines. The focus of these measures is twofold timeliness and quality of response. Timeliness A diary system was established with effect from 1st January 2014 whereby all complaints registered on the Trust s incident reporting system Datix now have a diary card set up on the date the management plan is sent out, with specified actions to be taken on identified due dates. This is managed daily by the Complaints Management Unit. In Q4 the number of complaints that breached their deadline saw a month by month reduction; falling from 17 in December, to eight in January, five in February and three in March. In addition, the closure rate for complaints through the month was more evenly spread and no longer last minute, easing the team s relationships with the divisions and CSS 95% 93% 91% 80% Medicine 73% 84% 73% 69% Other 93% 100% 82% 63% Surgery 72% 72% 69% 78% Women s & Children s 85% 96% 83% 86% 37

38 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts encouraging them to provide more timely responses going forward. have submitted comments on both and await the final outcome. Across Q4 84% of complaints closed within the agreed timeframe, each month showing a better performance than the previous one. Quality The complaint response template letter was redrafted to provide a clearer, more methodical response to all complaints. It has helped to focus attention on whether the investigation has actually addressed the complaint that was put to us. The Complaints Manager has rejected a number of investigation reports because they were not robust, or did not address the complaint that was raised. There has been a need to ensure the divisions are undertaking investigations in an open and accountable way. The benefits of this approach will become more evident over the coming year. The outcome of this focus on quality will be to reduce the number of complaints that return to us to be reopened for further investigation. As at 31st March 2014 there were seven reopened cases, two of which were reopened in 2012 but remain unresolved. The management of reopened cases will now be controlled under the same diary system mentioned above, so that timely responses are issued and we make it clear to complainants when local resolution has been completed. After completion of local resolution, a number of complainants will take their complaint to the Parliamentary & Health Service Ombudsman (PHSO). This is not necessarily a reflection of the quality of our response but often just a disagreement with our findings. An analysis of the number of referrals to PHSO is therefore of limited value; the outcome of the independent review is key. As at 31st March 2014 there were eight complaints with the Parliamentary & Health Service Ombudsman (PHSO). Seven of these were referred to PHSO during the year under review; one was referred there in We have received draft investigation reports on two of these complaints and the Ombudsman s proposal is to uphold the complaint in part or whole. We Moving Forward It is vital that, as a trust, we embrace the learning that has emerged from the Francis Report and the Clwyd review. The Ombudsman comments on the toxic cocktail that arises from a culture of defensiveness in hospitals, the reluctance of staff to hear and address concerns, and the ensuing reluctance of patients, carers and families to complain. The Complaints Management Unit will play an active part in supporting this shift and ensuring the Trust exceeds the expectations of those who have reason to complain or raise concerns. Improvements in patient and carer information During the Patient Information Review Group continued to work with staff across the hospital to develop new patient and carer information and to refresh existing information. moving forward Our Readers Panel, service users, and patient involvement groups support Trust staff to ensure that the information we produce is clear, jargon free and user friendly. For example, our Fighting Infection Together (FIT) public involvement group worked with the Trust Infection Control Team to review and update an MRSA leaflet and Clostridium Difficile leaflet. The information leaflets provide patients with information about the infection, symptoms and treatment. A Working Together leaflet has been developed this year and will be available early in This leaflet explains our aim of wanting patients to feel safe, comfortable, informed, and involved during their stay in hospital. It describes how staff will work together with the patient to ensure that we achieve this aim, setting out what patients should expect. The leaflet also includes a helpful checklist to prompt patients to think about what they may 38

39 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts need to know before going home and a leaving hospital section where follow up arrangements can be entered. In line with recommendations from the Francis Inquiry Report the leaflet also contains a box where the names of the consultant and the senior ward sisters/charge nurses can be added. The Trust has developed a number of paediatric leaflets which are reviewed by parents prior to publication and distribution. Examples of leaflets are: Allergy Leaflets, such as egg and latex Welcome to the Paediatric Department. The Trust is developing a guide for mothers and families who lose a baby in early pregnancy explaining the different options for funeral arrangements. The guide is being developed in response to feedback from a mother who was not aware that she could arrange a private funeral. Other condition/service specific information produced this year includes: Short Synacthen test Prolonged glucose tolerance test Fractured Neck of Femur Using strong opioids to manage pain. Consultation and engagement The Trust is committed to involving and consulting with members, patients and the local community in the planning of service provision, the development of proposals for change, and decisions about how services operate. The Trust continues to engage and consult with service users, public and the wider local community in decisions about general service delivery to ensure that services are designed and adapted to better respond to individual needs. Examples include the transfer of services to an out of hospital location and the development of a midwifery-led unit. The Governors and members will clearly have an important role in any consultation and engagement on major service changes. However the Trust will seek to ensure that such engagement reaches beyond our membership, particularly where a group that is underrepresented in our membership is affected. The Trust is actively involved in the North West London Shaping a Healthier Future (SaHF) programme. Regular updates are provided by the Chief Executive and Trust management at our People in Partnership (PIP) meetings and during staff briefings. Updates are also provided to members via the Foundation Trust magazine (The Pulse). A programme of future engagement is being planned to engage staff, public and patient representatives in the project development. The Trust did not undertake any formal consultations in the past year. A selection of examples of public engagement activities undertaken during the year are outlined below: Members of the Board have attended Hillingdon Council s External Services Scrutiny Committee on three occasions during In April 2013 the Chief Executive and Medical Director presented the Trust s draft Quality Report. In June 2013, the Chief Executive, Chief Operating Officer and Medical Director provided an update on developments at the Trust and those planned for the year ahead. In September 2013, the Chief Executive and the Executive Director of Patient Experience & Nursing provided an update on the provision and performance of Trust services, with a particular emphasis on nursing care. The Trust continues to hold bi-monthly meetings of its People in Partnership forum. These events enable the Trust to listen to the views and opinions of the communities we serve; share information about the Trust s current and planned activities; and provides an opportunity for members to meet and communicate with staff, Governors and fellow members. People in Partnership meetings are organised by the Lead Governor and Head of Patient and Public Engagement, and are chaired by a Public or Staff Governor. Meetings are rotated between a hospital and community setting with some of the meetings held during the day. These changes have helped attract new members and led to different issues being raised. 39

40 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Governors, members, patients and the public are offered the opportunity to get involved in projects and groups such as Fighting Infection Together, Maternity Services Liaison Committee, People Improving Cancer Services, Readers Panel and the Patient-led Assessment of the Care Environment (PLACE). A focus group of public members was held in September 2013 to help inform the priorities in the quality report. meetings. This year the Trust has worked closely with Healthwatch on the consultation for the priorities for the quality report, Patient-led Assessment of the Care Environment (PLACE) inspections and follow up action. The Chief Officer of Hillingdon Healthwatch holds regular meetings with the Trust s Chief Executive and Director of Patient Experience & Nursing to discuss health care issues. As part of our commitment to engage with, and better understand the needs of our black and minority ethnic (BME) population, members of staff met with a local Afghan Women s group to discuss their experiences and expectations of our services. The aim was to bring together the views of a group of Afghan mothers who had a recent experience of having a baby at Hillingdon Hospital; to capture and understand their experiences, manage expectations, improve their experience for the future and measure improvements over time. It was also an opportunity for members of staff to provide information about maternity services provided by the Trust. Over the last year and following engagement such as this with user representatives, there has been an increase in volunteer applications from minority communities. This highlights our commitment to involve users which, in turn, adds value to our service and provides an opportunity for individuals to gain valuable work-place skills prior to pursuing a career in health and social care. The Trust sought the views of carers and patients with dementia as well as the Hillingdon Alzheimer s Society throughout the design of the project to create a dementia friendly environment on Beaconsfield East ward. The Trust has continued to work in close partnership with Healthwatch Hillingdon and appreciates the valuable contribution that Healthwatch provides to the organisation. Representatives from Healthwatch have regularly attended focus groups and committees and are regular attendees at our People in Partnership The Trust has a number of regular patient support groups providing information and improving awareness on: Age related macular degeneration Glaucoma Care of the colon ( semicolon group ) Psoriasis Cardiac care. The sessions are delivered by clinicians and are organised both in the hospital and in the community. For example, the Trust organised a visit to the local Hindu/Jain community to speak about diabetes and treatment to a section of the community who have a high rate of diabetes; over 100 attendees appreciated the opportunity to listen and ask questions about diabetes and the importance of diet and exercise as a means of controlling blood sugar levels. The Trust s Head of Patient & Public Engagement manages the Foundation Trust Office and has a central role in coordinating the Trust s relationship with third party voluntary organisations such as the Hillingdon League of Friends, the Mount Vernon Comforts Funds, Hillingdon Diabeticare, Hospital Radio Hillingdon and Hospital Radio Mount Vernon. The Trust has a further 100 volunteers who represent the local community by volunteering on wards and in departments at both Hillingdon and Mount Vernon Hospitals. Our staff Staff consultation and engagement The Trust has a range of mechanisms for communicating information on matters of concern 40

41 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts to staff including regular communication from the Chief Executive, and the Team Brief an electronic monthly update. The magazine for staff and public members of the Foundation Trust, The Pulse, is distributed throughout the Trust s hospitals. There is a weekly General Information bulletin to communicate other information such as upcoming events or policy changes. Hospital management and union representatives meet regularly at the Joint Negotiating and Consultative Committee to share information and discuss a broad range of subjects that may affect staff. Seven members of the Council of Governors are elected by staff; and a further Governor is appointed by the Joint Negotiating & Consultative Committee in recognition of the importance of partnership working between the unions and Trust management. Staff members are actively informed and encouraged to contribute to the Trust s performance via the above communication mechanisms and specific briefing items. Open briefing sessions with the Chief Executive are held regularly at both hospitals. Bright ideas, the Trust s Staff Suggestion Scheme was launched in This scheme asks for suggestions from staff on a wide range of ideas they may have including ways of saving money, time, or making improvements in our hospitals. One example of a change made as a result of a suggestion put forward by a member of staff was the painting of a zebra crossing at one of the entrances of the hospital to improve safety for pedestrians crossing at this point. CARES CARES is the acronym used to describe the Trust s core values of Communication, Attitude, Responsibility, Equity, and Safety. These values were developed in consultation with Trust staff and were launched in 2011 to clearly define the underpinning behaviours expected from all staff in the delivery of high quality and patient centred care. Since the launch significant work has been undertaken to promote and raise awareness of these values in a variety of ways. There are now 29 CARES Ambassadors, made up of our staff from a range of backgrounds including consultants, domestics, administrative and clerical staff, nursing, midwifery and therapies staff. These staff have volunteered their time to bring the CARES values to life by raising awareness, advocating the behaviours and helping staff to understand how to incorporate them into everything we do. This year they launched the Show you CARES day giving staff the opportunity to recognise the work of individuals or teams. In 2013 bespoke customer care and leadership training programmes were rolled out across the Trust, which incorporate the CARES values. The customer care training was developed using the CARES framework, patient complaints and feedback from patients and staff. Progress this year has been notable, with the CARES programme shortlisted for two national awards and receiving the runners up award from the Patient Experience Network. In addition, the national staff survey shows an 8% increase in the number of staff aware of the CARES values. Future priorities will include the further embedding of CARES through values based recruitment, the launch of the Trust s Staff Awards in April 2014 and continuing the roll out of the customer care training. Progress will be communicated to staff using a variety of methods, including The Pulse, Team Brief, and other appropriate communication channels. 41

42 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts NHS staff survey Summary of performance The NHS staff survey provides the Trust with valuable feedback on the views of our staff. In 2013, 45% of staff responded to the national staff survey compared to 44% in 2012, and a national response rate of 49%. Overall, staff engagement was above (better than) average when compared to other acute trusts and an improvement on In the survey, Trust staff gave more positive comments compared with other Trusts on a range of issues. These included staff motivation, recommending the Trust as a place to work or receive treatment, feeling satisfied with the quality of work they are able to deliver, and staff appraisals. The largest local change from the 2012 survey saw the percentage of staff working extra hours reduce from 75% to 68%. Scores were less positive than other trusts on: support from immediate line managers, team-working, receiving health and safety training and equality and diversity training, availability of hand washing materials, incident reporting measures, staff feeling pressure to attend work when feeling unwell, staff feeling able to contribute towards improvements at work, job satisfaction, equal opportunities for career progression, and staff experiencing discrimination at work. Tables 2 and 3 identify the Trust s top and bottom ranking indicators. Table 1: Trust Response Rate Trust Improvement/ Deterioration Response rate Trust National Average Trust National Average 44% 50% 45% 49% Increase by 1% point Table 2: Trust s Top Four Ranking Scores Trust Improvement/ Deterioration Top Four Ranking Scores Trust National Average Trust National Average KF8 Staff receiving a wellstructured appraisal in last 12 months KF7 Staff appraised in last 12 months KF13 Staff witnessing potentially harmful errors, near misses or incidents in the last month KF1 staff feeling satisfied with the quality of work and patient care they are able to deliver 46% 36% 46% 38% No change 94% 84% 93% 84% Decrease by 1% point 29% 34% 28% 33% Decrease by 1% point 79% 78% 82% 79% Increase by 3% point 42

43 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Table 3: Trust s Bottom Four Ranking Scores Trust Improvement/ Deterioration Bottom Four Ranking Scores Trust National Average Trust National Average KF10 Staff receiving health and safety training in last 12 months KF27 Staff believing the trust provides equal opportunities for career progression or promotion KF28 Staff experiencing discrimination at work in last 12 months KF17 staff experiencing physical violence from staff in last 12 months 65% 74% 66% 76% Increase by 1% point 84% 88% 82% 88% Decrease by 2% 15% 11% 15% 11% No change 4% 3% 3% 2% Decrease by 1% Future priorities The Trust s priorities around the staff experience for will be informed by the national staff survey, closely linking with the CARES programme. These priorities will include: Publicising the staff survey results for 2013 throughout the Trust utilising various communication channels. Further analysing the results to identify and address any significant directorate or staff group differences. Implementing changes to the frequency and method of delivering statutory and mandatory training including health and safety and equality and diversity. This work has already started with the implementation of self service for training and more options around e-learning and e-assessment. Setting up of a Dignity at Work group as part of the CARES programme to promote the Dignity at Work Policy and focus on issues arising around staff experiencing harassment, bullying and abuse from the public and staff. We will communicate the outcome of this work to all staff as soon as possible. Friends and Family Test In 2014 the Trust will implement the staff Friends and Family Test (FFT) which is required of all NHSfunded acute, community, ambulance and mental health organisations. The FFT for NHS staff is a short two question survey which asks staff whether they would recommend the NHS service they work for, to friends and family who need treatment, or as a place to work. The annual staff survey asks similar questions, however the staff FFT will be measured more frequently, on a quarterly basis. There is growing evidence to suggest strong links between employee engagement, employee advocacy and the quality of care provided and received. As a result of the information that will be gathered from the staff FFT, and the frequency of the test, the Trust will be able to identify and address areas of concern quickly. Policies in relation to disabled employees and equal opportunities The Trust has an Equality and Human Rights Policy and a single equality scheme which set out very clearly for our staff, patients and the community that we are committed to delivering an equality 43

44 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts and human rights-based approach to healthcare. The policy outlines how we will provide equality and fairness for all those in our employment and not discriminate on grounds of any of the legally designated protected characteristics (gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, gender, sexual orientation, disability, and age). The Trust s policy is implemented in accordance with all current legislation relating The Equality Act The Trust is accredited with the two-ticks symbol which is awarded by Job Centre Plus to employers who have made commitments to employ, retain, and develop the abilities of, disabled staff. In April 2014 the Trust updated its Equality Objectives with specific objectives around staff culture and values, including fair and inclusive recruitment processes. Progress against this objective is monitored by the Experience and Engagement Group. Occupational Health and sickness absence data The Trust has an Occupational Health department who provide advice on how to protect individuals from harm, to help identify all those aspects of health which affect employees capacity to work efficiently, and improve their quality of life in a safe working environment. Staff have access to the Employee Assistance Programme (EAP) and a free confidential helpline that can provide advice and support on a range of issues such as financial difficulties, workplace difficulties, and health and wellbeing. Information on sickness absence is contained in note 6.2 to the accounts. Regulatory ratings Health and sickness Monitor, the independent Regulator of Foundation Trusts, assigns Foundation Trusts two risk ratings each quarter. During Monitor introduced a revised regulatory regime to take account of the changes introduced by the Health & Social Care Act 2012 which established a system whereby Monitor licences providers of NHS services. Until 30th September 2013 Foundation Trusts (FTs) were subject to Monitor s Compliance Framework under which FTs were given: A financial risk rating (rated 1-5, where 1 represents the highest risk and 5 the lowest); and A governance risk rating (rated red (highest risk), amber-red, amber-green or green (lowest risk)). The financial risk rating was based on a range of metrics across four areas: achievement of plan, underlying performance, financial efficiency, and liquidity. The governance risk rating was based on a combination of: service performance (measured on the Trust s performance against key performance indicators selected by Monitor from the Department of Health s Operating Framework); the views of third parties such as the Care Quality Commission and the NHS Litigation Authority; the provision of the mandatory services that foundation trusts were required to provide; and other instances where the Board had failed to accurately certify on their performance or governance. In addition, Monitor had the discretion to amend the governance risk rating should a foundation trust fail to meet the statutory requirements of other bodies. For the period of that the Compliance Framework was in place the Trust had a financial risk rating of 3, and a green governance rating. This was consistent with the ratings expected by the Board in the Trust s Annual Plan. This performance was also consistent with the performance during The green governance rating reflects the Trust s strong performance against the required performance targets including those relating to healthcare associated infections and access to services. From 1st October 2013 the Risk Assessment Framework replaced the Compliance Framework. As part of these changes the financial risk rating was replaced by a continuity of services rating and the nature of governance rating changed. Whilst the existing financial risk rating was intended to identify breaches of FTs terms of authorisation on 44

45 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts financial grounds, the continuity of services risk rating identifies the level of risk to the ongoing availability of key services. The continuity of services risk rating incorporates two measures of financial robustness: a. liquidity: days of operating costs held in cash or cash-equivalent forms, including wholly committed lines of credit available for drawdown; and b. capital servicing capacity: the degree to which the organisation s generated income covers its financing obligations. A rating of 1 to 4 is given for each of these two areas and the overall continuity of services rating is the average of the two measures, rounded up. A rating of 4 is the lowest risk, whilst 1 indicates the highest level of financial risk. As before, the governance risk rating continues to be generated by Monitor considering a range of information about an FT. From 1st October 2013 this information covers the following areas: Performance against national access and outcomes requirements Care Quality Commission judgements Third party information Quality governance indicators Continuity of services and aspects of financial governance. Monitor can also consider any other relevant information when calculating the governance risk rating. Where there are no grounds for concern at a trust, Monitor will assign a green rating. Where Monitor has identified a concern at a trust but not yet taken action, it will provide a written description stating the issue at hand and the action it is considering. A red rating will be assigned when Monitor has begun enforcement action. The Trust has retained its green risk rating under the new framework, as it continues to perform strongly against the nationally set performance targets. It improved its continuity of services risk rating with an actual overall rating of 3 compared to an expected score of 2.5 (3). The liquidity measure of the overall rating ended the year at 3 compared to an expected score of 2, which was due to the actual timing of cash required to service capital investment. A full quarter by quarter breakdown of the Trust s risk ratings in and is presented below. There have been no formal interventions by Monitor at the Trust. Annual Plan Q Q Q Q * Under the Compliance Framework Financial risk rating Governance risk rating Green Green Green Under the Risk Assessment Framework Continuity of Service rating 4 3 Governance rating Green Green Annual Plan Q Q Q Q Under the Compliance Framework Financial risk rating Governance risk rating Green Green Green Green Green *The Q4 risk ratings are based on the Trust s submission to Monitor at the end of April 2014: the Trust does not have Monitor s confirmed Q4 ratings at the time of finalisation of the report (May 2014). 45

46 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Financial and other public interest disclosures Research and development The Trust is committed to the NHS Research & Development (R&D) agenda and supports clinical trials which help to establish if new treatments are safe, have any side effects, and are better than those already available. All of our research activity is scrutinised for quality and compliance to the standards expected by the Research Governance Framework. In addition we work to comply with the Department of Health National Institute of Health Research (NIHR) objectives. The majority of the Trust s research and development activities are NIHR portfolio adopted multi-centre studies where the Trust acts as a recruiting site on behalf of the lead centre. Our research portfolio is a balance of observational and treatment studies across many clinical areas including cancer, stroke, haematology, cardiology and many of the general medicine and surgical specialities. This year we plan to become more active in research in ophthalmology, obstetrics and rheumatology. The Trust also supports a small number of studies undertaken by our own staff and students from the local universities undertaking PhD and Masters courses. The R&D Team based at Hillingdon Hospital inform patients about research that is relevant to them and offer, to those who choose to, the opportunity to take part in clinical trials. Participation in research and development enables patients to access new treatments that would not have otherwise been available and supports our clinicians to stay abreast of the latest treatments whilst helping to improve the quality of care provided. Information governance The Trust takes its responsibility to keep personal data safe very seriously. New staff receive information governance training during induction in their first week at the Trust and it is mandated that all staff undertake information governance training annually. The Board is required to annually certify against the Trust s compliance with NHS information governance standards via the Information Governance Toolkit. In October 2013 the Trust received an Information Commissioner s Office (ICO) Ruling following a patient data loss in June 2012 (this was detailed in last year s Annual Governance Statement). The Ruling, which the Trust agreed and signed, was a formal undertaking to demonstrate compliance with the Data Protection Act. The actions required were duly acted upon and monitored through the Trust s Information Governance Steering Group. In January 2014 the ICO undertook a desk-top review of evidence to ascertain if the Trust had sufficiently followed through the actions required. The ICO were satisfied that the Trust had appropriately addressed the actions agreed in the undertaking. The table below contains details of other reported personal data related incidents as categorised by the Department of Health. Summary of personal data related incidents in Category Nature of incident Total I II III Loss/theft of inadequately protected electronic equipment, devices or paper documents from secured NHS premises Loss/theft of inadequately protected electronic equipment, devices or paper documents from outside secured NHS premises. Insecure disposal of inadequately protected electronic equipment, devices or paper documents IV Unauthorised disclosure 2 V Other 0 46

47 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts The Hillingdon Hospitals NHS Foundation Trust has complied with the cost allocation and charging guidance issued by HM Treasury. There is no additional charge for material made available to meet the needs of particular groups of people, e.g. in Braille or other languages. has taken place. New terms of reference and committee membership will be in operation in the next financial year. The Committee will consist of clinical and non-clinical senior managers from across the Trust and its main purpose will be health and safety strategy implementation and planning. Policies and procedures in relation to countering fraud and corruption The Hillingdon Hospitals NHS Foundation Trust will not tolerate any form of fraud, bribery or corruption by, or of, its employees, associates, or any person or body acting on its behalf. The Trust is committed to ensure that the number of offences is kept to a minimum and that all allegations will be investigated thoroughly and the strongest sanctions including criminal sanctions will be taken against anybody found to have committed a fraud, bribery or corruption offence. The Trust engages TIAA (The Internal Audit Agency) as its Local Counter Fraud Specialist (LCFS) in accordance with Secretary of State Directions to support its work in this area. The Trust s Audit & Assurance Committee agrees the annual work-plan for the LCFS and receives sixmonthly reports on progress against its delivery. The Committee has agreed the Trust s policy for dealing with suspected fraud, bribery and corruption. Health and safety Through its Health and Safety Strategy the Trust continues work towards best practice standards of health and safety for all our staff in the workplace, for members of the public, patients, and others who come in to our premises. Health and safety governance: The Health and Safety Committee has met quarterly and the Board has received quarterly reports on health and safety issues and performance throughout the year. Following an internal audit review of health and safety that gave an opinion of limited assurance, a review of the Trust s Health and Safety Committee A fire safety audit was also undertaken by the Trust s internal auditors which gave an opinion of adequate assurance. Following this, a more robust process for local fire safety management has been implemented and the number of fire wardens and marshals required for each ward and department has increased. Training: All new members of staff receive health and safety training during their corporate induction and are able to access refresher training via an e-learning package and face to face courses. Fire safety training has been completely reviewed and as a result, attendance has increased. Performance: During this reporting period there were a total of 1,423 incidents reported indicating a downward trajectory in incident reporting resulting in a 26% (513) decrease. 33 of these incidents were reportable to the Health & Safety Executive (HSE) under RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrence Regulations). Non-NHS income Section 43(2A) of the NHS Act 2006 (as amended by the Health and Social Care Act 2012) requires that the Trust s income from the provision of goods and services for the purposes of the health service in England must be greater than its income from the provision of goods and services for any other purposes. In , the Trust met this requirement, with 96% ( 197m) of the Trust s income generated by activities for the purpose of the health service in England. As the vast majority of Trust income is categorised as generated by activities for the purpose of the health service in England, it is the Board s view that other income does not detract from NHS provision to any material extent. Where other income is 47

48 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts generated it supports the Trust to make optimum use of all its assets and is used to directly support principal patient care activities. Financial risk management In relation to the use of financial instruments, an indication of the financial risk management objectives and policies of the Trust and the exposure to price risk, credit risk, liquidity risk and cash flow risk can be found in note 1.37 of the accounts. Employee benefits Accounting policies for pensions and other retirement benefits are set out in note 1.10 of the accounts. Details of senior employees remuneration can be found in the remuneration report. The NHS Foundation Trust Annual Reporting Manual states that it is best practice for NHS Foundation Trusts to disclose the number of, and average additional pension liabilities for, individuals who retired early on ill-health grounds during the year. Two staff retired on grounds of ill health at a cost of 77k. In , there were four such staff retirements at a cost of 165k. The Trust is not liable for the cost which is borne by the NHS Business Services Authority. This disclosure is shown in note 6.3 of the accounts. Payment of creditors The Trust aims to comply with the Better Payment Practice Code which is that 95% of invoices in terms of numbers and value are paid by the due date of payment. Details of the Trust s compliance in this matter can be found in note 7.1 of the accounts. The Board confirms that for each individual who was a Director at the time that this report was approved (28th May 2014): So far as the Director is aware, there is no relevant audit information of which the NHS Foundation Trust s auditor is unaware; and The Director has taken all the steps that they ought to have taken as a Director in order to make themselves aware of any relevant audit information and to establish that the NHS Foundation Trust s auditor is aware of that information. Important events affecting the Foundation Trust occurring since the end of the financial year The Board confirmed at its meeting on 28th May 2014 at which this annual report and accounts were approved, that there were no events that required disclosure. Directors statement on the annual report and accounts At the time of approval (28th May 2014) the Directors consider the Annual Report and Accounts, taken as a whole, is fair, balanced and understandable and provides the information necessary for patients, regulators and stakeholders to assess the NHS Foundation Trust s performance, business model and strategy. The Trust paid out 4k in for interest on late payments under the Commercial Debts (Interest) Act 1998 ( 8k in ). Trust s auditors The Council of Governors has appointed Deloitte as the Trust s external auditors. Further information is contained later in the report in the section on the Audit & Assurance Committee. 48

49 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Our governance Who does what The Trust is headed by the Board of Directors (often referred to as the Board ). The Board s key responsibilities are to: Provide leadership to the Foundation Trust within a framework of processes, procedures and controls which enable risk to be assessed and managed. Ensure the Foundation Trust complies with its Licence; its Constitution; requirements set by Monitor; and relevant statutory and contractual obligations. Set the Foundation Trust s vision, values and standards of conduct. Set the Foundation Trust s strategic aims and ensure that the necessary human and financial resources are in place to deliver these. Ensure the quality and safety of the healthcare services provided by the Foundation Trust. Ensure that the Foundation Trust exercises its functions effectively, efficiently and economically. The Board undertakes these responsibilities through a set business cycle that includes approving strategic documents such as the forward plan and other strategies, and receiving monitoring reports on areas such as key risks, financial, operational, and quality performance. The Board has approved a Scheme of Reservation and Delegation which outlines the decisions that must be taken by the Board and the decisions that are delegated to the management of the hospital. For example, contracts or investment proposals over a certain financial value must be approved by the Board, whereas the approval of lower value contracts is delegated to management. Board Directors collectively and individually have a legal duty to promote the success of the Trust so as to maximise the benefits for members and for the public. They also have a duty to avoid conflict of interests, not to accept any benefits from third parties and declare interests in any transactions that involve the Trust. The Council of Governors is responsible for representing the interests of the Foundation Trust members and partner organisations in the governance of the Foundation Trust. The Council of Governors is responsible for providing feedback from the membership and stakeholders on strategic developments at the Trust, including for example on the Trust s strategic plans, and in turn should keep members and stakeholders informed about developments at the Trust. This role is encapsulated in the Council of Governors two statutory duties: (a) to hold the Non-Executive Directors individually and collectively to account for the performance of the Board of Directors; and (b) to represent the interests of the members of the corporation (Foundation Trust) as a whole and the interests of the public. The Council of Governors has a number of statutory powers to assist them discharge these duties. The Council of Governors statutory powers are to: Appoint, and if appropriate, remove the Trust Chairman. Appoint, and if appropriate, remove the Non-Executive Directors. Decide the remuneration and terms and conditions of office of the Chairman and the Non-Executive Directors. Approve the appointment of the Chief Executive. Appoint, and if appropriate, remove the Foundation Trust s external auditor. Receive the Foundation Trust s annual accounts, any report of the auditor on them, and the annual report. Approve a significant transaction. 7 Approve any proposal to increase the proportion of total income earned from non-principal purpose activities by five percentage points or more (e.g. from 2% to 7% of the Trust s income). Approve any proposal for the merger, acquisition, separation or dissolution of the Trust. 7. What constitutes a significant transaction is outlined in the Trust s Constitution. 49

50 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Vote on whether the Trust s income from nonprincipal purpose activities will significantly interfere with the Trust s principal purpose or its ability to perform its other functions. The Council of Governors and the Board of Directors must both approve any amendments to the Trust s Constitution. Whilst the Council of Governors is responsible for holding the Board, and in particular the Non- Executive Directors, to account and ensuring that the Board is acting in a way that means the Trust will meet its obligations, it continues to remain the Board s responsibility to oversee the running of the hospital. A formal procedure is in place should there be a dispute between the Board and Council of Governors. This comprises three stages. The first stage is informal discussion between the relevant Directors and Governors, coordinated by the Chair (or the Senior Independent Director if the dispute involves the Chair). The second stage would be a resolution meeting open to all members of the Board of Directors and Council of Governors. The Chair may decide to appoint an independent facilitator to assist in reaching an agreement at the meeting. If the resolution meeting fails to resolve the issue to the satisfaction of the representatives of the Council of Governors and Board of Directors present, then the third and final stage would be for a subsequent meeting of the Board of Directors to make the final decision on the disputed issue. This would not however replace the requirement set out in the Constitution for certain decisions to have the approval of the Council of Governors, nor the ability of the Council of Governors to refer an issue to Monitor or the Independent Panel for advising Governors, in certain circumstances. In the three years since the Trust s authorisation as a foundation trust no issues have required escalation to this process. Board of Directors As at 31st March 2014 the Board comprised seven Non-Executive Directors, a Non-Executive Chairman and six Executive Directors 8. Details of Board members as at 31st March 2014 are outlined below. Mike Robinson: Chair Prior to joining the Trust in July 2009, Mike was Chairman of NHS Hillingdon, (formerly Hillingdon PCT). He has a BA from Queens University, Belfast and post graduate qualifications in teaching and planning. He worked for Bristol City Council as Director of Housing then as Chief Executive In March 1994 he was appointed Deputy Under Secretary at the Ministry of Defence until June 1995, and from September 1995 until September 2003 he was Chief Executive of South Gloucestershire Unitary Council. Mike is also an advisor to a number of local authorities. Mike s term of office expired on 31st March 2014 and following five years with the Trust, Mike retired from his role. Prior to leaving the Trust Mike chaired the Board of Directors Nominations Committee. Katey Adderley: Non-Executive Director Appointed in December 2010, Katey is a former Director and Partner of Charterhouse Capital Partners, one of Europe s largest private equity companies, where she worked for 11 years. In her early career Katey worked in strategy consulting and as a financial analyst at Procter and Gamble. As well as bringing up a young family, Katey is a Non- Executive Director of BPP University and is active in local voluntary work. She has a First Class Honours degree in Economics from Cambridge University and a Master s degree (Distinction) in Economic Evaluation in Healthcare. She is also a Chartered Management Accountant. Katey is Chair of the Trust s Audit & Assurance Committee. Katey s term of office expires on 30th November Further information on the Board of Directors and Council of Governors is outlined below. 8. Whilst the Medical Director role has been undertaken as a job-share from 1st January 2013, only one of the job share partners sits on the Board at any time, thereby counting as one Executive member of the Board. 50

51 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Carol Bode: Non-Executive Director Appointed in April 2012, Carol is an organisational development specialist with 30 years experience in retail, customer services, financial services, health and education. Previous roles have included Non-Executive Chairman of Southern Health NHS Foundation Trust, Trustee on the Foundation Trust Network Board, and a Corporate Board Director with a General Motors Company. Carol is an Associate consultant with both Foresight Partnership and QGI, and a Senior Advisor to Newton Europe. Carol is also a Magistrate in North Hampshire, and a Director of The Costello School (an Academy Trust) in Basingstoke. Carol s term of office expires on 31st March Professor Soraya Dhillon MBE: Non-Executive Director Appointed in February 2014, Soraya is a clinical academic and Dean of School of Life and Medical Sciences at the University of Hertfordshire. Soraya has a PhD in clinical pharmacology and has held a number of key senior academic posts. Her research interests are in chronic disease management, prescribing, medicines optimisation and patient safety. Soraya is the former Chairman of Luton and Dunstable Hospital NHS Foundation Trust and is currently a member of the General Pharmaceutical Council and a Board Director of Eastern Academic Health Science Network. Soraya is a fellow of the Royal Pharmaceutical Society and was awarded an MBE for her contribution to health services in Bedfordshire. Soraya brings expertise in strategic leadership, academia and patient safety to the Board. Soraya s term of office expires on 31st January Professor Elisabeth (Lis) Paice OBE: Non-Executive Director Appointed in February 2014, Lis trained as a doctor at Trinity College Dublin and Westminster Medical School before being appointed as a consultant Rheumatologist at the Whittington Hospital. For 15 years Lis was Dean Director of London Deanery, overseeing the postgraduate training of doctors. As Chair of the Inner and Outer North West London Care Programmes and Co-Chair of the Integrated Care Programmes Lis currently has a leading role in developing integrated care in North West London and has special responsibility for encouraging partnerships with people using health and social care services. Lis holds the ILM Diploma in Executive Coaching and Leadership Mentoring, and was named NHS Mentor of the Year In 2011 she received an OBE for services to Medicine. Lis is a Fellow of the Royal College of Physicians. Lis term of office expires on 31st January Pradip Patel: Non-Executive Director and Deputy Chair Appointed in August 2011, Pradip qualified with a First Class Honours degree in Pharmacy from the London School of Pharmacy and has an MBA from Nottingham University. He has worked for Boots for over 34 years, of which the last 18 years have been at senior and Board levels. He was Managing Director for Boots Opticians and Executive Chairman following its merger with Dolland and Atchison, and is currently Director of Healthcare Strategy for Alliance Boots. He is a Fellow of the Chartered Institute of Management and a Member of the Royal Pharmaceutical Society of Great Britain. Pradip chairs the Board s Remuneration Committee. Pradip s term of office expires on 31st July On 19th March 2014 the Council of Governors reappointed Pradip for a second three year term that will run from 1st August 2014 to 31st July Dr James Reid: Non-Executive Director and Senior Independent Director First appointed in February 2008, James is a former Chief Executive of a privately owned oil refining and trading company, with extensive risk management experience within the oil and gas industry. He has a PhD in Mathematics from Edinburgh University, and worked for Shell for many years holding senior management positions in Shell s trading and shipping organisation. During James chaired the Quality & Risk Committee and was a member of the Audit & Assurance Committee. James is also a Non-Executive Director of West Indies Oil Company and has advised various oil companies. James term of office expires on 31st March On 19th March 2014 the Council of Governors 51

52 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts appointed James as the Trust s Interim Chair from 1st April 2014 (this is explained further below). Craig Rowland: Non-Executive Director First appointed in October 2006, Craig is a qualified accountant and former Managing Director of BT Group s UK Business Division. Prior to his career at BT, Craig worked for Coopers & Lybrand (now PricewaterhouseCoopers - PwC) where he qualified as a Chartered Accountant. He then moved to BT where he performed a number of Finance Director roles before moving into general management. Before leaving BT Craig played a lead role in setting up BT s Openreach Division. Craig is also a Board member of the Christian charity Tearfund. Craig is a member of the Trust s Audit & Assurance Committee and Chair of the Transformation Committee. Craig s term of office expires on 30th September Shane DeGaris: Chief Executive First appointed as the Trust s Deputy Chief Executive & Chief Operating Officer, in May 2012 Shane was appointed as the Trust s substantive Chief Executive following a period as Acting Chief Executive. Shane is an experienced NHS Director having worked in a number of London trusts in senior management roles including as Director of Operations at Barnet & Chase Farm Hospitals NHS Trust and as Deputy Chief Executive at Epsom & St Helier University Hospitals NHS Trust. Australian by birth, he began his healthcare career in 1990 after training as a Physiotherapist in Adelaide, South Australia. Shane has been appointed by the Board as the Trust s Director of Imperial College Health Partners, and is also a Board member of the North West London Local Education & Training Board (a sub-committee of Health Education England), which is a nonexecutive role. Dr Richard Grocott-Mason: Medical Director (job-share)* Appointed as Medical Director on a job-share basis in January 2013, Richard Grocott-Mason is a consultant in Cardiology and General Medicine at THH and Harefield Hospital. His clinical work at THH covers general adult Cardiology and acute medicine cover. At Harefield Richard is an interventional Cardiologist and is on the rota covering the heart attack centre. Prior to taking up the position of Medical Director he was the Trust s Clinical Director for the Division of Medicine and Emergency Care. Richard has been involved in the Clinical Expert Panel setting adult emergency care standards for NHS London and part of the audit team reviewing acute trusts in London. Richard is the Trust s Responsible Officer for Revalidation. Dr Abbas Khakoo: Medical Director (job-share)* Appointed as Medical Director on a job-share basis in January 2013, Abbas Khakoo is a consultant in Paediatrics and the care of newborn babies. Abbas also runs a children s allergy service at Hillingdon Hospital and at St Mary s Hospital, part of Imperial College Healthcare NHS Trust, and chairs the North West London Paediatric Clinical Implementation Group. Prior to taking up the position of Medical Director at THH he was the Trust s Clinical Director for Quality and Safety. * whilst Dr Khakoo and Dr Grocott-Mason undertake the role of Medical Director on a jobshare basis, the Board member responsibilities are held by one of the job-share partners at any given time. Dr Khakoo sits on the Board January to June, with Dr Grocott-Mason holding these responsibilities July to December. Professor Theresa Murphy: Executive Director of the Patient Experience & Nursing Theresa joined the Trust in May 2013 having been the Director of Nursing at North Middlesex University Hospital NHS Trust. Theresa qualified in general nursing in 1987, before specialising in Neuroscience and Critical Care nursing. Theresa has also held a number of clinical and managerial posts in both teaching and general hospitals. Theresa was awarded the Florence Nightingale leadership scholarship for 2012, and is an Honorary Professor for the City of London University, and has an LLB. Theresa holds Board level responsibility for nursing, clinical governance, infection prevention and control, safeguarding people, and the patient experience and engagement. 52

53 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Karl Munslow Ong: Chief Operating Officer After joining the Trust as Director of Operational Performance, Karl was appointed as the Trust s substantive Chief Operating Officer in October 2012 following a period as Acting Chief Operating Officer. Karl is an experienced senior manager who has worked in a number of operational management roles in trusts across London. Karl has also worked at Strategic Health Authority level and in the private sector for one of the big four accountancy firms. Karl holds Board level responsibility for the management of the clinical divisions, emergency planning, the QIPP programme (Quality, Innovation, Productivity and Prevention), the Trust s strategy and business planning, as well as for ensuring the Trust meets and exceeds all national and local patient access standards. David Searle: Executive Director of Corporate Development Appointed in 2007 from a 20 year career in the Royal Navy as a Fleet Air Arm pilot, where senior roles included second in command of a major Air Defence warship and the Commanding Officer of a large front line Naval Air Squadron, David subsequently worked in the aerospace and defence industries where he held senior positions in procurement, commercial management, business development and marketing. He was latterly Director, Wider Markets in the Defence Aviation Repair Agency before he was appointed to this role in the NHS. He is a Chartered Director, and has Board-level responsibility for estates and facilities, corporate governance (including risk management and information governance), health and safety, business development, communications and marketing. Paul Wratten: Finance Director Appointed in 2000, Paul is a member of the Chartered Institute of Public Finance and Accountancy and has spent almost all his working life within the NHS. This has included working in a variety of different NHS provider organisations as well as a strategic performance management role for the NHS in London. In addition to the finance and payroll functions, Paul also holds Board-level responsibility for healthcare contracts, purchasing and supplies, and the Trust s information services and information technology functions, which includes the clinical coding team. The following also served as Board members during the year. Claire Gore: Director of People Claire joined the Trust in 2010 as Director of People, and was appointed as an Executive member of the Board by the Board of Directors Nominations Committee in March Claire is a Fellow of the Chartered Institute of Personnel and Development (FCIPD) and has worked at a senior level in human resources and training and development in a number of public sector organisations including the London Borough of Brent and the Metropolitan Police Service. Claire has Board level responsibility for human resources (including recruitment, employee relations and temporary staffing), occupational health, nurse training, workforce and organisational development. Following a decision to reduce the size of the Board, Claire ceased to be a member of Board on 30th November 2013; since that time Claire has attended Board meetings in a non-voting capacity. Alan McLeod: Non-Executive Director First appointed in October 2008, Alan s second term of office as Non-Executive Director expired on 30th November Alan s background is in the international telecommunications industry from a sales, marketing and technical perspective. Anthony Palmer: Non-Executive Director Appointed in April 2012, Anthony is an Independent Nursing consultant and Expert Witness providing advice to lawyers, Coroners, and the Crown Prosecution Service. Anthony was previously Deputy Chief Executive and Director of Nursing for Luton & Dunstable Hospital NHS Foundation Trust, and held Executive Director Board positions for over 14 years. Anthony resigned from his role at the Trust with effect from 31st December 2013 due to his work commitments. 53

54 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Jacqueline Walker: Acting Executive Director of the Patient Experience & Nursing Jacqueline was Acting Executive Director of the Patient Experience & Nursing from 22nd October 2012 until Theresa Murphy took up post in May Following Theresa s arrival at the Trust Jacqueline returned to her substantive role as the Trust s Deputy Director of Nursing. The Constitution states that the Council of Governors will appoint one of the Non-Executive Directors as the Deputy Chairman, whilst the Board, in consultation with the Council of Governors appoints the Senior Independent Director. In April 2013 James Reid was appointed as the Senior Independent Director and Pradip Patel as the Deputy Chairman; these appointments were not explicitly time limited and therefore run until the remainder of their term of office, unless revised by the Board and Council of Governors respectively. In March 2014 the Council of Governors appointed James Reid as the Trust s Interim Chair. This appointment runs for a year or until a substantive successor is in post (whichever is sooner). At that time, James will return to his position as Non-Executive Director for any remaining period of his term of office in that role (31st March 2015). In April 2014 the Board and Council of Governors agreed that Pradip Patel would undertake the roles of Deputy Chair and Senior Independent Director temporarily whilst James was Interim Chair. risk management; and human resources. In two new Non-Executive Directors with a clinical background were appointed which further strengthened the balance of the Board. The Board therefore confirms that the current composition is considered to be appropriate. This is supported by the conclusions of a recent external review of the Trust s quality governance systems undertaken by KPMG which praised the robust strength of challenge at Board and Board Committee meetings. Taking account of the NHS Foundation Trust Code of Governance published by Monitor, the Board considers the Chairman and all of the Non-Executive Directors to be independent. Whilst Craig Rowland and James Reid were first appointed to the Board of The Hillingdon Hospital NHS Trust more than six years ago (in October 2006 and February 2008 respectively), the Board s view is that both Directors retain an independent viewpoint, and ability to challenge and scrutinise management. Board members other commitments and Register of Interests Company directorships and other significant commitments held by Board members are outlined above. Board members are required to enter their relevant interests in the Register of Directors Interests which is formally reviewed by the Board at least annually. The full register is available from the Trust Secretary on Statement on the balance, completeness and appropriateness of the membership of the Board The Board of Directors Nominations Committee is responsible for reviewing the structure, size and composition of the Board and makes recommendations to the Council of Governors on the skills required for any upcoming Non- Executive Director appointments. As outlined in the biographies of Board members, the Board comprises individuals with senior level experience in the public and private sectors, across a range of disciplines including clinical and patient care; commercial development; business transformation and change management; finance; governance; As outlined above, Mike Robinson, the Trust Chair during , is an advisor to a number of local authorities. He had no other significant commitments. James Reid, Interim Chair from 1st April 2014 is also a Non-Executive Director of the West Indies Oil Company and an Independent Oil Industry consultant. Appointment and removal of Board members In accordance with the requirements of the NHS Act 2006, the Foundation Trust Constitution outlines the respective responsibilities of the Directors and Governors in appointing and removing Board members. 54

55 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts The Council of Governors is responsible for appointing, and if necessary, removing the Chairman and Non-Executive Directors. The Council of Governors Nominations & Remuneration Committee has been established to make recommendations to the Council of Governors on the appointment and remuneration of these positions, including identifying suitably qualified candidates for appointment. At the start of the recruitment process the Board of Directors Nominations Committee makes recommendations to the Council of Governors Nominations & Remuneration Committee on the capabilities required for these appointments in light of the current Board composition and the challenges facing the Trust. When considering the appointment and remuneration of Non-Executive Directors, the Council of Governors Nominations & Remuneration Committee consists of the Trust Chairman (who chairs the Committee), three Public Governors, one Staff Governor and one Appointed or Staff Governor. When considering the appointment and remuneration of the Chairman, the Committee consists of three Public Governors, one Staff Governor, one Appointed or Staff Governor, and one Non-Executive Director (who chairs the Committee on these occasions this was James Reid as Senior Director until January 2014, at which point Pradip Patel, Deputy Chair, took over this role on the Committee for the conclusion of the Chair appointment process). The Chief Executive and Director of People are invited to attend to provide advice to the Committee. Should any such circumstances arise, the Council of Governors Nominations & Remuneration Committee is responsible for investigating the grounds for any resolution to remove the Chairman or a Non-Executive Director, and preparing a report on this issue with recommendations for the consideration of the Council of Governors. Removal of the Chairman or a Non-Executive Director requires the approval of three-quarters of the members of the Council of Governors. The Chief Executive is appointed by the Board of Directors Nominations Committee which comprises the Chairman (Committee chair) and all of the Non-Executive Directors. The appointment must be approved by the Council of Governors. The Board of Directors Nominations Committee is responsible for agreeing the removal of the Chief Executive should this be required any such decision does not require the Council of Governors approval. The Board of Directors Nominations Committee is responsible for appointing and removing the Executive Directors. The Chief Executive is also a member of the Committee when it is considering the appointment and removal of the Executive Directors. The Director of People is invited to attend the Committee to provide advice as required. The Trust Secretary provides secretarial support to the Board of Directors Nominations Committee and the Council of Governors Nominations & Remuneration Committee. Performance evaluation of the Board, its Committees, and Board members The Board usually reviews its performance annually. This process draws upon a self-assessment by each Board Committee, which includes a review of each Board Committee s terms of reference. In October 2012 the Board agreed a number of changes to the Board Committee structure in light of this review process. The Integrated Risk Management Committee and the Clinical Quality & Standards Committee were merged into a single Committee (the Quality & Risk Committee) that focuses on all matters relating to risk and clinical quality, in order to ensure an alignment of the consideration of risk and issues relating to clinical quality and standards. The Board also concluded as part of this review that greater Board focus and scrutiny was required on the transformation that is essential for the Trust to be able to respond to the challenging financial and operating context. The Board therefore replaced the Finance & Investment Committee with a new Committee the Transformation Committee which seeks to replace a backward review of past financial statements with a more forward look at change projects. 55

56 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts The Board Committees reviewed their performance in 2013, taking account of the impact of these changes. Following this review the meetings of the Quality & Risk Committee were extended to ensure sufficient time is available for the agenda items to be discussed in detail. In September 2013 the Board commissioned an external review of the Trust s position against Monitor s quality governance framework. The review, which was undertaken by KPMG in late 2013 and early 2014 included examination of the work of the Board and its Committees in relation to quality and safety, and included observation of the Board, Audit & Assurance Committee, and the Quality & Risk Committee. As noted earlier in the report, the review concluded that the strength of challenge at the Board and Committees was robust and appropriate; it also noted the complementary challenge and insight from the Non-Executive Directors and the individual interest and depth of scrutiny over quality issues shown by all Board members. An action plan was developed to address the areas identified for further improvement including strengthening accountability and the use of information across the clinical divisions, and ensuring the Trust s quality priorities are aligned with its other strategic aims. In commissioning the review, the Board agreed that it would then commission a further piece of work to examine the Board s operation and effectiveness more widely. It was agreed that this would be undertaken at the start of the year following the appointment of the new Chair. This would be three years after the Trust s authorisation as a Foundation Trust and would be consistent with the requirement in the Code of Governance to undertake an externally facilitated Board evaluation at least once every three years. This work will take place in June and July 2014 and be undertaken by KPMG as a follow-up to their review of the Board s governance in relation to clinical quality and safety. KPMG did not provide any other services to the Trust in Board members are subject to an annual individual performance appraisal. The Chair s appraisal is led by the Senior Independent Director, whilst the Chairman leads the appraisal of the Non-Executive Directors. The Council of Governors, through the Council of Governors Nominations & Remuneration Committee, feed in their views to these appraisals and the full Council of Governors is formally briefed on the outcomes. The outcomes of the appraisals, including the objectives, were considered at the July 2013 Council of Governors meeting. The Chief Executive undertakes the appraisal of the Executive Directors, and the Chair undertakes the appraisal of the Chief Executive. The Board of Directors Remuneration Committee oversees the Chairman s monitoring and evaluation of the Chief Executive s performance, and the Chief Executive s monitoring and evaluation of the Executive Directors performance. The Committee provides input into this process midway through the year and at the end of the year. Nominations Committee meetings in Board of Directors Nominations Committee The Committee met four times in The Committee reviewed the composition of the Board and in light of this and the challenges facing the Trust, made recommendations to the Council of Governors Nominations & Remuneration Committee in respect of the two Non-Executive positions that became vacant during the year. For the first position, that held by Alan McLeod, the Committee agreed that the position should not be reappointed to in order to reduce the size of the Board. In relation to the vacancy created by Anthony Palmer s resignation, the Committee recommended that the Council of Governors appoint a NED with significant and senior level expertise gained in the health sector with a nursing or clinical background. 56

57 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts The Committee recommended a person specification and job description for the recruitment of a new Chair to the Council of Governors Nominations & Remuneration Committee. In line with its terms of reference, the Committee also reviewed talent management and succession planning at the Trust, and reviewed and commented on proposals for restructuring the Executive portfolios and senior management structure. In March 2014 the Committee reviewed the composition of the Board and recommended that Pradip Patel is reappointed for a second term of office and recommended the broad person specification for the position that would become available when Craig Rowland s term of office ends later in The Committee agreed that for this position the Trust should seek a candidate with financial experience, with capital development and investment experience being an additional desirable criterion. Council of Governors Nominations & Remuneration Committee The Committee met seven times during At its meeting in July 2013, the Committee provided input on behalf of the Governors to the Chair s and Non-Executive Directors appraisals which were to be undertaken by the Senior Independent Director and Chair respectively. At that meeting the Committee also reviewed and updated the expense rates payable to the Chair and Non-Executive Directors which were recommended to the Council of Governors for approval. The Committee s main two areas of work during the year were to oversee the appointment processes for Trust Chair and to the Non-Executive Director (NED) position created by Anthony Palmer s resignation. The Committee engaged the executive search agency, Veredus, to assist with these processes. In terms of the Chair process, the Committee agreed a person specification and job description for the role drawing on the recommendations of the Board of Directors Nominations Committee. The position was then externally advertised with Veredus assisting with the search process. The Committee met to agree a long-list of candidates who were invited for an initial interview by Veredus. In light of Veredus reports on the candidates interviews, the Committee agreed a short-list of candidates who were due to attend the final stage of the appointment process in January This was due to involve presentation to an audience of stakeholders, and a series of interviews. Due to factors out of the Trust s control these interviews were rescheduled to a later date; however following a withdrawal by a candidate shortly before the rescheduled interviews in March the Committee agreed to pause the recruitment process. As Pradip Patel, Deputy Chair, was unable to act as Chair due to work commitments the Committee had agreed in January that the Non-Executive Directors should be asked to express an interest in undertaking the Interim Chair role should the reconvened process in March fail to lead to a substantive appointment. James Reid was the only NED to put himself forward for this position and, following the decision not to proceed with the interviews in March, the Committee recommended that the Council of Governors appointed James as Interim Chair. The Council of Governors agreed on 19th March 2014 to appoint James as Interim Chair with effect from 1st April 2014 for a term of office of up to a year or until a new Chair is in post (whichever is sooner). The Council of Governors Nominations & Remuneration Committee will recommence the process to appoint a substantive Chair in the first half of the year. In terms of the process to appoint a NED to replace Anthony Palmer, the Committee agreed a person specification and job description for the role drawing on the recommendations of the Board of Directors Nominations Committee. The position was externally advertised with Veredus assisting with the search process. Veredus then undertook initial interviews with applicants and recommended a short-list of candidates for a final interview. These interviews were undertaken by a panel comprising Mike Robinson, Trust Chair, and three of the five Governor members of the Committee. The Committee recommended the appointment of both 57

58 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Lis Paice and Soraya Dhillon as the appointment of an additional NED would aid with succession planning given all of the NEDs terms of office end in the financial year. It would also ensure the required number of NEDs on the Board should one of the NEDs be required to act as Interim Chair. At its meeting in January 2014 the Council of Governors supported these recommendations and appointed Lis Paice and Soraya Dhillon as Non-Executive Directors from 1st February 2014 for a three year term of office. The Board approved the temporary expansion of the Board this double appointment required. The Council of Governors Nominations & Remuneration Committee met in March 2014 to consider the Board of Directors Nominations Committee s recommendations regarding the positions held by Pradip Patel and Craig Rowland. The Committee supported these recommendations and the Council of Governors subsequently reappointed Pradip for a second three year term of office. The recruitment of Craig s successor will commence in the first half of Audit & Assurance Committee The Trust s Audit & Assurance Committee comprises three Non-Executive Directors, one of whom (the Committee Chair) has recent and relevant financial experience. The Committee is usually attended by the internal and external auditors, the Finance Director and the Executive Director of Corporate Development. The Local Counter Fraud Specialist attends at least two meetings a year, and other Directors and senior managers attend when invited by the Committee. The Trust Secretary is the Committee Secretary. The Committee is responsible for providing an independent and objective review of the Trust s systems of internal control (both financial and nonfinancial) and the underlying assurance processes in place at the Trust. The Committee is also responsible for ensuring that the Trust has in place independent and effective internal and external audit functions. The Committee s work in undertaking these responsibilities is outlined in an annual report to the Board. Key elements of the Committee s work include reviewing the Board Assurance Framework, and reviewing the findings of the Trust s internal and external auditors and Local Counter Fraud Specialist. The Committee is responsible for reviewing the annual financial statements, with particular focus given to major areas of judgement and changes in accounting policies, the basis of the Board s determination that the Trust remains a going concern, and the Annual Governance Statement. The Committee also reviews the assurance available from the Trust s clinical audit function, and has developed an increasing role in reviewing the robustness of data quality at the Trust. In addition to its own annual selfevaluation, the Committee reviews the performance of internal audit, external audit, and the Local Counter Fraud Specialist each year. External audit The Audit & Assurance Committee (AAC) is responsible for making recommendations to the Council of Governors on the appointment and removal of the external auditor. On the Trust s authorisation as a Foundation Trust in 2011, the Council of Governors agreed that full market testing would be undertaken in time to enable the Council of Governors to appoint the external auditor for the audit cycle; this was because Deloitte had provided external audit services to the NHS Trust and Foundation Trust for five years. This market testing was in line with the recommendations of the AAC and is consistent with Monitor guidance. In October 2012 the Council of Governors agreed a process for undertaking this market-testing, based on recommendations from the AAC. A working group comprising the AAC and representatives of the Council of Governors was established to agree the specification for the tender and make recommendations to the Council of Governors on the appointment. The process involved running a mini-competition amongst the 11 audit providers on the Government Procurement Service (GPS) Framework Agreement. The framework agreement included all of the firms who would be expected to bid for the service and by using the framework the Trust was able to benefit from the 58

59 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts economies of scale of working across Government. The working group agreed the criteria for the submissions which included price, quality of services, relevant experience, technical merit, and risk and deliverability. Three firms submitted offers. Following evaluation of these, the working group invited all three to deliver a presentation on their offer. The working group scored the written submissions and presentations against the agreed criteria. Deloitte, the Trust s existing external auditor, received the highest score. The working group therefore agreed that Deloitte should be appointed as the Trust s external auditors for a three year period starting with the audit with an option for two one year extensions (bringing five years in total). The Council of Governors agreed this recommendation at their meeting in October In line with the Code of Governance this reappointment is subject to annual review. This annual review involves the Audit & Assurance Committee (AAC) members meeting following the completion of the year end audit to evaluate external audit s performance against a number of aspects of best practice. The Chair of the AAC then presents a report to the July meeting of the Council of Governors on the outcomes of this review and whether external audit s appointment should be confirmed. Internal audit The Trust s internal audit service was provided for a number of years by the NHS audit consortium Parkhill; in 2014 Parkhill merged with TIAA (The Internal Audit Agency) who are now the Trust s internal auditors. The scope and work of the Trust s internal auditors, which is consistent with NHS Internal Audit Standards, is set out in a charter approved by the Audit & Assurance Committee. Internal audit provides an independent and objective opinion on risk management, control and governance by measuring and evaluating the effectiveness by which organisational objectives are achieved. Through detailed examination, evaluation and testing of the Trust s systems, internal audit play a key role in the Trust s assurance processes. The Audit & Assurance Committee agree a work plan for internal audit at the start of each financial year, taking account of the risk assessment undertaken by internal audit. The Committee review the findings of internal audit s work against this plan at each quarterly meeting. The Head of Internal Audit reports to the Committee and is managed by the Finance Director. The Head of Internal Audit has a right of direct access to Committee members. The audit fee for was 73,500 ( 59,500 for the financial statement audit and 14,000 for work on the quality report). At their meeting in October 2013 the Council of Governors agreed an updated policy on the engagement of the external auditors to undertake additional services, which had been reviewed and recommended by the working group established to oversee the tendering of the external audit service. Under the policy, the Council of Governors has delegated to the Audit & Assurance Committee the authority for commissioning additional services from the external auditor. Any such work will then be reported to the Council of Governors. No such additional work was commissioned in Key issues considered by the Committee In addition to the presumed risk of management override of controls and management s responsibility for the prevention and detection of fraud, external audit identified four specific audit risks for the Trust: recognition of NHS revenue; valuation of property assets; accounting for capital expenditure; and the successful delivery of cost improvement plans. At its meeting in January 2014 the Committee approved the external audit plan which focused on these issues and reviewed external audit s findings on these risks at its meeting on 27th May At its meeting in April 2014, the Committee considered a number of issues relating to the year-end accounts including property valuation and 59

60 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts impairments. The Committee agreed the accounting treatment adopted in the financial statements. Over the year, the Committee reviewed in depth the Trust s response to internal audit reviews that received an opinion of limited assurance, and received follow-up reports from management to outline the action that had been taken to address the issues identified in these audit reviews. A particular focus for the Committee was the review into consultant job planning; the Medical Director attended to regularly provide updates on the Trust s progress in addressing internal audit s recommendations and the Committee amended the internal audit work plan to include additional follow-up by internal audit to provide assurance that the required actions had taken place. Following never events involving retained swabs at the Trust, the Committee supported the amendment of the internal audit work-plan in year to provide assurance to the Board in relation to the Trust s theatre processes. The Committee reviewed the draft annual report and accounts to ensure the information contained within was consistent with that reviewed by the Committee during the year and that presented to the wider Board. This supported the Directors confirmation that the document is fair, balanced, and understandable and provides the information necessary for stakeholders to assess the Trust s performance, business model and strategy. Other Board Committees In addition to the Nominations Committee and Audit & Assurance Committee, the following Board Committees are in place. Each of these is chaired by a Non-Executive Director. The Board of Directors Remuneration Committee, which comprises all of the Non- Executive Directors, is responsible for agreeing the remuneration and terms of service for the Chief Executive and Executive Directors. Further information on the Committee is outlined in the remuneration report. The Charitable Funds Committee assists the Trust in its role as corporate trustee for The Hillingdon Hospitals NHS Foundation Trust charity and has been established to make and monitor arrangements for the control and management of the Trust s charitable funds. The Quality & Risk Committee provides assurance and makes recommendations in matters relating to clinical quality and standards, and to ensure that risks to the delivery of the Trust s services are identified and addressed. The Transformation Committee assists the Board with the shaping, review and challenge of service transformation, development and redesign, and to provide assurance that the strategy for the management of human, financial, estate, and IT resources support such business transformation. 60

61 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Attendance at Board and Board Committee meetings The following table outlines Board members attendance at Board and Committee meetings during against the total possible number of meetings for which an individual was a member. Committee attendance is shown in relation to those Committees of which a Director was formally a member. Board of Directors (13 meetings) Audit & Assurance Committee (5 meetings) Board Nominations Committee (4 meetings) Board Remuneration Committee (4 meetings) Charitable Funds Committee (3 meetings) Quality & Risk Committee (4 meetings) Transformation Committee (6 meetings) Katey Adderley 11 of 13 5 of 5 4 of 4 4 of 4 3 of 3 Carol Bode 12 of 13 4 of 4 4 of 4 2 of 3 4 of 4 Shane DeGaris 11 of 13 4 of 4 4 of 4 5 of 6 Soraya Dhillon 2 of 2 0 of 1* 0 of 2* Claire Gore 7 of 9 0 of 2 Richard Grocott- Mason 5 of 6 2 of 3 Abbas Khakoo 6 of 7 4 of 4 3 of 3 Alan McLeod 7 of 9 1 of 3 1 of 2 2 of 4 Karl Munslow Ong 13 of 13 2 of 4 6 of 6 Theresa Murphy 10 of 10 0 of 2 3 of 3 3 of 5 Lis Paice 2 of 2 0 of 1* 1 of 2* Anthony Palmer 6 of 10 2 of 3 2 of 2 1 of 3 Pradip Patel 11 of 13 4 of 4 4 of 4 5 of 6 James Reid 13 of 13 5 of 5 4 of 4 4 of 4 4 of 4 Mike Robinson 12 of 13 4 of 4 4 of 4 3 of 3 5 of 6 Craig Rowland 12 of 13 5 of 5 2 of 4 2 of 4 5 of 6 David Searle 13 of 13 4 of 4 Jacqueline Walker 3 of 3 1 of 1 1 of 1 1 of 1 Paul Wratten 13 of 13 3 of 3 * These meetings were held shortly after Lis and Soraya s appointments were made. 61

62 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Council of Governors The role and powers of the Council of Governors are outlined earlier in the report. The composition of the Council of Governors is outlined in the Trust s Constitution. As at 31st March 2014 there were 28 positions on the Council of Governors: 17 elected to represent the public members, seven elected to represent the staff members, and four appointed by partner organisations (Hillingdon Council, Hillingdon Clinical Commissioning Group, the London Ambulance Service, and the Trust s Joint Negotiating & Consultative Committee). The members of the Council of Governors who served during are outlined below: Name Date took office and method (see key below) Term of office expires Public Governors David Bishop 01/04/2011 (CE) 31/03/2014 Tony Ellis 01/04/2011 (CE) 31/03/2014 North (5) Ahmad Mallick 01/04/2011 (CE) 31/03/2014 Alvan Seth-Smith 12/04/2011 (CE) 31/03/2014* Pamela Taverner 28/05/2012 (CE) 31/03/2014* Donald Dakin 01/04/2011 (CE) 31/03/2014 Martin Elliott 17/05/2012 (CE) 31/03/2014 Central (5) Neil Fyfe 17/05/2012 (CE) 31/03/2014 Kerstin Rolfe 01/04/2011 (CE) 31/03/2014 Roger Shipton 01/04/2011 (CE) 31/03/2014 John Coleman 01/04/2011 (CE) 31/03/2014 John Davies 01/04/2011 (CE) 31/03/2014 South (6) Graham Hawkes 17/05/2012 (CE) 31/03/2014 Asma Jalal 01/04/2011 (UE) 31/03/2014 Abid Majeed 01/04/2011 (UE) 31/03/2014 Sharda Mohan 01/04/2011 (UE) 31/03/2014 Rest of England (1) Stuart Marshall 06/08/2012 (UE) 31/03/

63 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Name Date took office and method (see key below) Term of office expires Staff Governors Doctors & Dentists (1) Alvan Pope 17/05/2012 (CE) 31/03/2014 Nurses, Midwives, Healthcare Assistants (3) Allied Health Professionals (1) Support Staff (2) Bev Hall 01/04/2011 (CE) 31/03/2014 Amanda O Brien 11/05/2012 (UE) 31/03/2014 Angela Wilson 01/04/2011 (CE) 31/03/2014 Graham Coombs 01/04/2011 (CE) 31/03/2014 Gay Bineham 01/04/2011 (CE) 31/03/2014 (Ceased to be a Governor on 3/11/13 when retired from the Trust s employment) Jennifer Roma 22/11/2011 (CE) 31/03/2014 (Resigned from Governor position on 14/11/13) Appointed Governors Hillingdon Clinical Commissioning Group (1) No appointment made London Borough of Hillingdon (1) Cllr Mary O Connor 6/11/2012 (A) Reappointed 10/07/13 11/05/ /03/2014 London Ambulance Service (1) Joint Negotiating & Consultative Committee (1) Peter McKenna 01/04/2011 (A) 31/03/2014 Lesley Dixon 01/04/2011 (A) 31/03/2014 Key: CE contested election UE uncontested election A appointed by partner organisation * The Constitution states that where a vacancy arises for an elected Governor other than by the end of a term of office, the Council of Governors may invite the next highest polling candidate for that seat at the most recent election, who is willing to take office, to fill the vacant seat until the next election, at which time the seat will fall vacant and be subject to election for any unexpired period of the term of office. In accordance with these provisions, Alvan Seth-Smith & Pamela Taverner were invited to take up the positions vacated by Governor resignations. Therefore whilst the term of office is shown as 31st March 2014, if there had been an election in the first half of in the North Public Constituency then the two seats would have fallen vacant and been subject to election for the period until 31st March

64 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts In the Council of Governors formally met five times. Governor attendance at these meetings is outlined below. Where a Governor was not in office for all five meetings, the maximum possible attendance is shown. Governor Meetings attended David Bishop (Public) 5 of 5 Tony Ellis (Public) 5 of 5 Ahmad Mallick (Public) 4 of 5 Alvan Seth-Smith (Public) 5 of 5 Pamela Taverner (Public) 3 of 5 Donald Dakin (Public) 3 of 5 Martin Elliott (Public) 1 of 5 Neil Fyfe (Public) 4 of 5 Kerstin Rolfe (Public) 2 of 5 Roger Shipton (Public) 5 of 5 John Coleman (Public) 5 of 5 John Davies (Public) 4 of 5 Graham Hawkes (Public) 4 of 5 Asma Jalal (Public) 4 of 5 Abid Majeed (Public) 3 of 5 Sharda Mohan (Public) 1 of 5 Stuart Marshall (Public) 3 of 5 Alvan Pope (Staff) 5 of 5 Bev Hall (Staff) 4 of 5 Amanda O Brien (Staff) 5 of 5 Angela Wilson (Staff) 4 of 5 Graham Coombs (Staff) 4 of 5 Gay Bineham (Staff) 2 of 3 Jennifer Roma (Staff) 2 of 3 Cllr Mary O Connor (Appointed) 4 of 4 Peter McKenna (Appointed) 3 of 5 Lesley Dixon (Appointed) 5 of 5 Governors are required to declare any relevant interests which are then entered into the publicly available Register of Governors Interests. The Register is formally reviewed by the Council of Governors annually and is available from the Trust Secretary on

65 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Governor elections In early a working group of members of the Board and Directors and Council of Governors met to review the Trust s Constitution and recommend amendments in response to the changes brought about by the Health and Social Care Act The opportunity was also taken to consider whether any further amendments were required in light of experience and changes in context since the Constitution was first developed prior to the Trust s authorisation. The Governor members on the working group proposed reducing the number of Public Governors on the Council of Governors as it was felt this would enable a more cohesive body and improve the effectiveness of Council of Governors meetings. This proposal was subsequently approved by the Board of Directors and the Council of Governors, and then confirmed by a vote at the Trust s Annual Members Meeting in September From 1st April 2014 the Council of Governors is compromised as follows: Public Governors (elected) North Constituency 4 Central Constituency 4 South Constituency 4 Rest of England Constituency 1 Sub total 13 Staff Governors (elected) Doctors and Dentists 1 Nurses and Midwives (including Health Care Assistants) 3 Allied Health Professionals 1 Support staff 2 Sub total 7 Partner Governors (appointed) Hillingdon Clinical Commissioning Group 1 London Borough of Hillingdon 1 Joint Negotiating & Consultative Committee 1 London Ambulance Service 1 Sub total 4 Total 24 65

66 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Elections to these positions were held in the last quarter of The members of the Council of Governors at the start of are listed below: Public Constituency North Public Constituency North Public Constituency North Public Constituency North Public Constituency Central Public Constituency Central Public Constituency Central Public Constituency Central Public Constituency South Public Constituency South Public Constituency South Public Constituency South Graham Bartram Ian Bendall David Bishop Tony Ellis Harkishan Chander Don Dakin Neil Fyfe Roger Shipton John Coleman Keith Saunders Rekha Wadhwani Doreen West Public Constituency Rest of England Position unfilled * Staff Constituency Doctors & Dentists Staff Constituency Nurses, Midwives & HCAs Staff Constituency Nurses, Midwives & HCAs Staff Constituency Nurses, Midwives & HCAs Staff Constituency Allied Health Professionals Staff Constituency Support Staff Staff Constituency Support Staff Alvan Pope Sheila Bacon Sheila Kehoe Amanda O Brien Graham Coombs Paul Cornford Jack Creagh These elected Governors are joined by the four Governors appointed by stakeholder groups. London Ambulance Service Hillingdon Council Hillingdon Clinical Commissioning Group Joint Negotiating & Consultative Committee Pauline Cranmer Cllr Mary O Connor Dr Mayur Nanavati Lesley Dixon *Nominations for the position will reopen to seek to elect a Governor for this position. 66

67 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Lead Governor In line with Monitor s Code of Governance, the Council of Governors elects one of the Public Governors to be the Lead Governor. The main duties of the Lead Governor are to: Act as a point of contact for Monitor should the Regulator wish to contact the Council of Governors on an issue for which the normal channels of communication are not appropriate. Be the conduit for raising with Monitor any Governor concerns that the Foundation Trust is at risk of significantly breaching its Licence, having made every attempt to resolve any such concerns locally. Chair such parts of meetings of the Council of Governors which cannot be chaired by the Trust Chair or Deputy Chair due to a conflict of interest in relation to the business being discussed. In April 2013 the Council of Governors elected John Coleman as Lead Governor to run until 31st March The Council of Governors reappointed John as Lead Governor for the year at their meeting on 28th April an opportunity for members of the public and Governors to ask questions of the Board members present. Members of the Board also attend the Trust s People in Partnership meetings and Annual Members Meeting to liaise with members and Governors. Attendance by Board members at the five meetings of the Council of Governors and the joint meeting between the Board and Council of Governors in is outlined opposite. During the Council of Governors did not exercise its formal power under paragraph 10C of schedule 7 of the NHS Act 2006 to require one or more of the Directors to attend a Governors meeting for the purpose of obtaining information about the Foundation Trust s performance of its functions or the Directors performance of their duties (and deciding whether to propose a vote on the Foundation Trust s or Directors performance). people in partnership The Board s liaison with governors and members All Board members have a standing invitation to attend Council of Governors meetings in order to ensure they understand the views of Governors and members. The arrangements for Council of Governors meetings were changed during the year to help facilitate the Council of Governors undertake their statutory duty to hold the Non-Executive Directors (NEDs) to account. These changes involve the NEDs having a greater role at the Council of Governors meetings in responding to questions raised by the Governors. The Board and Council of Governors meet jointly at least annually as part of enabling the Governors to input into the Trust s strategic plans and also to discuss any other matters of joint concern. In this meeting was held in December 2013 to provide an opportunity for Governors to comment on the development of the Trust s strategy and strategic issues affecting the Trust s forward planning. Board and Council of Governors meetings are held in public and there is 67

68 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Board Member No of Council of Governor meetings attended in (including joint Board/Governor meeting) Mike Robinson (Chair) 6 of 6 Katey Adderley (Non-Executive Director) 3 of 6 Carol Bode (Non-Executive Director) 5 of 6 Shane DeGaris (Chief Executive) 5 of 6 Soraya Dhillon (Non-Executive Director) 0 of 1 Claire Gore (Director of People) 1 of 4 Richard Grocott-Mason (Joint Medical Director) 1 of 6 Abbas Khakoo (Joint Medical Director) 2 of 6 Alan McLeod (Non-Executive Director) 1 of 3 Karl Munslow Ong (Chief Operating Officer) 3 of 6 Theresa Murphy (Executive Director of the Patient Experience & Nursing) 4 of 5 Lis Paice (Non-Executive Director) 0 of 1 Anthony Palmer (Non-Executive Director) 1 of 3 Pradip Patel (Deputy Chair & Non-Executive Director) 5 of 6 James Reid (Senior Independent Director & Non- Executive Director) 4 of 6 Craig Rowland (Non-Executive Director) 3 of 6 David Searle (Executive Director of Corporate Development) Jacqueline Walker (Acting Executive Director of the Patient Experience & Nursing) 2 of 6 1 of 1 Paul Wratten (Finance Director) 5 of 6 68

69 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Membership The Foundation Trust membership is divided into two categories: public membership and staff membership. Public membership There are four public constituencies, which are collectively known as the Public Constituency. The majority of the public members are drawn from the three public constituencies which cover the electoral wards in Hillingdon borough together with several neighbouring electoral wards. The fourth public constituency covers all other electoral areas in the rest of England. Public membership is open to individuals aged 16 years or over living within the Public Constituency, who are not eligible to be a staff member of the Foundation Trust. The Constitution includes two further disqualifications on public membership. 9 Staff membership The staff constituency is a single constituency divided into the following classes: Doctors and dentists Nurses and midwives (including health care assistants) Allied Health Professionals Support staff. Staff membership is open to all those employed by the Trust on a permanent basis, those who have a fixed term contract of at least 12 months, and those who have been working at the Trust for at least 12 months. These staff are automatically members of the Staff Constituency unless they opt-out from membership. In addition, those working at the Trust 9. An individual may not become or remain a member of the Trust if during the five years prior to their application, they have demonstrated aggressive or violent behaviour at any hospital or towards any person working for a health service body and following such behaviour has been excluded from any hospital or other health service body under either the Trust s or other health service body s policy for withholding treatment from violent/aggressive patients, or equivalent. Nor can anyone become or continue as a member of the Trust if they have been confirmed as a vexatious complainant in accordance with the Trust s complaints handling policy. through the temporary staffing bank become staff members providing they have been registered on the Trust s bank for at least 12 months and continue to be registered. So far no staff have opted out from being a member of the Foundation Trust. Staff membership will cease at the point that the member leaves the service of the Trust. Anyone eligible to be a staff member of the Foundation Trust cannot be a public member. Membership Development & Engagement Strategy The Board approved a three year Membership Development and Engagement Strategy in February The strategy describes the Trust s objectives for the membership and the approach to ensure the Trust develops and engages with a representative membership. It outlines our plans for raising awareness about membership and for the recruitment, retention and involvement of members. It also defines how we will measure the success of 69

70 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts the strategy. The strategy was produced with the guidance and input of the Council of Governors. The Hillingdon Hospitals NHS Foundation Trust is committed to recruiting members from the diverse population served by the Trust. Membership is open to all those eligible to be a member regardless of gender, race, disability, ethnicity, religion or any other groups covered under the Equality Act The membership base is regularly reviewed to ensure that the membership is representative of those eligible to be members. Specific groups that appear to be under-represented are targeted in recruitment campaigns in order to seek to increase membership representation in these areas, such as young people between the ages of 16 and 45. The Trust s targets for membership growth are as follows: Public Constituency Staff Constituency ,650 7,750 3,187 3,187 Total 10,837 10,937 In order to achieve the above targets there will be a need to recruit approximately an additional 500 public members each year to replace those who cease to be a member by virtue of moving or passing away. The above targets represent a broad indication of our objective to increase the membership but our primary focus is to maintain the current level of membership, address areas of under-representation and focus on engagement rather than growth. Key actions that have been undertaken or form our action plan to grow membership include: Utilising existing publications (e.g. Hillingdon People), local groups (e.g. Resident Associations) and local events (e.g. May Day Fair and community events). Attending local community and voluntary group meetings i.e. AGMs, conferences. Attending joint public engagement meetings with Hillingdon Clinical Commissioning Group, Central and North West London NHS Foundation Trust and London Borough of Hillingdon. Promoting membership at Trust engagement events, including armed forces, black and minority ethnic focus groups and patient support groups. Encouraging Governors and members to sign up family, friends and members of the public. Inviting ex-staff, their family and friends to become public members. Exploring the use of social media to reach out to younger members. Making membership forms available in local libraries. 70

71 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts st March 2014 % of membership Population Base % of area Central 2, , North 1, , South 2, , Rest of England Total 7, ,071 Public membership As at 31st March 2014, the Trust had 7,086 public members. The table above illustrates the number of public members for each constituency compared to the total population. During , the Foundation Trust recruited 225 new public members and lost 310 public members due to members passing away, moving away without providing a new address, or cancelling their membership. This has contributed to the Trust not meeting the target of 7,650 members. The majority of members who have been removed from our membership database are those who have moved away or provided incorrect contact details when they completed their membership form. The Trust is establishing a Council of Governors Membership Development and Engagement Group in April 2014 to enable Governors to become engaged in a programme of focused recruitment and engagement with members. As at 31st March 2014 the Trust had 3,038 staff members. The following table provides a breakdown by staff group: Staff Class Number of members Doctors and Dentists 252 Nurses, Midwives & Healthcare Assistants (including bank staff) Allied Health Professionals (including bank staff) Support staff (including bank staff and volunteers) 1, ,022 Total 3,038 Reviewing the Membership Development & Engagement Strategy A high level action plan to deliver the Membership Development and Engagement Strategy has been developed with progress reported to the Council of Governors each quarter and the Board annually in April. The report to the Board in April 2013 considered actions taken by the Trust to develop the membership and provided an outline of potential recruitment and engagement activities for the year ahead. A similar report was presented to the Board in April Engagement between governors and members The Trust organises People in Partnership meetings which enable the Governors, particularly the Public Governors, to engage with the members they represent. The meetings are held at a variety of locations and times during the year and are chaired by a Governor. They are preceded by an opportunity for members and Governors to meet over refreshments. The Trust encourages and facilitates linkages between the Council of Governors and groups and organisations which represent patients, public and the wider community. During , Public Governors attended Resident Associations across the Borough, Street Champion meetings and other community events for example the May Fair in West Drayton and a local Carnival in the Park to communicate with local residents and public members. Governors are encouraged to attend meetings in the community and report back to the wider Council of Governors in order to ensure that the Council of Governors is aware of public comments and concerns which have been raised in these meetings. The Trust provides Governors with information on the Trust s strategy and performance at various 71

72 03 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts meetings such as the formal quarterly Council of Governors meetings, monthly informal meetings with the Chair and Chief Executive, and the joint meetings between the Board and Council of Governors. Governors can then feed this information back to the members and organisations they represent. These meetings also provide the opportunity for Governors to feedback issues of concern raised by members. During , such issues included car-parking at the Hillingdon site, the booking of out-patient appointments, and discharge and pharmacy processes. The Trust has continued to include these latter two areas as priorities in the quality report, whilst car-parking was subject of a working group involving Governors which made recommendations to the Board. Governors are also able to communicate with members through the quarterly members newsletter the Pulse which regularly features a Governor article. In the Trust will be seeking to work with the new Council of Governors to develop the arrangements by which Governors engage with the members and feed members views back to the Board. As the first stage in this, a joint working group comprising the Interim Chair, Public Governors and members of staff will be established to identify and oversee improvements in these arrangements. As noted above, this will also seek to help facilitate increased membership recruitment. Post: Foundation Trust Office, Hillingdon Hospital, Pield Heath Road, Uxbridge, UB8 3NN. Compliance with the NHS Foundation Trust Code of Governance In December 2013 Monitor published an updated NHS Foundation Trust Code of Governance which took effect from 1st January The Board has identified that the Trust is currently non-compliant with the following provisions of the updated Code. Provision A.1.1: The Trust is compliant with this provision in that the Trust s Scheme of Reservation and Delegation includes a schedule of matters reserved for the Board and a statement on the roles and responsibilities of Governors. This document was reviewed and updated in February 2014 and in light of the new requirements of the updated Code will now be reviewed annually by the Audit & Assurance Committee. The Trust is however not fully compliant with this provision in that the procedure for how conflicts between the Board and Council of Governors are to be resolved is not in this document, but in a separate document that covers the engagement between the Board and Council of Governors. This is felt to be a more suitable location within the Trust s governance documents. The Trust s arrangements are consistent with the principles of the Code in that a clear written dispute resolution process is in place. The Membership Development & Engagement Strategy approved by the Board outlines the Trust s policy on the involvement of members, patients and wider public, including a statement on the Trust s approach to consultation, and addressing the overlap and interaction between the Governors and other consultative and representative groups. The strategy is available on the Trust s website. Contacting Directors and Governors Directors and Governors can be contacted through the Foundation Trust Office: foundation@thh.nhs.uk Phone: Provision A.3.1: The Trust is not compliant with this provision. James Reid had served on the Board of the Foundation Trust and preceding NHS Trust for just over six years at the time of taking on the role of Interim Chair. The Board is clear that despite this time served, James retains his independent mind-set as evidenced by an ability to challenge. Furthermore, this is intended to be a short-term arrangement for which the need arose following a rigorous process that was unable to appoint a substantive Chair. Provision B.4.2: The Trust is not currently fully compliant with this provision which states that 72

73 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts the chairperson should regularly review and agree with each Director their training and development needs as they relate to their role on the Board. The Trust is compliant with this provision in relation to the Non-Executive Directors and Chief Executive; however it is not currently compliant in relation to the Executive Directors. The Chair, through the Remuneration Committee provides feedback with the other Non-Executive Directors on Executive Directors performance, which includes areas for Executive Directors development both in terms of their role on the Board and their functional management role. However, this is fed back to individual Executive Directors by the Chief Executive rather than the Chair as there is not a separate appraisal in relation to Executive Directors Board role. The Board has discussed this issue and agreed that the Trust should seek to comply with this provision in future. The Board agreed that forthcoming Board development work to be undertaken later in will assist in the identification of how Directors individually and collectively can be more effective and the outputs of this work will assist the Chair in agreeing development needs with Board members individually and collectively. with this provision and the terms of reference will be provided to the Council of Governors in July when the Audit & Assurance Committee reports on the auditors performance. In addition, the Board has identified areas where the Trust s compliance with the Code could be strengthened, most notably in relation to the Governors consultation and engagement with the membership (provision B.5.6). As highlighted earlier in the report, a working group is being established in early to seek to develop these arrangements. The disclosures required by the Code of Governance in relation to the Board, Council of Governors, Nominations Committees, Audit Committee, and membership are included in the governance section of the Directors report. The disclosures required by the Code in relation to the Remuneration Committee are contained in the remuneration report that follows this section. Provision C.3.2: The Trust is compliant with the majority of the provision in that the Audit & Assurance Committee s terms of reference are publicly available and include the responsibilities set out in this provision. However, the Trust has not complied with the requirement to consult the Council of Governors on the Audit & Assurance Committee s terms of reference as this was a new addition to the updated Code that was published in December There was, and continues to be, close working between the Council of Governors and the Committee; for example, the joint working group on the external auditor appointment, and also the Audit & Assurance Committee Chair reports annually to the Council of Governors on the external auditor s performance. This ensures that the Trust s arrangements are in line with the partnership approach envisaged under the Code, and that the Council of Governors can ensure the AAC is effectively working with external audit. Moving forward, the Board has agreed to comply 73

74 04 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Remuneration report 74

75 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Board of Directors Remuneration Committee The Board of Directors Remuneration Committee comprises all of the Non-Executive Directors and is chaired by the Deputy Chair. The Chief Executive and Director of People are invited to attend to provide professional advice, except when the Committee is considering these individuals remuneration and/or performance. The Trust Secretary attends to take minutes of the Committee s meetings. The Committee s role and responsibilities are primarily two-fold: to agree the remuneration and terms of service for the Chief Executive and the Executive Directors; and to oversee the performance monitoring of the Chief Executive and Executive Directors. The Committee also reviews at a high level the remuneration of the Trust s most senior employees beneath the Board (i.e. the first line reports to the Executive Directors and the Trust s consultants) to ensure this remains appropriate to the remuneration paid to the Executives. The Committee met four times in At its meeting in May 2013 the Committee agreed to award a 1% cost of living increase to the remuneration of the Chief Executive and Executive Directors for the year, in line with the increase awarded to staff on nationally defined terms and conditions. The Committee also reviewed a report on the level of senior management and consultant remuneration at the Trust. The Committee requested and received a follow-up report to its meeting in September 2013 on the highest paid consultants. At its meeting in September 2013 the Committee agreed to commission remuneration consultants to report on executive remuneration. In order for this information to be available for the Committee s next meeting, the Committee delegated to the Committee Chair the authority to agree the consultants to be appointed in consultation with Committee members outside of the meeting. Capita were subsequently commissioned to provide a benchmarking report for the Committee which benchmarked the executive remuneration at the Trust against other Foundation Trusts. The Committee considered the report in March To ensure independence and objectivity, neither the Chief Executive nor Director of People was present whilst the Committee discussed their respective remuneration. Capita s services were limited to providing the benchmarking report for the Committee and did not attend any meetings of the Remuneration Committee. The fee for this report was 1,800. Prior to considering the Capita report on executive remuneration in March 2014, the Committee first considered reports from the Chair and Chief Executive on the performance of the Chief Executive and Executive Directors respectively. The Committee confirmed the Trust s executive pay policy is to set remuneration at the median to upper quartile of comparator Trusts, taking into account the following factors when setting individual Executives pay: performance; experience; importance to the organisation; and marketability and likelihood of moving elsewhere. The Committee reviewed each Executive s remuneration against this policy, using the benchmarking scales in the Capita report, and made adjustments to Executive salaries where the Committee agreed this was in line with the policy. The Committee also agreed that the Executives should receive the 1% cost of living increase should this be confirmed for Agenda for Change staff (which it subsequently was for those staff not receiving an increment). The Committee agreed that these amendments would take effect for 1st April The Committee has agreed that executive remuneration should not include provisions for bonus payments or proportions subject to performance conditions. However, the Committee considers individual and overall Trust performance when determining executive remuneration as part of the pay policy outlined above. 75

76 04 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts In April 2014 the Committee met and agreed revised wording for the pay policy to ensure that this not open to misinterpretation. In particular, around the fact that it is not the default position that all executive positions are paid at least at the median of comparator Trusts. The Committee agreed that the pay policy is to set executive remuneration between the median and upper quartile of comparator Trusts when individuals have a demonstrable track record of high performance against agreed objectives and in their overall contribution to the Trust over a sustained period of time. In making decisions on executive remuneration the Remuneration Committee will also consider the organisation s performance, and the individual s experience, marketability and likelihood of moving elsewhere. Executive remuneration does not currently include provisions for bonus payments linked to the delivery of performance targets. As noted above, the Committee reviews the pay of the first layer of management beneath the Board to ensure that there is appropriate differential between the remuneration of the Executive Team and their direct reports. This report, alongside that on consultant remuneration, was presented to the Committee in March 2014 when it considered adjustments to executive remuneration. The Committee s standard approach is to award the cost of living increases that are awarded to staff on Agenda for Change terms and conditions to the Executive Team. Neither the Chief Executive nor the Executive Directors are currently appointed for fixed term contracts. The Board believes that such contracts would make it harder to attract and retain highquality Executives in a competitive recruitment environment, and can lead to uncertainty affecting service delivery towards the end of the contract. The Trust s policy on notice periods and termination payments for Executive Directors is six months, in line with generally accepted practice at this level in the NHS. Any decision to allow an Executive Director to leave the Trust s employment without this full notice period is subject to a risk assessment by the Board of Directors Nominations Committee, in line with the Code of Governance. As outlined earlier in the report, Jacqueline Walker acted up from her substantive role as the Trust s Deputy Director of Nursing to be the Acting Executive Director of Patient Experience & Nursing. Following Theresa Murphy taking up the position of Executive Director of Patient Experience & Nursing in May 2013, Jacqueline returned to her substantive role. The terms of office of the Chair and Non-Executive Directors are outlined earlier in the annual report. Attendance at Remuneration Committee meetings in is outlined earlier in the governance section of the Directors Report. Non-Executive remuneration The Council of Governors is responsible for agreeing the remuneration of the Chair and Non-Executive Directors. At their meeting in October 2011 the Council of Governors agreed that the remuneration for the Chair and Non-Executive Directors should be increased to 45k pa and 13k pa respectively to reflect the additional responsibilities arising from Foundation Trust status. In agreeing this increase, the Council of Governors was mindful of the wage restraint in the NHS and agreed that the increase would not take effect until 1st April 2012 (and therefore a year after authorisation as a Foundation Trust) and that Non-Executive remuneration would not be increased for a further two years. The Council of Governors Nominations & Remuneration Committee reviewed benchmarking information collated by the Foundation Trust Network at its meeting in December The Committee agreed that the remuneration and time commitment was comparable to that in other Foundation Trusts. The Committee therefore recommended to the Council of Governors that no changes were required to the remuneration. This recommendation was accepted by the Council of Governors at its meeting on 21st January

77 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Non-Executive appointments are not within the jurisdiction of Employment Tribunals and there is no entitlement for compensation for loss of office through employment law. As outlined above, in making decisions on Non- Executive remuneration, the Council of Governors draws on the recommendations of the Council of Governors Nominations & Remuneration Committee. Attendance at the Committee s seven meetings in is outlined below. Name Mike Robinson (Trust Chair) John Coleman (Public Governor) Stuart Marshall (Public Governor) Cllr Mary O Connor (Appointed Governor) Pradip Patel (Deputy Chair & Non-Executive Director ) Alvan Pope (Staff Governor) James Reid (Senior Independent Director) Roger Shipton (Public Governor) Number of meetings attended 4* of 4 7 of 7 4 of 7 7 of 7 1 of 1 6 of 7 5 of 5 7 of 7 Directors remuneration in For the purposes of the remuneration report, the Chief Executive has confirmed that the definition of senior manager covers the members of the Board plus the Director of People who attended Board meetings throughout the year, in line with the definition in Monitor s Annual Reporting Manual that senior managers are those persons in senior positions having authority or responsibility for directing or controlling the major activities of the Foundation Trust. The total aggregate gross pay for the Executive and Non-Executive Directors in was 1.018m. Further details are contained in note 6.1 to the accounts. The table opposite includes the payments made to current and former senior managers in that require disclosure under the Foundation Trust Annual Reporting Manual. No Executive Director currently serves as a Non-Executive Director of another organisation. The Directors received no benefits in kind. * A number of the meetings related to the appointment of Mike Robinson s successor. Mike was not therefore present at these discussions with the meeting chaired by James Reid (Senior Independent Director) and then Pradip Patel (Deputy Chair) as outlined earlier in the report. 77

78 04 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Directors remuneration (excluding pension contributions) fell within the following ranges: Real Increase in Cash Equivalent Transfer Value Cash Equivalent Transfer Value at 31st March 2013 Cash Equivalent Transfer Value at 31st March 2014 Lump Sum at age 60 related to accrued pension at 31st March 2014 Total accrued pension at age 60 at 31st March 2014 Real increase in pension at age 60 Real increase in lump sum pension at age 60 Salary (excluding social security costs) Salary (excluding social security costs) (bands of 5000) (bands of 2500) (bands of 2500) (bands of 5000) (bands of 5000) Notes Executive Directors 000s 000s 000s 000s 000s 000s 000s 000s 000s Shane DeGaris Chief Executive Claire Gore, Director of People N/A N/A N/A N/A N/A N/A N/A 1 Richard Grocott-Mason, Joint Medical Director Abbas Khakoo, Joint Medical Director Karl Munslow Ong, Chief Operating Officer N/A Theresa Murphy, Executive Director of the Patient Experience and Nursing David Searle, Executive Director of Corporate Development Jacqueline Walker, Acting Executive Director of Patient Experience and Nursing 4 Paul Wratten, Finance Director Non Executive Directors Michael Robinson, Chair N/A N/A N/A N/A N/A N/A N/A Katey Adderley, Non-Executive Director N/A N/A N/A N/A N/A N/A N/A Carol Bode, Non-Executive Director N/A N/A N/A N/A N/A N/A N/A 5 Soraya Dhillon, Non-Executive Director 0-5 N/A N/A N/A N/A N/A N/A N/A N/A 6 Alan McLeod, Non-Executive Director N/A N/A N/A N/A N/A N/A N/A 7 Lis Paice, Non-Executive Director 0-5 N/A N/A N/A N/A N/A N/A N/A N/A 8 Anthony Palmer, Non-Executive Director N/A N/A N/A N/A N/A N/A N/A Pradip Patel, Non-Executive Director N/A N/A N/A N/A N/A N/A N/A James Reid, Non-Executive Director N/A N/A N/A N/A N/A N/A N/A Craig Rowland, Non-Executive Director N/A N/A N/A N/A N/A N/A N/A 3. Commenced employment with Trust and took office on 30th May Left office on 9th June 2013 and continued to be employed by the Trust. 5. Commenced office on 1st February Left office on 30th November Commenced office on 1st February Left office on 31st December No Performance Bonuses were paid to the above Senior Staff in or NOTES: 1. Clinical work in band of 60k to 65, Director work in band of 90k to 95k. Recharges out to Royal Brompton and Harefield NHS Foundation Trust not included in above. Included in salary was a Clinical Excellence Award in band of 20k to 25k which was Trust funded and was included in clinical work. 2. Clinical work in band of 65k to 70k, Director work in band of 105k to 110k. Recharges out to NHS Central London CCG not included in above. Included in salary was a Clinical Excellence Award in band of 25k to 30k. This was centrally funded and was included in clinical work Band of Highest Paid Director s Total Remuneration ( 000) Median Total Remuneration 30,845 30,801 Ratio The HM Treasury Financial Reporting Manual (FReM), requires the Trust to disclose the median remuneration of the Trust staff and the ratio between this and the mid-point of the banded remuneration of the highest paid director. The calculation is based on full-time equivalent staff of the Trust at 31st March 2014 on an annualised basis.

79 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Governor and Director expenses The Governors and Directors are entitled to claim for certain expenses incurred whilst undertaking their role at the Trust. The rates payable to Governors are approved by the Board of Directors, whilst the rates payable to the Chair and Non-Executive Directors are approved by the Council of Governors. These are both based on the rates payable to the Trust s staff on Agenda for Change Terms and Conditions. The Chief Executive and Executive Directors are eligible to claim expenses under the rates payable to staff employed on the Agenda for Change terms and conditions. The table below outlines the expenses paid to members of the Board of Directors and Council of Governors in and as required by the Foundation Trust Annual Reporting Manual Actual Actual Total number of Directors in office in the reporting period Number of Directors receiving expenses in the reporting period 10 9 Total value of expenses paid to Directors in the reporting period 5,213 2,509 Total number of Governors in office in the reporting period Number of Governors receiving expenses in the reporting period 0 0 Total value of expenses paid to Governors in the reporting period

80 04 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Reporting of off-payroll engagements The following information is presented in accordance with the requirements of the NHS Foundation Trust Annual Reporting Manual. Table 1: For all off-payroll engagements as of 31st March 2014, for more than 220 per day and that last for longer than six months No. of existing engagements as of 31st March Of which... No. that have existed for less than one year at time of reporting. 2 No. that have existed for between one and two years at time of reporting. 0 No. that have existed for between two and three years at time of reporting. 4 No. that have existed for between three and four years at time of reporting. 0 No. that have existed for four or more years at time of reporting. 4 The Trust has 10 engagements falling within the current definition compared to a total headcount of 2,806 employed staff. Of the 10 engagements only two would have been included using the threshold criteria applied last financial year. The Trust has not yet fully implemented its revised internal processes to take account of the new lower threshold and therefore full assurance is not available. All engagements have been written to in order to confirm their requirement to correctly pay tax and have been asked to provide written confirmation they have done so. The Trust will review responses and ensure it gains sufficient information to complete a risk based assessment for each individual. Table 2: For all new off-payroll engagements, or those that reached six months in duration, between 1st April 2013 and 31st March 2014, for more than 220 per day and that last for longer than six months No. of new engagements, or those that reached six months in duration, between 1st April 2013 and 31st March 2014 No. of the above which include contractual clauses giving the Trust the right to request assurance in relation to income tax and National Insurance obligations 2 0 No. for whom assurance has been requested 0 Of which... No. for whom assurance has been received 0 No. for whom assurance has not been received 0 No. that have been terminated as a result of assurance not being received. 0 The Trust has not currently fully implemented its amended internal processes to adequately account for the reduced threshold criteria applied this year. As a result the Trust is not yet assured all engagements contain contractual clauses allowing the Trust to seek assurance as to individual tax obligations. All engagements have been contacted to verify whether their contract includes the required clauses and where not a new contract will be issued. 80

81 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Table 3: For any off-payroll engagements of board members, and/or, senior officials with significant financial responsibility, between 1st April 2013 and 31st March 2014 No. of off-payroll engagements of board members, and/or, senior officials with significant financial responsibility, during the financial year. No. of individuals that have been deemed board members and/or senior officials with significant financial responsibility during the financial year. This figure should include both off-payroll and on-payroll engagements Shane DeGaris Chief Executive 28th May

82 04 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Quality Report Improving your local hospitals our report to you 82

83 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts contents About the Trust s Quality Report 84 Executive summary 84 Part 1 Statement from the Chief Executive 86 Part 2 Review of quality priorities for improvement 88 Key quality achievements for Looking back 89 Quality priorities for improvement How did we do? Performance against core quality Indicators Looking forward 100 Our new Clinical Quality Strategy 100 Quality priorities for improvement in Patient Safety Collaborative Programme Formal statements of assurance from the Board 107 Provision of NHS Services 107 Participation in clinical audit 108 Participation in research 113 Lessons learned from Serious Incidents 114 Goals agreed with our commissioners 115 Care Quality Commission registration 115 Data quality 117 Information governance toolkit 117 Clinical coding error rate 117 Part 3 Other key quality improvements we have made in Part 4 Statements from our stakeholders Statement from Hillingdon Clinical Commissioning Group (CCG) Statement from our local Healthwatch (formerly LINks) Statement from External Services Scrutiny Committee The Hillingdon Hospitals NHS Foundation Trust response to the consultation Independent Auditor s Report Statement of Directors responsibilities in respect of the Quality Report 137 Glossary

84 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts About the Trust s Quality Report What is the Quality Report? This is produced for the public by NHS healthcare providers about the quality of services they deliver. All NHS providers strive to achieve high quality care for all their patients, and the Quality Report provides the Trust an opportunity to demonstrate its commitment to quality improvement and show what progress we have made in The Quality Report is a mandated document which is laid before Parliament before being made available on the NHS Choices website and our own website ( What is included in the Quality Report? The Quality Report is a statutory document that contains specific mandatory statements and sections. There are also three areas that are mandated by the Department of Health (DH) which give us a framework in which to focus our quality improvement programme. These are patient safety, patient experience and clinical effectiveness. The Trust undertook extensive consultation and engagement in developing this report to ensure that the quality improvement priorities reflect those of our patients, our staff and our partners and the wider public. Part 2 of the report highlights the Trust s quality priorities and includes: Executive summary This Executive Summary provides a very brief overview of the information in this year s report. The Quality Report is a summary of our performance during in relation to our quality priorities and national requirements. The detail of our key quality achievements and improvements are outlined in the main body of the report. Overall the Trust has performed very well across a wide range of core quality indicators during this past year which has resulted in us achieving green status for governance in Monitor s risk rating system. Particular successes include the reduction in the Trust s mortality rate, the reduction in Health Care Associated Infections and achieving Level 2 status in our recent NHS Litigation Authority risk management standards assessments for acute general and maternity care. To demonstrate progress against our quality priorities during we have included information that shows how clinical teams have changed the way they deliver care in order to improve the quality of services for patients in our hospitals. Even though our five priorities for have not been fully achieved, some elements of the improvement work have been fully realised and targets met. Some examples of our achievements in the five priority areas are listed below. Finally we have set out our quality priorities for and the targets we aim to achieve. The areas identified for improvement in What the priority was How we performed against the targets And what this means for our patients. There is also a section in Part 2 on the quality priorities that have been identified for improvement projects in There is a useful glossary at the back of the report which lists the abbreviations and terms included in the document. 84

85 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Quality Priorities for Improvement How did we do? Quality priority How did we do? The First Contact Project Improving the Outpatient Experience Reduced call abandonment rate (target <10%) 12% improved by 16% from Reduced Did Not Attend rates for outpatient appointments (target 8%) Reduced by 0.6% to 9.1% Improving People s Experience of Leaving Hospital / Improving Inpatient Care Achieve average Length of Stay to 3.5 days Earlier therapy and specialist review for >400 patients Reduced from 4 to 3.6 days 463 patients via our Home Safe project Improving Emergency Care Reduction of Hospital Standardised Mortality Ratio (HSMR) to London average Achieved lower than national average, but remains slightly above London average Improved response rate for A&E in the Friends and Family Test 19.4% against a national target of 15% CQUINS (Commissioning for Quality and Innovation) Electronic requesting for radiology and pathology Improving the experience of both patients and staff (measured using the Friends & Family Test) 100% achievement 100% achievement Embedding our culture and values framework CARES Staff completing their Personal Development Review (PDR) Achieved 84% against a target of 90% Improved result in Compassionate Care question as part of the local patient experience survey Achieved 96% against a target of 85% Quality Priorities for Improvement in What do we aim to do? Continuing to Improve the Outpatient Experience Continuing with the Improving Inpatient Care Project Improving patient safety in Emergency and Maternity Care Introducing and embedding patient care bundles/pathways Improve responsiveness to patient need. During the Trust has published a new Clinical Quality Strategy to support its delivery of high quality care over the next three years. The purpose of the new Strategy is to provide a structure for delivering quality governance to ensure ongoing improvement in the quality and safety of patient care. The quality priorities outlined in this year s Quality Report reflect the clinical quality priorities outlined in our Strategy. The mandated statements/sections within this Quality Report include information on our participation in national audits and our research activity during In addition, information is provided on our registration as a healthcare provider with the Care Quality Commission (CQC) and the result of our unannounced visit during This Quality Report and the priorities for are presented as a result of consultation and engagement with our Foundation Trust members, our Governors, our staff, Healthwatch and our Commissioners. 85

86 05 Part 1 Statement from the Chief Executive The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts This Quality Report provides the Trust an opportunity to demonstrate our commitment to delivering high quality care to all. It outlines our quality improvement work and the progress we have made in I am extremely proud of our achievements and of the ongoing commitment from our staff in striving to continue to improve the care and services that we deliver. I know that what patients want is reassurance that they can trust their local hospital to provide reliable, high standards of care 24 hours a day, seven days a week. This Quality Report confirms our commitment to you to achieve this and ensures that we always put our patients at the forefront of service development and improvement. In this report you will read of the extensive quality improvement work that has been taking place across our hospitals to support this ethos and the elements of clinical care and service delivery that we aim to further improve to provide the safe and high quality care that our patients expect and deserve. Within North West London the Shaping a Healthier Future * (SaHF) programme outlines a five year strategy which places the Hillingdon Hospital site as one of the five major hospitals for providing a full range of 24/7 emergency care in the region. The programme is based on implementing the London Health Programme (LHP) quality standards for emergency care across all the major hospitals and in all specialties that take part in the provision of this service. The Trust has undertaken a self-assessment on its current position against these standards and key actions are being driven forward as part of our clinical quality strategy. The SaHF programme also places an emphasis on the provision of a wider range of out-of-hours primary and urgent care, and we are working closely with our GP commissioners * and other providers to ensure that across the healthcare community patient care is provided in the right place at the right time. During there has been an increased focus on how we measure and monitor quality at the Trust. The Trust has considered and made reference to key NHS investigations and reviews, and in particular the Francis Inquiry into the failings at Mid Staffordshire NHS Foundation Trust where the standard of services put patients at risk. Not only was this a salutary reminder that things can go wrong when quality is not put at the heart of what we do but it has also served to focus us all on continuously striving to provide the safest possible care. Our new Clinical Quality Strategy outlines the learning and recommendations from the Francis Report and other key quality reviews; these underpin our key aims and objectives for quality improvement. In addition we have reviewed our current quality performance alongside national and regional quality data and referenced local feedback from both staff and patients in informing our new Strategy. We have also undertaken a thorough review of our governance structures and processes in relation to delivering a robust quality management system in accordance with Monitor s Quality Governance Framework. INCREASED FOCUS We have performed very well on our quality performance during across a wide range of indicators which has resulted in us achieving green status for governance with regard to Monitor s risk rating system. Under the Care Quality Commission s new Intelligent Monitoring System of acute trusts (where trusts are assessed against 188 different indicators) we have been assessed as being in 86

87 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts the lowest level of risk category (band 6) for two consecutive assessment periods. We have also achieved Level 2 status in our recent NHS Litigation Authority (NHSLA) and the Clinical Negligence Scheme for Trusts (CNST) maternity assessments. This demonstrates the Trust has robust risk management processes in place which have been checked for compliance and that staff see it as one of their concerns to keep patients safe. In addition, the Trust was Highly Commended in the 2013 Dr Foster Hospital Guide awards for the improvement in its performance for weekend emergency HSMR (Hospital Standardised Mortality Ratio). This is recognition of the good work that has been done to not only improve weekend mortality but importantly to maintain overall performance. We have received over 15,800 patient responses to the Friends and Family Test (FFT) during with the majority of patents recommending our wards and emergency department to family and friends. Where problems were highlighted we have looked to address these. An example of this is our Comfort at Night programme, recognised as a very positive outcome on action taken as a result of feedback from the FFT. Despite a very positive quality performance record for , we are not complacent. Weaknesses in our systems are dealt with promptly and openly to ensure that better and safer systems of care can be developed. The aim of this report is not only to report on our achievements and the improvements we have made in the last year but to give a balanced view and to highlight the areas that we know we need to focus on to make our services even more safe and of a higher quality. In developing our quality priorities for we have made reference to national best practice and reviewed our current quality performance in line with local, regional and national performance. The report is the result of consultation with a wide group of stakeholders, including our Governors, Commissioners, People in Partnership and our local Healthwatch. I hope that this Quality Report provides you with a clear picture of how important improvement and safety are to us at The Hillingdon Hospitals NHS Foundation Trust. I confirm that to the best of my knowledge the information in this document is accurate. Yours sincerely Shane Degaris Chief Executive The Hillingdon Hospitals NHS Foundation Trust 28th May

88 05 Part 2 Review of Quality Priorities for Improvement The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts In this part of the report we tell you about the quality of our services and how we have performed in the areas identified for improvement in These areas are called our quality priorities and they fall into the three areas of quality as mandated by the Department of Health (DH): patient safety, patient experience and clinical effectiveness, and we are required to have a minimum of one priority in each area. Firstly, the information below provides an overview of some of our key quality achievements in These are important indicators for the public and our key stakeholders to provide assurance on the quality of care and services that are delivered at the Trust: Key Quality Achievements during Achieved Level 2 accreditation for NHS Litigation Authority standards* Dr Foster Good Hospital Guide Highly Commended for improvement on weekend mortality Achieved Level 2 accreditation for Clinical Negligence Scheme for Trusts (CNST) for Maternity standards* Monitor the Trust is rated green (no Evident concerns) for its performance on quality Care Quality Commission achieved Band 6 (lowest level of risk) in two consecutive assessments Trust ranks among the best in London for patients on the fractured hip pathway *There are four NHSLA/CNST Levels: 0, 1, 2 and 3 being the highest level higher levels indicate a reliable, robust and embedded risk management system across an organisation. 88

89 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts LOOKING BACK j Part 2.1 Quality priorities for improvement How did we do? PRIORITY 1 The First Contact Project Improving the outpatient experience We said: We would continue with the First Contact Project (improving the outpatient experience) to further embed the way patients are contacted and reminded about their appointments. The Call Management System (CMS) which was introduced in 2012 needed further development during to ensure we were getting our messages right for patients. We also wanted to further centralise bookings of new and follow-up outpatient appointments across the Trust, having only partially achieved our plans during How did we do? We have been successful in significantly reducing the call abandonment rate to just 12% and realising improvement across the other key indicators. It has been recognised that the targets that were set for for this project were very ambitious and based on performance in the private sector. During a working group has been meeting to further facilitate this service development and add insight about the challenges patients face when booking outpatient appointments. The group have reviewed the quality targets concerning reducing the call abandonment rate, answering calls in 60 seconds and call resolution. Times that patients are more likely to contact the Outpatient Appointment Centre (OAC) were suggested and a system has been introduced which enables an increase in staff to cover high call volumes. The opening times of the OAC were discussed and it was felt these offered patients choice and good accessibility. For improving the target of where patients do not attend their appointment it was agreed that patients should have an option to cancel their appointment without being transferred to a call agent. Following introduction of this streamlined cancellation service during the latter part of the DNA rate has fallen below the target of 8%. Furthermore in February 2014 work commenced to pilot an enhanced reminder service to one specialty and the impact is currently being tracked. Evaluation of this pilot will report on-going work in Also, following feedback from patients, the text message format was changed to include the specialty of the appointment. In addition, an Electronic Document Transfer system (EDT) is being introduced which supports the delivery of clinical documentation securely between secondary and primary care in real time. The EDT Hub will be used to send clinical correspondence such as attendance notifications and outpatient letters from Q2 onwards. Annual Quality Report Projects KPI Dashboard Target Reduced call abandonment rate N/A 28% 12% <10% No of telephone calls answered within 60 seconds Resolution of queries in the first contact with patients Reduced DNA rates for outpatient appointments N/A N/A 75% 95% N/A N/A 55% >90% 9.8% 9.7% 9.1% 8% 89

90 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts What does this mean for our patients? The outpatient pathway has been a key area of focus for the Trust over the past few years in really driving forward improvement around the patient experience and that the systems we have in place become much more efficient. The local outpatient experience survey demonstrates that patients are generally satisfied with the experience within the outpatient department with an overall satisfaction score of 87% across a range of indicators. We have heard through our local Healthwatch however that there are a number of elements in relation to the outpatient pathway that need to continue to improve, particularly in relation to the number of appointment letters that a patient may receive and the resolution of enquiries to the OAC. This is why our improvement work will continue as a priority into as identified by our FT members, our local Healthwatch and our staff. PRIORITY 2 Improving people s experience of leaving hospital/improving inpatient care We said: We would continue with the Leaving Hospital Project to further improve the patient journey through the hospital thereby decreasing length of stay and to ensure an improved experience for patients leading up to and including discharge from hospital. We advised that we had reviewed our goals and priorities and re-launched the project as Improving Inpatient Care. Our aims were to enhance early assessments for elderly people and to reduce any unnecessary lengths of stay in hospital, as well as reducing readmissions. We said we would improve the discharge process by better co-ordination of teams and closer working together with doctors, nurses, pharmacists and therapists when reviewing a patient s needs before they leave hospital. How did we do? The specific goals we set for the project and the performance are outlined below. The Improving Inpatient Care Programme has continued to evolve and has been focussed on a number of key services that either avoid hospital admissions or reduce length of stay by ensuring comprehensive consultant-led assessment at an early stage in the patient s pathway. Last year we also said that we would implement new electronic whiteboards to provide reminders of all patients next steps for all teams who work on the wards. A new electronic white board system has now been implemented, with full roll out to every ward now completed. This has improved communication between all staff on the wards, improved the daily handover and now the staff can clearly see what each patient is waiting for, and act promptly to ensure minimal delays. The ambulatory care service that has previously focussed on seeing and treating patients presenting with deep vein thrombosis has now expanded to include conditions such as community acquired pneumonia, kidney infections and pulmonary embolus. On average when compared with the Annual Quality Report Projects KPI Dashboard Target Reduce average length of hospital stay (LoS) by 12%, achieving average LoS to 3.5 days (national upper quartile level) Trust overall 3.5 elective inpatients 3.5 Percentage of discharges leaving hospital before midday 29% 23.6% 40% Earlier therapy and specialist review (numbers of patients via Home Safe project) N/A Reduction in avoidable readmissions by 230 cases fewer

91 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts previous year the service now treats an additional 200 patients per month. The Home Safe team has evolved from the acute care of the elderly service that was previously piloted in the emergency assessment ward and is working proactively with community services and Age UK to provide expert clinical review. The level of specialist input facilitates high quality patient discharge for the care of the elderly group. The Home Safe team, led by a consultant geriatrician provide a high quality multidisciplinary care team review and provide individualised plans of care that may include referral to a variety of services both in and out of hospital. Overall, length of stay has continued to reduce within the division of Medicine (by 0.7 days for ) and since the formal introduction of Home Safe in January 2014, the average length of stay for care of the elderly has fallen from 14 days to 11.5 days for two consecutive months. From November 2013 until end of March 2014 the Home Safe team screened 463 patients and assessed 189 patients. 118 of these patients were able to be sent home at an earlier stage with 58 receiving additional support from a range of services. What does this mean for our patients? Reducing the length of stay in hospital for our patients means that they spend less unnecessary time in hospital. The Home Safe project ensures there is a multidisciplinary approach to planning for discharge as soon as the patient is admitted. Going forward there are plans to expand the service to be able to offer Home Safe discharge from our specialty wards. This will mean that patients who have undergone surgery or who have had an extended length of stay in hospital will also be able to benefit from this innovative new service. Although length of stay has achieved the target during we have not been able to improve further on patients leaving hospital before midday. Our local Healthwatch have advised us that they continue to receive this feedback and that this is a real concern for our patients, often waiting for medication or for community services to be organised resulting in discharges happening much later in the day. New initiatives to be explored in the forthcoming year include opening a medication dispensary on the new acute medical unit. This is expected to reduce the time that patients wait for their medications resulting in an increased number of earlier discharges per day. Reducing readmission rates is a key priority for the Trust in achieving high quality care. Despite aiming to reduce readmissions our current workstreams have not had significant impact in Readmissions to hospital within 28 days in was and in it reduced to slightly above the national average of 100 (this data is sourced from Dr Foster and is a standardised measure that looks at case-mix, identifying whether we have more or less or the same readmissions as would be expected). A recent audit that was undertaken in partnership with Hillingdon CCG has revealed that there are opportunities to improve the existing workstreams to improve communication and documentation across primary and secondary interfaces and also to support increased empowerment of patients to manage their own condition more effectively. The audit findings also suggested there is an opportunity to work with local nursing homes to provide their staff with advice and guidance on management of common conditions where admission to hospital could perhaps be avoided. This work will be driven forward in as part of our clinical quality strategy and action plan. PRIORITY 3 Improving emergency care We said: We would improve emergency care by aiming to achieve key elements of the London Health Programme Emergency Care Standards. We advised that nationally there is evidence to show that there are significant differences in the mortality rates for patients admitted as an emergency during the week compared with patients admitted as an emergency 91

92 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts at the weekend and that nationally, and in London, reduced service provision at weekends has been associated with a higher mortality rate. We stated that as a Trust we are committed to achieving these quality standards and that we had already invested in additional senior doctor time, out of hours Monday to Friday and also at the weekends. Notably we had provided consultant ward rounds twice a day on our medical Emergency Assessment Unit (EAU). The focus of work for was to ensure that there was a senior doctor (consultant level) review within 12 hours of a patient being admitted to the hospital and that we would aim to reduce the measure of mortality known as the Hospital Standardised Mortality Ratio to the London average and reduce the variation between weekday and weekend mortality. We also stated that we would improve participation of attending patients in the Friends and Family Test so that we could better gauge the patient s experience of emergency care. How did we do? Consultant review within 12 hours of how decision to admit The trust has made did we further investments in our do? Emergency Department and EAU resulting in increased consultant cover seven days per week. The rapid assessment service is now well embedded in the department and means that all emergency admissions benefit from an initial review by a senior doctor. The January audit showed that 64% of patients were reviewed by a consultant within 12 hours once admitted to the EAU against a target of 90%. Additional investment in the consultant body in will enable further expansion of ambulatory care pathways and will ensure that the vast majority of patients are seen by a consultant within 12 hours of admission. This will be a key focus in as part of the London Quality Standards recommendations and our local action plan. Reduction of HSMR to London average During trust weekday and weekend mortality rates have reduced based on benchmarking data available from Dr Foster (historically re-based annually). The overall Hospital Standardised Mortality Ratio (HSMR) is currently lower (84.1) than the national average for weekdays (up until February 2014) with statistical significance. HSMR is also lower than the national average at the weekends (98.2) however for it remains slightly above the London average. The Trust is tracking the HSMR at specialty level within clinical divisions and is carrying out regular reviews of all deaths in hospital. Participation of attending A&E patients in the Friends and Family Test We advised that we wanted to improve the participation in the Friends and Family Test in the Accident and Emergency Department because participation had been 8% for against a target of 15%. There has been significant improvement in this area where the trust now has the second highest response rate of all emergency departments in London. Our overall response rate for is 19.4% against the national target of 15%. The Friends and Family Test reports a netpromoter score whereby the patient would either highly recommend or recommend the emergency department to their friends and family. The vast majority of comments are extremely positive (see page 127) and very importantly actions have been taken where there have been recommendations for improvement. What does this mean for our patients? We are committed to ensuring that the care we deliver to patients who are admitted as an emergency is of the highest quality in relation to patient safety, patient experience and clinical effectiveness. We have been commended by Dr Foster for our reduction in HSMR for weekend mortality; this means that our patients are receiving improved care throughout the week. We will continue to focus on this improvement work during in relation to implementing the London Quality Standards. 92

93 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts PRIORITY 4 CQUINS (Commissioning for Quality and Innovation) The key aim of the Commissioning for Quality and Innovation (CQUIN) framework is to secure improvements in quality of services and better outcomes for patients, whilst also maintaining strong financial management. In there were ten Acute CQUIN schemes agreed, six of which were locally derived by Hillingdon Clinical Commissioning Group. In we have achieved 78.6% of our acute CQUIN target demonstrating a material improvement on in which we achieved 73%. How did we do? See table below. What does this mean for our patients? The CQUIN framework supports improvements in the quality of services and aims to provide better outcomes for patients. It enables commissioners to reward excellence, by linking a proportion of healthcare providers income to the achievement of local quality improvement goals. Having fully and partially achieved nine out of the ten CQUINS for will mean that the quality of our services and the care that we deliver to our patients has improved. CQUIN Targets for Achievement Commentary National Schemes Improving the experience of both patients and staff (measured using the Friends & Family Test) Promoting harm free care for patients (as measured by the Patient Safety Thermometer) Improving services for patients with dementia 100% achievement Partial achievement Partial achievement The Trust had a challenging target of 50% reduction in pressure ulcers (as measured by the Patient Safety Thermometer) for and started the year lower than the national average. The Trust achieved an overall year-end reduction of 37% but continues to see significant variation in the number of community acquired pressure ulcers and so will need to continue to work with community colleagues to best support and reduce these for As part of the dementia CQUIN the Trust was required to provide complete monthly carers surveys, implement staff training and to find, assess, investigate and refer 90% of elderly patients admitted through emergency methods. The Trust has achieved both the training and carers surveys but despite significant improvement of 70%, has been unable to achieve the 90% target. Preventing blood clots 100% achievement 93

94 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts CQUIN Targets for Achievement Commentary Local & Regional Schemes Home Safe (enables patients to be safely discharged sooner from hospital) Consultant assessments within 12 hours of emergency admission Electronic requesting for radiology and pathology Improving Colorectal services Improving communications between GPs and hospital consultants Reducing the length of time patients wait for treatment in A&E 100% achievement Not achieved 100% achievement Partial achievement Partial achievement Partial achievement The Trust had a target of consultant assessments within 12 hours of emergency admission however this has proved particularly difficult to achieve with performance of between 50 and 60%. This included reducing wait times for colonoscopies, comprehensive post-operative assessment by a geriatric specialist, and GP education. The Trust was successful in all but the GP education element where a small take up by GP practices made the face to face element particularly challenging. The Trust achieved its target to develop referral pathways with local GPs but did not fully achieve the target to provide an advice line service for GPs calling with condition-specific queries. 80% of calls from GPs were connected but the small volume of calls in some specialties meant that it was difficult to achieve the target of 92.5%. This CQUIN continues to have focus with roll out to additional specialties. A&E Rapid Access and Triage was a success within the first three quarters, however the Trust was not able to sustain reduced waits over the winter months leading to partial achievement of the CQUIN of 75%. 94

95 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts PRIORITY 5 Embedding our culture and values framework CARES pressures during winter resulted in staff not being able to be released to attend training, therefore a decision was made to postpone sessions and re-start them in April We said: Our goal was to deliver the best possible experience to our patients and to our staff. We felt we could make real improvement in this area through embedding our culture and values framework, CARES (Communication, Attitude, Responsibility, Equity and Safety). Formally launched in May 2012 CARES provides clear core values supported by a framework that sets out the standard in terms of attitude and behaviours we expect from our staff. This supports our staff to deliver care with compassion as well as ensuring it is safe and effective. How did we do? Performance Indicator Staff completing their Personal Development Review (PDR) Staff completing the Customer Care Training Performance Target for % 90% 50% 33% Whilst the target was not achieved for staff completing their PDR, this is a good return given the extension of the Talent Management (TM) process to around 500 staff significantly more than the previous year. The TM process incorporates a more detailed review for each individual and as a result requires much more time for both preparation and conversations with staff members. The Customer Care Training was introduced to raise awareness of our CARES values to all of our staff so that they could understand the impact of their behaviours on patients and their colleagues. We have not achieved our target because additional Learning from complaints improving behaviour and attitude We said that we would ensure that all complaints were addressed using the CARES framework and that we would make the framework an integral part of the investigation process to identify behavioural and attitudinal issues as well as the technical aspects so that we can learn from them. There have been significant changes in our Complaints Management Unit team during this year; this has meant that the focus has been on ensuring that complaints are investigated thoroughly and within the agreed timescale. Many of our senior sisters and matrons now successfully use the CARES framework when investigating and sharing the complaint with their teams. In this way they can bring the CARES values to life encouraging individuals to evaluate whether they have demonstrated the expected attitude and behaviour. Our key targets also included improvement in the communication, involvement, information and compassionate care questions in our local satisfaction survey: Performance Indicator Communication, involvement and information using the cluster of questions in the inpatient survey Compassionate Care overall were you treated with kindness and understanding while you were in the hospital? Performance Target for % Improve baseline (88%) result by 2% 96% Achieve 85% 95

96 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts What does this mean for our patients? Improvement in the patient experience indicators outlined above demonstrate that the measures we have put in place this year such as staff receiving feedback on CARES as part of their personal development review and the delivery of an extensive programme of customer care training has had a positive impact on staff attitude and behaviours. We will continue to deliver on improving staff attitude and behaviour in line with our CARES values in the forthcoming year; some of these workstreams are outlined in Priority 5 for Part 2.2 Performance against Core Quality Indicators In this part of the report the Trust is required to report against a core set of national quality indicators to provide an overview of performance in The following page provides information which has been obtained from the recommended sources and is presented in line with the detailed Monitor guidance. Data Inconsistencies A number of indicators are showing changes to data that was published in last year s Quality Report. There are several reasons for this as follows: 1. The statutory timescale within which the Quality Report is published is very tight. Not all of the latest data was available at the time of publication last year and so the Trust has taken the opportunity to update indicators with full year updates which are now available 2. National Indicators based on statistical methods by definition require re-basing (e.g. standardised readmissions, HSMR, SHMI) 3. Data quality or data completeness issues may have affected last year s indicators. If these have been identified then they have been rectified in this year s report. 96

97 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts : Summary Hospital-Level Mortality (SHMI) 2: the percentage of patient deaths with palliative care coded at diagnosis 3: Emergency readmissions to hospital within 28 days of discharge from hospital: children of ages 0-15 [Standardised] (Crude) 4: Emergency readmissions to hospital within 28 days of discharge from hospital: Adults of ages 16+ [Standardised] (Crude) Performance 0.9 (As Expected) Target Performance As Expected or Lower Than Expected 0.89 (As Expected) London Trusts National Benchmark Source n/a n/a HSCIC Oct-2012 to Sep % n/a 23.0% 23.6% 20.9% HSCIC Oct-2012 to Sep-2013 [9.11%] (5.60%) [11.88%] (7.55%) 5: Clostridium difficile 23 cases (18.0 Cases per 100,000 beddays) n/a [8.28%] (6.28%) n/a [12.11%] (7.62%) 14 Cases (Absolute) 12 Cases (8.5 Cases per 100,000 beddays) [7.81%] [10.01%] [HSCIC] [PAS] [12.17%] [11.45%] [HSCIC] [PAS] 17.0 Cases per 100,000 beddays 17.3 Cases per 100,000 beddays Benchmark Period Lowest Performing Trust Highest Performing Trust [Standardised] [Crude] [Standardised] [Crude] 6: Venous Thromboemolism (VTE) 91.9% 95.0% 95.2% 95.5% 95.7% NHS England Apr-2013 to Feb 2014 (National/ London) Oct-2013 to Dec-2013 (Lowest/ Highest Performers) 7: PROMS (Health Gain), Groin Hernia, EQ-5D Index/VAS 8: PROMS (Health Gain), Hip Replacement, EQ-5D Index/VAS 9: PROMS (Health Gain), Knee Replacement, EQ-5D Index/VAS 10: Friends and Family Test question 12d If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation 11: Trust s responsiveness to personal needs of our patients 12: [a] The number, and where available, rate of patient safety incidents reported within the period, and; [b] the number and percentage of such patient safety incidents that resulted in severe harm or death 13: Self certification against compliance with requirements regarding access to healthcare for people with a learning disability 0.119/ /4.471 n/a 0.086/ HSCIC Apr-2013 to Dec / / n/a 0.439/ HSCIC Apr-2013 to Dec / /2.691 n/a 0.33/5.8 HSCIC Apr-2013 to Dec % (46% agree 13% strongly agree) n/a 62% (46% agree 16% strongly agree) WYE VALLEY NHS TRUST, Band 1 (Higher than Expected) TAUNTON AND SOMERSET NHS FOUNDATION TRUST 0% THE ROYAL WOLVERHAMPTON HOSPITALS NHS TRUST 14.94% SHEFFIELD CHILDRENS NHS FOUNDATION TRUST 17.15% PHE North Tees & Hartlepool had 61 Trust aportioned Cases (30.8 cases per 100,000 beddays) 77.7% - NORTH CUMBRIA UNIVERSITY HOSPITALS NHS TRUST BMI - FAWKHAM MANOR HOSPITAL GUY S AND ST THOMAS NHS FOUNDATION TRUST HOMERTON UNIVERSITY HOSPITAL NHS FOUNDATION TRUST SPIRE LEEDS HOSPITAL WALSALL HEALTHCARE NHS TRUST 67% n/a Picker Institute 2013 Mid Yorkshire Hospitals NHS Trust and North Cumbria University Hospitals NHS Trust (33% agree 7% strongly agree) 65% n/a 66.4% n/a n/a n/a n/a n/a n/a 4758, 8.0% 38, 0.8% Fully Compliant n/a 5242, 8.9% 56, 1.1% Fully Compliant Fully Compliant 12569, 7.0% 138, 1.1% , 7.4% 893, 0.7% NRLS Apr-2013 to Sep-2013 Based on [a] WALSALL HEALTHCARE NHS TRUST (4888, 14.49%) Based on [b] BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUST (106, 3.1%) n/a n/a n/a n/a n/a n/a The Whittington Hospital NHS Trust Band 3 (Lower Than Expected) EAST AND NORTH HERTFORDSHIRE NHS TRUST 44.9% AINTREE UNIVERSITY HOSPITALS NHS FOUNDATION TRUST (Plus 50 other Trusts) 0% QUEEN ELIZABETH HOSPITAL NHS TRUST (Plus 45 other Trusts) 0% Following Trusts had Zero Cases of Cdiff in 2012/2013, Alder Hey Children s, Birmingham Women s, Liverpool Women s, Moorfields Eye Hospital, Queen Victoria Hospital 100.0% - BRIDGEWATER COMMUNITY HEALTHCARE NHS TRUST; QUEEN VICTORIA HOSPITAL NHS FOUNDATION TRUST; ROYAL NATIONAL HOSPITAL FOR RHEUMATIC DISEASES NHS FOUNDATION TRUST; SOUTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST NUFFIELD HEALTH, IPSWICH HOSPITAL 0.24 DARTFORD AND GRAVESHAM NHS TRUST BMI - THREE SHIRES HOSPITAL EAST AND NORTH HERTFORDSHIRE NHS TRUST BMI - THE CLEMENTINE CHURCHILL HOSPITAL NORTH TEES AND HARTLEPOOL NHS FOUNDATION TRUST Salford Royal NHS FT 89% (42% agree 47% strongly agree) Based on [a] WRIGHTINGTON, WIGAN AND LEIGH NHS FOUNDATION TRUST (1539, 3.54%) Based on [b] THE ROTHERHAM NHS FOUNDATION TRUST (0, 0%) 97

98 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Supporting Information about the indicators required in accordance with the Quality Account regulations The Hillingdon Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: Indicator 1: National reporting shows the Trust to be within the As Expected range and that it has had a stable ratio over the past three years. The Trust intends to take the following actions to further improve on this indicator and so the quality of its services: Improve the variation between weekdays and weekends by implementing the London Quality Standards Examine any specialty outliers. Indicator 2: During the last year there has been a marked increase in our palliative care coding towards the national average. This is in line with rates of palliative care coding having increased nationally. Dr Foster has reported that it is unclear as to whether this is as a result of increased number of patients receiving palliative care or improvements to the clinical coding processes for these patients or whether there have been changes to the way trusts interpret the guidance around coding of palliative care. It is noted that there is also significant variation in coding rates across trusts. The Trust intends to take the following actions to maintain performance on this indicator and so the quality of its services: Monitor performance and ensure that reporting systems are robust and efficient through audit. Indicators 3 and 4: The Trust is aware from a variety of data sources that the figures are higher than expected for the +16 age group. The Improving Inpatient Care initiative has been working to reduce this rate during as outlined on pages 90 and 91. The trust intends to take the following actions to further improve on this indicator and so the quality of its services: Continuing with the Improving Inpatient Care project as a Quality Priority for as outlined on page 103 and 104 Develop improved integrated care pathways. Indicator 5: The Trust successfully achieved a significant reduction in Clostridium difficile (C. diff) this year and reported 12 cases, a 48% reduction from the previous year s total of 23. This was achieved through a number of focused activities across the organisation as outlined on page 122. The Trust intends to take the following actions to improve on this indicator and so the quality of its services: Undertaking further work on antimicrobial prescribing including monitoring compliance to policy by specialty. This will be reflected in audits undertaken by clinical teams in the next year. Indicator 6: The Trust has shown an improvement over the last three years. This was a CQUIN for and there was 100% achievement in relation to the CQUIN requirements; this has supported the Trust in achieving this target. The Trust intends to take the following actions to maintain the performance on this indicator and so the quality of its services: Monthly monitoring of VTE performance via the Patient Safety Thermometer To continue with Root Cause Analysis investigation of hospital acquired VTEs. Indicator 7: The Trust has significantly better outcomes reported for Groin Hernia repair with the pre-operative participation rate being well above the national average however the drive on post-operative responses needs significant attention. The Trust intends to take the following actions to improve on this indicator and so the quality of its services: Promotion of the importance of the patient responding to the survey Improve data collection, submission and response rates through governance forums with clinical leadership driving this forward to ensure we achieve compliance. Indicator 8 and 9: For the Knee replacement PROMs performance the most recent figures available for comparisons of national data indicate we are only marginally below the national average score. The Trust intends to take 98

99 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts the following actions to improve on this indicator and so the quality of its services: Since the Professor Briggs report Getting it Right First Time (2012), we have pulled together a detailed action plan. An Orthopaedic consultant has been nominated as the clinical lead and on reviewing the Trust s results it was considered that a deep dive into the make-up of the PROM score which comprises of participation rate, health gain and patient satisfaction was required. In all aspects Hip surgery results performed better than the national average however performance on the Knee PROM was below national average in the patient satisfaction element. The review on post-operative outcomes for the Knee PROM showed that our scoring for participation rate is above national average however we had a dramatic drop in our EQ-5D responses for Mobility, Self-Care, Usual Activity and Anxiety. The Pain element however has seen the biggest improvements year on year within knee surgery. We are actively encouraging all patients to attend our joint school to ensure their expectations of recovery are discussed at length. Indicator 10: This indicator has improved on the previous year by 3% although further work is required to ensure we are in line with the London trusts average. The Trust intends to take the following actions to improve on this indicator and so the quality of its services: More in-depth scrutiny of the results is taking place, enabling targeted support, action planning and interventions within the Divisions and Departments, to improve advocacy Our first Staff Friends and Family Test will run from 19th May which will support us receiving immediate feedback from staff on this element. Indicator 11: We have improved our performance in relation to this indicator during this past year and seen significant improvement in many areas covered in the national patient survey and local patient surveys in relation this element of care. Our implementation of intentional rounding principles and taking action on feedback provided through the Friends and Family Test have supported staff in responding to patient needs in a much more timely and proactive way. Embedding our CARES values has also supported staff in demonstrating the right behaviours when responding to patients needs. The Trust intends to take the following actions to improve on this indicator and so the quality of its services: Delivering on priority 5 for outlined on pages 106. Indicator 12: Following the publication of the Francis Report and several reviews that followed, such as Berwick and Keogh, the Trust has supported a safety culture where staff feel able to report incidents. Staff have been encouraged to be open and honest so that we can learn from when things go wrong in order to improve the quality of care we provide. Our reporting rate to the National Reporting and Learning Service has increased from 6.6 (1 April September 2012) to 8.33 (1 April September 2013). The increase in incident reporting will also result in an increase in those incidents that resulted in severe harm or death. The Trust intends to take the following actions to improve on this indicator and so the quality of its services: Continue to raise awareness of the importance of incident reporting Ensure there is thorough investigation of all severe/death reported incidents to support learning and changes in practice. Definitions of the two mandated indicators for substantive sample testing by the Trust s auditors are: 1. Percentage of patients receiving first definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer. 2. C. difficile. 99

100 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts LOOKING forward f Part 2.3 Our new Clinical Quality Strategy The Trust has published a new Clinical Quality Strategy ( ) to support its delivery of high quality care over the next three years. The purpose of the new Strategy is to help the Trust achieve its vision To put compassionate care, safety and quality at the heart of everything we do. The Strategy provides a structure for delivering quality governance to ensure ongoing improvement in the quality and safety of patient care. It builds on the local and national context of service change that so critically affects quality of care for all its patients and ensures that the trust s approach and commitment to high quality care is clearly defined. The Strategy also outlines the responsibilities of its staff and is supported by the Trust s culture and values framework, CARES (Communication, Attitude, Responsibility, Equity and Safety) which embraces a culture that empowers staff to report incidents and raise concerns about quality in an open, blame-free working environment. The Strategy will ensure that clinical quality governance and risk management are integrated into the Trust s culture and everyday management practice and that all members of staff are clear on their role and the drive to continually improve the quality of care. In building its Strategy the Trust has considered the local and regional health economy and national contexts and has made reference to key NHS investigations, such as the Francis Report and the Berwick and Keogh reviews. The Trust has also reviewed its current position in relation to key quality and performance data alongside other acute providers in order to focus its priorities and to be in line with local, regional and national best performance. The priorities focus on those areas which are the most important based on a balance of greatest impact on patient care, national profile and public profile, as well as those where performance is below expected. Key principles that support our strategy and which have been key recommendations from national investigations include: Always putting the patient first Clearly understood fundamental standards of care and measures of compliance Openness, transparency and candour throughout our organisation Improved support for compassionate and committed nursing Strong and patient centred leadership Accurate, useful and relevant information. The Strategy will help to ensure that the ethos of a clinically-led, quality and patient-focused organisation is strengthened and that the Trust Board is provided with robust and detailed information on quality so that it can be assured that the clinical quality agenda is being appropriately identified, assessed, addressed and monitored. The clinical priorities outlined in the Strategy reflect the quality priorities outlined in this year s Quality Report.The full Clinical Quality Strategy is available via our website at: patients/safety/index.php. Quality priorities for improvement in In this part of the report, we tell you about the areas for improvement in the next year in relation to the quality of our services and how we intend to assess them. We call these our quality priorities and they fall into three areas: patient safety, patient experience and patient outcomes. In arriving at these priorities, agreed by the Trust Board, there was a process of engagement with our foundation trust members, our governors, our staff, Healthwatch and our commissioners. In addition, the Trust triangulated data from several sources to identify themes and recurring trends. Over the last year there has been more active engagement with our local Healthwatch including incorporating their members on several of our Trust working groups. 100

101 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts This has proved valuable in being able to hear on an ongoing basis the feedback it receives from people it engages with. During the consultation period there was a strong opinion from our stakeholders that we should continue with some of our projects started in the previous year/s where further outcomes needed to be achieved to fulfil their potential. Hence the projects relating to an improved outpatient experience and improving inpatient care with effective discharge are being retained. Quality Report Consultation Respondent Category Quality Priority Topic Patient Safety Staff Healthwatch Governors and FT members GP Commissioners Implementing the Emergency and Maternity Care Standards Reduction in weekend mortality Improve pathways/bundles of care to provide reliable care Achieving reduction in patient harms. such as falls/pressure ulcers, associated with the Patient Safety Thermometer Improve staff / patient ratios Improving staff feedback mechanisms in relation to incidents Better support for patients discharged from Accident and Emergency Ensure proactive care ward rounds are happening as expected particularly in relation to continence care in inpatient areas and A&E Better support for patients discharged from Accident and Emergency Implementing the Emergency and Maternity Care Standards especially senior clinician review 7 days a week Patient Experience Staff Healthwatch Improve responsiveness to need Improve learning from patient feedback Review of complaints management Improve staff / patient ratios Continuing with improving the outpatient experience Continuing with the improving inpatient care project (includes leaving hospital) reduce length of stay Improvements in the outpatient appointment system/call management system continuing with improving the outpatient experience Improvement in the management of letters for outpatient appointments Improve medical engagement/staff attitude further work on CARES Look at other ways of getting patient feedback Display information on patient experience feedback on information boards on each ward/department Improve the participation in the Friends and Family Test in some areas Ensure new pathways of care include metrics on the patient experience 101

102 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Respondent Category Quality Priority Topic Governors & FT members GP Commissioners Patient Outcomes Staff Healthwatch Governors and FT members GP Commissioners Improvements in the outpatient appointment system continuing with improving the outpatient experience Improve medical engagement/staff attitude further work on CARES culture and values Look at other ways of getting patient feedback Improvements in hospital patient transport Improving the hospital grounds Achieving the A&E target Improving admissions avoidance/ambulatory care pathway Implementing the Emergency and Maternity Care Standards Reducing number of readmissions Improving diagnostic reporting times Drive forward early supported discharge work streams Improve Dementia indicator FAIR assessment Better support for patients discharged from Accident and Emergency Improvement in improving inpatient care workstream to ensure actions are being progressed as planned Understanding outcomes for patients with regard to early supported discharge schemes Better and quicker access for tests Consultant access for GPs Achieving the A&E target The Board considered all of the suggestions put forward and the priorities below have been recommended for inclusion in the Quality Report for These have been identified as falling under the three domains of safety, clinical effectiveness and patient experience as follows: No. Priority Safety Clinical Effectiveness Patient Experience 1 First Contact Continuing to Improve the Outpatient Experience 2 Continuing with the Improving Inpatient Care Project 3 Improving patient safety In Emergency and Maternity Care 4 Introducing and embedding patient care bundles/pathways 5 Improve responsiveness to patient need Further information on these priorities and what we will be measuring in can be found on the following pages. 102

103 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts PRIORITY 1 Accessible and Responsive Services Continuing to improve the outpatient experience Why is this one of our priorities? The Trust s outpatient productivity scheme has highlighted areas in appointment management (listed below) that would benefit from further service redesign. In addition, our patients are telling us that they continue to experience some difficulties with the booking of their appointments and communication with the hospital. The introduction of information software that assists in planning outpatient capacity to meet the referral demand. Management of appointment cancellations will move from the Patient Administration System (PAS) team to the outpatient appointment centre (OAC). This will ensure greater scrutiny of appointment cancellations and challenge to specialities. Correspondence about appointments will be centralised to improve the accuracy and consistency of information given to patients. How are we doing so far? Although we have made many improvements in the last few years we recognise that there are still concerns from patients about their experience of the outpatient pathway. We have changed the way patients are contacted and are reminded about their outpatient appointments. We have reduced the call abandonment rate when patients are making calls to the OAC and very recently our DNA rate has reduced (please see Priority 1 for ). Continuing with this priority has come from a number of sources, including the public membership focus group and from our local Healthwatch. Our aims for : The performance targets we will use to measure the impact of the changes and new initiatives are: Percentage of clinics cancelled with six weeks notice Performance for shows that 2.3% of clinics were cancelled with less than six weeks notice (average of 115 clinics per month). The target for is set at 1.5% (75 clinics per month); this will provide some tolerance for unexpected leave/ urgent reasons. Clinic Utilisation In new information software was designed to enable managers and clinicians to have better visibility about the activity in their outpatient services. This information will assist in planning capacity to meet the referral demand. The data for shows that 85.6% of outpatient slots were utilised. The target for is set at 90%. This will provide some flexibility to manage changes in demand. Local outpatient experience survey The aim is to achieve an overall satisfaction target of 88%. Patient experience will be monitored via a local survey on a quarterly basis. Patients are asked six questions covering staff attitude, communication about waiting times, respect and dignity and overall satisfaction. This target will enable monitoring of experience which is implicit across the different development areas. Current performance against the existing questions averages 87%. PRIORITY 2 Continuing with the Improving Inpatient Care Project Why is this one of our priorities? Reducing the length of stay for inpatients has been a priority service improvement goal for a number of years. We know that the longer patients are in hospital, the more risks there are to the patient, and fundamentally, we know people do not want to be in hospital. We want to remove all unnecessary waits and support our patients to return to their 103

104 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts homes safely and be supported in the community as soon as clinically appropriate. The need for improvement in this area has been identified from a variety of sources including information from our local Healthwatch referencing patient feedback of lengthy delays on the day of discharge, priorities within our new Clinical Quality Strategy and the aim to work with our local health and social care partners in delivering integrated care pathways and more care in the community. In addition, Dr Foster Intelligence data shows the trust to be an outlier in relation to its readmission rate. How are we doing so far? Following the successful introduction of our Home Safe project we want to make sure that the principles adopted for this project are shared in order to examine additional opportunities for early supported discharge schemes. We have implemented our leaving hospital principles across all of our wards and we have reviewed our goals and priorities. The overall objective of this programme of work is to ensure we provide an improved experience to all inpatients by improving the patient journey, timeliness of interventions and thereby decreasing their overall length of stay. Our performance for this past year is outlined under Priority 2 in the priorities for Our aims for are: Reducing readmissions The rate of readmissions will be tracked per specialty and will be benchmarked against national figures for readmission rates. Specialties that are currently showing high rates of readmissions will be scrutinised to identify different pathways of care. The aim is to reduce readmissions in relevant specialties by 1%-2%. Ambulatory care pathway The aim is to see > 200 patients per month with the expectation that 80% 90% of patients would be suitable to be treated via ambulatory pathways of care. The aim of developing this service further is to increase capacity and treat a broader range of conditions to include Deep Vein Thrombosis, Cellulitis, Pyelonephritis and Pulmonary Embolism. An important part of developing this service further will be to gauge the patient s experience of this type of service so that we can be assured that it is effectively meeting the needs of our patients. Early supported discharge workstream The aim of this workstream will be to assess in excess of 300 patients on the Home Safe pathway over a three-month period and to provide a comprehensive geriatric assessment for patients requiring multidisciplinary team input. In addition we wish to expand the service from the EAU to incorporate patients who have had an inpatient stay on one of the specialty wards. Specific targets include: Achieve a reduction in our length of stay of three days for patients over the age of 65 years old who are eligible for the Home Safe programme Division of Medicine to monitor the patient experience of the Home Safe pathway as a key metric. Leaving Hospital Improvement Project, including discharge from A&E To aim to discharge =/>25% of our patients from the inpatient wards before midday We aim to achieve a target of 72% of patients leaving hospital with a positive experience through the use of the Leaving Hospital questionnaire. PRIORITY 3 Improving patient safety in Emergency and Maternity Care Why is this one of our priorities? There is national and London data to show that there are significant differences in the mortality rates for patients admitted as an emergency during the week compared with patients admitted as an emergency at the weekend. Reduced service provision at weekends has been associated with this higher mortality rate. In response to the data, the London Quality Standards (LQS) were developed 104

105 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts to try and describe what good care should look like and to ensure that there was a well-recognised minimum quality of care that patients attending an emergency department or admitted as an emergency should expect to receive in every acute hospital in London. Similarly, the maternity services quality standards represent the minimum quality of care women who give birth should expect to receive. As part of the Shaping a Healthier Future (SaHF) programme there is proposed expansion of our maternity facilities to allow for an anticipated increase in births taking the total number to 6,000 each year. This expansion in facilities will enable the Trust to make improvements in the models of care offered and to support the LQS, in particular by providing a dedicated midwifery-led unit to provide additional choice for women. At the end of 2013 London s hospitals were asked to self-assess their progress towards meeting the standards and provide information on action taken in acute medicine and emergency general surgery services throughout The results from our self-assessment highlight our progress towards meeting the LQS, as well as the need to continue on the journey of improvement and investment. In addition, feedback from our staff and our commissioners highlights the need for us to drive forward this improvement work in Our aims for are: Seven day working for Emergency Care with earlier senior decision-making seven days a week: Achieve consultant physician presence at weekends in Medicine 12hrs/day Patients seen by a consultant within 12 hours within Medicine, Surgery, Paediatrics and Gynaecology Access to multi-professional assessment and radiological diagnostics and reporting within specified timeframes. PRIORITY 4 Introducing and embedding patient care bundles/pathways Why is this one of our priorities? Care bundles/pathways are tools that include a collection of healthcare interventions and that can be used to manage the quality of care that is delivered by standardising care processes. It has been shown that their implementation reduces variability in clinical practice and improves patient outcomes in the acute care setting. They promote more organised and efficient patient care based on evidence-based practice, whereby locally agreed standards help a patient with a specific condition or diagnosis receive a consistently high standard of care. How are we doing so far? We have already invested in additional senior doctor time, out of hours Monday to Friday and at the weekends. Notably we have provided consultant ward rounds twice a day on our medical EAU. This has ensured that our patients continue to receive care from our most senior doctors irrespective of the day of the week. We have found some elements of this work challenging however the Trust is fully committed to implementing the standards in a phased approach over the forthcoming years. How we are doing so far? The Trust has demonstrated good progress in this area in order to support high quality care introducing care bundles and improved clinical care pathways for a variety of diagnoses and care interventions. However there is more work to be done to ensure the well-recognised care bundles/ pathways are truly embedded and that where there are gaps in consistency of approach to best practice for particular diagnoses that these are addressed. Our aims for are: Implement the Acute Kidney Injury (AKI) Pathway, in line with a London wide AKI pathway and show some improvement Sepsis Care Bundle to achieve =/> 70% compliance 105

106 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts FAIR assessment completed for >90% of elderly patients per quarter To achieve a 20% reduction in falls without harm Catheter Care Bundle to achieve =/> 95% compliance Improvement against the NHS Safety Thermometer with focus on pressure sores to realise a 25% reduction, from a baseline of 3.2% to a final value of 2.4%. PRIORITY 5 Improve responsiveness to patient need Why is this one of our priorities? Patient experience is a recognised element of highquality care and understanding and improving how patients experience their care is key to delivering high-quality services. Using a variety of different approaches and seeking feedback from different pathways will help staff to gain greater insight into our patients perspective of their care. Key stakeholders (our staff, our Governors, Healthwatch) advise us that we need to ensure that there is focus on improving the patient experience further and that our services, and how they are delivered, are truly responsive to individual patient needs. How we are doing so far? The Trust participates in the annual national patient survey programme and in addition a number of local patient surveys have also been developed and implemented. The Friends and Family Test has also been fully rolled out to inpatient areas, the emergency department and maternity. This will be rolled out to outpatients and day care settings in During 2013 our Complaints Management Unit went through an unsettled period with a change in management and support staff. With a substantive team now in place a number of changes have already taken place which include more robust processes for managing open complaints aiming to always contact the complainant by telephone to discuss their concerns and agreeing an appropriate timescale for conclusion. In we aim to undertake a complaints review in line with the recommendations from Designing Good Together (DGT): Transforming Hospital Complaint Handling (2013) and develop a local action plan. The Trust has always carried out an annual ward staffing review but the outcomes of these reviews have not generally been reported to the Trust Board. In addition, professional judgement has been the main approach used to inform the review. New guidance from the National Quality Board has set out a more robust approach to ensure that we have the right skills, in the right place at the right time. To improve Care at the Bedside we will implement a quarterly cycle of acuity and dependency assessment with quarterly reports received by the Nursing and Midwifery Assembly and a bi-annual paper to the Trust Board setting out the outcome of a review of staffing levels and skill mix. Our CARES (Communication, Attitude, Responsibility, Equity and Safety) values and associated behavioural framework were launched in May To raise awareness of the values and to help staff to understand their application a customer care programme was procured. The programme was developed using patient complaints, feedback from staff and incidents to ensure the scenarios included local issues that staff could relate to. The programme was introduced in June 2013 and so far 1,087 staff members have completed the programme. We will continue to deliver Customer Care training to our staff and we will aim to incorporate the CARES behaviours as a weighted element of performance related pay progression and for this to be fully implemented by We will reward staff who demonstrate the expected behaviours through the staff awards event, giving recognition to staff that do a good job. We will also introduce the Staff FFT questions to measure staff engagement levels as an indicator of their attitude towards the organisation. Our aims for : Improvement in baseline compassionate care indicator (baseline to be established calculated from Q1 result) 106

107 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts % of additional staff (from ) to receive customer care training Friends and Family Test Q4 response rates >20% A&E / >30% Inpatients Friends and Family Test March 2015 response rate >40% Improvement in the net promoter score of FFT for inpatient and A&E surveys. improvement and patient safety work and will look to the collaborative for support and structure. The Director of Nursing and Patient Experience has been appointed as the trust director with responsibility to oversee medication error incident reporting and learning and the Terms of Reference for a multiprofessional group to drive forward this work are being drawn up. Our quality priorities will be monitored by the individual clinical and management teams, through their divisional performance reviews and quarterly through reports to the Board or Board Committee and the results will be reported in the Trust Annual Report. Patient Safety Collaborative Programme The Berwick Review which was commissioned following the Mid Staffordshire Hospitals enquiry and the publication of the Francis Report includes recommendations to ensure a robust nationwide system for patient safety. The challenge is for our whole healthcare system to systematically support and foster a culture of continual learning and improvement that supports staff to provide the safe care they all want to, ensuring patients are at the centre of care. NHS England s Patient Safety Domain and NHS Improving Quality have therefore introduced the Patient Safety Collaborative Programme with the formation of 15 Patient Safety Collaboratives (PSCs), enabled to create and nurture sustainable local continual learning environments. This fundamental focus on continual learning systems will encourage the kind of organisation and system-wide patient safety culture that can deliver definitive improvements in specific patient safety issues and build local capability and energy for change. NHS England has advised that there is unlikely to be significant additional funding available through this programme to purchase additional capacity for improvement activity. Healthcare organisations will be expected to undertake quality improvement as part of their usual business. Part 2.4 Formal statements of assurance from the Board Information for our regulators Our regulators need to understand how we are working to improve quality so the following two pages are specific messages they have asked us to provide: Provision of NHS Services During The Hillingdon Hospitals NHS Foundation Trust provided medicine, surgery, clinical support services and women s and children s NHS services. The Hillingdon Hospitals NHS Foundation Trust has reviewed all the data available to them on the quality of care in all of these relevant health services. The income generated by these relevant health services reviewed in represents 100% of the total income generated from the provision of the relevant health services by the Hillingdon Hospitals NHS Foundation Trust for One of the core clinical priorities is Medication Errors the prescribing, dispensing and administration of medicines is a huge area where error and poor process has the potential to affect large numbers of patients, making this a priority area for reducing harm. The Trust will ensure that it actively participates in this key piece of 107

108 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Participation in clinical audit National audits During , 29 national clinical audits and three national confidential enquiries covered NHS services that The Hillingdon Hospitals NHS Foundation Trust provides. During that period The Hillingdon Hospitals NHS Foundation Trust participated in 86% of national clinical audits and 100% of national confidential enquiries for which it was eligible to participate in. The national clinical audits and national confidential enquiries that The Hillingdon Hospital NHS Foundation Trust was eligible to participate in during are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. Audit Participated Cases submitted Acute Myocardial Infarction Yes 100% Adult Critical Care Case Mix Programme No N/A. Decision to not participate in this audit by clinical leads; to be reviewed in National Bowel Cancer Audit Programme Yes 100% National Chronic Obstructive Pulmonary Disease Audit Programme Yes Data submission in progress National Adult Diabetes Audit, includes National Diabetes Inpatient Audit (NADIA) National Paediatric Diabetes Audit (Royal College of Paediatric and Child Health) Elective Surgery (National Patient Reported Outcome Measures (PROMS) Programme) Partial Participation in NADIA only 35 patients included in the audit. The trust is reviewing National Adult Diabetes Audit requirements with a view to participate fully in the future. Yes 100% Yes Percentages unavailable, numbers are: Hip replacements 255 Knee replacements 297 Groin hernia 138 Varicose veins 10 Emergency Use of Oxygen (British Thoracic Society) No N/A. Non participation was as a result of local clinical decision. Trust is reviewing requirements with a view to participate in Epilepsy 12 Audit (Royal College of Paediatrics and Yes 100% Child Health) National Childhood Epilepsy Audit Falls and Fragility Fractures Audit Programme including Yes 100% National Hip Fracture Database Head and Neck Oncology (Data for Head and Neck Yes 100% Oncologists) Heart Failure Audit Yes Expected 75% 108

109 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Audit Participated Cases submitted Inflammatory Bowel Disease Yes 100% for the inpatient audit. Trust not currently participating in Biologic Therapy Audit, following recruitment of Biologic s Co-ordinator it is expected we will participate going forward. National Lung Cancer Audit Yes 100% Moderate or severe asthma in children (College of Yes 100% Emergency Medicine) National Audit of Seizures in Hospitals Yes 100% National Cardiac Arrest Audit Yes 100% in hospital cardiac arrests. The trust needs to extend this to ensure we include pre-hospital cardiac arrests this has been put in place from January National Comparative Audit of Blood Transfusion Yes 100% Audit of the use of Anti-D National Emergency Laparotomy Audit (NELA) Yes Data submission in progress National Joint Registry Yes Hillingdon: 62% Mount Vernon Treatment Centre: 92% National Neonatal Audit Programme Yes 100% National Oesophago-gastric Cancer Audit Yes 100% Paediatric Asthma (British Thoracic Society) Yes 100% Paediatric Bronchiectasis (British Thoracic Society) Yes 100% Paracetamol overdose (College of Emergency Yes 100% Medicine) Rheumatoid and early inflammatory arthritis No N/A. Non participation is as a result of local review/decision and is being added to the risk register. Sentinel Stroke National Audit Programme Yes 100% Severe Sepsis and Septic Shock (College of Emergency Yes 64% Medicine) Trauma Audit & Research Network Yes 22.9% Clinical Outcome Review Programmes Maternal, New-born and Infant Clinical Outcome Yes 100% Review Programme (MBRRACE-UK) Lower Limb Amputation (National Confidential Enquiry Yes Data submission in progress into Patient Outcome and Death (NCEPOD) Subarachnoid Haemorrhage (NCEPOD) Yes 100% 109

110 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Taking actions The reports of 12 national clinical audits were reviewed by the provider in and The Hillingdon Hospitals NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided. Audit National Comparative Audit of Blood Transfusion Blood Sample Labelling and Collection Actions Frequency of training for staff on blood transfusion has been reduced from annually to every two years and this is now in line with recommendations from the Medicine and Healthcare Products Regulatory Agency and National Patient Safety Agency. This will result in the Trust being better able to train all relevant staff within the new extended time period. Also training sessions have been increased in frequency and this has resulted in 78% of relevant staff now trained. National Lung Cancer Audit National Oesophago-gastric Cancer Audit National Cardiac Arrest Audit (NCAA) National Diabetes In-patient Audit Falls and Fragility Fractures Audit Programme including National Hip Fracture Database (NHFD) The trust Blood Transfusion Policy has been updated and now has zero tolerance for incorrect labelling. A process is being implemented where the Transfusion Practitioner receives a weekly report from the Pathology Lab on the number of incorrectly labelled samples, the areas and the member of staff responsible. This will be investigated and staff reminded of the correct protocol and the importance of ensuring all information is completed and correct. A spirometer is to be purchased in order to improve our figures regarding measurement of respiratory function. Spirometry is an important part of the patient assessment for curative treatments such as surgery and radical radiotherapy and is also a key indicator in the National Lung Cancer Audit data fields. Treatment for Oesophago-gastric cancer patients is part of a pathway within the London Cancer Alliance (LCA). The trust works closely with the specialist centres involved and follows the LCA guidelines as part of its action plan in response to the audit. The trust joined NCAA in July We have received our first report and have reviewed our practice within this. As we continue to receive the quarterly reports an action plan identifying any required improvements will be developed. We recently identified that we had not submitted all required patients for the first quarter, as we did not include pre-hospital cardiac arrests; we have now amended this and submit all required patients. As a result of the audit a programme of hypoglycaemia training is now in place approximately 70% of staff have undertaken this. In addition, a pilot has taken place using a revised hypoglycaemia proforma, which has proven successful for use in the Trust. Overall, the trust performed well in this audit. One area for improvement was collection of follow up data once the patient has been discharged from hospital. A process has now been put in place where we are working with Hillingdon Community Rehabilitation Team to capture available follow up information and provide this back to the Trust for submission to NHFD. 110

111 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Audit National Neonatal Audit Programme Sentinel Stroke National Audit Programme College of Emergency Medicine Renal Colic College of Emergency Medicine Fractured Neck of Femur Alcohol Related Liver Disease: Measuring the Units (NCEPOD) Subarachnoid Haemorrhage: Managing the Flow (NCEPOD) Actions Neonatal Unit notes have been modified with a prompt for senior consultation with parents within 24 hours. Year on year the percentage of parents seen by senior staff within 24 hours is increasing we do try to ensure that parents are spoken to as soon as possible after admission. The division is continuing to focus on improving breast feeding rates for all babies of all gestations. Hot on Cold Babies is currently being promoted to prevent hypothermia in the new-born. As part of implementation of recommendations from this audit, the trust intends to review the Early Supported Discharge pathway and potential implementation. After reviewing the results of the renal colic audit we identified issues regarding note keeping especially when it came to recording pain scores and adequate analgesia. To improve practice, on induction days junior doctors are educated by one of our consultants on the importance of adequate record keeping and the necessity to record and re-evaluate pain scores. The Accident and Emergency (A&E) Department Matron also has regular sessions with the nursing team during handovers and sisters meetings reminding the nurses about the importance of pain score documentation and reassessment. An A&E Registrar and a Radiology consultant are in the process of developing a renal colic pathway which will include a pain relief protocol. Once the pathway is ready a separate A&E renal colic pathway for patients over 65 years of age, which will include instructions regarding the exclusion of Abdominal Aortic Aneurysm, will be developed. This audit identified issues regarding the recording of pain scores and adequate analgesia. The education that takes place in Accident and Emergency (A&E) will cover patients with a Fracture Neck of Femur. One of the A&E consultants has also written to all staff reminding them of the importance of recording and re-assessing pain scores. Some work has already been put in place for this group of patients including: an update to our nursing assessment booklet which now includes an alcohol assessment this was put in place from July 2013; an Alcohol and Liver Disease study day took place on 28th March 2014, to further educate and support Nurses and Allied Healthcare Professionals. The trust is currently working with Central North West London Foundation Trust on the further implementation of the recommendations within this NCEPOD report. CNWL have employed an Alcohol Nurse Specialist who is helping to support patients with alcohol-related admissions to engage with community alcohol services. As a result of the recommendations within this NCEPOD report the trust is in the process of reviewing and updating relevant clinical guidelines. 111

112 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Local audits The reports of 81 local clinical audits were reviewed by the provider in and examples of The Hillingdon Hospitals NHS Foundation Trust actions to improve the quality of healthcare provided: Clinical Record Keeping Standards Audit Re-audit of Staff Survey of Caring for Vulnerable Patients including those with a Learning Difficulty Preventing Surgical Site Infection re-audit Do Not Actively Resuscitate (DNAR) re-audit WHO Surgical Safety Checklist Audit WHO Surgical Safety Checklist and SWAB Count in Maternity Safe Sedation Paediatric Casualty Card Audit in Minor Injuries Unit (MIU) Supporting Carers of People with Dementia During the trust reviewed and updated our clinical record keeping standards and have agreed that audit against these will take place every six months. To improve record keeping standards stamps are being provided to help to clearly identify who wrote in the patient record, their designation and their bleep number. A small project group has been developed to improve standards within the division of Medicine a teaching session to all foundation year doctors has been organised and posters are being produced promoting the trust record keeping standards. We have continued to drive improvements through Safeguarding Adults/Learning Disability training, specifically raising awareness to use pictorial easy read information, Patient Administration System alert and Patient Passport. It is highlighted, within training, that all information is available on dedicated Safeguarding Intranet pages. We are in the process of purchasing additional thermometers and evaluating evidence on new patient warming systems. To make sure we involve patients/families in the DNAR decision-making process we are in the process of producing a leaflet. This will help to inform them of the DNAR process and what discussions/decision will take place. To raise continued awareness on the use of the WHO surgical safety checklist posters are displayed in Theatres. A teaching session in March 2014 at the theatre/anaesthetic departmental meeting included WHO, Consent and Sedation. One of our anaesthetic consultants is producing a presentation for e-induction and will include this in local induction packs for all staff (doctors/nurses/other theatre staff). To reinforce the requirements for use of the WHO Checklist and SWAB count processes, standard risk management training, in Maternity, has been changed to include this. Future plan is for 2 Maternity theatre staff to attend a full theatre training course to enhance their knowledge and skills to disseminate within the service. A teaching session took place in March 2014 at the theatre/anaesthetic departmental meeting which included WHO, Consent and Sedation. The WHO checklist has been revised to include safe sedation elements. A stamp has been purchased and is in use to provide proof that copies of all paediatric notes are sent to the Paediatric Liaison Health Visitor. Awareness has been raised and any necessary further training provided to ensure GP registration is checked electronically, this is then documented in children s notes re-audit has shown 100% compliance. To improve information provided to carers, dementia resource folders are being distributed to all wards within the hospital. The folders include information such as, leaflets on different types of dementia and local contacts to go to for support. 112

113 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Mortality Audit Process An initial mortality audit took place and was reported on in September Actions include the process where a list of National Early Warning Score (NEWS) calls is handed out at Medical hand-back meeting on Monday mornings so that patients who have needed urgent review out of hours are prioritised for review, by the appropriate teams. A further action includes nursing progress notes being recorded on the same progress sheets as medical entries. This will help medical staff to better monitor events relating to patients. In October 2013 the Trust introduced an ongoing Mortality audit to help to ensure we consistently provide high quality care for all patients who die in hospital. The first full report was presented to our Quality and Risk Committee in April Participation in research Commitment to research as a driver for improving the quality of care and patient experience The number of patients receiving relevant NHS health services provided by The Hillingdon Hospitals NHS Foundation Trust in that were recruited during that period to participate in research approved by a research ethics committee was 650. The Hillingdon Hospitals NHS Foundation Trust has a good track record for research for a hospital of its size. We are continuing with our strategy to broaden our research portfolio and this has enabled us to offer a greater number of patients, from different clinical areas the opportunity to participate in research. This year we invested in a research nurse to support our Cardiologists and Diabetes consultants as a means of increasing commercially funded and portfolio-adopted research activity in these areas. This post is now fully funded by the commercial income it generates. Participation in clinical research demonstrates the trust s commitment to improving the quality of care we offer and to making our contribution to wider health improvement. This allows our clinical staff to stay abreast of the latest treatment possibilities while active participation in research allows our patients access to new treatments that they would otherwise not have. With this in mind we aim to offer our patients the opportunity to participate in a wide range of clinical research projects. These studies are both funded by the pharmaceutical industry and by the Department of Health via the North West London Comprehensive Research Network (CLRN). We received 464,284 in from the CLRN for this work. The money generated from this research activity funds research nurses and data managers to support the clinicians in this work. The majority of our studies are National Institute for Health Research (NIHR) portfolio-adopted multi-centre studies where we are acting as a recruiting site on behalf of the lead centre. Our research portfolio is a balance of observational and treatment studies across many clinical areas in the Trust including Cancer, Stroke, Haematology, Paediatrics and many of the General Medicine and Surgical Specialties. This year we plan to become more research active in Ophthalmology, Obstetrics and Rheumatology. We also support PhD and Masters Students from the local universities giving them access to our patients and staff for their projects. During we had 63 open or follow-up studies. We recruited 639 patients into 40 NIHR Portfolio Studies, supported the repatriation of ten patients recruited into treatment studies at other hospitals and supported six Masters or PhD student studies. All of our research activity is scrutinised for quality and compliance to the standards expected by the Research Governance Framework. In addition we work to comply with the Department of Health NIHR objectives. 113

114 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Lessons learned from Serious Incidents During , the trust reported ten Serious Incidents and two Never Events where panel investigations were conducted. Protecting patients from avoidable harm is something to which there is universal agreement and the Trust has clearly defined processes and procedures to follow to help avoid these events occurring. Lessons learnt as a result of the Serious Incidents include: Area Division Summary 1:1 observation of patients with increased observation need All divisions Review of the trust s Specialling Policy on the 1:1 supervision of patients Nursing documentation All divisions A patient specific risk assessment form, an individual patient care plan outlining level of observation and a behavioural monitoring chart included in the revised specialling policy Availability of specialist nursing staff Specialist training for nursing staff All divisions Medicine Recruitment of Registered Mental Health Nurses to the nurse bank Introduction of mental health training for nursing staff in A&E and the Emergency Admissions Unit (EAU) Specialist psychiatric input Medicine Work with CNWL on raising awareness and availability of the psychiatric liaison service Safety in A&E and EAU Medicine Environmental health and safety risk assessments completed Managing Sepsis All divisions New sepsis care bundle created and launched. Full audit and review of the Bundle undertaken Managing the Deteriorating Patient All divisions Reinforcing the Patient At Risk policy discussed at staff meetings and information provided within departments Mortality Reviews All divisions Implementation of a robust mortality review process Record Keeping All divisions Best practice training and medical notes audit programme Specialist Referral Pathways and Processes Escalating Concerns - medical management of a patient Neurosurgical pathway to tertiary centre Clinical management/ pathway for patients requiring limb amputation for non-vascular/trauma reasons Clinical handover of care from the Intensive Care Unit All divisions All divisions Medicine Surgery Surgery Review of referral pathways and processes to ensure these are robust and gaps are identified Importance of early escalation to highest level reinforced with staff where medical management issues cannot be resolved Involvement of tertiary centre to resolve issues associated with neurosurgical referral process and pathway Decisions on consultant responsibility, operation arrangements and availability of vascular services as part of North West London vascular network agreements Agreed protocol for handing-back the care of an ITU patient to the parent team communicated to consultants Review of CT scans C & CSS Reinforced to all consultant radiologists that the review of CT scans should take place in multi-plane views 114

115 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Area Division Summary Discussion of emergency gastrointestinal cases Care of the seriously ill woman in Maternity Mentoring of student midwives WHO Maternity surgical safety checklist Surgery Maternity Maternity Maternity Patients with an emergency acute gastrointestinal problem are discussed in an appropriate forum (x-ray/mdt meeting) regardless of the primary specialty of the admitting team Training completed by all staff on the recognition of the seriously ill woman, including the completion of the Maternity Early Warning System (MEWS) chart and the escalation procedures Ensuring the mentoring of students is to Nursing and Midwifery Council standards mandatory training incorporates the responsibilities of the mentor WHO Maternity surgical safety checklist reviewed and strengthened and documentation standard improved Maternity theatre processes Maternity Review of Maternity Theatre processes including pre, intra and post-operative procedure Midwifery staff training in surgical competencies Maternity Clarity on training, responsibilities and accountability in relation to surgical/operative procedures Review of surgical swabs Maternity Review of surgical swabs in maternity theatres/labour rooms Patient advocacy All divisions Importance of patient advocacy in decision-making where mental capacity may be affected or a patient is vulnerable Review of Safeguarding Policy All divisions To ensure there is clarity on the importance of escalation and 2nd/3rd opinions in relation to mental capacity assessments Goals agreed with our commissioners (CQUINs) A proportion of The Hillingdon Hospitals NHS Foundation Trust s income in was conditional on achieving quality improvement and innovation goals agreed between The Hillingdon Hospitals NHS Foundation Trust and any person or body we entered into a contract, agreement or arrangement with for the provision of relevant health services, through the Commissioning for Quality and Innovation payment framework. Total CQUIN income for , is expected to be 2,943,523 for National and Local schemes, and 234,314 (91% of potential available income) for Specialised Commissioning which includes 100% achievement of drugs QIPP at 1.1% of contract value. In the previous year ( ) total income for National and Local schemes was 2,719,136 (73% of potential available income) and 78,858 (100% of potential available income) for Specialised Commissioning. Further details of the agreed goals for and for the following 12 month period are available electronically at: Care Quality Commission registration The Hillingdon Hospitals NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is that it is registered without conditions. The CQC paid an unannounced visit in October 2013 as part of their planned review of the Trust. The report issued from this visit stated the Trust was not fully compliant with the Essential Standards of Quality and Safety; one moderate staffing concern was raised and two minor concerns regarding cleanliness and infection control, and safety and suitability of premises. The Trust set out an action plan to close the gaps in compliance and awaits further CQC inspection to review its compliance level. An action plan was submitted to the CQC and further updates on progress have been provided. 115

116 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts The actions taken include for cleanliness and infection control: cleaners and cleaning supervisors have been reminded of the standards required and performance will be monitored through regular cleaning audits. The Waste Manager has ensured wards are reminded not to overfill clinical waste bins monitored as part of the monthly audit process; a revised curtain changing template has been devised; increased auditing around cleaning medical equipment, checking protective covers on equipment, inspections around catheters and wound drains are carried out fortnightly. For safety and suitability of premises all estates staff have been reminded of the safety standards required; the improved maintenance requirements have been carried out; regular environment audits occur e.g. PLACE (Patient-Led Assessment of the Care Environment) and mini PLACE, actions that arise from these are monitored by the PLACE group which includes estates and nursing staff. For staffing: the staffing level and skill mix on each ward is being reviewed against best practice guidance and where required staffing mix realigned to reflect these recommendations. A bi-annual establishment review to ensure that the right people with the right skills are in the right place at the right time is now in place; acuity and dependency is reviewed using accredited tools and this information used when agreeing staffing establishment and skill mix; ward leaders have been appointed on each extra capacity ward along with a small team of substantive staff. This forms a core team of experienced nurses with additional nurses recruited from the nurse bank as required. Staff are encouraged to escalate and report all occasions when staffing levels fall below the established profile using the trust incident system. Moving forward, the trust s processes for CQC compliance will be internally assessed using both the established desk-top style review of outcomes, and a revised peer review process which will be based on different levels of review and frequency from daily ward based checks to monthly Executive/Non-Executive led Observations of Care ward visits and external peer review from another NHS trust. The Hillingdon Hospitals NHS Foundation Trust has not participated in any special reviews or investigations by the CQC during the reporting MOVING FORWARD 116

117 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts period. The Care Quality Commission has not taken enforcement action against the Hillingdon Hospitals NHS Foundation Trust during Data quality The Hillingdon Hospitals NHS Foundation Trust submitted records during April January for to the Secondary Uses Service (SUS) for inclusion in the Hospital Episode Statistics (HES) which are included in the latest published data. The percentage of records in the published data which included the patient s valid NHS number was: 98.5% for admitted patient care 99.8% for outpatients care 96.7% for accident and emergency care. The percentage records in the published data which included the patient s valid General Medical Practitioner Code was: 100% for admitted patient care 100% for outpatient care 100% for accident and emergency care. Information governance toolkit The Hillingdon Hospitals NHS Foundation Trust s Information Governance Assessment Report overall score for was 81%. This is termed as unsatisfactory as one of 43 requirements relevant to the Trust remains at level 1; all the other scores are at level 2 or 3. The level 1 score relates to the fact that currently 70% of staff have undertaken their information governance training rather than the required 95% annually. An action plan is in place to drive compliance to the required level going forward which includes a revised approach to the annual refresher training and improved performance management of non-compliance. Clinical coding error rate THHFT was not subject to the Payment by Results Clinical Coding Audit during by the Audit Commission. These figures are based on the SUS DQ Dashboard released by the HSCIC covering the period Apr to Jan The Hillingdon Hospitals NHS Foundation Trust will be taking forward the following actions to improve data quality: The Trust will continue its Integration Engine programme to link disparate clinical systems across the Trust, enhancing the quality of electronic patient information The Trust will continue to review and action data quality issues at its data quality meetings Daily data quality reports are published on the Trust s web based management information system for action and rectification. 117

118 05 Part 3 Other key quality information and improvements we have made in The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts In this part of the report we have included other key quality indicators which have been selected by the Board in consultation with stakeholders. They represent those indicators that are of national importance that patients will want to know about and they include targets used by Monitor as part of Monitor s Risk Assurance Framework. The indicator set includes patient experience, patient safety and clinical effectiveness indicators. The indicators covered in this year s report are consistent with those from last year s Quality Report. Narrative has been provided on some of these indicators to outline our performance. Indicator 2 Readmissions to hospital within 28 days Despite several initiatives undertaken by the Trust, the Clinical Commissioning Group, Social Services and Intermediate Care, in 2014 there has been little change in the performance over the previous year. This continues to be a priority area in Indicator 3 Non-clinically justified single sex accommodation breach There was one mixed sex breach during This occurred when a patient was deemed fit to be discharged from the Intensive Therapy Unit but there was no suitable step down bed available within six hours. Indicators 4-7 Cancer performance The Trust successfully achieved all of the cancer access targets for the second year in a row. The Trust s performance on the 62 day cancer waiting time however reduced by 3.2%; this pathway relates to patients we treat here who breach but also patients we refer to tertiary specialist centres that then go on to breach the 62 day pathway. In we saw an increase in shared breaches, up from 19 to 46 the Trust has to accept half of each of those breaches even though the patient did not breach the pathway whilst at our hospital. In we accounted for 306 pathways with 11 full breaches and 19 shared breaches. In there were pathways with ten full breaches and 46 shared. Extensive re-modelling has been undertaken with other providers to ensure that the care of patients on complex pathways is properly co-ordinated between organisations. This means that patients can have their procedure booked at another hospital while they are still undergoing investigations at this Trust. Indicators 8-10 Referral to treatment waiting times All 18 week targets for both admitted and nonadmitted patients were achieved and exceeded. The Trust consistently achieves this target and has been one of the strongest performers in London for the past three years. The Trust s continued high performance means that other organisations have been in contact requesting support with delivering their elective 18 week activity. In the last year the Trust supported two organisations in undertaking elective work. Indicator 12 Accident and Emergency (A&E) waiting times The Trust achieved the target for 95% (all types) of patients to have a total time in A&E of less than four hours, with a mean performance throughout 118

119 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Performance Target Performance London Trusts National Benchmark Source Benchmark Period 1: In Hospital Standardised Mortality Ratio 96.7 ( ) < ( ) 81.8 ( ) 100 Dr Foster Apr-2013 to Feb : Readmissions to hospital within 28 days ( ) < ( ) 95.8 ( ) 100 Dr Foster Apr-2013 to Nov : Non clinically justified single sex accommodation breach, rate per 1,000 finished consultant episodes 0.05% 0.0% 0.02% 0.50% 0.20% NHS England Apr-2013 to Feb : Cancer: Two week wait from GP referral to seeing a specialist (suspected cancer)/(breast symptoms) 97.9% 98.0% 93.0% 93.0% 97.9% 94.7% 95.0% 95.3% 95.6% 95.5% NHS England Apr-2013 to Dec : Cancer: 31 day maximum wait from diagnosis to first treatment 99.2% 96.0% 99.3% 97.9% 98.3% NHS England Apr-2013 to Dec : Cancer: 31 day maximum wait from diagnosis to subsequent treatment, drug or surgery 100.0% 100.0% 98.0% 94.0% 100.0% 100.0% 99.7% 95.8% 99.8% 97.0% NHS England Apr-2013 to Dec : Cancer: 62-day maximum wait from referral by GP/screening service/consultant upgrade to treatment 93.5% 93.9% 98.6% 85.0% 90.0% 85.0% 90.3% 97.8% 96.9% 82.9% 93.1% 92.2% 85.8% 94.5% 92.1% NHS England Apr-2013 to Dec : Referral to treatment waiting times - admitted 97.4% 90.0% 97.1% 90.2% 91.4% UNIFY2 Apr-2013 to Feb : Referral to treatment waiting times - non admitted 98.8% 95.0% 98.6% 96.8% 96.9% UNIFY2 Apr-2013 to Feb : Referral to treatment waiting times - Incomplete 97.3% 92.0% 97.4% 92.8% 94.1% UNIFY2 Apr-2013 to Feb : Fractured neck of femur emergency patients in theatre within 36 hours 88.4% 90% 92.4% n/a n/a Local Indicator n/a 12: Total time in A&E: 4 hours or less (All Types/ Type 1) 96.7% 94.6% 95.0% 96.0% 92.1% 95.5% 92.6% 95.7% 93.5% UNIFY % 13: Number of last minute elective operations cancelled for non clinical reasons 0.61% 0.8% 0.85% 0.83% 0.79% NHS England Apr-2013 to Dec : Percentage of patients not treated within 28 days of having operation cancelled for non-clinical reasons 6.0% 0% 0.0% 4.3% 5.1% NHS England Apr-2013 to Dec : Percentage of women in the relevant PCT population who have seen a midwife or a maternity healthcare professional, for health and social care assessment of needs, risks and choices by 12 weeks and 6 days of pregnancy 80.4% 95% 83.1% 77.0% 86.1% NHS England Jan-2013 to Mar : Percentage of women in the relevant PCT population who have seen a midwife or a maternity healthcare professional, for health and social care assessment of needs, risks and choices by 12 weeks and 6 days of pregnancy (excluding late Referrals) 93.2% 95% 97.2% n/a n/a Local Indicator n/a 17: Stroke patients: Percentage of Patients that have spent at least 90% of their time on the stroke unit 99.6% 80% 97.3% 94.3% 84.8% NHS England 2012/ : Stroke patients: Percentage of high risk Transient Ischaemic Attack (TIA)/mini stroke patients who are treated within 24 hours 100% 75% 100% 81.2% 74.0% NHS England 2012/ : Meticillin-Resistant Staphylococcus Aureusis (MRSA) 1 cases (0.8 Cases per 100,000 beddays) 0 1 Case (0.7 Cases per 100,000 beddays) 1.7 Cases per 100,000 beddays 1.2 Cases per 100,000 beddays PHE 2012/ : Inpatient Experience Programme (local survey results) 88% 88% 91% n/a n/a n/a n/a 21: Outpatient Experience Programme (local survey results) 87% 88% 87% n/a n/a n/a n/a 22: Maternity Experience Programme (Local survey results) 86% 87% 86% n/a n/a n/a n/a 23: Independent assessment of cleanliness of hospital* - Very High Risk areas - High risk areas 87% 95% 92% 94% 95% n/a n/a n/a n/a 24: Percentage of complaints responded to within agreed timescale 74.5% 90% 73.6% n/a n/a n/a n/a Definitions for the indicators are included in Monitor s Risk Assessment Framework (available on 119

120 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts the year of 96%. Initial performance was affected by a challenging start to the year (April and May) when the Trust did not meet the required standards. An extensive review was undertaken and a number of measures were introduced which improved performance. Additional winter funds were made available to the A&E department for the final quarter of the year. Extra medical, nursing and phlebotomy staff were recruited. In addition, on site senior managerial support was provided over the weekend. This had a significant positive impact on performance, and the Trust achieved 96.8% in quarter four. The number of acutely unwell patients continued to increase throughout the year. Between April 2013 and February 2014, 1,777 blue light ambulances attended the trust compared to 1,633 for the same period last year. This represents an 8.8% increase (144 attendances). Blue light ambulances convey the sickest patients to the hospital who require admission to the A&E resuscitation unit and intensive support. It takes on average seven hours to stabilise patients before they can be transferred to another location in the hospital. On average 4.8 patients per day are treated in the resuscitation unit. Despite the increase in the number of blue light conveyances, non-elective (unplanned / emergency) admissions are slightly down on the previous year. During there were 23,672 non-elective admissions compared to 23,442 for This is equates to an average decrease of 4 admissions per week. Indicator 13 Number of last minute elective operations cancelled for non-clinical reasons The total number of operations cancelled on the day for non-clinical reasons was 203. The majority of these cancellations were due to short notice surgeon/anaesthetist illness. Indicator 15 Percentage of women who have seen a midwife or maternity healthcare professional within 12 weeks and six days of pregnancy There is now an identified lead within the Clinical Commissioning Group to work on this project. This work includes proactive public engagement through dissemination of information in public venues such as children s centres and public libraries as well as potentially working with local shops that sell pregnancy tests, offering leaflets with relevant information around when and how to book to encourage early engagement. This is an ongoing piece of work which includes public health and the Trust supporting the process. Indicator 21 & 22 Outpatient and Maternity local patient experience surveys There has been detailed examination of the key issues identified by our patients when attending the outpatients department during this past year. As a result improvement actions have been implemented across the various specialties. The department is now piloting the FFT which will allow for more immediate feedback from patients. As a result the local patient experience survey has changed and reporting on this will take place on a quarterly basis. The Maternity Unit has continued to ensure that it learns from women s feedback on their experience of maternity care. Engagement activities during the year have included meeting with the Afghan Women s Group to better understand their needs and their expectations of Maternity Services. Staff have also been involved in presenting patient stories at the Experience and Engagement Group. Through the Maternity Services Liaison Committee staff are receiving direct feedback of women s experience through the Walk the Patch initiative. For the forthcoming year the staff hope to engage with the Travelling Community to understand their experiences and expectations as well as being involved in further future public engagement events. The maternity unit has now been incorporated in to the Friends and Family Test initiative. 120

121 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Indicator 23 Independent assessment of cleanliness of hospital The monthly cleaning audits, local patient satisfaction surveys and the Friends and Family Test feedback has all indicated a significant improvement in cleaning services during The cleaning audits taking place during the latter part of the year have been showing an average score of 95% each month, which is in line with the standards expected in the National Standards of Cleanliness in the NHS. Indicator 24 Percentage of complaints responded to within agreed timescales In the number of complaints due for response was 405, compared to 503 in ; this represents a reduction of 19%. The response rate was 73.6% which means that 298 of the 405 complaints were answered within the timescale agreed with the complainant. It is important to note that the Complaints Management Unit went through a period of significant change this year, with the long term Complaints Manager leaving, followed by the two Complaints Administrators. Following a new permanent appointment to the Complaints Manager post in December 2013, enhanced processes were established and new ways of working introduced. An analysis of the performance for the first three quarters of the year identified that the complaints team was working on a just in time basis. This meant that there was limited time to get the response letters approved or to get additional information if the reply was not complete. The new Complaints Manager has implemented a number of control measures in order to enhance performance and support the divisions in meeting their deadlines. The focus of these measures is twofold timeliness and quality of response. Performance improved in March 2014 to 90.6%. Indicator 25 The Tust continues to fully comply with the requirements regarding access to healthcare for people with a learning disability. The Trust intends to take the following actions to maintain performance on this indicator and so the quality of its services: Continue to review improvement work at the Safeguarding Committee, including action plans based on patient and carer feedback, and work collaboratively with the Community Learning Disability Team. Patient Safety During we have undertaken targeted work to reduce patient harms and we have achieved the following improvements to ensure that we keep our patients safe: Reducing patient harms improving safety 48% reduction in Clostridium difficile infections 94.5% of patients have received harm free care as measured by the PST* National average is 93.1% 15.7% reduction in patient falls 38% reduction in patient falls resulting in a fracture 37% reduction in pressure ulcers as measured by the PST Venous Thromboembolism (VTE) assessment compliance 95.2% *Please note that the percentage shown is the overall percentage of harm free care, as measured by the Patient Safety Thermometer (PST), includes patients admitted into the Trust with pre-existing pressure ulcers, old urinary tract infections (UTIs) in patients with catheters. Old UTIs are defined as those where treatment had started outside of the Trust and old VTE (defined as those where treatment for the VTE started outside of the Trust). 121

122 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts A key part of ensuring a safety culture throughout the organisation is to engage with staff this is an important part of our new clinical quality strategy. Listening and learning from the multi-disciplinary team is a key part of creating a strong culture of openness and candour. As part of widening the scope of engagement, the Medical and Nurse Directors have scheduled meetings with junior doctors, student nurses and therapists to gain a granular understanding of how our organisation can improve both patients and staff experience. In the Trust Board received feedback from our junior doctors on how we could make further improvements in our safety culture. Through triangulating the themes that we have amassed via complaints, feedback and surveys this presents opportunities to conduct deep dives into our services for patients. The Trust has just approved for 2014, the implementation of Schwartz rounds which will include executive leadership and enhance ward to board feedback and action. Infection Control Prevention and Control MRSA The Trust has sustained performance for a second year reporting only one MRSA bloodstream infection MRSA bloodstream infections for Whilst this is over NHS England s zero tolerance approach with a zero target, it is well within the limit set by Monitor. The one attributed case was complex with multiple admissions across two acute trusts over a five month period. Under the new MRSA infection review system the case ultimately lies with the organisation that has the most learning opportunities, and for this case it was the acute sector across two trusts. Due to the constraints of the new process only one acute trust can be recorded and this is the one where the blood culture was taken. Clostridium difficile was a challenge for the Trust as our C. diff objective target reduced to 14 cases from 24 the previous year. Having finished the previous year ( ) under the objective with 23 cases achieving a reduction of nine further cases in one year required a significant amount of attention. It was therefore a major achievement to complete the year reporting only 12 cases. This is a 48% reduction in 12 months and a substantial accomplishment. The trust had learnt through detailed investigation in that for the previous 23 cases some samples should not have been included for testing. This was either due to the patient taking laxatives or samples not taken early enough when admitted with diarrhoea. Ongoing work from

123 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Clostridium difficile toxin positive has therefore focused on staff understanding when samples should be sent and clear involvement with the clinical team. A key development for this year has been a new Bristol Stool Chart. This new chart now includes easy identification of those patients with a history of bowel surgery or chronic bowel condition as well as clear information on laxatives and their effectiveness. Using this new chart is now standard practice across the organisation and this has really supported clinical decision making. Work has also been ongoing on antimicrobial prescribing and this year the organisation further engaged senior colleagues with a Start Smart Then Focus action plan based on the Department of Health guidelines. Antimicrobial performance was also reviewed with a move from focusing on just restricted antibiotics but to all other antibiotics and the compliance to policy by specialty. This will be reflected in audits undertaken by clinical teams in the next year. Patient Experience Listening to our patients We aim to be a listening and learning organisation. We want concerns that are raised by patients to be understood, shared and responded to. Listening to feedback enables our staff to gain a real insight into the patient s experience of care. We use a number of different approaches, all of which provide us with information about what we are doing well and where we need to improve. These include: National and local surveys PALS concerns Compliments/Complaints Friends and Family Test Observations of Care. What our patients have told us in our local surveys for inpatient care: 96% of our inpatients were treated with kindness and understanding 89% for communication, involvement and information 93% for our responsiveness to patient needs Source: Local inpatient survey year end results 123

124 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts How we have responded to patient experience feedback Complaint Breakdown in communication about discharge plans We ve revised discharge planning documentation Friends and Family Test It s too bright and noisy at night Comfort at Night campaign We ve implemented a standard for lights out at night Observations of Care I don t always know what the uniforms mean We re creating uniform posters and information for the intranet to describe uniforms and roles Listening and Improving National Patient Survey A survey of inpatients is part of the annual mandatory survey programme for acute trusts; this assists organisations to find out about the experience of patients when receiving care and treatment at their hospitals. Between September 2013 and January 2014, a questionnaire was sent to 850 recent inpatients at each trust. Responses were received from 344 patients that had been inpatients in July 2013 at the Hillingdon Hospitals. Based on the patients responses to the survey the Trust scored About the Same as most other trusts that took part in the survey for all of the key grouped sections of the survey. The Trust has improved in 48 questions from the 2012 survey, and has seen significantly higher scores (improvement) in the following areas: Admission date changed by the hospital Feeling threatened whilst in hospital by other patients or visitors Response to the call bell Hospital staff discussing adaptations required at home after discharge Overall, experience was very poor very good (score 1 very poor to 10 very good) Saw or was given information about how to complain. There were no significant deteriorations from last year s survey however our scores were lower in seven questions: Privacy when being examined / treated in A&E Involved in decisions about care or treatment Anaesthetist explained how he/she would anaesthetise and control pain Involved in decisions about discharge Given enough notice about discharge Told about medication side effects when going home Given written and printed information about medicines. The Trust was worse than most other trusts in only two questions: Privacy when being examined / treated in A&E Cleanliness of the room or ward. 124

125 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Historically, there has been a small year on year improvement in the question about cleanliness of the ward. It is disappointing that the result this year still places us in a position that is worse than most other trusts. However, following cleaning services moving in house there was a comprehensive review of cleaning schedules and frequencies across all areas of the Trust, with many areas having an increase in cleaning input hours. This took shape from mid- August 2013 and was refined through September and October onwards which unfortunately was after the sample period for this survey. The monthly cleaning audits, local patient satisfaction surveys and the Friends and Family Test feedback has all indicated a significant improvement in cleaning services since that time. The cleaning audits taking place have been showing an average score of 95% each month, which is in line with the standards expected in the National Standards of Cleanliness in the NHS. The Board and the Trust s Experience and Engagement Group will be driving forward the improvements that we expect to see in all areas that are reflected in the National Patient Survey. DETRACTORS PASSIVE PROMOTERS net promoter score = % promoters % detractors 125

126 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Friends and Family Test The Friends and Family Test (FFT) provides a simple way of gathering feedback about patient experience to drive improvement. It is a simple standardised question which asks patients to consider their recent experience in the hospital and rate how likely they would be to recommend that particular ward, service or department to a friend or family member if they required similar care or treatment. The patient can choose from six responses ranging from extremely likely to extremely unlikely, with a don t know option for those who remain undecided. Most importantly we also ask patients a further question: what was good about your care, and what could be improved. The comments received help us to gain an insight into the experience and understand what really matters to patients and identify areas for improvement. This gives a score of between -100 and +100, with +100 being the best possible result. The FFT has been implemented using a phased approach. This is illustrated below. During over 15,800 patients completed an FFT survey. Our March 2014 scores are set out below: The inpatient score was 71, this is based on 557 responses The A&E score was 62, this is based on 419 responses The maternity score was 67, this is based on 231 responses. The overall Trust score for March 2014 was 67. To calculate the results we use a Net Promoter Score. The idea is simple: if you like using a certain product or doing business with a particular company you like to share this experience From the answers given three groups of people can be distinguished. These are: Promoters people who have had an experience which they would definitely recommend to others Detractors people who would probably not recommend you based on their experience, or couldn t say Passive people who may recommend you but not strongly. November 2012 Inpatients and A&E Department September 2013 Maternity May 2014 Several Outpatients and Day care settings 126

127 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts How do our FFT results compare with others? Our response rates are considerably higher for both inpatient areas and A&E. We do much better than the national and London average in relation to fewer extremely unlikely / unlikely scores for both inpatient areas and A&E. We have a higher number of extremely likely / likely responses for A&E however it is slightly lower than national and London average for inpatient areas. We do much better than the national and London average in relation to fewer extremely unlikely / unlikely scores for both inpatient areas and A&E. Response rates 50% 40% 30% 29.1% 31.3% 42.8% Response rate AE Response rate IP 20% 10% 13% 15.2% 19.4% 0% National London THHFT Positive responses (extremely likely/likely) 96% 94% 92% 93.7% 92.7% 91.2% Extremely likely/likely AE 90% 88% 87.3% 88% 88.7% Extremely likely/likely IP 86% 84% National London THHFT Negative responses (extremely unlikely/unlikely) 7% 6% 5% 4% 3% 2% 1% 0% 5.9% 5.6% 2.6% 1.7% 2.1% 1.5% National London THHFT Extremely unlikely/ unlikely AE Extremely unlikely/ unlikely IP 127

128 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Friends and Family Test What patients have told us is good about their care The midwives were polite and reassuring, if I had any worries or concerns they helped me through them Smiling, welcoming faces that are caring and provide personal care by listening and knowing the patient rather than treating me like a robot Everything was perfect, the treatment and the information given by the doctor. I felt that I am in safe hands What patients have told us could be improved The only thing that could be improved is the slamming of the treatment room door, which shakes the whole ward. When you are trying to get off to sleep it is annoying Action Our estates team have checked the door and made some adjustments to reduce the noise It would be helpful if patients could be introduced to contacts when they come to the bedside Action We are going to support a national campaign locally by encouraging our staff to start every contact with a patient by introducing themselves by name and role My partner had to wait for an hour before being told where I had been moved to, after he was asked to leave whilst I was being examined Action Staff have been reminded of the importance of keeping family members informed in these circumstances 128

129 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Annex 1 Statements from our stakeholders Statement from Hillingdon Clinical Commissioning Group (CCG) The Hillingdon Clinical Commissioning Group welcomes the opportunity to provide this statement on The Hillingdon Hospitals NHS Foundation Trust Quality Accounts. We confirm that we have reviewed the information contained within the Account and checked this against data sources where this is available to us as part of existing contract/performance monitoring discussions and is accurate in relation to the services provided. This Quality Account has been reviewed within Hillingdon Clinical Commissioning Group and by colleagues in the Brent Harrow Hillingdon (BHH) Federation of Clinical Commissioning Groups and NHS North West London Commissioning Support Unit. We have reviewed the content of the Quality Account and confirm that this complies with the prescribed information, form and content as set out by the Department of Health. We believe that the Account represents a fair and robust summary of the overview of the quality of care at the Trust for the services covered in the report. We have taken particular account of the identified priorities for improvement for the Trust and how this work will enable real focus on improving the quality and safety of health services for our local population. We agree with the priorities for improvement and particularly welcome a focus on improving patient safety in Emergency and Maternity care, embedding patient care bundles and pathways and an improved responsiveness to patient need. We are pleased to see the development of a new Clinical Strategy and look forward to reviewing how this is being embedded in the coming year. We welcome the focus within this Strategy on the Trust s approach to safety and compassion in care. We acknowledge the progress made to date on specific goals for and the areas of underperformance but would like to emphasise that these still remain areas of focus and priority in the forthcoming year. In particular the consultant review within 12 hours of decision to wait, the reduction of HSMR to London average and continuing to embed the culture and values framework. We would like to commend the work being undertaken in relation to the reduction in HSMR for weekend mortality and look forward to seeing a continuation of this improvement work during in relation to implementing the London Quality Standards. We acknowledge 100% participation in the National Clinical Audit Programme and the commitment to research as a driver for improving the quality of care and patient experience. We also recognise some of the challenges the Trust faces with the fabric and estate and how this impacts on the quality of our care for patients and how Estates have been working hard to address some of these issues. We are very happy to work collaboratively with you to help shape how we move the quality agenda forward both from a commissioner and provider perspective. Given the publication of the Francis Inquiry and subsequent Berwick, Keogh and Cavendish reports clearly our agendas will continue to evolve further as we embed the recommendations. Overall we welcome the vision described within the Quality Account, agree on the priority areas and will continue to work with the Trust to continually improve the quality of services provided to patients. We look forward to receiving the final version which will include an easy read format. Yours sincerely, Dr Ian Goodman Chair Hillingdon CCG 16th May

130 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Statement from our local HealthWatch Introduction Healthwatch Hillingdon wishes to thank the Trust for the opportunity to comment on the Trust s Quality Report for the year Healthwatch Hillingdon has a close working partnership with the Trust. We welcome their continued commitment to engage with us and the value the Trust places upon our relationship. We meet regularly with The Chief Executive Officer, the Chair and Director of Nursing of the Trust, are lead assessors for the Patient Led Assessment of the Care Environment, and Healthwatch representatives sit on a number of important groups to monitor patient experience and quality. Through our work we have witnessed and acknowledge the Trust s commitment to improve the quality of the services they provide and their desire to have a positive impact upon the experiences of their patients. Quality Report In the main, Healthwatch Hillingdon found this year s Quality Report, well set out, logical and easy to read. It is an honest and balanced assessment of the Trust s performance on the quality of their services. We are again pleased that the Trust has been candid in its reporting, acknowledging that although there are many areas in which they have shown improvement, they have recognised where targets have not been met and have committed to making further improvements through their priorities. We are however uncomfortable with the use of the label partially achieved. This term does not give a clear indication to the public of achievement and although the Trust has been frank in giving a full explanation where targets were not fully achieved, it was felt that for some targets, not achieved would be a fairer reflection of accomplishment. We would however acknowledge that in our response to last year s quality report we did indicate that some of the targets set by The Trust were perhaps overly ambitious and this has been taken into account in our assessment of this year s performance. The Trust should be congratulated on those priorities where it has clearly shown improvement this year. We are particularly delighted to see the joint work with Age UK and community services, which has led to a reduced length of stay for elderly patients. Whilst there is some reference to versus performance in the Quality Report, this is mainly in relation to national CQUINs, or other national targets rather than the local targets. As the quality account reporting process is now well established and previous data is available, we feel it would be helpful for the general public to now see performance over time which would demonstrate continuous improvement. This would be specifically useful where the priorities are part of a long term programme, such as the First Contact project which has been a priority for the last 3 years. We would suggest this could be achieved by publishing a table outlining 11-12, and performance, with targets. This would give a clear and easily understood view of performance over time, and would demonstrate continuity, consistency and where progress has been made. We support the Trust in their choice of quality priorities and thank them for taking into account the views of Healthwatch and the wider public membership. Having previously indicated that last year we questioned the ambitiousness of some of the targets and the affect this would have on patient expectation, this year we feel the opposite has happened. Some set targets seem easily obtainable, such as discharging at least 1 patient from each acute inpatient ward area before 12pm. We would like to see realistic targets set that are neither easily achieved, nor totally unattainable. Healthwatch Hillingdon look forward to continuing the relationship we have with the Trust and working with them, through a joint commitment, to focus on the monitoring and improving of quality. We are especially pleased about two initiatives agreed with 130

131 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts the Trust for 2014, which will see us work together to look at the quality of mealtime provision, through the Patient Assessment of the Care Environment programme and quarterly scheduled meetings, which will review the progress of quality priorities and take an overview of quality through the evaluation and comparison of patient experience, complaints, and friends and family data. Graham Hawkes Chief Executive Officer Healthwatch Hillingdon 9th May 2014 Statement from External Services Scrutiny Committee for its work to improve weekend emergency HSMR (Hospital Standardised Mortality Ratio) from to whilst also maintaining overall performance. Although it is understood that the format and content of the Quality Report is largely predetermined, the Committee believes that it would benefit from a simpler configuration to ensure that it is more easily read and understood. For example, the data contained within the report which illustrates what the Trust has achieved in comparison to its targets (and supported by a commentary) is not set out as simply as it could be. The Trust s five Quality Priorities during were: Response on behalf of the External Services Scrutiny Committee at the London Borough of Hillingdon The External Services Scrutiny Committee welcomes the opportunity to comment on the Trust s Quality Report and acknowledges the Trust s commitment to attend its meetings when requested. The Committee is particularly pleased to note that the Trust has been highly commended in the Dr Foster Hospital Guide The First Contact Project improving the outpatient experience 2. Improving people s experience of leaving hospital / improving inpatient care 3. Improving emergency care 4. CQUINS (Commissioning for Quality and Innovation) 5. Embedding out culture and values framework CARES 131

132 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Although the Committee recognises the amount of work that has been undertaken by the Trust over the last year with regard to achieving its Quality Priority targets, it is disappointing to note that none of them had been achieved in full (all five priorities had resulted in partial achievement overall). However, the Trust s achievements with regard to the reduction of mortality rates and Health Care Associated Infections should be celebrated. Insofar as The First Contact Project is concerned, it is noted that the Call Management System that was introduced in June 2012 has needed further development over the last year. However, the Committee is disappointed to note that the call abandonment rate for outpatient appointment queries was 12% (missing the target of 10%). Furthermore, only 75% of calls were answered within 1 minute (the target was 95%) and just 90% were answered within 2 minutes. As such, the Committee is reassured to note that improvements to the outpatient experience will continue to be a priority for the Trust over the next year and we look forward to seeing significant improvements. The Committee is pleased to note that, following an audit and the identification of work stream improvements, work will continue during to reduce the number of avoidable readmissions. Despite aiming to reduce readmissions over the last three years, these have remained fairly static: 7.5% in ; 7.8% in ; and 7.6% in It is noted that the Trust has developed five key areas for improvement in on which the following draft Quality Priorities for have been based: 1. Continuing to improve the outpatient experience 2. Continuing with the improving inpatient care project 3. Improving patient safety in emergency and maternity care 4. Introducing and embedding patient care bundles / pathways 5. Improve responsiveness to patient needs Looking forward, improvements to the outpatient and inpatient experiences have been deemed important enough to again be included in this year s priorities. The Committee welcomes this move and looks forward to seeing improvements over the next year. Overall, the Committee is pleased with the continued progress that the Trust has made over the last year but notes that there are a number of areas where further improvements still need to be made. We look forward to being updated on the progress of the implementation of priorities outlined in the Quality Report over the course of and the impact that the Clinical Quality Strategy has in supporting the delivery of high quality care. We would like to congratulate the Trust on achieving a 19.8% response rate for the Friends and Family Test (FFT) within the A&E Department between April 2013 and February 2014 (the target was 15%) this is a vast improvement on the 8% response rate in It is noted that FFT will be rolled out to Outpatients and Day Care settings during and it is hoped that a good response rate will be achieved in these areas. 132

133 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts The Hillingdon Hospitals NHS Foundation Trust response to the consultation The Hillingdon Hospital NHS Foundation Trust thanks all its stakeholders for their comments about the Quality Report. The Trust is pleased that our key stakeholders recognise the trust s commitment to improve the quality of the care and services that we provide and to work closely with them in achieving further improvement. The Trust enjoys a good working relationship with both Healthwatch and with the Hillingdon Clinical Commissioning Group and it looks forward to further collaborative working to help shape the quality agenda and the delivery of safe, high quality care. The Trust is also pleased that its key stakeholders are in agreement with its quality priorities for , recognising where we have made good progress in quality improvement across a range of quality indicators and also where further work needs to be driven forward to realise the expected outcomes that we wish to achieve. The Trust has taken comments on board as part of the consultation for the Quality Report and as such these are aligned with our partners views on where we need to focus our efforts. These are recognised by our key stakeholders and it is very positive that both Healthwatch and our local commissioners wish to continue to work closely with us on projects such as the Accessible and Response Services project continuing to improve the outpatient experience and more generally on the monitoring and improving of quality. The trust acknowledges the feedback from Healthwatch on the categorisation of achievement for the quality priorities for (achieved; partially achieved and not achieved) and as such has reviewed the presentation, so that it is not confusing to our patients and the public as to how we have performed. To help understand the Trust s position information has now also been included in simple tables to reduce some of the narrative within the report; this also allows patients to see our performance over time on some of our local indicators, where this information is available. It is hoped that this will also address a concern raised from the External Services Scrutiny Committee on presentation of the information and readability. Our commissioners and the External Services Scrutiny Committee have recognised and commended our work to improve weekend emergency HSMR (Hospital Standardised Mortality Ratio) whilst also maintaining overall performance, and our commitment to deliver improvements in Maternity and Emergency Care in relation to the London Quality Standards. It has also been acknowledged that there is a firm commitment once again this year to continue to improve the patient s experience of care, having made good improvements on this in in the National Patient Survey, the Friends and Family Test and our local patient experience surveys. Our stakeholders have recognised that we have presented an honest and robust summary of the overview of quality of care at the Trust, acknowledging, alongside our achievements, that some targets have not been met and that we are committed to making further improvements in This was taken as feedback from Healthwatch in last year s report. This year we have been very thorough in our assessment of our current position in relation to the priorities we have set and have endeavoured to set realistic goals that are both achievable but also stretching. Our local Healthwatch rightly noted that a target of discharging one patient per ward before midday as part of the Improving Inpatient Care Project did not appear very ambitious this has been amended in the report to ensure the percentage of patients that we aim to discharge by midday as part of our overall patient discharges per day is clear. We look forward to continuing our very positive working relationships with our key stakeholders to support the delivery of improved quality of care and patient experience, and in particular working with Healthwatch on the Patient Led Assessment of the 133

134 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Care Environment and a quarterly review of quality data so that progress of the quality priorities can be reviewed and an overview of quality provided. We are keen to learn from our consultation exercise on the Quality Report for this year so that we can have an even more robust and inclusive approach for next year our aim will be to host a large stakeholder event earlier on in the process so that we can ensure wide engagement and have the opportunity of following up on the outputs from the event in a planned and timely way. 134

135 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Independent Auditor s Report to the Council of Governors of The Hillingdon Hospitals NHS Foundation Trust on the Quality Report We have been engaged by the Council of Governors of The Hillingdon Hospitals NHS Foundation Trust to perform an independent assurance engagement in respect of The Hillingdon Hospitals NHS Foundation Trust s Quality Report for the year ended 31st March 2014 (the Quality Report ) and certain performance indicators contained therein. This report, including the conclusion, has been prepared solely for the Council of Governors of The Hillingdon Hospitals NHS Foundation Trust as a body, to assist the Council of Governors in reporting The Hillingdon Hospitals NHS Foundation Trust s quality agenda, performance and activities. We permit the disclosure of this report within the Annual Report for the year ended 31st March 2014, to enable the Council of Governors to demonstrate they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Council of Governors as a body and The Hillingdon Hospitals NHS Foundation Trust for our work or this report, except where terms are expressly agreed and with our prior consent in writing. Scope and subject matter The indicators for the year ended 31st March 2014 subject to limited assurance consist of the national priority indicators as mandated by Monitor: Number of clostridium difficile infections reported; and Maximum 31 day cancer waiting time from Decision to Treat a Cancer diagnosed patient to the beginning of treatment (first day definitive treatment). We refer to these national priority indicators collectively as the indicators. Respective responsibilities of the directors and auditors The directors are responsible for the content and the preparation of the quality report in accordance with the criteria set out in the NHS Foundation Trust Annual Reporting Manual issued by Monitor. Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that: the quality report is not prepared in all material respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual; the quality report is not consistent in all material respects with the sources specified in the Detailed Guidance for External Assurance on Quality Reports; and the indicators in the quality report identified as having been the subject of limited assurance in the quality report are not reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual and the six dimensions of data quality set out in the Detailed Guidance for External Assurance on Quality Reports. We read the quality report and consider whether it addresses the content requirements of the NHS Foundation Trust Annual Reporting Manual, and consider the implications for our report if we become aware of any material omissions. We read the other information contained in the quality report and consider whether it is materially inconsistent with: board minutes for the period April 2013 to 27 May 2014; papers relating to quality reported to the board over the period April 2013 to 23 May 2014; feedback from the Commissioners; the 2013 national staff survey; Care Quality Commission quality and risk profiles; 135

136 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Care Quality Commission intelligent monitoring; the Head of Internal Audit s annual opinion over the trust s control environment dated 27 May 2014; and any other information included in our review. We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with those documents (collectively the documents ). Our responsibilities do not extend to any other information. We are in compliance with the applicable independence and competency requirements of the Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team comprised assurance practitioners and relevant subject matter experts. Assurance work performed We conducted this limited assurance engagement in accordance with International Standard on Assurance Engagements 3000 (Revised) Assurance Engagements other than Audits or Reviews of Historical Financial Information issued by the International Auditing and Assurance Standards Board ( ISAE 3000 ). Our limited assurance procedures included: Evaluating the design and implementation of the key processes and controls for managing and reporting the indicators. Making enquiries of management. Testing key management controls. Limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation. Comparing the content requirements of the NHS Foundation Trust Annual Reporting Manual to the categories reported in the quality report. Reading the documents. A limited assurance engagement is smaller in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement. Limitations Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information. The absence of a significant body of established practice on which to draw allows for the selection of different, but acceptable measurement techniques which can result in materially different measurements and can affect comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision of these criteria, may change over time. It is important to read the quality report in the context of the criteria set out in the NHS Foundation Trust Annual Reporting Manual. The scope of our assurance work has not included governance over quality or non-mandated indicators which have been determined locally by The Hillingdon Hospitals NHS Foundation Trust. Conclusion Based on the results of our procedures, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2014: the quality report is not prepared in all material respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual; the quality report is not consistent in all material respects with the sources specified in the Detailed Guidance for External Assurance on Quality Reports; and the indicators in the quality report subject to limited assurance have not been reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual. Deloitte LLP Chartered Accountants St Albans 29th May

137 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Annex 2 Statement of Directors responsibilities in respect of the Quality Report The Head of Internal Audit s annual opinion over the Trust s control environment dated April 2014 CQC Quality and Risk Profiles dated from 1 April 2013 to 31 March The Directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 as amended to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS Foundation Trust Boards on the form and content of Annual Quality Reports (which incorporate the above legal requirements) and on the arrangements that NHS Foundation Trust Boards should put in place to support the data quality for the preparation of the Quality Report. In preparing the Quality Report, Directors are required to take steps to satisfy themselves that: The content of the Quality Report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual ; The content of the Quality Report is not inconsistent with internal and external sources of information including: Board minutes and papers for the period April 2013 to May 2014 Papers relating to quality reported to the Board over the period April 2013 to May 2014 Feedback from the Commissioners dated 16th May 2014 Feedback from the Governors dated 28th April 2014 Feedback from Healthwatch dated 9th May 2014 The Trust s Complaints Report published under Regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 28th May 2014 The latest national patient survey published 8th April 2014 The latest national staff survey 25th February 2014 The Quality Report presents a balanced picture of the NHS Foundation Trust s performance over the period covered; The performance information reported in the Quality Report is reliable and accurate; There are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice; The data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and The Quality Report has been prepared in accordance with Monitor s annual reporting guidance (which incorporates the Quality Accounts Regulations) as well as the standards to support data quality for the preparation of the Quality Report (available at uk/annualreportingmanual). The Directors confirm to the best of their knowledge and belief they have complied with the above requirement in preparing the Quality Report. By order of the Board Shane DeGaris Chief Executive 28th May 2014 James Reid Interim Chair 28th May

138 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Glossary A Ambulatory Care Pathway Allows patients who are safe to go home be managed promptly as outpatients, without the need for admission to hospital, following an agreed plan of care for certain conditions. B Berwick Review Commissioned following the Mid Staffordshire Hospitals enquiry and publication of the Francis Report. The review includes recommendations to ensure a robust nationwide system for patient safety. C Call Management System (CMS) Care Pathway Care Quality Commission (CQC) Care Quality Commission (CQC) Intelligent Monitoring System Cellulitis Clinical audit Clinical Negligence Scheme for Trusts (CNST) Maternity Clostridium Difficile infection Comfort at Night campaign A database, administration, and reporting application designed for complex contact centre operations with high call volume. Anticipated care placed in an appropriate time frame which is written and agreed by a multidisciplinary team. The independent regulator of health and social care in England. A form of monitoring to give CQC inspectors a clear picture of the areas of care that need to be followed up within an NHS acute trust. Together with local information from partners and the public, this monitoring helps the CQC to decide when, where and what to inspect. 160 acute NHS trusts are grouped into six priority bands for inspection based on the likelihood that people may not be receiving safe, effective, high quality care. Band 1 is the highest priority trusts and band 6 the lowest. Cellulitis is an infection of the skin and the tissues just below the skin surface. Any area of the skin can be affected but the leg is the most common site. A quality improvement process that seeks to improve patient care and outcomes by measuring the quality of care and services against agreed standards and making improvements where necessary. Administered by the NHS Litigation Authority (NHSLA), provides an indemnity to members / their employees in respect of clinical negligence claims. Trusts are assessed on their level of risk management against detailed standards. A type of infection that occurs in the bowel that can be fatal. There is a national indicator to measure the number of C. Difficile infections that occur in hospital. This campaign supports reducing disturbances at night and includes increasing staff awareness of the issue and changing staff attitude ensuring that essential nursing and midwifery standards are applied. 138

139 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Commissioning for Quality and Innovation (CQUIN) Community Acquired Pneumonia A payment framework enabling commissioners to reward quality by linking a proportion of the trust s income to the achievement of local quality improvement goals. Inflammatory condition of the lung usually caused by infection and acquired from normal social contact (that is, in the community) as opposed to being acquired during hospitalisation. D Department of Health (DH) Dr Foster The government department that provides strategic leadership to the NHS and social care organisations in England. An organisation that provides healthcare information enabling healthcare organisations to benchmark and monitor performance against key indicators of quality and efficiency. E Eighteen (18) week wait Electronic Document Records System A national target to ensure that no patient waits more than 18 weeks from GP referral to treatment. It is designed to improve patients experience of the NHS, delivering quality care without unnecessary delays. This helps the trust to manage clinical records in electronic format making records management more efficient and ensuring patient records are more accessible to clinicians. F FAIR assessment for dementia Foundation Trust (FT) Friends and Family Test (FFT) Find, Assess, Investigate and Refer (FAIR) - The identification of patients with dementia and other causes of cognitive impairment that prompts appropriate referral and follow up after they leave hospital and ensures that hospitals deliver high quality care to people with dementia and support their carers. NHS foundation trusts were created to devolve decision making from central government to local organisations and communities. They still provide and develop health care according to core NHS principles - free care, based on need and not ability to pay. An opportunity for patients to provide feedback on the care and treatment they receive. Introduced in 2013 the survey asks patients whether they would recommend hospital wards, A&E departments and maternity services to their friends and family if they needed similar care or treatment. G Getting it right first time (GIRFT) Governors The Getting it right first time (GIRFT) report published by Professor Briggs in late 2012, considered the current state of England s orthopaedic surgery provision and suggested that changes can be made to improve pathways of care, patient experience, and outcomes with significant cost savings. The Hillingdon Hospitals NHS Foundation Trust has a Council of Governors. Governors are central to the local accountability of our foundation trust and helps ensure the trust board takes account of members and stakeholders views when making important decisions. 139

140 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts GP Commissioners GP Commissioners are responsible for ensuring adequate services are available for their local population by assessing needs and purchasing services. H Health and Social Care Information centre (HSCIC) Healthwatch (formerly LINk) Hospital Episode Statistics (HES) Hospital Standardised Mortality Ratio (HSMR) The HSCIC is an Executive Non Departmental Public Body (ENDPB) set up in April It collects, analyses and presents national health and social care data helping health and care organisations to assess their performance compared to other organisations. Healthwatch is a new independent consumer champion that gathers and represents the views of the public about health and social care services in England. The national statistical data warehouse for the NHS in England. HES is the data source for a wide range of healthcare analysis for the NHS, government and many other organisations. A national indicator that compares the actual number of deaths against the expected number of deaths in each hospital and then compares Trusts against a national average. I Indicator Inpatient Inpatient Survey A measure that determines whether the goal or an element of the goal has been achieved. A patient who is admitted to a ward and staying in the hospital. An annual, national survey of the experiences of patients who have stayed in hospital. All NHS trusts are required to participate. K Keogh Review A review of the quality of care and treatment provided by those NHS trusts and NHS foundation trusts that were persistent outliers on mortality indicators. A total of 14 hospital trusts were investigated as part of this review. L Local Clinical Audit London Health Programme Standards A type of quality improvement project involving individual healthcare professionals evaluating aspects of care that they themselves have selected as being important to them and/or their team. Programme to improve the quality and safety of acute emergency and maternity services based on achieving key standards of practice. M Monitor Multidisciplinary team meeting (MDT) Meticillin-resistant staphylococcus aureus (MRSA) The independent regulator of NHS foundation trusts. A meeting involving healthcare professionals with different areas of expertise to discuss and plan the care and treatment of specific patients. A type of infection that can be fatal. There is a national indicator to measure the number of MRSA infections that occur in hospitals. 140

141 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts N National Clinical Audit A clinical audit that engages healthcare professionals across England and Wales in the systematic evaluation of their clinical practice against standards and to support and encourage improvement and deliver better outcomes in the quality of treatment and care. The priorities for national audits are set centrally by the Department of Health and all NHS trusts are expected to participate in the national audit programme. National Reporting and Learning System (NRLS) Never events NHS Litigation Authority (NHSLA) NHS number The National Reporting and Learning System (NRLS) is a central database of patient safety incident reports submitted from health care organisations. Since the NRLS was set up in 2003, over four million incident reports have been submitted. All information submitted is analysed to identify hazards, risks and opportunities to continuously improve the safety of patient care. Never events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. Trusts are required to report nationally if a never event occurs. Established to indemnify NHS trusts in respect of both clinical negligence and non-clinical risks. It manages both claims and litigation and has established risk management programmes against which NHS trusts are assessed. A 12 digit number that is unique to an individual, and can be used to track NHS patients between organisations and different areas of the country. Use of the NHS number should ensure continuity of care. O Operating Framework Outpatient Overview and Scrutiny Committee (OSC) An NHS-wide document outlining the business and planning arrangements for the NHS. It describes the national priorities, system levers and enablers needed to build strong foundations whilst keeping tight financial control. A patient who goes to a hospital and is seen by a doctor or nurse in a clinic, but is not admitted to a ward and is not staying in this hospital. OSC looks at the work of NHS trusts and acts as a critical friend by suggesting ways that health-related services might be improved. It also looks at the way the health service interacts with social care services, the voluntary sector, independent providers and other Council services to jointly provide better health services to meet the diverse needs of the area. P PAS Patient Administration System Pressure ulcers The system used across the trust to electronically record patient information e.g. contact details, appointment, admissions. Sores that develop from sustained pressure on a particular point of the body. Pressure ulcers are more common in patients than in people who are fit and well, as patients are often not able to move about as normal. 141

142 05 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Priorities for improvement PROMs (Patient Reported Outcome Measures) Pulmonary Embolism (PE) Pyelonephritis There is a national requirement for trusts to select three to five priorities for quality improvement each year. This must reflect the three key areas of patient safety, patient experience and patient outcomes. PROMs collect information on the effectiveness of care delivered to NHS patients as perceived by the patients themselves. Hospitals providing four key elective surgeries invite patients to complete questionnaires before and after their surgery The PROMs programme covers four common elective surgical procedures: groin hernia operations, hip replacements, knee replacements and varicose vein operations. A blood clot in the lung. A kidney infection that can cause an unpleasant illness which is sometimes serious. R Re-admissions Root Cause Analysis (RCA) A national indicator. Assesses the number of patients who have to go back to hospital within 30 days of discharge from hospital. A method of problem solving that looks deeper into problems to identify the root causes and find out why they re happening. S Safety Thermometer Schwartz Round Secondary Uses Service (SUS) Sepsis Serious Incidents Shaping a Healthier Future (SaHF) The NHS Safety Thermometer is a local improvement tool for measuring, monitoring and analysing patient harms and harm free care. hscic.gov.uk/thermometer This offers healthcare staff scheduled time to openly and honestly discuss the social and emotional issues they face in caring for patients and families. A national NHS database of activity in trusts, used for performance monitoring, reconciliation and payments. A potentially fatal whole-body inflammation (a systemic inflammatory response syndrome) caused by severe infection. An incident requiring investigation that results in one of the following: Unexpected or avoidable death Serious harm Prevents an organisation s ability to continue to deliver healthcare services Allegations of abuse Adverse media coverage or public concern Never events. A programme to improve NHS services for people who live in North West London bringing as much care as possible nearer to patients. It includes centralising specialist hospital care onto specific sites so that more expertise is available more of the time; and incorporating this into one co-ordinated system of care so that all the organisations and facilities involved in caring for patients can deliver high-quality care and an excellent experience. 142

143 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Single sex accommodation Summary Hospital-level Mortality Indicator (SHMI) A national indicator which monitors whether ward accommodation has been segregated by gender. The Summary Hospital-level Mortality Indicator (SHMI) is an indicator which reports on mortality at trust level across the NHS in England. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there. V Venous thromboembolism (VTE) An umbrella term to describe venous thrombus and pulmonary embolism. Venous thrombus is a blood clot in a vein (often leg or pelvis) and a pulmonary embolism is a blood clot in the lung. There is a national indicator to monitor the number of patients admitted to hospital who have had an assessment made of the risk of them developing a VTE. Languages/ Alternative Formats Please call the Patient Advice and Liaison Service (PALS) if you require this information in other languages, large print or audio format on: Fadlan waydii haddii aad warbixintan ku rabto luqad ama hab kale. Fadlan la xidhiidh Jeżeli chcialbyś uzyskać te informacje w innym języku, w dużej czcionce lub w formacie audio, poproś pracownika oddzialu o kontakt z biurem informacji pacjenta (patient information) pod numerem telefonu: 如果你需要這些資料的其他語言版本 大字体 或音頻格式, 請致電 查詢 إذا كنت تود الحصول على هذه المعلومات بلغة أخرى باألحرف الكبيرة أو بشكل شريط صوتي يرجى االتصال بالرقم التالي

144 06 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Statement of Accounting Officer s Responsibilities 144

145 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts STATEMENT OF THE CHIEF EXECUTIVE S RESPONSIBILITIES AS THE ACCOUNTING OFFICER OF THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST The NHS Act 2006 states that the Chief Executive is the Accounting Officer of the NHS Foundation Trust. The relevant responsibilities of the Accounting Officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by Monitor. Under the NHS Act 2006, Monitor has directed The Hillingdon Hospitals NHS Foundation Trust to prepare for each financial year a statement of accounts in the form and on the basis set out in the Accounts Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of The Hillingdon Hospitals NHS Foundation Trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year. The Accounting Officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS Foundation Trust and to enable him/her to ensure that the accounts comply with requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the NHS Foundation Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities. To the best of my knowledge and belief, I have properly discharged the responsibilities set out in Monitor s NHS Foundation Trust Accounting Officer Memorandum. Shane DeGaris Chief Executive 28th May 2014 In preparing the accounts, the Accounting Officer is required to comply with the requirements of the NHS Foundation Trust Annual Reporting Manual and in particular to: observe the Accounts Direction issued by Monitor, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis; make judgements and estimates on a reasonable basis; state whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual have been followed, and disclose and explain any material departures in the financial statements; ensure that the use of public funds complies with the relevant legislation, delegated authorities and guidance; and prepare the financial statements on a going concern basis. 145

146 07 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Statement of Directors Responsibilities in Respect of the Accounts 146

147 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts STATEMENT OF DIRECTORS RESPONSIBILITIES IN RESPECT OF THE ACCOUNTS The Directors are required under the National Health Service Act 2006 to prepare accounts for each financial year. Monitor, with the approval of the Secretary of State, directs that these accounts give a true and fair view of the state of affairs of the Trust and of the Statements of Comprehensive Income, Financial Position, Tax Payers Equity, Cash Flow and all disclosure notes in the Annual Accounts. In preparing those accounts, Directors are required to: apply on a consistent basis accounting policies according to the NHS Foundation Trust Annual Reporting Manual with the approval of the Secretary of State; Make judgements and estimates which are reasonable and prudent; State whether applicable accounting standards have been followed, subject to any material departures disclosed and explained in the accounts; Comply with International Financial Reporting Standards. The Directors are responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the Trust and to enable them to ensure that the accounts comply with requirements outlined in the above mentioned direction of the Secretary of State. They are also responsible for safeguarding the assets of the Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities. The Directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the accounts. 147

148 08 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Independent Auditor s Report 148

149 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts INDEPENDENT AUDITOR S REPORT TO THE Council of GovernorS AND BOARD OF DIRECTORS OF THE HILLINGDON HOSPITALS NHS FOUNDATION TRUST We have audited the financial statements of The Hillingdon Hospitals NHS Foundation Trust for the year ended 31st March 2014 which comprise the Statement of Comprehensive Income, the Balance Sheet, the Cash Flow Statement, the Statement of Changes in Taxpayers Equity and the related notes 1 to 31. The financial reporting framework that has been applied in their preparation is applicable law and the accounting policies directed by Monitor Independent Regulator of NHS Foundation Trusts. This report is made solely to the Board of Governors and Board of Directors ( the Boards ) of The Hillingdon Hospitals NHS Foundation Trust, as a body, in accordance with paragraph 4 of Schedule 10 of the National Health Service Act Our audit work has been undertaken so that we might state to the Boards those matters we are required to state to them in an auditor s report and for no other purpose. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the trust and the Boards as a body, for our audit work, for this report, or for the opinions we have formed. Respective responsibilities of the accounting officer and auditor As explained more fully in the Accounting Officer s Responsibilities Statement, the Accounting Officer is responsible for the preparation of the financial statements and for being satisfied that they give a true and fair view. Our responsibility is to audit and express an opinion on the financial statements in accordance with applicable law, the Audit Code for NHS Foundation Trusts and International Standards on Auditing (UK and Ireland). Those standards require us to comply with the Auditing Practices Board s Ethical Standards for Auditors. Scope of the audit of the financial statements An audit involves obtaining evidence about the amounts and disclosures in the financial statements sufficient to give reasonable assurance that the financial statements are free from material misstatement, whether caused by fraud or error. This includes an assessment of: whether the accounting policies are appropriate to the trust s circumstances and have been consistently applied and adequately disclosed; the reasonableness of significant accounting estimates made by the Accounting Officer; and the overall presentation of the financial statements. In addition, we read all the financial and non-financial information in the annual report to identify material inconsistencies with the audited financial statements and to identify any information that is apparently materially incorrect based on, or materially inconsistent with, the knowledge acquired by us in the course of performing the audit. If we become aware of any apparent material misstatements or inconsistencies we consider the implications for our report. Opinion on financial statements In our opinion the financial statements: give a true and fair view of the state of the trust s affairs as at 31st March 2014 and of its income and expenditure for the year then ended; have been properly prepared in accordance with the accounting policies directed by Monitor Independent Regulator of NHS Foundation Trusts; and have been prepared in accordance with the requirements of the National Health Service Act Opinion on other matters prescribed by the National Health Service Act 2006 In our opinion: the information given in the Strategic Report and the Directors Report for the financial year for which the financial statements are prepared is consistent with the financial statements. 149

150 08 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Matters on which we are required to report by exception We have nothing to report in respect of the following matters where the Audit Code for NHS Foundation Trusts requires us to report to you if, in our opinion: the Annual Governance Statement does not meet the disclosure requirements set out in the NHS Foundation Trust Annual Reporting Manual, is misleading or inconsistent with information of which we are aware from our audit. We are not required to consider, nor have we considered, whether the Annual Governance Statement addresses all risks and controls or that risks are satisfactorily addressed by internal controls; proper practices have not been observed in the compilation of the financial statements; or the NHS foundation trust has not made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. Certificate We certify that we have completed the audit of the accounts in accordance with the requirements of Chapter 5 of Part 2 of the National Health Service Act 2006 and the Audit Code for NHS Foundation Trusts. Craig Wisdom FCA Senior Statutory Auditor for and on behalf of Deloitte LLP Chartered Accountants and Statutory Auditor St Albans, UK 29th May

151 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Annual Governance Statement 151

152 09 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts ANNUAL GOVERNANCE STATEMENT 1. Scope of responsibility As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS Foundation Trust s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the NHS Foundation Trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum. 2. The purpose of the system of internal control The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of The Hillingdon Hospitals NHS Foundation Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in The Hillingdon Hospitals NHS Foundation Trust for the year ended 31st March 2014 and up to the date of approval of the annual report and accounts. 3. Capacity to handle risk The Board is responsible for reviewing the effectiveness of the system of internal control, including systems and resources for managing all types of risk. The Trust Board approved Risk Management Strategy and Policy (including Board Assurance Framework) ensures that the Trust approaches the control of risk in a strategic and organised manner. It sets out the responsibilities of the Executive Directors and Senior Managers in relation to their leadership in risk management and makes it clear that all employees have a role to play in risk management appropriate to their level within the organisation. The Board has established a committee structure to provide assurance on and challenge to the Trust s risk management process. Each of these committees are chaired by a Non- Executive Director to enhance this challenge, and the committee chairs report formally to the Board to escalate issues that require further Board discussion. An example of this is the attendance at the Quality & Risk Committee (QRC) of clinical and managerial staff to present on quality assurance work and risk management issues. This provides the opportunity to discuss clinical audit and progress of work in relation to learning from clinical incidents; supports frank open discussions with Executive and Non- Executive colleagues and the opportunity to escalate, particularly where there is on-going risk. At the January 2014 QRC there was a presentation on clinical audit into maternity theatre practice including the use of the World Health Organisation (WHO) checklist and swab counts; this was presented by the Clinical Risk Midwife and follows the declaration earlier in the year of two never event incidents involving retained swabs. The Risk Midwife was able to present an honest account of learning that has taken place, actions that have been implemented and further improvement work that is underway. The two main Board committees for risk management are the Audit & Assurance Committee (AAC) and the QRC. The AAC provides assurance that there is a sound system of internal control and governance. The QRC ensures that risks to the delivery of the Trust s services are identified and addressed. Corporate risks are reported from ward to Board/QRC via Divisional Governance Boards using the online risk register managed by the Trust s Corporate Governance department. Local divisional/ department/ward risks have also progressed onto the online risk management system this year and have meant that they are managed more robustly. The Trust successfully attained level 2 in March 2014 for NHSLA for the acute hospital, and level 2 CNST 152

153 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts for the maternity services in April 2014 providing further assurance of the establishment of the risk management process. The QRC also provides assurance in matters relating to clinical quality and standards. The Medical Director and Director of Patient Experience & Nursing together provide leadership in Clinical Governance, supported by the Assistant Director of Clinical Governance & Quality. The Board Assurance Framework (BAF) is the key proactive risk identification tool for the Trust. The Trust s Strategy on a page which includes strategic objectives, reviewed annually, is mapped into the BAF. The BAF aims to provide the Board with assurance that significant threats to achieving the principal Trust objectives have been identified and are being appropriately controlled, and that there is timely and reliable assurance in place to evidence this. Action plans within the BAF address how assurances will be provided; or, where assurances have identified inadequate controls, how controls will be improved. The BAF provides a structure for the evidence to support the Annual Governance Statement. Any unacceptable residual levels of risk remaining are further risk assessed and added to the corporate risk register to ensure the gaps in control are reduced or closed as soon as reasonably practicable. The BAF has cross references from the delivery of strategic objectives to the corporate risk register; to regulatory standards e.g. NHSLA, CQC in order to demonstrate where a strategic objective links with a regulatory standard and the risks currently associated with the delivery of the objective; and to the monthly performance targets where trends in poor performance are picked up, noted in the BAF and the actions taken to mitigate the poor performance stated. The AAC and QRC have the opportunity to review and shape the BAF at their quarterly meetings. The Trust Board reviews the BAF twice a year and there is an annual Board Strategy Session which focuses on refreshing the BAF to ensure the principal risks have been identified. No significant gaps in control have been identified by the Board/Board committees this year. There are structured processes in place for incident reporting, the investigation of Serious Incidents and following up outcomes from Board commissioned external reports. The Trust Board, through the Risk Management Strategy & Policy (including Board Assurance Framework) and the Incident Policy (including Serious Incident), promotes open and honest reporting of incidents, risks and hazards. The Trust has a positive culture of reporting incidents enhanced by accessible online reporting systems available across the Trust. The latest available National Reporting Learning System (NRLS) report (March 2013) has shown the Trust to be in the 50th percentile for incident reporting. Clinical and non-clinical events that are assessed using the Trust Incident (including Serious Incident) policy to be a Serious Incident (SI) are forwarded to the Chief Executive or designated Executive to confirm if the incident is an SI. Once declared, SIs are reported on the Department of Health Strategic Executive Information System (STEIS); to Monitor; and a monthly update to the Trust Board on the progress of investigation/action progress and lessons learnt. Lessons learnt are shared within and where appropriate across Divisions. Further information on the SIs at the Trust, and the actions taken by the Trust as a result of the learning from these, is included in the Quality Report. The Board has proactively commissioned external assurance when the information reviewed by the Board, such as from SIs, mortality data, and ward visits has indicated that there is scope for further investigation and improvement. The Patient Safety and Quality Report, which aims to triangulate information on patient safety, patient experience and clinical effectiveness is presented quarterly at the QRC and the Clinical Governance Committee (CGC). This includes learning from SIs, complaints, claims and references work that is being taken forward to reduce risk; it also includes the provision of a quality dashboard with red, amber green (RAG) rating against the best available national/ local standard and includes exception reporting. Regular monthly reports for complaints and incidents (including SIs) are presented to each Divisional Clinical Governance Board. The QRC is able to review quality 153

154 09 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts reports and initiatives and risk in a more integrated fashion than with previous arrangements where risk and quality were overseen by different committees. This supports the triangulation of quality data and more effective and critical decision-making. Risk management training and awareness is included in the mandatory New Employees Week programme for all new employees. The Trust s Health and Safety team deliver risk management training appropriate to all levels across the Trust including the Trust Board. The Nursing Education Skills Programmes are reviewed three monthly, and updated to ensure the latest evidence-based/ best practices are incorporated. This would include learning from NPSA alerts; for example in December 2013 NPSA put out a Patient Safety Placement devices for nasogastric tubes (NGT) alert which does not replace initial NGT placement checks. This is now incorporated in training programmes, bespoke ward sessions and all ward areas were alerted at the time regarding this issue. The Board is committed to a culture of continual learning and quality improvement. Learning from risk management activities such as trends in incidents, complaints and claims are monitored and acted upon at Divisional level. Where appropriate, Internal Audit and Clinical Audit are used to provide assurance that changes to practice have become embedded. For clinical audit, the National Hip Fracture Database confirmed that, for this group of patients, the Trust had improved standards for time to theatre, Abbreviated Mental Test (AMT) scoring and Geriatrician input. To further provide assurance using clinical audit, the Trust has introduced an ongoing Mortality Audit, which commenced in October This process will help to ensure we consistently provide high quality care. Major reports from Healthcare Regulators are used to assess what lessons the Trust can learn from significant incidents and events in other healthcare organisations in order to evaluate and improve our practice. Further to the Trust s discussions during 2013 with staff and its key stakeholders on the learning from the Francis Inquiry there has been an increased focus on how we measure and monitor quality and there has been a review of the information that is received both at the Board and at QRC. This has enabled the Trust to form a new clinical quality strategy to be delivered over the next three years. An intrinsic part of the strategy will be the implementation of the recommendations of the Francis report. The Trust has developed an action plan in response to Francis which also takes the recommendations from the Keogh and Berwick reports into consideration. The Trust is currently reviewing the nursing and midwifery workforce, in particular to improve nursing/midwifery care at the bedside, and we will monitor the quality of care through our patient surveys, detailed and patient focussed nursing performance templates, and establish further mechanisms for measuring compassionate care. The Trust has developed a series of pledges that will be embedded within the Trust and against which we will track progress and produce a public annual report discussed at the Board. The Keogh Report measured 14 acute Trusts that were persistent outliers on mortality indicators against a variety of safety indicators; this has informed our strategy and forms an integral part of our ambition to ensure that we continue our work on reducing hospital mortality, particularly the variation between weekend and weekday mortality rates. INCREASED FOCUS 4. The risk and control framework The system of internal control is based on an on-going risk management process that is embedded in the organisation and combines many elements. The aforementioned comprehensive Risk Management Strategy & Policy (including BAF) is available to all staff on the Trust s intranet site. All staff are responsible for managing risks within the scope of their role and responsibilities as employees of the Trust. The purpose of this risk management policy is to ensure that the Trust manages risks in all areas using a systematic and consistent approach. The document describes the Trust s overall risk management process and the Trust s risk identification, evaluation and control system, which includes the risk matrix used to evaluate risks. Risks are identified reactively and proactively. 154

155 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts All risks are assessed against one standard tool. This ensures that a consistent approach is taken to the evaluation and monitoring of risk in terms of the assessment of likelihood and impact. Risks are monitored through a formal reporting process where the assessed level of risk and its strategic significance determines where it will be reviewed and monitored. The monitoring of risks and action plans have been undertaken by the Trust Board/ Trust Board committees during These committees are supported by Executive chaired committees/groups and Divisional governance structures that channel information up to and down from the Board/Board committees via the online risk register. Risk appetite as well as risk tolerance is covered in the risk strategy. The Board has not set specific limits for this, but will view risks and the progress of actions designed to mitigate risk, on an individual risk basis. The accepted risks are reviewed at least annually by QRC/Divisional Governance Boards to check that the controls for these accepted risks still stand. The Board s QRC recommends which corporate risks may be accepted based on the level of the required resource; assurance that all reasonable measures have been put in place to mitigate any risks; and that there is assurance that these are monitored regularly. Risk consequences are considered as part of cost improvement plans, business cases, capital expenditure projects and staffing and workforce priorities regarding vacancy authorisation. This ensures that the Trust is taking account of the key inter-linking priorities and dependencies of finance, operation and service quality risk in order to deliver the best quality service to patients. The Trust Board reviews all of the high corporate risks quarterly; the QRC reviews all the medium and high corporate risks quarterly and the Divisional Boards review all relevant risks at all levels quarterly. Part of the review will be to see what progress has been made to close down the gaps in control and whether the risk can be downgraded if sufficient measures have been put in place to control the risk. Significant clinical risks in-year: Suboptimal staffing issues in relation to paediatric A&E nursing and medical staff; suboptimal maternity staffing and winterflex wards (as identified as a moderate concern by the CQC). Mitigations regarding overall nursing staff include: regular recruitment drives; a biannual staffing establishment review; monthly tracking of nursing vacancies and report to the Director of Nursing at the monthly Nurse & Midwifery Assembly; QRC and Clinical Governance Committee are tracking the CQC action plan which includes safer staffing. The medical staffing risk has been closed in-year as we have increased consultant working at peak times e.g. evenings. We are currently fully recruited in paediatrics (from junior doctors to consultants). A lead paediatric nurse has been recruited in A&E. Failure to meet C difficile target. Mitigations include: Delivery of the Infection Prevention & Control (IP&C) strategy and annual action plan, including implementing actions from root cause analysis (RCA) learning and implementing Start Smart, Then Focus antimicrobial prescribing action plan. Infection control rates are reviewed by the Infection Control Committee, QRC and the Board. The Trust ended the year within the C difficile target. Through unsustainable demand, uncontrolled delays to the delivery timelines and an inability to deliver the required clinical workforce NW London Shaping a Healthier Future (SaHF) delivers precipitate, poorly planned change, which adversely impacts quality and safety. A programme implementation governance structure has been established to ensure that there is involvement from all major stakeholders and to monitor programme progress. Through an inability to meet the clinical standards, deliver the requisite workforce, deliver behavioural change, sustain expected patient experience and an unsustainable demand on the system SaHF does not deliver the planned 155

156 09 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts benefits to improve quality and safety of health and care across NW London. Clinical standards were approved in the Decision Making Business Case and all providers are now creating plans which support the delivery of these standards this will remain under review by the Implementation Clinical Board. Significant finance risks in-year: Financial financial performance, under delivery of Quality Innovation Productivity and Prevention (QIPP) and liquidity. This risk is mitigated by robust and prudent planning supported by a rigorous monthly and quarterly performance management framework, monthly formal QIPP reviews and monthly Trust Board reporting. The Trust has a committed working capital facility equivalent to an additional 30 days of operating expenses and an agreed contract with Hillingdon Clinical Commissioning Group (CCG) that reduced the risk of significant over performance cash lags. The risk of healthcare revenue falling and leaving the Trust with a deficit because of fixed costs that could not be reduced in-year was mitigated by an agreed contract based on a guaranteed minimum financial value. Due to the mitigations put in place by management during the year the Trust achieved its financial objectives generating a small year-end surplus. Fragile estate infrastructure and scale of long and short term investment required exceeds the Trust s financial capacity and leads to a failure of the financial plan and interruption of/reduced quality/ safety of service delivery as identified by the CQC. This is mitigated by a prioritised five year forward view of high and significant backlog maintenance requirements (based on a five yearly survey of the estate condition), risk assessed and rated against available capital and supported by a robust planning process and performance management regime; the capital expenditure plan for the estate has been achieved. Regular environment audits occurred e.g. Patient-led Assessment of the Care Environment (PLACE) and mini PLACE inspections to inform of any issues and improve the environment of care where required. The main future risks facing the Trust are summarised: Future clinical risks: Through SaHF transition of care to Hillingdon, there is a risk that the Trust is unable to maintain clinical quality as service is transferred, impacting adversely on patients and carers (particularly in relation to maternity and paediatrics. The risks include not having the available resource in place to safely manage the additional workload. This is to be mitigated by establishing clinical governance systems around changes to and transfers of services, agreeing key performance indicators and planning for staged and safe transfer; allowing for possible double running of services during transition; and ensuring quality metrics are tracked post-change so any undesirable trends can be identified and rectified early. There is continued close working with the Maternity and Paediatrics working groups and clinical implementation groups to develop transition plans. The large emergency care project (ECP) does not deliver the operational benefits as planned. This is mitigated by early clinical engagement to improve patient pathway efficiencies, reduce length of stay and ensure adequate communication for staff, patients and visitors. Failure to meet MRSA or C. difficile target. Actions to mitigate include: delivery of the IP&C strategy; delivery of HCAI plan, including implementing actions from RCA learning andimplementing Start Smart, Then Focus antimicrobial prescribing action plan. Infection control rates are reviewed by the Infection Control Committee, QRC and the Board. Failure to meet adequate levels of staffing implied in Francis Report due to financial & trained staff constraints. Actions to mitigate include: working with operational divisions to develop robust plans to pilot the supervisory senior sister s role; skill mix and staffing ratios are currently under review taking best 156

157 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts practice guidance and acuity and dependency assessments into consideration. tthese are to be reported monthly to the Board with regard to planned and actual numbers and staffing numbers to be displayed daily in clinical areas; a detailed staffing report to be presented to the Board twice a year (as a minimum) or when there is significant service change using the appropriate best practice guidance and evidencebased tools; increased weekend consultant cover, especially in General Medicine is planned for implementation in Failure to reduce weekend Hospital Standardised Mortality Ratios (HSMR), Actions to mitigate include: improve co-morbidity coding, working with clinical and coding teams; identify specialties with high HSMR and understand factors with implementation of clinical changes (e.g. bundles of care) as appropriate; learn lessons from audit and ensure there is a robust action plan that is monitored via the QRC; ensure actions are implemented in accordance with London Health Programme (LHP) standards, e.g. senior clinician review at weekends; mortality review process which involves case notes of patients who have died being reviewed by another consultant to check for correct coding, avoidable deaths, and any common themes which should pick up any differences in weekday versus weekend care, and the learning being shared. Inability to improve harm free care (target > 95% as a minimum); and variability in ward care (evidence via ward heatmaps); mitigated by implementation of the National Early Warning (NEW) scoring system with more effective identification and earlier response to the deteriorating patient; ward heatmaps reviewed quarterly at QRC and monthly at nursing forums. Future financial risks: Commissioning risk that Hillingdon CCG s significant out of hospital strategy results in a Trust deficit that is not covered by SaHF transitional funding; Commissioning risk if activity is not paid for, potentially leading to clinical and financial viability concerns; Operational and investment cash gets extremely tight and starts to impede on service delivery; and Unprecedented size of efficiency savings required in and for the next 5 years and its impact on quality of care provided. These risks are mitigated by: Continuing to agree contracts with Hillingdon CCG that promote robust collaborative working to redesign clinical pathways yet at the same time provide sufficient revenue to cover the Trust s fixed costs including guaranteed minimum financial values and or fixed cost transitional support. Regular internal meetings in relation to contract management performance with responsible managers. Agreed robust mitigation plans put in place to manage the financial consequences of a reasonable reduction in revenue as a consequence of services being decommissioned. Building up the Trust s cash reserves at a measured pace taking into account service investment requirements supplemented with contractual access to other cash facilities and supported with robust treasury management. All services have a project initiation document, which involve a risk assessment. Any significant risks need a comprehensive Quality Impact Assessment (QIA) which is reviewed by the Clinical Assurance Panel (CAP) led by the Medical Director. The CAP reviews, approves or rejects any schemes, thereby assuring the organisation that change and transformation programmes do not pose a material risk to the delivery of safe, high quality care. The CAP also reviews quality KPIs related to projects to track any changes alongside key changes to service 157

158 09 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts delivery. This process has proven effective and will continue into and future years. The structure set-up by the Programme Management Office (PMO) ensures that robust tracking and monitoring processes are in place to ensure that efficiency savings are identified, planned and delivered in line with the annual planning cycle. Throughout the year weekly/ fortnightly risk assessment allows early sign of potential areas of non-delivery to ensure mitigating actions are put in place to prevent slippage or non-delivery. Future Estate Risk: Access to sufficient resources to keep pace with the scale of short and long term investment required to deal with the backlog of maintenance required of a poor quality estate exceeds the Trust s financial capacity and leads to a failure of the financial plan and interruption of/ reduced quality/safety of service delivery. This is mitigated by a prioritised five year forward view of high and significant backlog maintenance requirements (based on a five yearly survey of the estate condition), risk assessed and rated against available capital and supported by a robust planning process and performance management regime; regular environment audits occur e.g. PLACE and mini PLACE inspections to inform priorities to improve the environment of care. This risk is also partially mitigated by earmarked funding through the SaHF programme. Public access to services and car parking capacity; planned mitigations include earmarking investment to increase the number of car parking spaces available. The Trust will remain focused on the tension between quality, safety, financial efficiency, and risk to ensure that patient care remains uncompromised. The Trust will do this by having regular Board and Executive reviews of progress and delivery of agreed plans and check that all schemes are quality impact assessed. Data Security For data security, the Trust has an established Information Security Management System (ISMS) similar to that defined within the International Standard (ISO) This entails the identification and classification of information assets, risk assessing those assets and then establishing control frameworks to keep those assets secure. The Trust has committed to establishing ISMS through its compliance with the Information Governance (IG) Toolkit. One key element of our compliance is having a current Information Risk Policy. The policy is supported by an Information Risk Strategy and accompanying procedures. These set out the arrangements for governing information risk processes, i.e. the framework of accountability and the roles and responsibilities of staff, management and committees. Together these contribute to the organisation meeting its legislative and regulatory requirements, as well as meeting requirements from the Department of Health for organisations to manage the security of their information, defined within the Connecting for Health IG Toolkit. Compliance evidence for version 11 of the IG Toolkit has been uploaded to NHS Connecting for Health and all requirements are at a level 2 or 3 except for the requirement to have 95% of staff trained annually in IG which is at level 1. There has been a new initiative this calendar year for IG refresher training where a refresher leaflet and quiz have been used to increase compliance; around 750 staff have completed their annual refresher training in this way. Despite this the March 2014 IG training compliance figures are 70% for all staff. IG training compliance will be driven further by a change in Trust Statutory and Mandatory Training Policy which provides monthly reporting of staff compliance to managers and repercussions for non-compliance. In October 2013 the Trust received an Information Commissioner Office (ICO) Ruling following Patient Data Loss in June 2012 (this was detailed in last year s Annual Governance Statement). The Ruling that the Trust agreed and signed was a formal undertaking to demonstrate compliance with the Data Protection Act (DPA). The actions required were duly acted upon and monitored through 158

159 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts the Information Governance Steering Group. In January 2014 the ICO undertook a desk-top review of evidence to ascertain if the Trust had sufficiently followed through the actions required. The ICO were satisfied that the Trust had appropriately addressed the actions agreed in the undertaking and have stated this on their website. Compliance with the NHS Foundation Trust condition 4 (FT Governance) The Assistant Director of Corporate Governance has put a system in place whereby compliance with the NHS Foundation Trust condition 4 (FT Governance) has been reviewed at least 6 monthly over the past financial year. The October 2013 AAC was presented with an assurance report that any risks identified by the Executive Team relating to the delivery of the Annual Monitor Corporate Governance Board Statements are being managed appropriately. Each element of the Corporate Governance Board Statements was presented alongside a column of assurances which include Internal and External Audits of Trust practice. The report was taken in context with the BAF and Corporate Risk Register. The principal risks to compliance have been captured within the risk section of this document and derive from the corporate risk register and BAF. The relevant risks to compliance within the governance condition relate principally to staffing, finance and the estate and these have been mitigated and addressed as advised in the earlier risk section. All statements were confirmed in the October AAC with no risks to compliance identified. The statements and assurances were reviewed and revised by corporate governance and the Executive Team ready for presentation at the April AAC, ahead of Trust Board review to confirm or not-confirm the Corporate Governance Board Statements. During this preparation process no residual material risks to compliance have been identified and therefore no outstanding mitigating actions were required. The Trust commissioned KPMG to undertake a review of its quality governance arrangements as it had been three years since the meticulous process to become a Foundation Trust and it is considered best practice to seek external assurance on the Board every three years. KPMG reviewed the Trust s position against Monitor s Quality Governance Framework. This provides assurance in relation to the effectiveness of governance structures, use of information, Board capability, reporting lines and accountabilities between the Board and its committees and the Executive team, and the degree and rigour of oversight the Board has over the Trust s performance. KPMG concluded that overall quality governance at the Trust appears good. Recommendations were made regarding how the Trust can strengthen its quality governance arrangements which will be addressed in an action plan. The Board will be commissioning KPMG to undertake a follow-up piece of work in June/July 2014 that will examine the Board s wider governance in issues other than quality which will provide further assurance as to the Trust s compliance with the governance condition in the Licence. Care Quality Commission (CQC) Compliance Compliance with the CQC essential standards of quality and safety are one of the elements of the organisation s risk management process. The Trust is registered with the CQC without conditions. The Trust is not currently fully compliant with the registration requirements of the Care Quality Commission following an unannounced inspection in October 2013 where one moderate Staffing concern was raised and two minor concerns regarding Cleanliness and Infection control, and Safety and Suitability of Premises. The Trust set out an action plan to close down the gaps in compliance and awaits further CQC inspection to review its compliance level. To ensure the Trust strives to be compliant with the CQC essential standards of quality and safety the following assurance processes are in place: QRC receives a CQC compliance report twice yearly and AAC annually. This report is produced by Corporate Governance and is an outcome-based review of all the regulated outcomes demonstrating where any concerns with potential non-compliance are arising. The provider compliance assessments (PCA) are used 159

160 09 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts to ensure the Trust has due processes in place to enable compliance. The CQC paid an unannounced visit to the Hillingdon Hospital site in October The resulting report from the CQC stated compliance in four out of the seven outcomes assessed against the essential standards of quality and safety. As mentioned above there was one area of moderate concern and two of minor concern that have been addressed by the Trust and await CQC re-inspection. Internal Audit undertook their annual CQC compliance audit review in March 2014 and judged the Trust to be at substantial level of assurance. Corporate Governance examines the Quality & Risk profile (which has now changed to the Intelligent Monitoring report); and produces a tracker risk profile for review by the Executive Team and senior management. The results are challenged and investigated where required and dialogue with the CQC inspectors is raised as necessary. The CQC changed this system in-year to a new risk banding system. In October 2013 and February 2014 the Trust was rated in band 6 the lowest risk band. CQC compliance moving forward will be internally assessed using both the established desk-top style review of outcomes based on patient experience and a revised peer review process which will be based on different levels of review and frequency from daily ward based checks to monthly Executive/Non-Executive led Observations of Care ward visits and external peer review from another NHS Trust. There have been some Internal Audit reports reviewed by AAC giving Limited Assurance this year. In these cases actions have been taken to close down the gaps and whilst high level actions have been addressed and owned appropriately some of the lower level more local actions require further diligence to drive them to completion. Compliance with the Code of Governance The Board has reviewed itself against the NHS Foundation Code of Governance. The Board has made the disclosures required by the Code in the governance section of the Directors Report, including explanations for non-compliance with provisions of the Code. Attendance records and coverage of work for each Board committee is also included in this section of the annual report. Public Stakeholders The Trust involves its key public stakeholders with managing the risks that affect them through the following mechanisms: Engagement with the local Health Overview and Scrutiny Committee Engagement with the Local Healthwatch The Council of Governors are consulted on key issues and risks as part of the annual plan Regular People in Partnership Forums which enables the Trust to listen to the views and opinions of the communities we serve, share information about what the Trust is doing, and planned future developments, and provides an opportunity for members to meet and communicate with staff, Governors and fellow members Annual Members Meeting Engagement with User Groups and Support Groups e.g. Fighting Infection Together, Maternity Services Liaison Committee, People Improving Cancer Services, Readers Panel and the Patient-led Assessment of the Care Environment (PLACE). Control measures are in place to ensure that all the organisation s obligations under equality, diversity and human rights legislation are complied with. Equality impact assessments (EIA) are integrated into core Trust business e.g. they are carried out as standard procedure for all Trust s policies. In addition the Trust has published its Statutory Equality & Diversity Reports: Workforce Equality Compliance Report and the Service Equality Compliance report January 2014 providing assurance that the Trust is compliant with Equality legislation. 160

161 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer s contributions and payments into the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations. The Hillingdon Hospitals NHS Foundation Trust has undertaken risk assessments and Carbon Reduction Delivery Plans are in place in accordance with emergency preparedness and civil contingency requirements, as based on UKCIP 2009 weather projects, to ensure that this organisation s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with. Adaptation reporting uses a risk assessment approach; coupled with regular detailed buildings condition survey, in conjunction with resilience planning, based on weather-based risks e.g. heat wave, extreme cold, drought, and flood. 5. Review of economy, efficiency and effectiveness of the use of resources The following key processes are in place to ensure that resources are used economically, efficiently and effectively: Scheme of Delegation and Reservation of Powers approved by the Board sets out the decisions, authorities and duties delegated to officers of the Trust. Standing Financial Instructions detail the financial responsibilities, policies and procedures adopted by the Trust. They are designed to ensure that an organisation s financial transactions are carried out in accordance with the law and Government policy in order to achieve probity, accuracy, economy, efficiency and effectiveness. Robust competitive processes used for procuring non-staff expenditure items. Above 25k, procurement involves competitive tendering. Cost improvement programmes (CIPs), which are assessed for their impact on quality with local clinical ownership and accountability. Use of National and London benchmarking for non-clinical support functions. The Trust Board has gained assurance from the AAC in respect of financial and budgetary management across the organisation. The AAC also receives quarterly reports regarding losses and compensations (with high value approved by the Board), write-off of bad debts and contingent liabilities. The AAC has reviewed levels of charges for overseas visitors to ensure they take account of the risk of non-payment. Value for money discussions take place at a management group chaired by the Chief Operating Officer where the discussion is based on service line reporting reviewing how much a service costs to run versus the income it generates and how it is performing both clinically and operationally. This is particularly the approach used around services where competition is greatest and or where a service is out to tender. Board strategy sessions then look at specific services and decide whether or not to expand them. Further information with reference to the Trust s financial future regarding the Going Concern assessment, is included in the Strategic Report of this Annual Report. This draws specific attention to the recent financial performance, the challenging financial context facing the Trust and the programme the Board is investing in to support the delivery of the savings identified going forward. There are a range of internal and external audits that provide further assurance on quality of financial data, economy, efficiency and effectiveness, including internal audit reports on creditors, financial reporting and budgetary control, healthcare contracting & payment by results, cash management, cost improvement programmes, and financial and activity data and how it is linked including clinical coding. These are all reported to AAC. All Internal Audit reports into finance functions have reported substantial assurance for the past four financial years. 161

162 09 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Annual Quality Report The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended) to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS Foundation Trust Boards on the form and content of annual Quality Reports which incorporate the above legal requirements in the NHS Foundation Trust Annual Reporting Manual During there has been an increased focus on how we measure and monitor quality and there has been a review of the information that is received both at the Board and QRC. Whilst undertaking this work the Trust has considered and made reference to key NHS investigations and reviews, and in particular the Francis Report, and the Keogh and Berwick reviews; this in turn has supported us in developing a new clinical quality strategy. Our new Strategy outlines the learning and recommendations from these key publications and these underpin our key aims and objectives for quality improvement. In addition we have reviewed our current quality performance alongside national and regional quality data and referenced local feedback from both staff and patients. The analysis of these and our recent award of a Band 6 Trust as part of the new CQC Hospital Intelligent Monitoring Band Ratings confirm the importance of strong quality performance across a range of indicators. The Trust s commitment to quality improvement and quality governance is clearly outlined in our refreshed clinical quality strategy; this describes a system of quality performance management, and a clear risk management process. Having the right structures and processes in place allied to an appropriate culture with supporting values and behaviours has been strongly emphasised. Development of our new clinical quality strategy has truly supported the Trust in engaging with key stakeholders, including FT members, Governors, Healthwatch, our commissioners and our staff on the quality agenda and has effectively assisted in developing this year s annual quality report priorities. In addition, the Trust has used existing systems for quality performance management to assess its current position in relation to regional and national performance. Information on quality is supplied to the Board, and the management team, by a specialist team in clinical governance. This team maintains oversight of quality information and provides regular data to the Board and the QRC. Alongside key quality indicators as part of the quality dashboard, information is also included on clinical incidents, and SIs and the learning from them, complaints and claims. This flow of information ensures that key threats and risks to quality are identified. The clinical governance team is led by a senior clinical manager who is supported by specialist risk facilitators and a clinical audit and effectiveness manager and audit team. Observations of care visits which are undertaken on a monthly basis where Board members accompany senior nurses and visit wards on a rotational basis to review the quality of care have also assisted the Board in maintaining an oversight on performance in relation to the quality of care. During the visit, the environment, attitudes and behaviours of staff, team working and specific aspects of patient experience and safety are assessed and discussed with staff. As part of its consultation on the annual quality report the Trust has also spoken with clinical staff via Divisional governance board meetings, via senior clinical and management staff meetings. The Information Team has also undertaken a triangulation exercise examining data sources that they regularly analyse for potential underlying issues of quality related to performance or data, not otherwise identified. All of the above has assisted the Trust in being clear on its targets and which areas need increased focus. The Trust has reflected on the progress of its priorities for and has discussed this with its key stakeholders in order to agree new priorities for Determining SMART objectives is work that is currently underway and this work is closely aligned with our clinical quality strategy objectives and our overall Trust Strategy measures of success. 162

163 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts The Trust has a comprehensive clinical audit work plan covering both national and local audits. Regular updates on clinical audit are reported to the QRC. Issues raised via Clinical Audit result in changes in practice within the Trust e.g. the aforementioned WHO theatre checklist audit. A theatre review conducted by our internal auditor and an external investigator has been completed in recent months. A CAP (Clinical Assurance Panel) is now embedded to assess the quality impact of any changing service brought about for QIPP. This is a multi-professional clinical panel, chaired by the Medical Director, which formally reviews all cross-divisional service changes. Nursing performance meetings continue to be conducted on a monthly basis with the Deputy Director of Nursing and each of the inpatient wards senior sisters/charge nurses and the relevant matrons. A nursing quality dashboard is reviewed within these meetings to allow for ward to Board reporting. The dashboard is also presented to the QRC on a quarterly basis. A framework exists for the management and accountability of quality of performance data and data quality. This is supported by a comprehensive audit programme and the Data Quality Policy, which consist of a set of quality data groups that run across the organisation. These groups report to an Executive Director-led steering group which feeds quarterly into the AAC. These quarterly data quality and performance quality reports cover the Monitor compliance data, reported to the Board, and other key data quality issues like NHS number and duplicate records. Key quality performance information is assessed monthly by the Trust Board which reviews the performance report both the targets table and the prose which interprets the numbers, discrepancies and any required actions. This, together with the data audit results, and the use of Data Quality Badges which are described in each monthly performance report, provides assurance to the Board on data quality and data performance issues and strength of internal control. Three key data areas have been identified this year where further actions are being implemented: 1. NHS Number coverage on clinical systems the programme to integrate information systems is continuing to address this. 2. Timeliness of data entry to increase timeliness of data entry and real-time data availability. 3. A&E data quality assurance regular review and local auditing. The priorities for the Annual Quality Report are drawn together and shaped via a structured timeline which engages our key stakeholders, such as Patients in Partnership, Governors, Healthwatch, the Clinical Divisions, Clinical Governance Committee and QRC. These processes and the leadership involved ensure the Quality Report represents a balanced view. 7. Review of effectiveness As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the Internal Auditors, clinical audit and the executive managers and clinical leads within the NHS Foundation Trust who have responsibility for the development and maintenance of the internal control framework. I have drawn on the content of the quality report attached to this Annual report and other performance information available to me. My review is also informed by comments made by the External Auditors in their management letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Board, the Audit and Assurance Committee, Quality & Risk Committee, and a plan to address weaknesses and ensure continuous improvement of the system is in place. The process that has been used to maintain and review the effectiveness of the system of internal control centres on: Development, review and challenge of the BAF which is compiled by Corporate Governance in conjunction with the relevant Executive Directors 163

164 09 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts and their senior managers; the BAF is then scrutinised quarterly at both the QRC and AAC prior to being reviewed by the Board twice yearly. The BAF is reviewed and challenged as described in section 3 above. There is then an annual examination and refreshing of the principal objectives cited in the BAF, new risks added if required or risks amended to suit the current climate. Internal audit have reviewed the BAF and the methodology involved in forming the tool and have given substantial assurance that the Trust has in place adequate and appropriate arrangements for gaining assurances about the effectiveness of the organisation s system of internal control. The work of Internal Audit to review the Trust s key processes of financial and non-financial internal control. The work-programme is risk based, and findings reported to the AAC. The Head of Internal Audit Opinion has given significant assurance that there is a generally sound system of internal control. A review commissioned by the Trust into its position against Monitor s Quality Governance Framework. The review, undertaken by KPMG, largely agreed with the Trust s self-assessment and scored the Trust at 2.5. The review concluded that quality governance at the Trust appears good and that the strength of challenge at the Board and Committees was robust and appropriate; it also noted the complimentary challenge and insight from the Non-Executive Directors and the individual interest and depth of scrutiny over quality issues shown by all Board members. KPMG also noted from their observations that there was a general sense that the culture amongst senior staff and the Board is one of openness, where problems are accepted and the focus is on finding solutions as opposed to a culture of defensiveness and self-protection. The Board Committees have continued to review their effectiveness during the year with changes made as required. Following this review the meetings of the Quality & Risk Committee were extended to ensure sufficient time is available for the agenda items to be discussed in detail. A framework exists for the management and accountability of quality of performance data and data quality as detailed in section 6 above. This, together with the data audit results and input to the AAC, provides assurance to the Board on data quality and data performance issues and strength of internal control. The cost improvement plan is always a challenge, however CAP provides me with assurance that clinical quality is not being compromised. The C. difficile and 4 hour A&E targets were tested alongside aspects of staffing, but performance remained within specified targets and the Trust has managed to attain a Financial Risk rating of 3 for the first part of the year at which point this changed to a Continuity of Services risk rating, and the Trust attained a score of 4 and 3 in quarters 3 and 4 respectively; and a green governance rating for all quarters of the year. On balance, I therefore conclude that the Board has conducted a review of the effectiveness of the Trust s system on internal controls and found them to be sufficient. Conclusion My review confirms that The Hillingdon Hospitals NHS Foundation Trust has no significant internal control issues and a generally sound system of internal control that supports the achievement of its policies, aims and objectives. Shane DeGaris Chief Executive 28th May

165 The Hillingdon Hospitals NHS Foundation Trust Annual Report and Accounts Annual Accounts