Bolton NHS Foundation Trust Annual Report and Accounts 2015/16

Annual Report and Accounts 2015/16

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Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006

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Contents

Page

Foreword 1

Performance Report

Overview of performance 5

Performance analysis 10

Accountability Report

Directors’ report 20

Remuneration report 28

Staff report 36

Code of Governance disclosures 47

Regulatory ratings 59

Statement of accounting officer’s responsibilities 61

Annual Governance Statement 62

Quality Report 74

Independent Audit Reports 126

Annual Accounts

Foreword Foreword The annual report and accounts have been prepared in accordance with the direction issued by Monitor under the National Health Service Act 2006. This report is intended to be self-standing and comprehensive in its scope. However where further information is available, for example in the Trust’s five year strategic plan, this will be cross-referenced within the report. For regular updates on our performance and any matters affecting the Trust please refer to our website www.boltonft.nhs.uk Preparation of Accounts and adoption of going concern The Accounts provided with the Annual Report have been included under a direction issued by Monitor under the National Health Service Act 2006. After making enquiries, the directors have a reasonable expectation that the NHS foundation trust has adequate resources to continue in operational existence for the foreseeable future. This judgement was based on the following factors:  Fundamentally all NHS bodies are financially backed by the government in the form of the Secretary of State for Health so it is not possible for Foundation Trusts to become insolvent in the way that a private company might.  The DoH operates a formal system to deal with Trusts that are designated as being financially unsustainable. Trusts in this position continue to receive cash support from the DoH and they themselves continue to prepare accounts on a going concern basis. The arrangements in regard of distress funding described above have not been changed by the Greater Manchester Health and Social Care Devolution.  In addition to the above the Board can be assured that the accounts should be prepared on a going concern basis because of the following: o Successful delivery of the 2015/16 financial plan and achievement of the planned Financial Sustainability Risk Rating of two in 2015/16 gives confidence in the organisation’s ability to deliver on its financial plans going forward. o The Trust ran a successful cash management improvement project in 2015/16 which meant the cash outturn in 2015/16 was better than would have otherwise been expected given the key components of the I&E position. o The Board has approved a five year strategic financial plan that shows the Trust generating surpluses going forward. o A detailed operational financial plan has been prepared to support the delivery of the planned £11.9m surplus for 2016/17. o The planned £11.9m surplus consists of a £2.7m surplus rewarded by a £9.2m payment from the national sustainability and transformation fund. Delivering this surplus will significantly enhance the Trust’s cash position meaning that the Trust has been able to plan for a £7.8m cash balance at the end of the 2016/17 financial year.

Foreword

Chairman’s Review - April 2016 In every constellation there is a star that shines the brightest and I am delighted to say that during the past twelve months our trust has become that star. You might be forgiven for thinking that the National Health Service is imploding upon itself, given the national headlines, but despite the huge pressures faced, Bolton Foundation Trust has delivered a quite fantastic performance. I couldn’t be more proud of every single member of staff and every governor and member of the trust for putting us on the map for all the right reasons. Our patients have been magnificent too, both in the way that they have interacted with us and in the way they have responded to some of the changes we have introduced. Achievements 2015 was a watershed for us; we were finally released from all the conditions and scrutiny, placed upon us in August 2012 by the health regulator, when we were considered to be in breach of our licence. More remarkably, it transpires that Bolton is the only trust ever to emerge from such conditions without the need for a merger or acquisition. This is indeed testimony to the success of our turnaround plan and the commitment of everyone in the trust. Our success was also highlighted by the Secretary of State for Health at a public forum as a benchmark to others. To put it into perspective, we delivered key performance targets including waiting times, cancer targets, diagnostic tests, stroke targets and many others. Our staff satisfaction scores continued to rise, with the majority now in the top 20% of the UK, and our patient feedback also improved, highlighting the effects of improved care throughout the trust. On the financial side we delivered our plan, a small surplus of £1.9m, and in doing so became the only trust in our peer group within the North West to manage within our budget. In truth, we are amongst the top 10 trusts in the UK for financial performance and we have been recognised nationally for our approach. Exceptionally, this marks the second successive year when we have managed our finances within budget. No other trust in the North West has managed this. Challenges We have of course faced very challenging times over the past few months. Our A&E department saw the biggest increase in attendances ever recorded and we were overwhelmed during the winter months. A combination of growing patient numbers, more complex needs and bed shortages in the trust and community all contributed to a massive pressure on our A&E and ward based staff during the winter period. I am eternally grateful for their resilience in dealing with the pressures and keeping patients safe. Unfortunately the impact of these pressures in the latter part of the year resulted in us failing our annual A&E target despite being on track during the first six months of the year. We now plan a radical overhaul of our A&E environment and staffing to tackle the issues faced and a major investment has been agreed by the board which hopefully will place us amongst the best performing trusts for A&E in the country. Investment In terms of investment, the good news is that the Trust also secured £30m during 2015 to cover developments required in our estate and IT. Over the next two years we will finally address some of the long term deficiencies suffered by staff and patients alike in parts of our estate that

Foreword were built in the 1800s. Our IT infrastructure has lagged behind many of our neighbours for several years and our investment marks the first instalment of a long term strategy to improve the efficiency and effectiveness of our systems. During the last year we were also involved in a review undertaken nationally by Lord Carter to identify the efficiency opportunities available to Trusts across the UK. We were delighted to discover that Bolton was hailed as a high performer and a benchmark for others. This was evidence of the successful turnaround during the last two years but also to the innovative approach adopted by the trust in the delivery and procurement of services. Awards Further good news was received with the nomination and shortlisting of Dr Jackie Bene in the HSJ’s CEO of the Year awards and the award of Finance Director of the year to Simon Worthington. Everyone in the trust can be rightly proud of them for their leadership and determination to do the right things for patients and for putting Bolton amongst the best Trusts in the country. I was also delighted with the opening of our new Bluebell ward, our first dementia friendly ward, and feedback from patients and families highlights that this approach should be the way forward for us. During the coming months we will continue to canvas for much needed funds to further improve the environment. The long awaited Care Quality Commission (CQC) review took place in March and although it will be several months before we receive the formal report the initial feedback was very good. I am keenly aware of how much work went in to preparing for the visit and I would like to publically thank everyone for their contributions. I must also single out our Trust Secretary, Esther Steel, for the preparation work and to Trish Armstrong-Child, our Director of Nursing for the direction and leadership throughout the process. Governors I would like to personally thank our Governors for their on-going help and support. Their involvement in unannounced ward visits, board meetings and walkabouts and their feedback to the management team all add hugely to our service improvement plans and their engagement with the board has been critical in helping us to focus on what is important to the Bolton population. The role of Governor is rarely understood or fully appreciated by the general public but they play a vital part in the development of the Trust’s long term strategy and in calling Board members to account. They meet the Board on regular occasions and they champion developments and improvements required for patient comfort and experience. Throughout the past year they have been active and engaged. Over the last twelve months we had a number of retirements and I would like to express my thanks to those who have left us for their unstinting support. Unfortunately we also lost Jeffrey Magnall who passed away after a short illness. He made a huge contribution as a Governor and we shall miss him. The Year Ahead The priorities for our trust are very clear. We must continue to deliver on the here and now; delivering great care efficiently and effectively to all the patients under our care. We must also play our part in Devolution Manchester and we must make closer collaboration with neighbouring trusts a reality. None of this is easy. Despite the promise of additional funding from Government, many trusts are forecasting continued deficits as they struggle with recurrent losses. Within Bolton we have signed a unique contract with our commissioners and we have agreed a Locality Plan encompassing the Trust, Commissioners, Mental Health and our local authority. Our aim is to work together to secure the best outcomes and to achieve the

Foreword best value for every pound spent in Bolton. It is important that we pull this off. Under Greater Manchester Devolution, Health and Social Care budgets will face a financial gap of £2bn by 2020. This represents a reduction of 33%. We must all therefore work towards eradicating waste, reducing overlaps and investing in new models of care. The Bolton Locality plan is the foundation stone for this but we will also have to work with other Trusts on finding ways to improve the efficiency of our services. Our plans for A&E must be progressed quickly. Bolton has one of the busiest A&Es in Greater Manchester but we are now seeing almost twice the 60,000 patients per year it was designed for. The last two winter periods have demonstrated the pressures we can expect in future years and we must be ready to handle them. Within our plans we intend to invest over £4m on re- fitting A&E, making it fit for purpose, and to address the current staffing levels. On top of this we must ensure that our other investment plans are undertaken on time and to specification. At the time of writing, we have faced a number of strikes by our junior doctors. I am extremely grateful for the reaction and support of everyone in the trust during the days affected by strike. The on-going uncertainty and the proposed imposition of a new contract pose significant risks to both patients and the trust and, like everyone else, I wish for a speedy resolution. Despite the daunting tasks and issues facing us, I look forward to the coming year with some optimism. Bolton has proven that it can stand comparison with the best Trusts in the UK. Our staff have been truly magnificent during the past year and I am confident that over the next twelve months we will continue to shine brightly.

David Wakefield Chairman April 2016

Performance Report

History and Statutory Background Bolton NHS Foundation Trust is an integrated care organisation providing care and support in the community at over 20 health centres and clinics as well as services such as district nursing and health visiting. We also provide intermediate care in the community and a wide range of services at the Royal Bolton Hospital. The Trust was authorised as a foundation trust in October 2008 and became an integrated care organisation in July 2011 following the transfer of services from the provider arm of NHS Bolton.

Review of 2015/16

£287.9m operating expenses

Performance Report Chief Executive Statement As I reflect upon our performance over 2015/16 I feel there is much about which we should feel justifiably proud. There is, of course, always more we can do to improve our performance but in the increasingly challenging environment that all NHS organisations now find themselves in some of our achievements are quite remarkable. I’m very pleased that we have continued to deliver on our commitment to drive down hospital mortality supported not least by continued improvements in infection control, and reduced harm in our care, particularly from falls and reduced medication incidents. The drive to increase incident reporting and transparency has been recognised nationally as good as has the learning from mistakes thus developing further the culture of openness we strive for. I’m also very pleased that we have been able to honour our commitment to patients for timely access to our services, most notably in cancer pathways where our performance has been one of the best nationally. We have struggled however, to maintain timely access via our Accident and Emergency pathway during the last six months after a good start in 2015. There are a number of contributory factors to this but we have developed a robust plan to mitigate continued under performance. I am especially pleased that we have seen significant growth and improved performance in our community services. As we move forward I believe these services will be pivotal in supporting primary care to better manage urgent care, complex and chronic diseases and end of life care out of hospital where it is often more appropriate to do so. None of this improved performance would have been possible without the commitment and determination of our staff of whom I am very proud and eternally grateful. I was very pleased therefore to see further improvement in some key metrics this year in the national Staff Survey and especially delighted that the most improved indicator was the number of staff who would recommend our Trust as a place to work or receive treatment. It is also significant that we continue to make strides in reducing staff sickness and I look forward to more of this as we attempt to further improve our productivity and efficiency in the forthcoming year. Finally our financial performance through 2015/16 has been exemplary. The continued effort and discipline around good financial stewardship has meant that despite significant demand pressures and efficiency/savings targets we have been able to end the year with a small surplus. This has proved crucial in securing investment in our infrastructure and will be a key enabler in delivering an even better performance in the year to come.

Jackie Bene Chief Executive Bolton NHS FT May 2016

Performance Report Purpose and activities The Trust’s operational plan for 2016/17 sets out our priorities for the year and builds on the remarkable progress made by the Trust over the last few years. The challenges in 2016/17 are not to be underestimated:  Continuing to deliver safe staffing levels to provide excellent care.  Building on our strength as a provider of integrated hospital and community services.  Working with our commissioners to make the right decisions to achieve consistent high quality care. And doing all the above within our financial means.

We believe in: High quality care centred on individual needs rather than the needs of professionals and organisations.  Integration across health and social care.  Accessible, convenient and responsive services 24/7.  Local wherever possible, centralised where necessary.  Empowering clients and patients to manage their own care and self-care with information.

Values The Bolton VOICE represents the values that we expect each of our staff to demonstrate. As an organisation we aim to live these values and provide “better care together” to our local population.

VISION OPENNESS INTEGRITY COMPASSION EXCELLENCE We have a plan that We communicate We demonstrate We take a person- We put quality and will deliver clearly to our fairness, respect centred approach safety at the heart excellent health patients, families and empathy in our in all our of all our services and care for future and our staff, with interactions with interactions with and processes generations, transparency and people patients, families working with honesty and our staff partners to ensure our services are sustainable

We make decisions We encourage We take We provide We continuously that are best for feedback from responsibility for compassionate care improve our long-term health everyone to help our actions, and demonstrate standards of and social care drive innovation speaking out and understanding to healthcare with the outcomes for our and improvements learning from any everyone patient in mind communities mistakes

Performance Report Principal Risks The Board has ultimate responsibility for the effective risk management of the Trust’s strategic objectives. We have an established risk management process to identify the principal risks that we face. This process relies on our judgement of the risk likelihood and impact and also developing and monitoring appropriate controls. The Board Assurance Framework is used to monitor the key strategic and operational risks, and ensure appropriate mitigating actions are implemented. The Board has considered and approved the Risk Management Strategy. The Audit Committee receives regular reports from management and internal and external auditors, detailing the risks that are relevant to our activity, the effectiveness of our internal controls in dealing with these risks and any required remedial actions along with an update on their implementation. The Audit Committee reports to the Board on the effectiveness of the risk management process, ensuring any issues raised in internal audit reports are escalated for action and if necessary further assurance. The day-to-day risk management is the responsibility of senior management as part of their everyday business processes. Further detail on the governance processes supporting our risk management can be found in our Annual Governance Statement on page 62 of this report. The tables below and on the following page sets out our key risks, the risk score at year end and movement on the score during the year with examples of relevant controls and mitigating factors. The Board considers these to be the most significant risks that may impact the achievement of our objective. They do not comprise all of the risks associated with the Trust and are not set out in priority order.

Risk Scores March 2016 Risk score Failure to reduce healthcare acquired 1 15 infections failure to provide appropriate skill mix for 2 20 “safe and suitable” staffing failure to provide an adequate timely response 3 20 to the deteriorating patient

4 Evolving clinical governance processes 12

5 failure to meet the A&E target 20

6 Low levels of staff engagement 12

To fail to deliver financial plan and maintain a 7 20 continuity of service rating of 2 or higher Failure to influence commissioners in shaping 9 12 future scope of services

11 Estates and IT investment 12

Performance Report

Principal Risks 2015/16

Risk Controls and mitigation Failure to reduce the number of hospital The Trust infection prevention and control team under acquired infections as a result of poor the leadership of the Director of Nursing in her role as compliance with policies and/or poor Director of Infection Control oversee the management operational control. of infection control. Regular reports and assurance is provided to the infection control committee. (further information within the quality report section page 74) Failure to meet minimum staffing levels Staffing levels have been agreed with recruitment plans because of vacancies and sickness could aiming to reach the required level. Action is taken on a compromise patient safety and daily basis to address gaps caused by sickness. experience A failure to provide a timely and Divisional action plans to improve response to early appropriate response to the warning scores are overseen by the Mortality Reduction deteriorating patient may lead to an Group. adverse impact on mortality and length The Trust now has an operationally closed critical care of stay unit. Failure to embed risk management and Progress made in 2015/16 with increase incident clinical governance processes could lead reporting and enhanced risk registers however three to poor patient care and experience further never events occurred during the course of 2015/16 indicating that this is still a risk. Failure to meet the A&E target as a Performance overseen though daily flow meetings. result of increased attendance, failure to Additional measures taken during the year deflect patients and insufficient On gong programme of improvement events operational control may lead to poor patient experience and potential regulatory intervention Low levels of staff engagement could The People Strategy was refreshed in December 2015. lead to reduced job satisfaction, higher Staff survey results (page 36) show an improvement in absence levels, increased turnover and the staff engagement score. reduced discretionary effort Failure to deliver the financial plan could The Trust’s system of financial governance with an lead to further regulatory action agreed financial plan including ICIPS is overseen by the Finance and Improvement Committee. (full detail on financial performance in 15/16 is included on page 13) There is a risk that commissioner and The Trust is working with partner providers and local authority led reconfiguration may commissioners to develop new models of care. reduce control of the Trust’s future scope of services

Performance Report Performance analysis Last year was a particularly challenging one for the NHS with all Trusts expected to provide the highest standards of care while achieving demanding efficiency savings. Despite a significant rise in demand for our services, the continued tough financial climate and one of the worst winters in terms of pressure on the NHS, we are very pleased to report that Bolton NHS Foundation Trust has continued to perform well. We continued to provide safe, high quality care to our patients and with the exception of the four hour A&E target continued to achieve all our access targets. Alongside this, in a climate where many other acute providers have struggled to achieve their financial plan, we were commended nationally for our financial performance. Measurement of performance The Trust has introduced an integrated performance dash board which the Board uses to monitor the performance of the organisation. The dash board contains contextual information and promotes a service line view of the organisation with equal visibility of key services. There is a monthly integrated performance meeting (IPM) between the Executive and the Division, chaired by the Deputy Chief Executive. At the meeting the Division present for each performance dimension  Progress against any previously agreed actions  Proposed mitigations against any newly identified performance risks or issues  Other assurances as required by the Executive Information from the IPM informs the assurance the Executive team provide to the Board. In 2015/16, the Trust continued to work towards the goals agreed in the 2013 – 2018 strategy

Performance Report

Goal 1 – quality, safety, and patient experience A detailed review of performance against our quality priorities is included with our Quality Report starting on page 74 of this document.

Goal 2 – to be a valued provider In our Operational Plan for 2015/16 we set ourselves a series of objectives to build on the advantages of being an integrated provider of local hospital and community-based health services. We undertook to work with our partners to provide the best care for patients throughout their healthcare journeys, developing a focus on prevention, early intervention and keeping people healthy, as well as continuing to provide excellent care for people who need treatment. In 2015/16 we delivered against all our access targets other than the target for Accident and Emergency Department waiting time. We continued to perform strongly against all cancer targets and achieved the target for ensuring patients do not wait longer than 18 weeks to be treated. Meeting the national four hour standard for A&E however, remains a challenge. A combination of factors, including staffing challenges and increased attendances within a department that is no longer big enough for the volume of patients who attend resulted in us failing to achieve this target. We are working with our commissioner on interventions to support accident and emergency performance. Actions planned for 2016/17, include estates investment of £4 million in the Accident and Emergency department to improve the environment for patients and staff, overseas recruitment to manage the shortfall in nursing and redesign of the medical workforce to mitigate the staffing challenge. We have also continued to deploy best practice as recommended by the Emergency Care Intensive Support Team to support urgent care.

Goal 3 – to be a great place to work Our ambition is clear: engaged, recognised and rewarded people deliver excellent integrated care. In 2015/16 the Trust has achieved good performance on a wide range of people indicators. Our overall Staff Engagement Score as calculated by NHS England in the annual staff survey has increased from 3.81 in 2014 to 3.89 in 2015. This overall indicator of staff engagement measures staff members’ perceived ability to contribute to improvements at work; their willingness to recommend the trust as a place to work or receive treatment; and the extent to which they feel motivated and engaged with their work. The 2015 survey was also consistent with quarterly family and friends testing and show that staff satisfaction is increasing. The year end results showing that 81% of our staff would recommend the Trust for treatment and 66% would recommend us as a place to work see us locally second only to Wrightington Wigan and Leigh NHS FT on these measures. Some of the reasons for this are clear:  We have a higher percentage of people than ever before having a regular and timely appraisal.

Performance Report

 The percentage of staff reporting good communication between management and staff is up.  Compliance with training requirements is much better and again is at an all-time high. Rates of sickness absence (measured on a 12 month rolling average basis) have reduced from 4.8% to 4.6% over the year. This has been equivalent to recruiting an additional 11 staff at a total cost of over £300k. Across the Trust we have seen fewer vacancies - down to 5.26% - by the end of March 2016, although they are far from equally distributed, and there are undoubtedly difficulties in some areas, for example A&E medical staff. We have complied with NHS Improvement’s cap in respect of our total aggregated expenditure on agency staff, we have however breached the caps on rates of pay in the areas of A&E and operating theatres. This has been reported in accordance with the guidance set by NHS Improvement. Further information can be found in the section headed Staff Report please see page 36. In 2016/17 we have signalled a sharper focus on workforce planning to ensure the efficient use of our workforce, and that we are fit for the future in terms of new job roles.

Goal 4 – to be well governed In our plan for 2015/16, we agreed a series of objectives to embed our improved governance arrangements. The actions we agreed included:  Improved management of risks  To ensure timely and demonstrable learning from incidents, claims, complaints, inquests, risks and alerts  A programme of Board and Governor development  To undertake a review using the Monitor Well Led Framework – the Board agreed part way through 2015/16 to defer this action to 2016/17 as the planned timing would have clashed with our CQC review With the exception of undertaking a “Well Led review”, we continued to make good progress against all these objectives. We have established weekly meetings to review and share learning from incidents, claims, complaints and inquests. We have continued to improve the management and oversight of our risk registers, both through our Risk Management Committee and through divisional governance meetings. We have had great success in increasing risk reporting, the last report issued by the National Reporting and Learning System (NRLS) places us in the top 25% of acute non specialist NHS Trusts for this measure. This is a significant improvement on our position two years ago when we were in the lowest 25%. In a recent review of learning from mistakes published by Monitor and the TDA in March 2016, we were rated as “good” for the fairness and effectiveness of procedures for reporting errors; near misses and incidents; staff confidence and security in reporting unsafe clinical practice; and the percentage of staff who feel able to contribute towards improvements at their trust.

Performance Report

Goal 5 - to be financially viable and sustainable Income and expenditure overview The Trust planned to improve its financial position by increasing its surplus to £1.6m in the 2015/16 financial year. As can be seen from the summary statement of comprehensive income below this target has been slightly overachieved. This second year of surplus since the Trust’s significant deficits in the period 2010/11 to 2013/14 marks a sustained financial recovery which is regarded by NHS Improvement as the best example of a single NHS organisation financial turnaround in the last decade. The Trust Board agreed the 2016/17 financial plan at its 30th March 2016 meeting. This plan identifies how the Trust can further to improve its financial position to deliver a surplus of £11.9m in 2016/17. Statement of Comprehensive Income Actual Actual Actual Plan 2013/14 2014/15 2015/16 2016/17 Revenue £,000 £,000 £,000 £,000 Operating revenue from continuing operations (patient care) 261,228 266,791 271,537 281,018 Other operating revenue 23,013 24,771 21,004 21,304 Operating expenses -288,872 -309,474 -287,918 -286,893 Operating surplus (deficit) -4,631 -17,912 4,623 15,429 Finance costs: Finance Income 32 41 35 41 Finance costs -777 -849 -642 -860 Finance expense - unwinding of discount on provisions -8 -122 -12 0 Public dividend capital dividends payable -2,746 -2,535 -2,152 -2,708 Net Finance Costs -3,499 -3,465 -2,771 -3,527

Surplus/(Deficit) -8,130 -21,377 1,852 11,902

Impairment of fixed assets -352 -21,937 0 0 Underlying Trading Surplus/(Deficit) -7,778 560 1,852 11,902

Income analysis The table below sets out the income trend in the period: Income Actual Actual Actual Plan 2013/14 2014/15 2015/16 2016/17 £,000 £,000 £,000 £,000 CCG's and NHS England 250,832 255,611 254,672 258,420 Local Authorities 7,257 8,538 10,450 11,675 Other 3,139 2,642 6,415 10,923 Sub total Total Income from activities 261,228 266,791 271,537 281,018 Other operating revenue 23,013 24,771 21,004 21,304 Total Revenue 284,241 291,562 292,541 302,322 There has been an increase of income between 2014/15 and 2015/16 of £1m, there is a further planned increase in income of £10m in 2016/17.

Performance Report

The net increase of £1m in income between 2014/15 and 2015/16 can be explained by the following factors:  NHS Tariff deflation of 1.9%  Increase in the marginal rate for non-elective admissions from 30% to 70% under the enhanced tariff option  Income improvements as part of the Trust’s income and cost improvement programme  Reduced CQUIN income  Hospital activity reductions  Non recurrent capital to revenue transfer of £4.1m  Investment in community services as part of the Better Care Fund  Income loss due to the transfer of the community 5 -19 service to another NHS body  The planned increase in income of 2016/17 of £10m results from the following factors:  £9.2m Forecast payment from the NHS Sustainability and Transformation fund. This national fund is designed to incentivise improved financial performance in the provider sector. The trust will only receive this income if it achieves the required improvements as determined by NHS Improvement  Tariff inflation of 1.9%  Quality and performance investments funded by Bolton CCG  Full year effects of service changes and investments in 2015/16  The planned transfer of the inpatient vascular service to another NHS Provider

Expenditure analysis The table below sets out the expenditure trend in the period: Expenditure trend Actual Actual Actual Plan 2013/14 2014/15 2015/16 2016/17 £,000 £,000 £,000 £,000 Employee expenses 200,574 203,002 205,073 201,417 Drugs 17,216 18,823 20,556 19,996 Clinical Supplies 20,140 19,975 20,588 20,488 Non Clinical Supplies 35,322 33,248 32,258 34,870 Depreciation and amortisation 5,547 5,536 5,539 7,562 Impairments of property, plant and equipment 352 25,255 0 0 Redundancy 2,130 97 0 0 Misc other operating Expenses 7,591 3,538 3,904 2,560 Total 288,872 309,474 287,918 286,893 Less impairments (352) (25,255) 0 0 Underlying expenditure trend 288,520 284,219 287,918 286,893

Performance Report

Impairments are excluded from this analysis as they do not count against the Financial Sustainability Risk Rating that is used by NHS Improvement to assess NHS Foundation Trusts financial performance. There has been an increase in expenditure of £3.7m between 2014/15 and 2015/16. There is a planned reduction in expenditure of £1m in 2016/17. The net increase of £3.7m in expenditure between 2014/15 and 2015/16 can be explained by the following factors:  Pay awards, increments and non-pay inflation  Savings delivered as part of the Trust’s income and cost improvement programme  Investments in staffing to ensure quality and safety  Revenue consequences of capital investments in Estates and IT  Revenue impact of investments in community services under the Better Care Fund The planned reduction in expenditure between in 2016/17 can be explained by similar factors, although there is planned to be a greater level of cost improvement relative to investments and other cost pressures. Expenditure on Consultancy related spend has reduced from £1.1m in 2014/15 to £0.3m in 2015/16

Income and cost improvements Actual Actual Actual Plan 2013/14 2014/15 2015/16 2016/17 £,000 £,000 £,000 £,000 Income and cost improvements 18,300 21,200 14,400 15,300 As % of income 6.4% 7.3% 5.0% 5.3% Over the last three years the Trust has delivered £53.9m of income and cost improvements, much higher than the national average. This has enabled the Trust’s sustained financial recovery at a time when the vast majority of other similar Trusts have moved into a significant deficit position. Delivery in 2015/16 was slightly below the plan of £15.3m but still significantly higher than has been delivered in other similar Trusts.

Capital spending As part of its financial recovery the Trust was able to secure funding of £30m (£7.8m in public dividend capital, £22.2m in long term non-commercial loans) to make necessary improvements in its Estate and IT infrastructure. This funding was formally agreed in quarter three of the 2015/16 year. This explains the increased expenditure over the normal level of operational capital spend in 2015/16 and the relatively high levels forecast in 2016/17.

Performance Report

Capital Actual Actual Actual Plan 2013/14 2014/15 2015/16 2016/17 £,000 £,000 £,000 £,000

Ongoing replacements 6,216 6,473 6,815 8,893 Estates Strategy 0 0 108 9,777 IT Strategy 0 0 2,390 2,295 Total 6,216 6,473 9,313 20,965

Cash Due to its deficit position in previous years the Trust relied on cash support from the Department of Health in order to continue to operate in 2012/13 and 2013/14. Due to the Trust’s financial recovery no such support has been required since then, although the Trust’s cash balance remains very low compared to what would normally expected for a Foundation Trust of its size. The cash balance is expected to increase in 2016/17 due to the large surplus forecast as a result of the national sustainability and transformation fund.

Cash Actual Actual Actual Plan 2013/14 2014/15 2015/16 2016/17 £,000 £,000 £,000 £,000 Total 408 5,265 1,470 7,800

Financial Sustainability Risk Rating NHS Improvement uses a risk rating for assessing the financial performance of NHS Foundation Trusts. Worst possible score is one the best four. The Trust was required to achieve a sustainable risk rating of two in order for NHS Improvement to lift its regulatory action on the Trust which it did in quarter three of 2015/16. It is expected that the Trust’s risk rating will improve to a four in 2016/17 due to the large surplus and improved cash balance planned

Actual Actual Actual Plan 2013/14 2014/15 2015/16 2016/17 FSRR 1 2 2 4

Performance Report

Goal 6 - to be fit for the future Being fit for the future starts with maintaining our current services. As reported elsewhere in this report, during 2015/16 we were successful in our bid for £30 million to support development of our Estates and IT. Work is already underway to invest this funding including the expansion of our Accident and Emergency Department and the expansion of our Endoscopy department. IT investment will support a significant upgrade in both our hardware and software, although there remains much to be done. We have continued to develop our role as an integrated provider of local hospital and community based health services, playing a full part in Bolton’s locality plan. The plan sets out the health challenges facing the people of Bolton and how we (all the health and care agencies in the borough) will work more closely together to meet them. For some of our services, being fit for the future is about working with our neighbouring trusts, particularly in Salford and Wigan. For example, we are creating a ‘single service partnership’ for general surgery that will see some of the highest risk surgery concentrated at Salford Royal site delivered by consultants working across more than one hospital site. In February 2015, the Government announced plans to devolve health and social care budgets and decision making powers to the NHS and Local Authorities within Greater Manchester, thus creating the Greater Manchester Health and Social Care Partnership. Since then, health and social care organisations within each of the 10 boroughs of Greater Manchester have been working together on the overall vision ie to make the biggest, fastest possible improvement to the health and wellbeing of the 2.8m people of Greater Manchester. Representatives from the Trust are also linked in to various work streams including finance, workforce, estates and pathology. It is too soon to say how devolution will impact on NHS providers and what changes it could mean to the future workforce across Greater Manchester, we will ensure that staff and key stakeholders are provided with regular updates as the programme progresses. Part of remaining fit for the future is to understand how others see us. In 2015 we surveyed the attitudes of stakeholders towards the trust. We received universal recognition and praise for the Trust coming out of breach and the effort and sacrifices involved; there was also a recognition of the growing need to collaborate with commissioners and providers.

Performance Report Each year we recycle:  90 tonnes of mixed cardboard Environmental impact waste Sustainability  160 tonnes of mixed metals  50 tonnes of confidential/office The Trust is committed to reducing the use of primary sources of energy and reducing the effect paper waste this has on the environment.  98% of waste electrical and electronic equipment. In line with this commitment the Trust is embarking on a major infrastructure programme to address the estate’s ageing infrastructure and reducing our current carbon footprint. This programme will deliver  The replacement of our coal boilers which produce a significant proportion of our CO² emissions with a Gas Combined Heat and Power Plant. This plant will generate electricity for the Hospital and heat buildings and hot water with its waste heat output.  Use of water from the on-site water borehole for use in all on-site water use after treatment approved by the Environment Agency standards.  Utilisation of existing on site electrical generation to support peak electrical demands.  Looking at opportunities to install energy-efficient heating services. Waste/Recycling All our clinical waste is treated on site, cutting down our transport costs and associated carbon footprint. This waste is incinerated and as a by-product steam is produced which in turn heats our buildings, domestic hot water, catering production and sterile services. This steam supply is economical to produce and satisfies around one third of the site steam demand.

Utility cost and consumption

2015/16 2014/15 Utility Cost £ Consumption Cost £ Consumption Gas 262k 9,142,919 KWh 402k 10,652,673 KWh Electric 1,835K 15,729,462 KWh 1,900k 14,727,395 KWh Water 254K 107,163 m³ 490k 198,276m³ Coal 252K 2067 tonnes 460k 2315 tonnes

Performance Report Social, community and human rights issues We recognise the need to forge strong links with the communities we serves so that we are responsive to feedback and can develop our services to meet current healthcare needs. We are committed to meeting our obligations in respect of the human rights of our staff and patients, which is closely aligned both to the NHS constitution and our values. NHS trusts are public bodies, and so it is unlawful to act in any way incompatible with the European Convention on Human Rights unless required by primary legislation. Trust policies are reviewed on a regular basis and all are subject to an equality impact assessment.

Modern Slavery Act 2015 – Statutory Statement The Trust is fully aware of the responsibilities it bears towards patients, employees and the local community and as such, we have a strict set of ethical values that we use as guidance with regard to our commercial activities. We therefore expect that all suppliers to the Trust adhere to the same ethical principles. In compliance with the consolidation of offences relating to trafficking and slavery within the Modern Slavery Act 2015, the Trust is currently reviewing its supply chains with a view to confirming that such behaviour is not taking place.

This performance report was approved by the Board of Directors on 26th May 2016

Signed on behalf of the Board

Jackie Bene 26th May 2016

Directors’ Report

Our Board of Directors Our Directors David Wakefield – Chairman appointed 8th August 2012 (by Monitor) Reappointed in July 2015 for a second three year term. David is a qualified accountant and, in addition to his finance roles, has held senior posts in sales, operations and project management. He worked in the furniture trade for 12 years and with Royal Mail for 27 years. He joined the NHS as a non-executive director in Milton Keynes and later became non-executive Chairman of Milton Keynes Community Health Services and, subsequently, Chairman of Milton Keynes Hospital NHS Foundation Trust. During 2014, David was appointed as a Non-Executive Director of Crown Commercial Services; this appointment was undertaken with the approval of the Council of Governors.

Executive Directors Dr Jackie Bene - Chief Executive Jackie was appointed to the Board as Medical Director in 2008 having worked at the Trust as a Consultant Physician as well as holding a number of clinical lead roles since 1998. She took up the role of Acting CEO in June 2013 and was appointed substantively to the role in January 2014. Her priorities throughout her career have been quality improvement and patient safety but she has recently led on the governance and strategic agendas for the Trust. Jackie still undertakes clinical practice for one session per week in Acute Medicine which she values enormously in keeping her close to our patient and staff experience.

Simon Worthington (ACCA) – Director of Finance and Deputy CEO Simon has worked in financial management in the NHS since 1988. Simon was appointed in February 2013. Prior to this, from June 2011, he was Deputy Director of Finance at South London Healthcare NHS Trust, a post he had taken up in order to gain experience of working in extremely financially challenged organisations. From July 2006 Simon was Finance Director and Deputy Chief Executive of the Yorkshire Ambulance Service. During his time at the Yorkshire Ambulance Service, Simon was Acting Chief Executive for eight months. Preceding this Simon was Finance Director of the Tees East and North Yorkshire Ambulance Service for two years and was Acting Finance Director at South Huddersfield Primary Care Trust for a year.

Directors’ Report

Trish Armstrong-Child - Director of Nursing appointed May 2013 Trish is a Registered General Nurse who has worked within the NHS since 1989. She has a vast wealth of experience within both nursing and operational management roles and has Executive leadership and professional responsibility for quality and patient safety. Her focus and primary aim is to ensure that excellent standards of care are received by patients and their carers and that they have a positive experience of care both within hospital and community settings, including care at home.

Andy Ennis - Chief Operating Officer Andy started his working life as a nurse, specialising in paediatrics and specifically intensive care. After various roles in nursing including Charge Nurse of B1 Children’s Ward at Bolton Royal he moved into operational management of services gaining experience in several other North West Trusts before returning to Bolton as Chief Operating Officer in January 2014. Andy’s primary role on the Board is to ensure the Trust delivers operational targets such as waiting times and that the infrastructure (Estates and IT) is fit for purpose.

Steve Hodgson - Medical Director Steve was appointed Medical Director in March 2014. He has been a consultant orthopaedic surgeon with an upper limb interest in Bolton since 1993. He has previously held a number of leadership roles in the trust including clinical lead, associate medical director and Head of Elective Care Division. He was acting Medical Director for seven months before being appointed to the substantive post. He is a member of the British Society for Surgery of the Hand Council, for whom he leads their overseas aid project. Steve's priorities are the delivery of high quality care for our population and leading the medical workforce

Mark Wilkinson - Director of Strategic and Organisational Development Mark joined the Trust in July 2014 from Barnsley CCG where he was Chief Officer. He joined the NHS in 1985, starting out in the finance profession before moving into general management as a PCT Chief Executive in East Lancashire. He has been a member of several provider and commissioner boards and has also worked at a national level promoting innovation, and in the pharmaceutical industry. His focus is on the strategic and organisational development of the Trust including responsibility for workforce, communications and engagement. He is passionate about the contribution motivated and well led teams can make to the delivery of high quality and seamless care.

Directors’ Report

Non-Executive Directors Dr Mark Harrison – Senior Independent Director initially appointed 1st April 2012 for three years and reappointed in 2015 for a second three year term. Mark Harrison, was appointed as a Non-Executive Director in April 2012. He has extensive board level experience and has delivered large scale change, technology and efficiency programmes, negotiated and managed major contracts and partnerships, overseen strategic planning and delivery, and shaped and delivered output services to the public. Mark is a member of the Finance Committee and the Audit Committee and is the nominated NED for whistle blowing.

Carol Davies - Chair of Audit Committee initially appointed in September 2010 and appointed September 1st 2013 for a second three year term. Carol is currently Director of Finance and Resources at Mount St Joseph Business and Enterprise College. She has held senior finance positions in a number of other organisations, including Bolton Council and Trafford Health Authority. She is a qualified accountant with the Chartered Institute of Management Accountants. Carol is Chair of the Trust’s Audit Committee and a member of the Quality Assurance Committee.

Neal Chamberlain Neal Chamberlain was appointed a Non-Executive Director in October 2014. Neal has 28 years’ experience as an HR professional, having held senior roles in companies including ICI, AstraZeneca, Unilever, Tata and Costain. Neal is a Fellow of the Chartered Institute of Personnel and Development (CIPD), a Member of its Manchester Branch Committee, and a Member of the International Coaching Federation. In addition to his Trust activities, Neal is also a Non-Executive Director for the Manchester Camerata chamber orchestra, and has recently established his own HR consulting business, A1 Performance Consulting Ltd. Neal is Chair of the Charitable Funds Committee

Directors’ Report

Allan Duckworth – Non Executive Director re-appointed 1st January 2016 for a second three year term A Chartered Management Accountant, Allan brings 24 years board level experience in high profile, consumer facing businesses, including fourteen years as Chief Executive of Burnden Leisure PLC, the parent company of Bolton Wanderers FC and De Vere Whites Hotel. Prior to this role he spent ten years as a finance director at Umbro International Ltd, Lo-Cost Stores Ltd (Safeway Group PLC) and Vernons Organisation Ltd (Ladbroke Group PLC). Allan is Chair of the Finance and Investment Committee and a member of the Charitable Funds Committee.

Ann Gavin-Daley Ann has a clinical background in nursing and quality and a passion for high quality patient focused care gained over 30 years nursing in acute and integrated community and mental health trusts in the North West. Her previous experience includes significant strategic management as an NHS Executive Director and Trust Board member with involvement in developing and managing innovative acute and community services at operational and strategic level in teaching and non-teaching NHS organisations. Ann has valuable Governor and public and private sector consultancy experience providing a broad, objective perspective and understanding of the NHS and the role of the Non-Executive Director. Ann is a member of the Quality Assurance Committee and the Audit Committee

Andrew Thornton Andrew joined the Board as an interim Non-Executive in August 2014 and was subsequently appointed substantively in March 2015. Andrew Initially started his career in the health service as a podiatrist and has remained within health and social care serving in a variety of senior leadership posts within both the public and private sector. Andrew has a strong ethos of quality in all aspects of service delivery and brings his experience of developing clinical and operational improvements to the Trust. Andrew is a member of the Quality Assurance Committee and from May 2016 took over the position of Chair of the QA Committee.

Directors’ Report

Disclosures Statement of register of interests The Trust Secretary maintains a register of other significant interests held by Directors and Governors which may conflict with their responsibilities. Access to the register can be obtained by submitting a written request to the Trust Secretary.

Pension disclosure The accounting policies for pensions and other retirement benefits are set out in note 1.9 to the accounts and details of senior employees’ remuneration can be found in the remuneration report on page 28.

Statement of accounts preparation The accounts have been prepared under direction issued by Monitor, the independent regulator for Foundation Trusts, as required by paragraphs 24 and 25 of Schedule 7 to the National Health Service Act and in accordance with the NHS Foundation Trust Annual Reporting Manual 2014/15. The Trust has complied with the cost allocation and charging guidance issued by HM Treasury.

Better payment practice code The Trust is expected to pay 95% of all creditor invoices within 30 days of goods being received or a valid invoice (whichever is the later) unless other payment terms have been agreed with the supplier. The table below shows performance against this target in 2013/14 and 2014/15.

Year ended 31 March 2016 Year ended 31 March 2015 Number £'000 Number £'000 Total non-NHS trade invoices 52,890 65,147 48,775 47,331 paid within the target Total non-NHS trade invoices 64,573 84,083 68,841 70,339 paid in the period Percentage of non-NHS trade 81.9% 77.5% 70.9% 67.3% invoices paid within the target Total NHS trade invoices paid 1,655 17,033 1,663 14,781 within the target Total NHS trade invoices paid in 2,279 26,160 2,269 21,027 the period Percentage of NHS trade 72.6% 65.1% 73.3% 70.3% invoices paid within the target

Directors’ Report

Income disclosure required by section 43 (2A) of the NHS Act 2006 (as amended by the Health and Social Care Act 2012) The Trust meets the requirement for income from the provision of goods and services for the purposes of the Health Service in England to be greater than its income from the provision of goods and services for any other purposes. The small amount of other income received by the Trust helps support the provision of NHS care. The Trust will continue to meet the requirement for its prime business to be the provision of goods and services for the purpose of the health service in England

Statement as to disclosure to Auditors Each of the Directors at the date of approval of this report confirms that: 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 Directors have taken all the steps that they ought to have taken as Directors 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.

Directors’ Report

Quality Governance

In March 2013 the Trust commissioned an external, independent review of its arrangements for quality governance against the criteria described in Monitor’s Quality Governance Strategy (Deloitte QGAF report 2013). The Deloitte Quality Governance report reviewed the Trust against the criteria as described in the Monitor Quality Governance Framework including strategy, capabilities and culture, processes and structures and measurement. Deloitte found several areas of good practice including the engagement of staff and support for staff. There were however areas where improvement was required including the management of risks, the production of information and the need for an overarching quality strategy.

Since the publication of the Deloitte report, the Board has overseen a programme of actions to address issues identified in this report and in other associated reports into governance and quality. The actions undertaken include:  The development of a new integrated performance report  The publication of a quality strategy  The publication of a new Patient Experience Strategy  The publication of a new People (workforce) Strategy  Development of a new complaints process  Review of the Board Assurance Framework (BAF)  A programme of Board and Governor development. The Trust have been able to provide Monitor with assurance that the recommendations in the Governance report have been addressed and in September 2015, Monitor issued the Trust with a certificate of compliance with all discretionary requirements and enforcement undertakings. A review using Monitor’s “Well Led Framework” which incorporates aspects of the Quality Governance Framework is planned for quarter 3 or 2016/17. Further information on governance including quality governance can be found in the annual governance statement on page 62.

Patient Care Further information on the quality of services provided by the Trust can be found in our quality report which is included in this report from page 74.

Directors’ Report

Stakeholder Relations Significant partnerships and alliances Devolution – Taking Charge in Greater Manchester In February 2015 the 37 NHS organisations and local authorities in Greater Manchester signed a landmark devolution agreement with the Government to take charge of health and social care spending and decisions in our region. We will work in collaboration with our partner Foundation Trusts to deliver best care for our most sick patients, and with commissioners and providers within Bolton to deliver place based care tailored to the needs of the Bolton population Acute Services Collaboration As part of the North West Sector of Greater Manchester our organisation is working in collaboration with Wigan, Wrightington and Leigh Foundation Trust and Salford Royal NHS Foundation Trust to develop single shared services for the benefit of the sector population. Discussions are currently underway around the foundation membership of a Hospital Group. Pre-implementation plans for a single service provision of high risk emergency general surgery, urgent, acute and emergency medicine and radiology are already well underway. Involvement in local initiatives The Bolton Health and Care 5 Year Locality Plan was developed and agreed by all Bolton commissioning and provider organisations in December 2015 this transformation plan will inform the future strategic direction of the Trust. Consultation with local groups and organisations We attend regular meetings with our local HealthWatch and Overview and Scrutiny Committee to share our plans for future services and to provide updates on challenges facing the Trust and the wider health economy. Public and patient involvement activities As a Foundation Trust with public members, the majority of our public and patient involvement is through our membership. We recognise the importance of involving our patients and the wider public in the development of services. During the course of the year we used our membership newsletter to provide updates on developments at the Trust and to invite members to participate in events and activities. These events included our Medicine for Members talks, participation in PLACE inspections and the Cancer Peer review process.

In Quarter 3 of 2015, we commissioned Deloitte LLP to undertake a stakeholder review to enable us to better understand the perceptions of our stakeholders. Responses from external stakeholders were provided by other NHS providers, commissioners and GPs, the Local Authority and the FT regulator Monitor. Although there were many positive elements within the feedback there is a perception held by some of our stakeholders that we do not collaborate to the extent that others would wish for. An action plan has been developed in response to this feedback.

Remuneration Report

Remuneration Report The remuneration report has been prepared in compliance with the relevant elements of sections 420 to 422 of the Companies Act 2006, Regulation 11 and Schedule 8 of the Large and Medium- sized Companies and Groups (Accounts and Reports) Regulations 2001, parts 2 and 4 of Schedule 8 of the Regulations as adopted by Monitor for the purposes of the Annual Report Manual and elements of the NHS Foundation Trust Code of Governance. Annual Statement on Remuneration I am pleased to present the remuneration report for 2015/16. As Chair of the Trust, I chair the two Committees charged with responsibility for Nomination and Remuneration:  a Board Nomination and Remuneration Committee with formal delegated responsibility for the nomination and remuneration of Executive Directors and  a Governor Nomination and Remuneration Committee for the appointment and remuneration of the Chair and Non-Executive Directors - this second committee acts in an advisory and supporting capacity for the full Council of Governors but does not have formally delegated powers. The exception to this arrangement is when my own performance or remuneration is being discussed. In these circumstances the Vice-Chair of the Trust will chair the Governor Nomination and Remuneration Committee. In 2015/16 the Committee reflected on the financial context of both the local and national health economy, decisions on remuneration reflected the current financial climate and the competitive market. Having made significant changes to the Board between 2012 and 2014, 2015/16 provided an opportunity for consolidation and team development. No changes were made to the Executive team and as a Committee; we feel the current team provide strong and stable operational leadership to the Trust. Unfortunately, at the start of the financial year one of our Non-Executive Directors resigned from her position on the Board due to ill health. The Governor Nomination and Remuneration Committee took the opportunity to review the composition of the Board and agreed to create an additional Non-Executive position bringing the total number of Non Executives to seven. Mr Andrew Thornton who had previously served as an interim NED was appointed substantively for a three year term. In consultation with our governors we used an open advert to attract potential Non Executives with strong clinical background. Shortlisted candidates were invited to attend for interview and assessment and, as a result of this process, Mrs Ann Gavin Daley was appointed as a new NED in August 2015. Ann and Andrew both join the Board with a strong background of senior clinical leadership. In 2013/14 benchmarking was used to agree and establish salary scales for Executive Directors and Very Senior Managers; these scales are described within the remuneration policy section of this report. On an annual basis we review national benchmarking data for both Executive and Non- Executive Director’s salaries to ensure the remuneration paid to our Board is within the range paid by other similar NHS organisations. We have not used other external advice when setting Non- Executive Director salaries In all debates and discussions pertaining to salaries for senior managers the Nomination and Remuneration Committee have ensured that the policies applied reflect those applicable to our staff on Agenda for Change contracts. As with Agenda for Change salary scales, staff not yet at the

Remuneration Report top of their salary band had the chance to progress as described in the next section but the bands were not increased. In 2016, our Chair of Audit will come to the end of her six year tenure, the Governor Nomination and Remuneration Committee has begun the process to appoint an appropriately qualified and experienced Non-Executive Director to Chair our Audit Committee. The Committee recognise the benefits of being able to draw from a wider pool of talent as possible and having staff that can relate to our diverse communities and will work with our appointed recruitment agency to ensure the candidate is selected from a diverse shortlist.

The Committee has a duty to ensure the Trust can recruit and retain and motivate the senior managers with the appropriate skills and values to lead the organisation. At the same time, the Committee recognises that this must be within the confines of public acceptability and affordability. The Chief Executive and Finance Director/Deputy Chief Executive are both paid more than £142,500 per anum. In both cases, the Committee reflected on benchmark salary information for comparative jobs within the NHS and concluded that the remuneration agreed was appropriate and reasonable for the current post holders.

Chairman

Remuneration Report

Future policy table

Element Link to strategy Operation Maximum Changes

Base salary To set a level of The aim is to offer For each role there is an No reward for benchmarked salary which agreed salary scale. performing the the committee consider When reviewing salaries, the core role appropriate for experience Committee take account of and performance. personal and organisational performance and any national award offered to the wider employee population

Taxable benefits

Annual performance The current remuneration policy of the Trust does not make provision for taxable related bonuses benefits or performance related bonuses Long term performance bonuses

Pension related To provide Directors are automatically Pension arrangements for the No benefits pensions in line enrolled in the NHS final Chief Executive and all with NHS policy salary pension scheme on the Executive Directors are in same basis as all other accordance with the NHS colleagues within the NHS Pension Scheme. The accounting policies for pensions and other relevant benefits are set out in Note 1.9 to the accounts.

For the purpose of the accounts and remuneration report the Chief Executive has agreed the definition of a “senior manager” to be Directors only.

Senior manager pay progression At appointment, a Director is placed at the appropriate point on the salary scale as determined by the Remuneration Committee having considered previous experience. The Remuneration Committee is firm in the view that progression through the salary ranges should not be automatic or linked to length of service but should be a true reflection of performance in the role as assessed through an effective appraisal system. For Directors other than the Chief Executive, the Chief Executive provides the Remuneration Committee with a report on each Director summarising the achievement of specific objectives within the wider frame of the performance for the whole organisation. The award may also be constrained by affordability.

Remuneration Report

The senior pay policy makes provision for sums paid to be withheld or recovered if required.

NED remuneration policy The fees payable to the Chair and Non Executives are determined by the Council of Governors. These fees were unchanged in 2015/16. Non-Executive Directors are appointed for a three year term of office. They must be considered independent at the time of appointment. A Non Executive Director's term of office may be terminated by the Council of Governors if the NED no longer meets the criteria for appointment as a NED.

Service Contract obligations Senior managers' service contracts do not include obligations on the Foundation Trust which could give rise to or impact on remuneration payments or payments for loss of office.

Policy on payment for loss of office Senior managers' service contracts include a six month notice period. In the event of a contract being terminated the payment for loss of office will be determined by the Nomination and Remuneration Committee. Payment will be based on contractual obligations. Payment for loss of office will not be made in cases where the dismissal was for one of the five "fair" reasons for dismissal.

Statement of consideration of employment conditions elsewhere in the Trust In setting the remuneration policy for senior managers, consideration was given to the pay and conditions of employees on Agenda for Change. The 2015 salary scales for Executive Directors were agreed following a review of salary data provided by the NHS Providers.

Remuneration Report

Annual report on remuneration Nomination and Remuneration committee The Nomination and Remuneration Committee met three times during the reporting period to consider the appointment, performance and remuneration of the Executive Directors. The Chief Executive, the Director of Strategic and Organisational Development and the Trust Secretary attended meetings other than when matters being discussed would have meant a conflict of interest. Minutes of meetings were recorded by the Trust Secretary. Attendance is shown in the table below.

Nomination and Remuneration Committee Attendance David Wakefield 3/3 Neal Chamberlain 3/3 Carol Davies 1/3 Allan Duckworth 2/3 Ann Gavin-Daley 2/2 Mark Harrison 3/3 Andrew Thornton 3/3 Dr Jackie Bene 3/3 Mr Mark Wilkinson 3/3 Esther Steel 3/3

Governor Nomination and Remuneration Committee The Governor Nomination and Remuneration Committee met three times during 2015/16:  to discuss the appointment of a new NED to replace G Ashworth  to consider a proposal to increase the number of Non-Executive Directors to seven  To consider and recommend the reappointment of Mr D Wakefield for a second period of office.  To receive the outcomes of NED appraisals.  To consider Non-Executive Director remuneration – The Committee approved a recommendation to maintain the current level of remuneration

During 2015/16, the Trust did not receive services or advice from any external parties other than legal advice on compliance with regulation.

Remuneration Report

Expenses paid to governors and directors The majority of the expenses claimed by Directors and Governors were for travel costs

Directors Governors 14/15 15/16 14/15 15/16 Total number of Directors 16 13 42 41 in office Number of Directors 10 8 5 6 receiving expenses Aggregate sum of expenses £6930 £5451 940 £668

Remuneration The following tables provide information which is subject to audit review about the salaries, allowances and pension and pension entitlements of employees and appointees.

Jackie Bene Chief Executive, 26th May 2016.

Remuneration Report

Noadditional taxablebenefits, annual performance or bonuses longterm performance bonuses were paid to ofany member the board.

Increases shown in pension related benefits reflect the changes to the pension accrual used for A Salary and Fees D Long term performance bonuses pension assessments upon retirement in accordance with the NHS Pension Scheme. For some Board B Taxable benefits E Pension related benefits members these have changed significantly in year following changes in contractual arrangements. C Annual performance related bonuses

The salary and fees for Bene and Hodgson include elements which are not part of their senior manager role including 0.1 wte consultant role and Clinical Excellence Allowance (CEA) in the case of Bene and the CEA in the case of Hodgson. This is as per guidance released in May 2016 stating that this should be all remuneration including that which is not for the performance of their senior manager role. Bene has an additional £11,951 (£9,586 consultant 0.10 wte salary and £2,365 CEA level 7 relating to this role) and Hodgson £28,253 (£23656 relating to 15/16 CEA and £4,435 relating to 14/15 arrears for CEA)..

Remuneration Report Total Pension Entitlement

Pension arrangements for the Chief Executive and all Executive Directors are in accordance with the NHS Pension Scheme. The accounting policies for pensions and other relevant benefits are set out in note 1.8 to the accounts.

Staff Report

Introduction Our organisation can only ever be as good as the people who work in it. Our goal for Bolton people is therefore simple: the team should feel fully engaged in their work, well recognised and fairly rewarded. Only as we achieve this can the Trust achieve its goals.

Staff numbers – by professional group

Staff numbers – by gender

Staff Report

Sickness absence data We work hard to ensure our staff are healthy and enjoy work and to see a year-on-year improvement in attendance. We have a comprehensive attendance management policy and encourage staff to seek professional medical support through our extensive occupational health and well-being services if needed. Sickness absence rate is calculated by dividing the sum total sickness absence days (including non-working days) by the sum total days available per month for each member of staff). The chart below shows the percentage of days lost to sickness during 2015/16.

The data in the table below is provided by the Department of Health through the Health and Social Care Information Centre1 (HSCIC) for the calendar year 2015 (with 2014 data for comparison)

Average FTE Adjusted FTE FTE-Days FTE-Days Lost Average Sick days lost to Available to Sickness Days per FTE Cabinet Office Absence definitions 2015 4,516 47,532 1,648,236 77,107 10.5

2014 4,546 Not provided 1,022,903 51,887 11.4 in 2014

Staff Report

Staff policies and actions Policies applied during the financial year for giving full and fair consideration to applications for employment made by disabled persons, having regard to their particular aptitudes and abilities It is our policy to give full and fair consideration to applications for employment received from disabled persons, having regard to their particular aptitudes and abilities, and wherever possible to continue the employment of, and to arrange appropriate training for, employees who have become disabled persons during the period of their employment. Bolton NHS FT provides the same opportunities for training, career development and promotion for disabled people as for other employees. The Trust’s Recruitment and Selection policy was revised in January 2015. The policy ensures that all recruitment undertaken by the Trust is done in a consistent manner, whilst also ensuring the elimination of discrimination and the provision of equality of opportunity. Section 6.4.1 of the Recruitment and Selection policy specifically outlines the Trusts commitment to the employment and career development of disabled people.

Policies applied during the financial year for continuing the employment of, and for arranging appropriate training for, employees who have become disabled persons during the period The Trust has recently revised the Attendance Management process to ensure clarity in supporting staff with long term conditions. The policy amendments have been made to ensure managers have the flexibility to make adjustments to working patterns and duties for staff who may suffer from a long term condition which may not, at this point in time, be classed as a disability. This policy was developed following a specific case that brought this matter to the attention of the HR team and staff side, and this element of the Attendance Management policy was developed with a view to ensuring adequate support to such staff.

Policies applied during the financial year for the training, career development and promotion of disabled employees All policies are subject to an Equality Impact Assessment. In relation to disabled employees the HR team give expert advice on the need for reasonable adjustments to be made to ensure that there is equal access to training and development and promotion opportunities.

Actions taken in the financial year to provide employees systematically with information on matters of concern to them as employees Communication with our staff takes many forms: we have a weekly bulletin and a monthly face to face team brief, alongside team meetings that cover a variety of practice-based topics. If we are considering a change that will impact on an individual or a team then we would always discuss our proposals within a consultation framework with the staff affected. The Trust also has a monthly meeting with the staff side organisations where information is shared on the Trust’s quality, finances, performance and workforce matters. To complement this the Chief Executive and Executive Directors undertake regular visits to different wards and departments across hospital and community teams to gain feedback from staff working at the front line.

Staff Report

Actions taken in the financial year to consult employees or their representatives on a regular basis so that the views of employees can be taken into account in making decisions which are likely to affect their interests During 2015/16, we held Staff focus groups to update our staff on a variety of issues, including Healthier Together and Greater Manchester Health and Social Care Devolution. The sessions have updated on the latest decision making and focussed on the possible impact on service delivery and workforce implications locally. Other forums for consultation with staff have included  Local staff focus groups to gain more granular level feedback on themes addressed in the annual staff survey and quarterly staff friends and family test.  Local consultation sessions with staff affected by transformational change.  Local action planning sessions around the 2015 Staff Survey results commenced in February 2016, with the view to publishing and implementing a comprehensive Trust- wide Action Plan at the end of April 2016

Actions taken in the financial year to encourage the involvement of employees in the NHS foundation trust’s performance As a Trust, we actively encourage the involvement of our employees at all levels in all aspects of performance. Activities during 2015/16 include:  Involvement of clinical & non-clinical staff in ‘Perfect Week’ events in acute and community settings  A staff consultation event was held in November 2015 to explore the theme of Innovation & Improvement, leading to the appointment of a Continuous Improvement Co-ordinator in the PMO.  Involvement of clinical staff and partners from Bolton Council and Bolton CCG in a one day accelerated discharge event in March 2016  Use of our Staff friends and family survey data in local sessions with teams to strengthen engagement and improve team performance

Occupational Health We are part of joint venture commercial collaborative Occupational Health service, set up in 2014. The service is hosted by Wrightington, Wigan and Leigh NHS Foundation Trust (WWL) and is managed jointly between WWL, Bolton and Lancashire Teaching Hospitals NHS Foundation Trust (LTH). The service is called Wellbeing Partners and provides Occupational Health services to a number of public and private sector organisations across Lancashire, including large service provision contracts with Edge Hill University, Bridgewater Community NHS Foundation Trust and Lancashire Care NHS Foundation Trust. The service vision is to develop a sustainable, clinician-led occupational health service for both public sector and private sector organisations in North Manchester and Lancashire that delivers excellent results and value for money for NHS organisations and for a broad client base. The service provided by Wellbeing Partners provides all our occupational health requirements, including, support on pre-employment health checks, health referrals, flu inoculations and

Staff Report

proactive health interventions such as fast track physiotherapy referrals and mental health drop in sessions.

Health and Safety Performance There have been no prosecutions or enforcement notices issued to the Trust by the Health and Safety Executive (HSE) during the reporting period. Similarly, the Trust has maintained its excellent accident/incident record of very low numbers of staff accidents requiring over seven days’ absence from work

Information on policies and procedures with respect to countering fraud and corruption The Trust has a Counter Fraud and Corruption Policy in place. A counter fraud work plan is agreed with the Director of Finance and approved by the Audit Committee. The local counter fraud specialist is a regular attendee at Audit Committee meetings to report on any investigatory work into reported and suspected incidents of fraud and to provide an update on the on-going programme of proactive work to prevent potential fraud.

Staff Survey Commentary Our approach to Staff Engagement has been informed by our new People Strategy which outlines a number of key priorities around culture, leadership & HR processes. In August 2015, the Trust appointed a Staff Engagement Lead. In the last 6 months, we have focused on the following initiatives:

 Creation of a Staff Engagement Steering Group, chaired by our CEO and with representation from Executive Directors, Divisional leaders, HR and staff side; this meets bi-monthly to guide our progress  Implementation of a Leadership Visibility Plan to improve access to Executive Directors and senior leaders within each Division, including monthly listening lunches with our CEO  Greater use of Staff friend and family test data to determine areas of good practice and ‘hotspots’ within the Trust; and work with local teams on improvement actions to strengthen engagement  Analysis work to explore the relationship between Staff FFT and Patient FFT/Complaints, with a view to developing integrated metrics around the staff/patient experience  Refresh of the Trust Values, involving staff consultation between November 2015 and January 2016, to reflect our positive performance and ambitions within the Greater Manchester Health & Social Care Devolution context  Greater use of local action planning within our Divisions to build a comprehensive Trust Action plan in response to the 2015 Staff Survey results

Staff Report

We continue to monitor our improving Staff Engagement scores through the Staff FFT, local staff surveys and the NHS Staff Survey. Our Listening Lunches with the CEO have been established since October 2015 and are covering all staff groups.

Summary of Performance – NHS 2015 Staff Survey

Our response rates in the most recent Staff Surveys are shown below:

2014/15 (2014 Survey) 2015/16 (2015 Survey) Trust improvement / deterioration Response Trust National Trust National Rate Average Average 46.6% 42.3% 44.7% 41.0% A reduction of 1.9% in Bolton response rate, but still above national average.

Our main areas of improvement from 2014 to 2015 have been as follows:

 Our overall Staff Engagement Score has increased from 3.80 (2014) to 3.88 (2015)  Our most improved Key Factor is KF1 (Staff Recommendation of the organisation as a place to work or receive treatment, moving from 3.68 to 3.83; this mirrors an upward trajectory in our Staff FFT results over the last few quarters  We have seen a statistically significant improvement in 10 Survey Questions, a number of which relate to improvements in the quality of line management within the Trust

2014/15 (2014 2015/16 (2015 Trust improvement / Survey) Survey) deterioration Top 4 ranking Key Trust National Trust National Factors Average Average * + KF9 3.86 3.75 3.92 3.77 An increase of 0.06, well Effective Team Working ahead of the national average KF10 3.74 3.75 3.88 3.66 An increase of 0.14, we are Support from Immediate above the national average Managers KF8 - - 4.03 3.93 A new factor in 2015, we are Staff satisfaction with ahead of the national level of responsibility average and involvement KF19 - - 3.76 3.59 A new factor in 2015, we are Organisation interest in ahead of the national and action on health & average wellbeing

* All Acute Trusts + All Combined Acute & Community Trusts

Staff Report

The areas where our performance has declined are:  We have seen a statistically significant decline in three Survey Questions, two of which relate to reporting of physical abuse/harassment/bullying/verbal abuse and one which concerns confidence in the organisation addressing unsafe clinical practice  In comparison to other Acute Trusts, we are significantly worse on two items; 14a (Physical violence from patients/service users, their relatives or other members of the public) and 15d+ (Last experience of harassment/bullying/abuse not reported) The following table shows our bottom four scores

2014/15 (2014 2015/16 (2015 Trust improvement / Survey) Survey) deterioration Bottom 4 ranking Key Trust National Trust National Factors Average* Average+ KF27 - - 15% 37% A new factor in 2015, we are % of staff / colleagues behind the national average; reporting most recent more work required to experience of spread awareness of the harassment, bullying need to record such or abuse incidents. KF22 17% 14% 19% 14% An increase of 2% from last % of staff experiencing year, we are above the physical violence from national average; this is a patients, relatives or priority area within our new the public in the last Trust Action Plan. 12 months KF28 33% 32% 32% 27% A decrease of 1% from last % of staff witnessing year, but we remain above potentially harmful the national average. errors, near misses or incidents in the last month KF25 28% 27% 29% 27% An increase of 1% from last % of staff experiencing year, we remain just above harassment, bullying the national average; this is a or abuse from priority area within our new patients, relatives or Trust Action Plan. the public in the last 12 months

* All Acute Trusts + All Combined Acute & Community Trusts

Future Priorities and targets

 Our focus on strengthening Staff Engagement will continue during 2016-17, prioritised around embedding our new Trust Values model and using integrated staff/patient metrics to inform supportive interventions  We are confident that our comprehensive Trust Action Plan will address the areas where our Survey scores have decreased.

Staff Report

 In particular, local actions identified within our Acute Adult Division will address both the perceived threat of violence from patients towards staff and the need to report such concerns; the increase in dementia patients with challenging behaviours will be an area of focus for us  Staff feedback is actively encouraged within our Trust and we are looking at harnessing Intranet & Smartphone technology to enhance the available feedback channels in 2016-17  Our Staff Engagement activity will be formalised into a strategic engagement framework during 2016 to demonstrate clearly aligned support for our People Strategy and our continued journey towards a high-performance healthcare organisation,

Expenditure on consultancy Expenditure on Consultancy related spend has reduced from £1.1m in 2014/15 to £0.3m in 2015/16

Off payroll engagements Statement on off payroll arrangements Our policy for off payroll arrangements is in line with the guidance provided by Monitor and based on HM Treasury guidance that:  board members and senior officials with significant financial responsibility should be on the organisation’s payroll, unless there are exceptional circumstances – in which case the Accounting Officer should approve the arrangements – and such exceptions should exist for no longer than six months;  engagements of more than six months in duration, for more than a daily rate of £220, should include contractual provisions that allow the department to seek assurance regarding the income tax and NICS obligations of the engagee – and to terminate the contract if that assurance is not provided; We have established processes in place by which the need for employees can be assessed and the appropriate individuals recruited. While our preference is to employ our own staff, The need may arise from time to time to cover areas of work which are specialist and outside our current areas of expertise and/or; particular circumstances dictate that someone outside the Trust should be engaged (e.g. certain investigations). In such cases a determination is made as to which method of resourcing is most appropriate Our preferred order of consideration would generally be  Employment  Agency  Self-Employed Contractor (off-payroll) The following tables provide detail of off-payroll engagements of more than £220 per day lasting for longer than six months Existing off-payroll engagements as of 31 March 2016

Staff Report

No. of existing engagements as of 31 March 2016. 2 No. that have existed for less than one year at time of reporting. 1 No. that have existed for between one and two years at time of reporting. 0 No. that have existed for between two and three years at time of reporting. 1 No. that have existed for between three and four years at time of reporting. 0 No. that have existed for four or more years at time of reporting. 0

All existing off-payroll engagements, outlined above, have been subject to a risk-based assessment as to whether assurance is required that the individual is paying the right amount of tax and, where necessary, that assurance has been sought.

New off-payroll engagements and those that reached six months in duration between 1 April 2015 and 31 March 2016

No. of new engagements, or those that reached six months in duration, 1 between 1 April 2015 and 31 March 2016 No. of the above which include contractual clauses giving the trust the right to 1 request assurance in relation to income tax and National Insurance obligations

No. for whom assurance has been requested 1 Of which... No. for whom assurance has been received 0 No. for whom assurance has not been received 1 No. that have been terminated as a result of assurance not being received. 0

The request for assurance has been acknowledged by the individual however this is their first year of trading and their accounts are currently being prepared by their accountant, so they have not yet been able to provide the proof of assurance.

Off-payroll engagements of board members, and/or, senior officials with significant financial responsibility, between 1 April 2015 and 31 March 2016

No. of off-payroll engagements of board members, and/or, senior officials with 0 significant financial responsibility, during the financial year.

No. of individuals that have been deemed “board members and/or senior 13 officials with significant financial responsibility” during the financial year. This figure includes both off-payroll and on-payroll engagements.

Staff Report

Fair Pay multiple

2015/16 2014/15

Highest paid director salary - (J Bene) £195,046 £195,748 Dr Bene salary includes her 0.1wte consultant role and accompanying CEA

Median Salary £27,090.00 £27,901

Median Salary Ratio 7.20 7.02

Employees receiving remuneration in excess of the highest paid director. none none

Remuneration range £6,000 - £6,000 - £195,000 £196,000

Total remuneration does not include severance payments, employer pension contributions and the cash equivalent transfer value of pensions.”

Exit Packages

Exit package cost Number of Number of Total number of Total cost band compulsory other exit packages £000 redundancies departures agreed

15/16 14/15 15/16 14/15 15/16 14/15 15/16 14/15

<£10,000 26 7 26 7 88 42

£10,001 - £25,000 3 3 3 3 40 55

£25,001 - 50,000 1 1 38

£50,001 - £100,000

£100,001 - £150,000

£150,001 - £200,000

>£200,000

Total 0 0 30 10 30 10 166 97

Staff Report

Exit packages: non-compulsory departure payments Exit packages: other (non-compulsory) departure Number of Total value of payments - 2015/16 Payments agreed agreements £000

15/16 14/15 15/16 14/15 Voluntary redundancies including early retirement 10 97 contractual costs Mutually agreed resignations (MARS) contractual costs 1 38

Early retirements in the efficiency of the service contractual costs Contractual payments in lieu of notice 29 129

Exit payments following employment tribunals or court orders Non-contractual payments requiring HMT approval

Total 30 10 166 97

of which: non-contractual payments requiring HMT approval made to individuals where the payment value was more than 12 months’ of their annual salary

Payments for loss of office and to past senior managers No payments have been made for loss of office or to past senior managers during the reporting year 2015/16.

Code of Governance Disclosures Statement of Compliance with the Code Bolton NHS Foundation Trust has applied the principles of the NHS foundation Code of Governance on a comply or explain basis. The NHS foundation Trust code of Governance, most recently revised in July 2014, is based on the principles of the UK Corporate Governance Code issued in 2012 The Trust Secretary reviews our compliance with the NHS Foundation Trust Code of Governance and prepares a report for the Audit Committee. The Audit Committee considered this report at its meeting on February 23rd 2016 and agreed that Bolton NHS Foundation Trust complied with the main and supporting principles of the Code of Governance. The Code is implemented through key governance documents, policies and procedures of the Trust, including but not limited to:  The Constitution  Standing Orders  Standing Financial Instructions  Scheme of Delegation  Schedule of Matters Reserved for the Board  Code of Conduct (for Directors, for Governors and for Senior Managers)  Staff Handbook  Governor Handbook.

Summary Schedule of Matters Reserved for the Board The Schedule of Matters reserved for the Board details the decisions and responsibilities reserved to the Council of Governors, the Board of Directors and those delegated to the agreed committees of the Board of Directors. In the event of any unresolved dispute between the Council of Governors and the Board of Directors, the Chair or the Secretary may arrange for independent professional advice to be obtained for the Foundation Trust. The Chair may also initiate an independent review to investigate and make recommendations in respect of how the dispute may be resolved. The overall responsibility for running an NHS foundation trust lies with the board of directors. The Council of Governors is the collective body through which the directors explain and justify their actions; the council should not seek to become involved in the running of the trust. Directors are responsible and accountable for the performance of the foundation trust; governors do not take on this responsibility or accountability. This is reflected in the fact that directors are paid while governors are volunteers.

The Council of Governors As set out in the constitution, the Council of Governors consists of 23 publicly elected Governors, six staff Governors and nine appointed partner Governors. The Council of Governors meets formally in public every two months The role of the governor is to:

Code of Governance Disclosures  hold the Non-Executive Directors individually and collectively to account for the performance of the board of directors  to represent the interests of NHS foundation trust members and of the public  Set the terms and conditions of Non-Executive Directors  Approve the appointment of future Chief Executives  Appoint or remove the Trust’s external auditor  Consider the annual accounts, annual report and auditor’s report  Be consulted by the Board of Directors on the forward plans for the Trust.  Approve changes to the constitution of the Trust  Take decisions on significant transactions  Take decisions on non NHS income. The Board of Directors and the Council of Governors enjoy a strong working relationship. The Trust Chairman chairs both and acts as a link between the two. Each is kept advised of the other’s progress through a number of systems, including informal updates via the Chairman, ad hoc briefings, exchange of meeting minutes and attendance of the Board of Directors at the Council of Governors and by individual Directors at Council of Governors sub-committees. The Governors have not had cause to exercise their power to require one or more of the directors to attend a governors' meeting. The Executive and Non-Executive Directors attend the majority of Governor meetings to provide information about the performance of the Trust and to develop the relationship between the two bodies. In 2015/16 an additional briefings between Executive Directors and Governors were introduced. A rolling bi-monthly programme is now in place for Governors to meet with each Executive for informal discussions on areas relevant to individual portfolios. Governors have a responsibility to canvass the opinions of the Trust’s members and the wider public with regard to their views on the forward plans of the Trust. Governors are able to attend local area forums to meet with members within their own areas of the public constituency. Governors also took the opportunity to network informally with members prior to the Annual Members’ Meeting and prior to Medicine for Members events. The Membership and Member Communication subgroup have agreed to focus on member engagement during 2016/17

Code of Governance Disclosures Public Governors

End of period of Meeting Name Area Date Elected office attendance Ann Bain Breightmet Oct13 Sept 16 5/5

Derek Burrows Kearsley Oct 13 Sept 16 4/5

Michael Connolly Westhoughton South Oct 13 Sept 16 5/5

Kate Cowpe Out of Area Oct 14 Sept 17 2/5

Ken Hahlo Heaton and Lostock Oct 15 Sept 18 4/5

Eric Hyde Little Lever and Darcy Lever Oct 14 Sept 17 4/5

Pauline Lee Westhoughton and Chew Moor Oct 15 Sept 17 3/5

Carol McBride Horwich and Blackrod Oct 13 Sept 16 1/5

Martin McLaughlin Halliwell Oct 13 Sept 16 4/5

Jeffrey Mangnall Rumworth Oct 13 1/3

Geoffrey Minshull Bromley Cross Oct 14 Sept 17 4/5

Champak Mistry Harper Green Oct 13 Sept 16 1/5

Meena Patel Hulton Oct 14 March 16 0/5

Jack Ramsay Bradshaw Oct 14 Sept 17 3/5

Bill Riley Astley Bridge Oct 13 Sept 16 2/5

Barbara Ronson Horwich NE Oct 14 Sept 17 3/5

Sorie Sesay Great Lever Oct 13 Sept 16 2/5

Jim Sherrington Tonge with the Haulgh Oct 13 Sept 16 5/5

Janet Whitehouse Smithills Oct 14 Sept 17 3/5

Staff Governors

Date End of Period of Name Area Elected Office Dipak Fatania All other staff Oct 13 Sept 16 3/5

Tracey Halliday Nurses and Midwives Oct 14 Sept 17 4/5

Sarah Hulme All other staff Oct 15 Sept 18 3/3

Dan Hindley Doctors and Dentists Oct 14 Sept 17 3/5

Janet Roberts Nurses and Midwives Oct 13 Sept 16 3/5

Sarah Rutherford AHPs and Scientists Oct 14 Sept 17 3/5

 Chair of a sub-committee and one of the three lead governors.

Code of Governance Disclosures Appointed Governors

Name Representing Date Appointed Meetings Jack Firth Bolton HealthWatch Dec 10 1/5

Jane Haworth Bolton University July 14 0/5

Dawn Hennefer Salford University Sept 14 5/5

Susan Howarth Bolton Metropolitan Borough Council April 2014 2/5

Samir Naseef Bolton Local Medical Committee Nov 12 2/5

Thaira Qureshi Bolton Council For Voluntary Services Oct 08 1/5

Leigh Vallance Bolton CVS July 14 4/5

Anna Maria Watters Bolton Metropolitan Borough Council Nov 12

Elections to the Council of Governors Elections to the Council of Governors were held according to the constitution in September 2015. Results were as reported below.

Seat Turnout Governor elected Heaton 44.2% Ken Hahlo All other staff 14/7% Sarah Hulme

There were no uncontested elections in the year 2015/16

Code of Governance Disclosures Lead Governor In consultation with the Chairman and the Trust Secretary, the Council of Governors decided to nominate the three chairs of the sub-committees to jointly act as lead governor. The lead governor role is undertaken in accordance with Monitor guidance as the point of contact between Monitor and the Council of Governors with no additional responsibilities. In 2015/16, the three Governors fulfilling these roles were Janet Roberts, Jack Ramsay and Jim Sherrington.

Directors’ and Governors’ Register of Interests A register is kept of Directors’ and Governors’ interests. Access to the register can be gained either by contacting the Trust Secretary or from the Trust website. In accordance with the disclosure requirements the Chairman advised the Council of Governors of his appointment to serve as a Non-Executive Director and Chair of Audit Committee for Crown Commercial Services.

Developing understanding The Board of Directors has taken steps to ensure that members of the Board, and in particular the Non-Executive Directors, develop an understanding of the views of Governors and members about their NHS Foundation Trust. David Wakefield chairs both the Board of Directors and the Council of Governors and with the assistance of the Trust Secretary is the link between the two bodies. The full Council of Governors meets a minimum of six times a year and these meetings are attended by representatives of the Executive Directors, the Senior Independent Director and the Non- Executive Directors. The Governors’ meetings provide the opportunity for the Governors to express their views and raise any issues so that the Executive Directors can respond. Minutes of the meeting are shared with the Board of Directors so they can pick up and respond to any issues raised. In 2014 at the request of the Governors, the part two section of the Board of Directors was opened up for Governors to attend and observe. Governors have provided feedback in support of this change which has allowed them to gain a greater degree of the understanding of the work of the Board. The Governors have two formal sub-committees dealing with Auditor appointment, and nomination and remuneration. These are attended by the Chair of Audit and Director of Finance (Auditor appointment) and by the Senior Independent Director (nomination and remuneration). The Governors also have three sub-groups, each chaired by a Governor nominated by the group. The chairs of the sub-groups meet with the Chairman on a regular basis, these groups are also attended by the Trust Secretary and other members of Trust staff as required. The Trust recognises the importance of being accessible to members. Council of Governors meetings are held in public and publicised on the Trust website, member newsletters and notices around the Trust. The Governors representing the electoral wards of Bolton are able to attend the local area forums run by Bolton Council to meet individual FT members and members of the public and hear their views.

Code of Governance Disclosures Board of Directors The Board of Directors comprises the Chairman, Chief Executive, Senior Independent Director, five other independent Non-Executive Directors and five Executive Directors. The Board meet monthly in public. Papers for the meeting including the minutes of the previous meeting are available on the Trust website. The Directors have collective responsibility for setting strategic direction and providing leadership and governance. The Scheme of Delegation which is included in the Trust’s standing orders, sets out the decisions which are the responsibility of the Board of Directors and those which have been delegated to a sub-committee of the Board. The Executive Directors of the Trust meet weekly to consider the operational management and the day to day business of the Trust. These meetings are supported by monthly integrated performance meetings with the divisions and bi-monthly Divisional Executive meetings attended by Executive Directors and the senior management team. The primary purpose of these meetings is to contribute to the forward strategy and review performance against the annual objectives agreed in accordance with the strategy.

Balance, Completeness and Appropriateness There is a clear separation of the roles of the Chairman and the Chief Executive, which has been set out in writing and agreed by the Board. The Chairman has responsibility for the running of the Board, setting the agenda for the Trust and for ensuring that all Directors are fully informed of matters relevant to their roles. The Chief Executive has responsibility for implementing the strategies agreed by the Board and for managing the day to day business of the Trust. The Board of Directors has continued to assess the independence of its Non-Executive Directors further to the requirements of the Code of Governance, and considers that each Non-Executive Director is independent in character and judgement. The Board considers that the Non-Executive Directors bring a wide range of business, commercial, financial and other knowledge required for the successful direction of the Trust. All Directors are subject to an annual review of their performance and contribution to the management and leadership of the Trust. A review of Board governance was commissioned from KPMG in June 2012, the implementation of the recommendations was completed during 2014/15. A further review under the Monitor Well Led Framework will be conducted in 2016/17. The external advisors used during 2015/16 have no other connections to the Trust.

Code of Governance Disclosures

Attendance at Board of Director meetings David Wakefield 11/11 Trish Armstrong Child* 7/11 Jackie Bene 11/11 Neal Chamberlain 11/11 Carol Davies 9/11 Allan Duckworth 11/11 Andy Ennis 10/11 Ann Gavin Daley 8/8 Mark Harrison 8/11 Steve Hodgson 10/11 Bev Tabernacle 4/4 Andrew Thornton 11/11 Mark Wilkinson 11/11 Simon Worthington 11/11 Esther Steel 11/11 * Attendance limited due to long term sickness

Code of Governance Disclosures Audit Committee The Audit Committee met on six occasions during the period April 1st 2015 and March 31st 2016. The purpose of the Audit Committee is to provide independent assurance to the Board that there are effective systems of governance, risk management and internal control for all matters relating to corporate and financial governance and risk management. A key aspect of the Audit Committee's work is to consider significant issues in relation to financial statements and compliance. As part of the preparation for the audit of financial statements, our external auditor KPMG undertook a risk assessment and identified risks as laid out in the table below:

Issues Mitigation

Valuation of land and buildings Review of revaluation basis Work to understand the basis upon which impairments to land and buildings have been calculated Assessment of the independence and objectivity of the surveyors and their terms of engagement

Recognition of NHS and Non NHS income Testing of the completeness, existence and and associated fraud risk accuracy of the balances recorded within the financial statements Investigation of a sample of contract variations Participation in the Agreement of Balances exercise with other NHS organisations

Fraud risk from management override of Testing of entries that are outside the Trust’s controls normal course of business or are otherwise unusual Audit testing of controls External Audit review of register of interests and disclosure of any related party transactions Local Counter Fraud support

In addition to the review of financial statements, other key activities during the period April 1st 2015 and March 31st 2016 were:  Consideration of the Going Concern report prior to approval by the Board of Directors.

Code of Governance Disclosures  Providing oversight of the financial governance improvement plan - the Audit Committee provided regular oversight of the financial governance improvement plan developed to address weaknesses identified in external and internal reviews of financial governance.  Reviewing the Board Assurance Framework and Risk Register - in addition to receiving the Board Assurance Framework the committee workplan scheduled a detailed focus on specific areas of the BAF, with the lead director required to attend the meeting to provide additional assurance that the risks to the Trust’s strategic objectives are managed with mitigations in place.  Receiving reports from the internal and external auditors and providing oversight to ensure agreed recommendations are addressed.  Receiving regular reports from the local counter fraud specialist to provide assurance of the on-going development of an anti-fraud culture and specific actions taken in relation to concerns raised both internally and through national fraud awareness initiatives.  Reviewing compliance with the Code of Governance.  Receiving and providing oversight of regular reports on losses, waivers and variations.

Audit Committee Attendance Members Carol Davies (Chair) 6/6

Ann Gavin Daley 3/4

Mark Harrison 4/6 Neal Chamberlain 5/6 Attendee Simon Worthington 5/6 Esther Steel 6/6

Auditor Appointment In 2015, a review of the Audit Committee, including both the Internal and External Audit functions was conducted using HFMA guidance. This review included consideration of value for money and the overall effectiveness of the committee. The Chair of the Audit Committee presented an overview of the Committee’s work to the Council of Governors in January 2016. The Chair of the Audit Committee presented the Annual Report of the Audit Committee to the Board of Directors in November 2015.

External Auditor The Trust is in the third year of a three year contract for External Audit services from KPMG. The appointment of KPMG as auditors was made by the Council of Governors in accordance with Monitor guidance. The value of external audit services (excluding the review of the charitable funds accounts) is £57,874 excluding VAT. On occasion the Trust may decide to request additional services from the external auditor. The Council of Governors delegated specific authority for commissioning additional services to the Trust’s Audit Committee, subject to an overall policy cap on directly attributable fees which 55

Code of Governance Disclosures should not exceed 50% in aggregate of the approved annual statutory audit fee in any twelve month period. This would be on the understanding that the Audit Committee takes responsibility for agreeing any specific areas of additional work to be undertaken and, in doing so, considers whether the external auditor or any other organisation is best placed to provide the service i.e. based on relevant experience, expertise in that particular area and value for money. The Trust did not commission any non-audit services from its external auditor during 2015/16. Internal Audit Internal Audit services are provided by Price Waterhouse Cooper (PwC) The Audit committee receive and approve the internal audit plan and through the course of the financial year receive regular reports on progress against the plan, accompanied by detailed reports providing the findings, recommendations and actions agreed following the audits agreed in the plan. The plan provides evidence to support the Head of Internal Audit’s opinion which in turn informs the Annual Governance Statement (page 62)

Code of Governance Disclosures

Membership Any member of the public over the age of 14 can become an FT member of Bolton NHS Foundation Trust and give their views on how they think we should develop our services. Through our members, we can really get to know what the public wants and, more importantly, act on that as our services evolve. Membership strategy We are committed to building a membership that is representative of and reflects the local communities we serve in terms of disability, age, gender, socio-economics, sexuality, ethnic background and faith. Public members Membership of the Trust is open to anyone who resides in England although we would expect the majority of our members to reside in Bolton and the surrounding areas of Salford, Wigan, Bury and South Lancashire. There is a lower age limit of 14 but no upper age limit. There are no limits on the number of people who can register as members. Public members are placed in constituencies based on where they live. There are 20 constituencies representing the electoral wards of Bolton and one to represent “out of area” members. Staff members We have an opt out arrangement in respect of staff membership. Under this arrangement, staff will automatically be registered as a member of the Trust unless they have completed the opt out form which was circulated with payslips prior to authorisation as a Foundation Trust. New members of eligible staff are provided with information and a form at induction. Staff membership is open to everyone who is employed by the Trust full or part time on a contract with no fixed term or those staff on fixed term contracts of 12 months or more. Membership is also available to those bank staff who have an agreement to work for the Trust and have done for 12 months or more. Staff working for the Trust’s contractor for portering and domestic services are also eligible for staff membership if they meet the above criteria. Staff membership ceases at the point that the member leaves the service of the Trust, but individuals can then choose to become a public member. Benefits of membership Although there are no financial benefits to FT membership, there are also no costs. There is, however, much satisfaction in being in a position which can help local people and local services. There are no benefits to members in terms of access to services. We will use our members as a valuable resource calling on those who have expressed a willingness to participate in surveys and focus groups to gain a snapshot view of the user’s perspective. Membership recruitment We aim to continue recruiting new members and are using a variety of methods to ensure we reach as many people as possible. People wishing to join can do so by registering online at www.boltonft.nhs.uk or by calling 01204 390654. Alternatively application forms are available throughout the hospital.

Code of Governance Disclosures Contact procedures for members that wish to communicate with Governors and/or Directors Members who wish to communicate with Governors may do so by email to [email protected] or by post c/o the Trust Secretary. To communicate with Directors contact [email protected]

Membership Statistics

Public Constituency At year start (1 April 2015) 4354 At year end (31 March 2016) 4487 Staff Constituency At year start (1 April 2015) 5244 At year end (31 March 2016) 4955

Analysis of current public membership

Public Constituency Number of members Eligible membership Age 0 - 16 4 3,646 17- 22 56 155,597 22+ 4185 252,135 Not known 242 Ethnicity White 3347 222,105 Mixed 34 4,750 Asian or Asian British 584 38,309 Black or Black British 84 4,457 Other 108 1,757 Not known 213 Socio-economic

groupings ABC1 395 38,240 C2 2032 55,395 D 1082 31,522 E 919 74,159 Not known 59 Gender Male 1752 134,865 Female 2673 136,513 Not known 62

Regulatory Ratings

Regulatory Ratings The continuity of services risk rating There are four rating categories ranging from one, which represents the most serious risk, to four, representing the least risk. A low rating reflects the degree of financial concern Monitor may have about a provider. Governance rating Monitor use a specified set of national metrics as proxies for overall standards of governance, including A&E waiting times, referral-to-treatment targets and rates of C. difficile infection. In addition, when the Care Quality Commission has serious concerns about a trust, Monitor will consider whether it is in breach of its licence and what action is needed. There are three categories to the governance rating applicable to all NHS foundation trusts:  A green rating is assigned where there are no grounds for concern at a trust.  Where Monitor have identified a concern at a trust but not yet taken action, they will provide a written description stating the issue at hand and the action being considered.  A red rating will be assigned when regulatory action has been taken. The regulatory ratings are based on self-certification received from trusts in their annual plan, in-year quarterly submissions and any exception reports, including any reports from third parties such as the Care Quality Commission (CQC). Monitor intervention

April 2012 The Trust was found to be in significant breach of two of the terms of its authorisation: its governance duty, and its healthcare targets and other standards duty. The decision was triggered by the failure of the Trust to meet healthcare targets (specifically A&E waiting times and the Referral to Treatment (RTT) 18 week target) and failings in Board governance.

August 2012 Monitor exercised their formal powers of intervention after finding the Trust had failed to comply with its terms of authorisation.

April 2013 The Trust became licensed with conditions which included discretionary requirements and enforcement undertakings

December 2014 The Trust was issued with a certificate of compliance with all enforcement undertakings and a statement of compliance in respect of the discretionary requirements relating to target breaches, board effectiveness and governance

September Monitor confirmed that the Trust was no longer in breach of the provider 2015 licence and had returned to a green governance rating

Regulatory Ratings

The ratings for Bolton NHS Foundation Trust over the last two years are summarised in the tables below. The ratings awarded at the start of the year are based on the expected performance at the time of the annual risk assessment in our annual plan. The quarterly ratings are based on actual performance reported to Monitor, via quarterly in-year submissions.

Annual Plan Q1 2015/16 Q2 2015/16 Q3 2015/16 Q4 2015/16

Continuity of 2 1 2 2 2 Service rating

Governance risk green red red green green rating

Annual Plan Q1 2014/15 Q2 2014/15 Q3 2014/15 Q4 2014/15

Continuity of 2 1 2 2 2 Service rating

Governance risk red red red red red rating

Statement of Accounting Officer’s Responsibilities

Statement of the Chief Executive's responsibilities as the Accounting Officer of Bolton 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 Bolton 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 Bolton NHS Foundation Trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year. In preparing the accounts, the Accounting Officer is required to comply with the requirements of the NHS Foundation Trust Annual Reporting Manual and in particular to:  observe the Accounts Direction issued by Monitor, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis;  make judgements and estimates on a reasonable basis;  state whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual have been followed, and disclose and explain any material departures in the financial statements;  ensure that the use of public funds complies with the relevant legislation, delegated authorities and guidance; and  prepare the financial statements on a going concern basis. The Accounting Officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS Foundation Trust and to enable him/her to ensure that the accounts comply with requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the NHS Foundation Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities. To the best of my knowledge and belief, I have properly discharged the responsibilities set out in Monitor's NHS Foundation Trust Accounting Officer Memorandum. Signed

Jackie Bene Chief Executive Date 28th May 2016

Annual Governance Statement

Scope of responsibility As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS foundation trust’s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the NHS foundation trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum. The purpose of the system of internal control The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an on-going process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of Bolton 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 Bolton NHS Foundation Trust for the year ended 31 March 2016 and up to the date of approval of the annual report and accounts. Capacity to handle risk Leadership As Accounting Officer I Chair the Risk Management Committee and have overall accountability for internal control. To support this role there are clear systems of accountability within the organisation with each Executive Director having specific areas of responsibility The Risk Management Strategy sets out details of the risk management structure and key risk manager roles. The role of the Board and Standing Committees is detailed, together with the individual responsibilities of the Chief Executive, Executive Directors and all staff in managing risk. In particular, the Risk Management Committee, the Quality Assurance Committee, the Informatics Committee, the Finance and Investment Committee, the Clinical Governance Committee and the Divisional Governance Boards provide the mechanisms for managing and monitoring clinical, operational, financial and information governance risks throughout the Trust. The Audit Committee oversees the systems of internal control and overall assurance process associated with managing risk. The Board of Directors routinely receives reports from its Standing Committees and also receives reports on all serious incidents. The Clinical Governance Committee receives detailed reports on the management of actions agreed following investigations into serious incidents (SIs). The executive team is supported by a divisional management structure consisting of four clinical divisions and an Estates and Facilities Division. Each division has a clinical Head of Division and a Divisional Director of Operations who are jointly responsible for the delivery of key objectives in their areas. Each division is supported by a Divisional Director of Nursing with specific responsibility for delivering on patient safety, quality and the governance agenda. Each

Annual Governance Statement

of the Clinical Divisions provides a detailed quarterly report to the Quality Assurance Committee. Performance monitoring The integrated performance report provides comprehensive information to the Board and its sub-committees and to the divisions. The report includes a ward to board heat map to provide ward level information. Operational focus on the performance report is conducted through the monthly integrated performance meetings between the Divisions and the Executive team The Quality Assurance Committee monitors the performance dashboard to provide assurance to the Board. Where concerns are identified using the heat map the QA Committee may seek further assurance that the issues are being managed and may at the discretion of the Chair escalate any concerns to the Board to ensure that the Board as a whole are appraised of and have the opportunity to challenge the planned actions. Training To ensure the successful achievement of the Risk Management Strategy and implementation of the Risk Management Policy, staff at all levels are provided with appropriate training in carrying out risk assessments and the reporting of incidents. The on-going programme of training within the Trust includes: managing safely, risk register training, fire safety training, manual handling, safeguarding training, major incident training and conflict resolution training. Medicine management training is delivered at doctors’ induction programmes and during educational and developmental sessions. Support and advice on medicine management is also provided at ward and departmental level by the Chief Pharmacist and link pharmacists. Risks and safety in respect of clinical equipment and devices are discussed and disseminated by the Medical Devices and Equipment Management Committee. All divisions are represented on this committee which also has a training sub group and each ward has a link nurse. General awareness raising on risk management issues is achieved through staff briefings, team brief, safety bulletins, induction and the intranet. The Executive Team and the Board of Directors monitors management capability, (leadership, knowledgeable and skilled staff, adequate financial and physical resources), to ensure the processes and internal controls work effectively.

The risk and control framework Risk management in the trust Risk management is recognised as a fundamental part of the Trust’s culture, and an integral part of good practice. It is integrated into the Trust’s philosophy, practices and business plans. Risk management is the business of everyone in the organisation. The Trust’s Risk Assessment process, investigating incidents, complaints and claims procedures are the principal sources of risk identification. The Risk Assessment process identifies the criteria for risk scoring both likelihood and consequence on a scale of 1 to 5, with the highest risk being accorded a score of 25 (5x5). The risk assessment process also requires an appropriate risk management plan. The Risk Assessment process clearly states the escalation of management seniority to monitor management and mitigation of the risk according to its overall likelihood and consequence.

Annual Governance Statement

The Risk Assessment process is applied to all types of risk, clinical, financial, operational, capital, and strategic. The Trust Risk Register procedure requires Divisions to maintain and monitor their own Risk Registers. All risks with a score rating of 15 or above are reviewed by the Risk Management Committee. All “business cases” have to be supported with a risk assessment. The scored risk rating strongly influences priorities within the Trust Capital Programme. The Board Assurance Framework helps provide assurance to internal and external stakeholders in relation to meeting the Trust objectives. Assurance of the system is also supported by independent assurance processes – internal and external, and achievement of satisfactory outcomes or results. The Assurance Framework identifies Bolton NHS Foundation Trust’s principal objectives and their associated principal risks and is developed in consultation with the Executive Team. The control systems which are used to manage these risks are identified together with the evidence for assurance that these are effective. Lead managers and Directors are identified to deal with gaps in control and assurance and are responsible for developing action plans to address the gaps. The Board ensures effective communication and consultation at all levels within the organisation and with external stakeholders. We engage with our main commissioner (Bolton CCG) in contract review meetings and through Joint Leadership meetings. A representative of Bolton CCG Group also has a seat on our Quality Assurance Committee. We engage with other key stakeholders at various forums including but not limited to, Council of Governor Meetings, Overview and Scrutiny Committee and Healthwatch. These meetings provide an opportunity for risk related issues to be raised and discussed. A Board approved assurance framework (BAF) was in place for the period 1st April 2015 – 31st March 2016 In 2015/16, the BAF was revised to include a description of risk appetite for each risk and additional background information including tracking the score of the risk over time. The Board receive a monthly update on the BAF within the Chief Executive’s report. This update highlights any changes to risks and ensures a continued focus on the risks to the achievement of the overall strategy.

Risk Appetite When approving the Board Assurance Framework the Board agree their risk appetite for each of the strategic goals of the organisation  Risk averse to risks that affect the quality of care and the experience of every person accessing our services  We will not knowingly take decisions to reduce safety or ignore safety issues  We will not tolerate failure in basic standards of compliance which could compromise licence conditions  We have an appetite for developing partnerships but will not enter into partnerships that convene our statutory duty as an NHS Foundation Trust.

Annual Governance Statement

Quality Governance Arrangements The Quality Governance Framework has been developed by Monitor as an assessment tool for Trusts to use to benchmark their arrangements for effective quality governance in four categories:  Strategy  Capabilities and culture  Process and structure  Measurement Strategy - Quality is embedded in the Trust’s overall strategy, the safety and effectiveness of care and the experience of patients are at the heart of all that we do. In 2013, the Trust approved and adopted a new five year Quality Strategy and strategies to reduce the rate of falls and pressure ulcers Capabilities and Culture - The Board is assured that quality governance is subject to rigorous challenge with full NED engagement in the Audit Committee and NED involvement in the assurance providing committees. Process and Structure - The Corporate Governance Structure was reviewed in 2013 to ensure clarity of reporting between wards and departments and the Board and between the Board and its supporting committees. A new Risk Management Committee was formed in September 2013 and the remit of the Clinical Governance Committee and the Quality Assurance Committee was clarified. Integrated Performance Meetings ensure clear routes of escalation to the Executive team. The Trust has clear process in place for:  Clinical incident and accident policy  Raising concerns (Whistle blowing)  Complaints  Management of SIs Action plans are put in place to address issues arising from these processes.

Performance information - A new integrated performance report was developed during 2014. This report provides a clear dashboard and high level apex report for the Board of Directors and Council of Governors with full reports reviewed in the Board sub committees and at the Integrated Performance Meeting. We recognise the importance of regularly reviewing the information provided to the Board and have started the process to review the format and content of this report in readiness for the launch of a new report in May 2016.

The foundation trust is fully compliant with the registration requirements of the Care Quality Commission. Assurance is obtained on compliance with CQC registration requirements and the fundamental standards to provide care that is safe, effective, caring, responsive and well led through the following mechanisms:  Divisional reports to the Quality Assurance Committee have been framed around the domains and standards set by the CQC. Divisions have undertaken self assessment

Annual Governance Statement

using the CQC KLOEs to evaluate the services they provide. Action plans are in place to address any areas identified as requiring improvement. These action plans are monitored through the quarterly reports to the Quality Assurance Committee.  A series of internal Quality Reviews has been implemented using the CQC format to undertake unannounced inspection visits to all areas of the hospital and the community. Findings from these inspection visits are reported to the Quality Assurance Committee and triangulated with the Divisional self assessments.  A “Better Care Together” group has been established to co-ordinate the programme of assessments. This group is chaired by the Director of Nursing with membership including senior leadership from each clinical division.  The CQC conducted a full inspection in March 2016, the results of this inspection will not be available until quarter two of 2016/17. Initial feedback from the CQC was positive with no immediate regulatory action.

Compliance with the NHS foundation trust condition 4 (FT governance) To assure itself of the validity of its annual governance statement required under NHS FT Condition 4 (8) b the Board of Directors receives an annual assurance statement and associated evidence. In addition, the Board of Directors has received quarterly reports which it has submitted to the sector regulator - Monitor regarding its principal risks to compliance with its Governance and Continuity of Service ratings. A review of the effectiveness of the Board of Directors and Board Committee was undertaken as part of the enforcement undertakings accepted by the Trust in 2013. A further review using Monitor’s Well Led Governance Framework is planned for 2016.

Compliance with NHS Pension Scheme As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments into the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations. In 2016, the Trust received assurance from its internal auditors that effective processes and procedures for the NHS Pension scheme process are well established and operate in a consistent manner. Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with. The 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.

Review of economy, efficiency and effectiveness of the use of resources

Annual Governance Statement

The Trust regularly reviews the economic, efficient and effective use of resources with robust arrangements in place for setting objectives and targets on a strategic and annual basis. These arrangements include:  Ensuring the financial strategy is affordable  Scrutiny of cost savings plans  Co-ordination of individual and departmental objectives with corporate objectives. In addition to the above, in 2015/16, the Trust was an early adopter of recommendations from the Carter review and was one of the 32 trusts that worked with Lord Carter of Cole to inform his report on operational productivity. Performance against objectives is monitored and actions identified through a number of channels:  Approval of the annual budgets by the Board of Directors  At Executive Director meetings  Bi-monthly reporting to the council of Governors  Monthly reporting to the Board of Directors and the Executive Board on key performance indicators  Integrated Performance Monitoring meetings to hold divisions to account for performance against quality, operational and financial objectives.  Monthly review of financial targets by the Finance and Investment Committee  Quarterly reporting to Monitor.

Finance The Trust achieved its financial plan in 2015/16 however a significant element of this delivery was from non-recurrent initiatives including a £4.1m capital to revenue transfer and over £3m of technical balance sheet measures.

Assurance is provided by: Internal audit - PwC were appointed as the internal auditor in June 2013. At the time of appointment a three year audit plan was agreed. This plan has been formulated based on PwC’s risk assessment of the inherent risk and the control environment. The Head of Internal Audit meets regularly with the Director of Finance and the Chair of the Audit Committee to review progress against the plan and to ensure the plan remains tailored to the needs of the Trust.

The Head of Internal Audit opinion is that the Trust has a “Generally satisfactory” system of internal controls During 2015/16 the Trust received the following internal audit reports.

Report Risk rated

Annual Governance Statement

Capital assets and accounting Medium risk Key financial controls Medium risk Serious incidents and complaints Low risk Service integration – risk management Low risk Cost improvement programme – idea generation Low risk Quality Assurance Committee effectiveness Low risk IT project assurance – PAS convergence High risk Discharging and outpatients Low risk Clinical coding Low risk Quality governance – pressure ulcer reporting Low risk Pensions charter Low risk Assurance Framework and risk management Low risk

The one high risk internal audit report focused on the implementation of the programme to converge the two patient administration systems used by the Trust. The high risk recommendations relate to the programme management of the project and do not have an impact on the wider system of internal control. Procurement of goods and services is undertaken thorough professional procurement staff and through working with neighbouring organisations within a procurement hub. In year cost pressures are rigorously reviewed and challenged, and alternatives for avoiding cost pressures are always considered.

Information governance and Data Security During 2015/16, there were no serious incidents relating to information governance including data loss or confidentiality breach. The Trust Information Risk Management Policy sets out key principles, the legislative and good practice framework, revised information governance structures, and roles and responsibilities, including the concept of Information Asset Owners. The Trust has encrypted all laptops and desktop PCs. Centralised storage has been rolled out across the Trust to ensure that all critical and sensitive data is held securely, not on local equipment. All portable devices such as memory sticks that are plugged into PCs and laptops have enforced encryption. Email encryption software has been procured which allows the encryption of emails containing sensitive information. An Email and Internet Access Policy has been approved to reflect the capabilities that new security applications now give the Trust. Staff have been reminded that email must not be used to send personally identifiable data, unless it is encrypted or NHSmail is used and messages remain within the NHS. The Trust recognises the information governance risks relating to the use of tablet devices and “cloud sharing” and has purchased the software to support and protect information processed on these devices. 68

Annual Governance Statement

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. Governance and Leadership In producing the Quality Account 2015, the Trust identified key areas for improvement of patient safety, clinical effectiveness and experience. To ensure a balanced view, the Board worked with Governors and other internal and external stakeholders to select the priorities on which the Trust would be reporting in 2016/17. In developing the report, consideration has been given to the comments made by internal and external stakeholders including our partner organisations and the External Auditors on previous reports. Policies and plans In 2014 the Board approved a new overarching quality strategy with supporting strategies for the reduction of harm from falls and pressure ulcers. The launch of these policies provided an opportunity to re-engage with staff across the organisation on the importance of zero tolerance of harm. Results reported in our quality account provide evidence that these strategies have been effective with significant reductions in patient harm reported. Data use and reporting We have used existing performance management arrangements to track progress throughout the year on the targets selected and have reported at year end on these to the Board. An external audit report on our 2014/15 Quality Account and a review of data accuracy have provided some assurance that the Trust has arrangements to ensure the accuracy of data. Data accuracy is however still a key priority for the Trust, until the Trust is in a position to implement a full electronic patient record this will remain a risk.

Assurance of 18 week Elective waiting time data The operational teams and Business Intelligence work collaboratively to ensure 18 week data is accurate and of a high quality In order to do this the following are in place:  Specific data quality suite of reports are run by Business Intelligence and circulated to specialties to review on a weekly basis.  Patient Tracking List (PTL) data on Info Flow is updated daily and this is used by the teams to review the patients within their specialties  PTL meeting takes place on a weekly basis chaired by Elective Care Division where all departments report back on patients on their PTL, discrepancies that have been corrected and action that is being taken where delays have been identified within the pathway  Validation of patients is carried out on a weekly basis by teams

Annual Governance Statement

 At the end of the month further validation is carried out by all departments  Business Intelligence circulate month end report which is reviewed by departments and where appropriate corrections are made prior to signoff and upload Testing of the 18 week RTT indicator by the external auditor for the 2015/16 quality report, identified a number of instances where pathways were incorrectly reported as a breach of the 18 week target – that is to say the Trust was underreporting on performance against this target. Assurance of cancer data Teams in Cancer Services and Business Intelligence work collaboratively to ensure cancer data is accurate and of a high quality. In order to do this the following is in place:  Discrepancy reports are generated by the staff in Business intelligence and shared across the trust to highlight any issues. These are actioned in a timely manner by both the centralised and devolved booking teams. LE2.2 / Somerset are corrected as appropriate, or justification provided for any genuine date anomalies.  In April 2015, a cancer workshop was created to focus on the five most challenging pathways. This included clinical and managerial teams working in collaboration to improve pathways.  All Cancer treatments are validated by Business Intelligence and signed off prior to uploading  All data uploaded for the various national cancer audits is validated by Business Intelligence staff prior to upload  A monthly Somerset report highlighting clock re-starts is produced and patients cross checked to ensure clocks are only restarted following DNAs.  All patient breaches for 2 week wait and breast symptomatic 14 day standard are validated  All 62 day, 31 day, screening, subsequent and upgrade breaches are validated  The Trust is part of the Greater Manchester Cancer Network and actively collaborates with the network to drive improvement work.

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 and the audit committee, and a plan to address weaknesses and ensure continuous improvement of the system is in place. Maintaining and reviewing the system of internal control The Board 70

Annual Governance Statement

The Chief Executive and Board of Directors have overall responsibility for the Trust’s Risk Management programme. The Audit Committee This Committee acts independently from the Executive, to provide assurance to the Board, based on a challenge of evidence and assurance obtained, that the interests of the Trust are properly protected in relation to financial reporting and internal control. It keeps under review the effectiveness of the system of internal control; that is the systems established to identify, assess, manage and monitor risks both financial and otherwise, and to ensure the Trust complies with all aspects of the law, relevant regulation and good practice. This Committee reports to the Board any matters in respect of which the Committee considers that action or improvement is needed, and makes recommendations as to the steps to be taken. The Risk Management Committee This Committee provides the Board with an objective review of, in relation to: -  Risk governance, the risk management frameworks and the promotion of behaviours and cultures that drive approaches to risk management.  The systems of internal control in relation to governance and risk management, in that these are fit for purpose, adequately resourced and underpin the Trusts performance and reputation  The overall risk governance process in that it gives clear, explicit and dedicated focus to current and forward-looking aspects of risk exposure The Quality Assurance Committee This Committee provides the Board with an independent and objective review in relation to:  All aspects of quality, specifically: clinical effectiveness, patient experience and patient safety; monitoring compliance against the essential standards of quality and safety set out in the registration requirements of the Care Quality Commission  Governance processes for driving and monitoring the delivery of high quality, clinically safe, patient-centred care  Performance against internal and external quality and clinical improvement targets, and directing management on actions to be taken on sub-standard performance  The overarching Quality Strategy  Assurance on safeguarding quality and to provide appropriate scrutiny to clinical effectiveness, patient safety and patient experience  Assurance (positive and negative) derived from clinical audits is reported through the Clinical Governance committee to the Quality Assurance Committee. The Finance and Investment Committee This Committee provides the Board with an objective review of, and assurances, in relation to: -  Finance, contracting and commissioning issues; presenting reports and recommendations in relation to ensuring we maintain cash liquidity and are an effective going concern

Annual Governance Statement

 Financial governance processes  Business cases referred to it by the Capital and Revenue Investment Group requiring major capital investment  Reviewing and challenging budgets  Compliance with legislative, mandatory and regulatory requirements in terms of the Committee’s scope The Executive Team has responsibility for the development and maintenance of the system of internal control and the outputs from its work provide me with assurance. The Board Assurance Framework itself provides me with evidence that the effectiveness of controls that manage the risks to the organisation achieving its principal objectives have been reviewed.

Significant Internal Control Issues The Trust identified the following internal control issues during 2015/16. These have been or are being addressed through the mechanisms described in this statement. A & E Performance Meeting the national four hour standard for A & E remains a challenge. Constraints on medical and nursing staffing resulted in the Trust concentrating on Ambulatory care, which although showing significant signs of success, were not enough to prevent continued failure to meet the standard through quarters three and four. The Trust is working with partners in the locality to support accident and emergency performance, has commenced overseas recruitment to manage the shortfall in nursing and is redesigning the medical workforce to mitigate the staffing challenge. The Trust has also continued to deploy best practice recommended by the Emergency Care Intensive Support Team to support urgent care and is investing £4 million in the Accident and Emergency department to improve the environment for patients and staff

Never Events In 2015/16, the Trust reported three never events relating to surgery Our three Never Events for 2015/16 are as follows:  Retained foreign object post procedure (retained sling – identified during other investigation and had not resulted in harm to the patient)  Retained foreign object post procedure (a throat pack was briefly left in situ but was removed before the patient was aware)  Wrong site surgery – an anaesthetic block was given to the wrong side prior to an eye procedure – the error was identified and rectified prior to surgery. Investigations have been undertaken/initiated for each incident, although each of these incidents is a never event, it is important to note that there was no lasting harm to the patient in any of the cases

Annual Governance Statement

In August 2015, The Royal College of Surgeons were commissioned to undertake an external review of surgery. An Action plan developed in response to this review was agreed and has been overseen by the Quality Assurance Committee.

Conclusion Despite the significant control issues identified above the Trust have made significant improvements to the system of internal control. Actions are in place to address the issues leading to the control issues and the Board are confident that there is a robust system in place to oversee the implementation of these actions.

Signed Chief Executive Date: 26th May 2016

Quality Report

Statement on Quality from the Chief Executive This last year was a particularly busy one for Bolton Foundation NHS Trust; however, our main priority and focus has been to ensure that our services are Safe, Effective, Caring, Well-led, and Responsive. Since the last publication of our Quality Accounts a key achievement for the organisation was to be taken out of breach of our Foundation Trust licence. This was achieved against a backdrop of strong performance on some of our key quality and safety indicators such as cancer targets, diagnostic tests, stroke targets, hospital acquired infections, falls and many others. I recognise that it is only through the hard work, commitment and support of all our staff that we have achieved this and it is of huge importance to me and the organization that we do everything we can to support our staff in their work. We were delighted therefore, that our staff satisfaction scores continued to rise this year, with the majority now in the top 20% of the UK, and our patient feedback has also improved, highlighting the effects of improved care throughout the Trust. For the period April 2015 – October 2015 the National Reporting and Learning System reported that the Trust was in the top 25% of acute non specialist NHS organisations for incident reporting – indicating that a healthy incident reporting culture thrives in the organisation, thereby enabling the Trust to learn from errors and reduce the risk of further errors. Data drawn from the 2015 NHS Staff Survey further confirms this via the NHS England March 2016 publication; ‘Learning from Mistakes League’ which positions the Trust 34th out of 230 NHS organisations and categorising the Trust as ‘Good: levels of openness and transparency’. Instilling a culture of openness and transparency is key to robust debate, challenge and decision-making giving us confidence that we provide well-led and responsive services. These achievements are also testimony to the commitment and engagement of everyone in the Trust; working together to drive quality improvements forward for the benefits of our patients. There is, however, room for improvement and as a Chief Executive and clinician I know from personal contact with patients and carers that we can always do better. I also know that the Board, Governors and every member of staff are fully committed to providing the very best services we can and that where gaps are identified they are quickly addressed. The Care Quality Commission (CQC) review of our Trust took place in March; the formal report will be available later in the year, but I am pleased to report initial feedback was very positive, with no serious concerns escalated by the CQC to the Trust either during or immediately after the inspection. So as we look to 2016/17 I am clear that our emphasis and focus will remain on delivering consistently high quality, efficient and effective care for all our patients. Devolution Manchester and Healthier Together also provides us with an opportunity to review how we work in collaboration with other healthcare providers in the region; in addition to working closely with our local commissioners to ensure we continue to meet the needs of patients local to Bolton. In terms of our key quality improvement priorities for the coming year, we have worked with our staff, our Foundation Trust members and our Council of Governors to select priorities which we feel will have the greatest impact on improving the quality of care for our patients. These are:  Recognising and responding to deteriorating patients  Stroke  End of Life Care

Quality Report

Finally, I would like to extend a warm thank you to all of the staff at Bolton NHS Foundation Trust who work tirelessly every day to better the lives of patients and the community we serve. To the best of my knowledge, the information we have provided in this Quality Report is accurate and I hope it provides you with a clear picture of how important continuous quality improvement, patient safety and experience are to us at Bolton NHS Foundation Trust.

Dr Jackie Bene, Chief Executive

26th May 2016

Quality Report

Statement of directors’ responsibilities in respect of the Quality Report The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 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 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 2014/15 and supporting guidance;  the content of the Quality Report is not inconsistent with internal and external sources of information including: o Board minutes and papers for the period April 2015 to April 2016 o papers relating to Quality reported to the Board over the period April 2015 to April 2016 o feedback from the commissioners dated o feedback from governors o feedback from local HealthWatch o feedback from local Health Overview and Scrutiny Committee. o the Trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, o the 2015 national patient survey o the 2015 national staff survey o the Head of Internal Audit’s annual opinion over the Trust’s control environment dated 05/2016  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  the Quality Report has been prepared in accordance with Monitor’s annual reporting guidance (which incorporates the Quality Accounts regulations) published at www.monitor.gov.uk/annualreportingmanual) as well as the standards to support data quality for the preparation of the Quality Report (available at www.monitor.gov.uk/annualreportingmanual).

Quality Report

The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report. By order of the Board

Chairman 26th May 2016

Chief Executive 26th May 2016

Quality Report How Quality Initiatives are prioritised in the Trust This Quality account identifies the progress made against the Quality and Safety strategies this year and identifies the Quality Improvement aims for 2016/17. The Safety and Quality programme will enable the Trust to maintain a focus on the Quality and Safety agenda, whilst delivering our clinical strategy to improve the health and outcomes of our local population based on the values and principles set by the Board and in line with the NHS outcomes framework. Following extensive consultation with our Commissioners, Patient Experience Committee and Foundation Trust Governors, the following key improvement priorities for 2016/2017 have been chosen:

Key Improvement Priorities for 2016/2017:  Recognising and responding to deteriorating patients  Stroke  End of Life Care Continuous improvement of clinical quality is further incentivised through the contracting mechanisms that include quality schedules, penalties and CQUIN payments. The Trust hosted a workshop and ensured a comprehensive consultation with our Commissioners and our Clinicians to set-up our CQUINs for 2016/2017 and agree a workplan for the delivery of these.

Quality Performance in 2015/16: In our Quality Report for 2014/15 we set ourselves a series of key priorities for improvement, these were:  Reducing Mortality  Infection Prevention and Control  Reduction in medication errors  Reduction in falls that result in harm to our patients  Reduction in staff Sickness The following pages of our report provide an update on the priorities we agreed for 2015/16

Quality Report

Priority one: Reducing Mortality We set ourselves the objective of continuing to reduce mortality towards our ultimate aim of being in the top 10% for risk adjusted mortality across the NHS

Achieved a reduction in crude mortality from 2.3% to 1.9%* *(2015/16 to February 2016 compared with 2014/15)

Outcome: There has been good progress in crude mortality with reduction in the overall number of deaths in Royal Bolton Hospital. Our risk adjusted mortality remains in the ‘as expected range’; with our Standardised Hospital Mortality Index (SHMI) at 104.0 (10/14 – 09/15) compared to 106.9 (2014/15)

Further improvements for 2016/17:

 Mortality rates will continue to be tracked at the monthly Mortality Reduction Group chaired by the Medical Director.

 The priorities for 2016/17 will focus on recognising and responding to the deteriorating patient and delivering high quality end of life care.

 We have a programme of staff training and robust audit of performance, supported by introduction of an electronic observation recording system.

 Continue our reduction in crude mortality and to be in the top 10% for risk adjusted mortality across the NHS.

Quality Report

Priority two: Infection prevention and control

We set ourselves an overall objective of preventing infection and harm to patients and identified that a key step in achieving this would be to achieve a 10% reduction in antibiotic prescribing through improved antibiotic stewardship

Achieved a 10% reduction in Trust apportioned MSSA cases*

*(2015/16 with 2014/15)

No significant change in antibiotic prescribing*

*(2015/16 with 2014/15)

Outcome:

MSSA: There has been a 10% reduction in Trust apportioned MSSA cases in 2015/16 compared with 2014/15.

25 20

Cases 10 5 0 2011/12 2012/13 2013/14 2014/15 2015/16 Trust Apportioned 17 20 16 18 15

Antibiotic Prescribing: Based on the quarterly antibiotic prescribing audits, there has been no significant change in antibiotic consumption in 2015/16 compared with 2014/15

MRSA There were seven Trust assigned MRSA bacteraemias in 2015/16. Four were “true” bloodstream infections, three were blood culture contaminants. Of the four infections, two related to line care, one was a recurrent infection from an earlier MRSA episode and one had no clear root cause.

MRSA (Trust Apportioned to 12/13, Trust Assigned 13/14-15/16) 30

25 20 15 10

No of Cases of No 5 0

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CDT: Of the 28 cases in 2015/16, three have been successfully appealed; with a further four due for appeal in May 2016. We are hoping to be successful in our appeal bringing our year end position to 21 cases, an increase of 1 (5%) on 2014/15.

250 200 150

Cases 100 50 0 20 20 20 20 20 20 20 20 20 07/ 08/ 09/ 10/ 11/ 12/ 13/ 14/ 15/ 08 09 10 11 12 13 14 15 16 Trust Apportioned 233 164 34 45 21 62 36 20 28

Further improvement identified for 2016/17:

MRSA and MSSA:  Establish a blood culture contaminant working group to focus on improvement of the blood collection process. By reducing the overall contaminant rate, the likelihood of MRSA cases related to contaminants is reduced  Revise Trust peripheral intravenous line care policy and peripheral line care plan; with training and audit plan to support implementation  Revise plans for a dedicated nurse led IV access service

CDT:  Trustwide roll-out of SIGHT (Suspect infection, Isolate, Gloves and aprons, Hand washing, Test for toxin), supported by a revised protocol for the management of patients with diarrhoea with no alternative cause and a new Diarrhoea Management Tool  Continued promotion to improve antibiotic prescribing standards led by our lead Consultant Microbiologist and supported by our junior doctor forum

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Priority three: Reduction in medication errors

We set ourselves a target of reducing incidents relating to missed doses of medication by 10%

Achieved a 2% reduction in incidents relating to missed doses*

 within a sub category of preparation and administration related incidents

Outcome: The number of reported medicines incidents (2014/15= 1146, 2015/16= 1143) and missed doses (2014/15= 120, 2015/16=118) remains constant – see chart below. However, missed doses fall within a sub category of preparation and administration related incidents and within this category missed doses have reduced by 2% since 2014/15

Missed Dose incidents reported 2014 - 2016 20 18 16

14 12 10 8

Incidents reported 6 4 2

Jul-14 Jul-15

Jan-15 Jan-16

Jun-14 Jun-15

Oct-14 Oct-15

Apr-14 Apr-15

Feb-16 Sep-14 Feb-15 Sep-15

Dec-14 Dec-15

Aug-14 Aug-15

Nov-14 Nov-15

Mar-15 Mar-16 May-15 May-14

Further improvement identified for 2016/17: We will continue to focus on the reduction of medication incidents related to the omission of medication and will do this by:  Developing an audit process for measuring the reduction for this group of incidents in quarter 1 to establish the baseline on which to measure the 10% improvement.  Monthly data regarding incidents will be monitored through the Medications Management Committee, clinical teams will produce actions plans based on the themes and trends identified  The medicines safety nurse will roll out a programme of education and audit.

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Priority four: Reduction in falls with harm We set ourselves the objective of achieving a 10% reduction in falls where patient experience severe harm

Achieved a 40% reduction in preventable falls with harm* Achieved a 47% reduction in falls where patients experience severe harm *

*Comparing data from April 2014-March 2015 with April 2015-March 2016

Outcome: The 12 month rolling picture continues to show a downward trend as indicated in the graphs below

Preventable falls with harm 12 month trend 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0

Rolling 12 month fall with severe harm 3.5 3 2.5 2 1.5 1 0.5 0

Further improvements achieved:  Improvements in most aspects of the 2015 National Audit of Inpatient falls (compared with 2014) in which Bolton performed better than the national average but with focus on the areas for improvement we can be better still.  Falls management plan embedded Trust-wide  Falls specific data at a divisional level for trend analysis and opportunities for improvement

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 Themes from Falls Harm Free Panel shared trust-wide  Staff training programme with 1225 staff now trained in fall prevention.  Establishment of trust-wide “Arms reach commode tagging”  A Harm Free intranet page providing all staff with access to falls related resources

Further improvement identified for 2016/17:

Reduction in falls remains a key priority for the Trust; due to the changing demographics of the patients now under our care, for example a rise in average age, complexity, frailty and frailty. Increasingly more of our patients are considered to be high risk of falls and therefore needing more care and attention from all staff than before. In 2015, the Trust contributed to the National falls and fracture audit, which highlighted areas for improvement. Actions for 2016/17 include:

 Falls Steering Group re-launch - feeding into the harm free committee  Further roll out of frame label to ensure safe patient mobility.  Improved compliance with completion of accurate lying and standing blood pressure to identify possible falls risk due to postural drop in blood pressure.  Review of the falls management plan to ensure optimum documentation of individual falls risks.  Better identification and treatment of delirium in collaboration with the dementia steering group to facilitate further reduce falls risks.  Medicine reviews to include assessment for medication likely to increase falls risk and adjustments made where appropriate.  Improved access to walking equipment for patients admitted out of core therapy hours.  Individualised continence assessments leading to appropriate continence care plans with falls risk taken into account.  Optimisation of staff distribution across bed based areas to ensure high visibility and regular contact with all high risk patients.  To capture and understand the patient experience following a fall and use any learning to further improve fall prevention strategies.

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Priority five: Reduction in staff sickness We set an objective of reducing staff sickness to 4.2%

Achieved a reduction in sickness levels from 4.99% to 4.64%* *(Year to date rolling sickness January 2015 compared with January 2016)

Outcome:

Sickness days % of days lost 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% Septemb Novemb Decembe April May June July August October January February March er er r 2014-15 Actual 5.17% 4.81% 4.60% 4.66% 4.57% 4.57% 5.06% 5.00% 5.39% 5.07% 4.96% 4.79% 2015-16 Actual 4.38% 4.31% 4.52% 4.87% 4.65% 4.40% 4.57% 4.33% 4.79% 5.02% 4.77% 4.80% 2015-16 Target 4.20% 4.20% 4.20% 4.20% 4.20% 4.20% 4.20% 4.20% 4.20% 4.20% 4.20% 4.20%

Further improvement identified for 2016/17:

 Development of a health and wellbeing strategy going beyond the focus on reducing sickness absence by addressing the common causes of poor health and helping people to improve their lifestyles.  Increased full time release of staff side representatives in order to improve the timeliness of sickness case management.  Ongoing training and coaching for our managers and supervisors on the Attendance Management Policy.  Monthly audits to ensure consistent application of the Policy amongst managers, with focused feedback and coaching provided to each manager.  Continuing fast track mental wellbeing sessions and physiotherapy treatment for staff.  Delivering interventions on staff engagement and leadership development in teams as required to improve team working, cohesion and leadership.

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Key Quality Priorities for 2016/17 Our Quality Improvement Strategy (2014-2017) outlines a number of quality improvement projects that we believe will lead to demonstrable improvements in outcomes, safety and patient experience; and we have been working on these projects for a number of years. We would, however, like to highlight the following projects as Bolton Foundation NHS Trust’s key improvement priorities for 2016/17:

Priority one: Recognising and responding to deteriorating patients

Background: Earlier recognition of acutely unwell patients improves their chance of survival and management may prevent critical care admission and means that a patient’s deteriorating condition is much less likely to result in a cardiac arrest. We also know that a number of factors can lead to patients not receiving the highest standard of care. Our audits of cardiac arrests, critical care escalation and end of life care demonstrate continued opportunities for improvement.

Aim: The overall aim of this workstream is to reduce the number of avoidable cardiac arrests within ward areas by 50% within one year. However, the work has a much wider remit and aims to ensure that the Trust has sustainable systems in place to prevent and respond to deteriorating patient and escalate.

What we will do In 2016/17 we aim to test, and if successful, implement a range of interventions that will:

 Provide early recognition and treatment of patients with deteriorating but reversible conditions  Identify patients whose care requires escalation and action in a timely manner  Identify patients in whom deterioration indicates+ the approaching end of life and make appropriate resuscitation status decisions to facilitate a dignified and peaceful death

Our interventions can be grouped into the following categories:

Culture, teamwork, accountability & sustainability  Clearly defined protocols and policies  Root cause analysis and learning  Simulation  Performance monitoring  Staff competencies

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Assessment & observation  High risk patients identified  Standardised processes for essential observations  90% compliance with observation policy  Care of the dying

Response  Immediate appropriate response to deterioration  Increased ward level capability  Optimal patient management – step up/ down  Escalation policy

Patient flow & communication  Ensure efficient and standardised handovers and transfers  Increased understanding of systems  Cascade of command  Quality improvement initiatives

Measurement: Outcome measure - 50% reduction in the number of avoidable cardiac arrests (33 in 2015/16)

Other measures we will monitor include:  Recording of National Early Warning Scores (NEWS) to Gold Standard. - *National Sepsis CQUIN (72.7% in 2014, 71.4% in 2015  Standardised Hospital Mortality (SHMI) (104 in 2015/16)  Risk Adjusted Mortality – rebased each year and therefore not used as a baseline for this report.

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Priority two: Stroke

Background: Stroke affects a wide range of individuals and has a variety of impacts upon their quality of life and on-going long term care needs. Bolton aims to provide fast, effective and evidence based care to meet the complex needs of the stroke population and their carers. Improving the care and outcomes for stroke patients involves a wide range of individuals and organisations, across the health and social care, professional and public, and statutory and voluntary and over the next year, Bolton NHS Foundation Trust will work with these organisations to maintain and improve Stroke care.

Aim: Every patient diagnosed as having suffered a stroke will receive best available, evidence based stroke care in line with the Greater Manchester stroke pathway delivered seamlessly and efficiently across partner organisations. This will include timely and effective communication with patients, families and carers to enable inclusive and informed decision making at all stages of the pathway.

What we will do: In 2016/17 we aim to implement a range of interventions that will:  Ensure sufficient capacity to deliver the appropriate levels of care in location best suited to the patients’ needs.  Ensure that the service is structured to comprise the staff with the skills, competency and knowledge to lead, adapt, develop and deliver the stroke service to ensure that all patients experience safe, responsive and effective care.  Ensure the timely collection, analysis and sharing of national audit data (SSNAP) to support the identification of areas of good practice and areas requiring improvement. This data will inform the stroke service action plan, detailing the objective, action, outcome and progress of any area identified for improvement.  Ensure participation in and compliance with the existing comprehensive network of forums and systems in place for the delivery of education and training, information sharing and two way reporting for all stakeholders, including service users.

Our interventions can be grouped into the following categories:

Responsive Care (across pathway)  Defined protocols and procedures for transfer of patients across the pathway  Root cause analysis and learning  Rapid identification of delayed discharges and escalation  Flexible capacity to meet surges in demand  Consideration of sector working for rehabilitation provision

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Effective and Timely Intervention  Standardised assessment and diagnosis protocols for clinical staff  Internal professional standards (health and social care)  Recruitment and retention initiatives for highly skilled staff

Transforming the Workforce  Workforce review and restructure  Shared learning and problem solving events  Staff competencies  Deliver of education and training programme

Information Intelligence  Access to and utilisation of newly implemented electronic systems.  Timely and consistent inputting of validated data into the SSNAP database  Performance monitoring

Measurement: We will use following the national key performance indicators from the Stroke Sentinel National Audit Programme (SSNAP) to track progress against our aims:

Indicator Q1 14/15 Q2 14/15 Q4 15/16 Q1 15/16 Q2 15/16 Q3 15/16

Scores not available for Q3 2014/15 Q3 for available not Scores Admission to a stroke unit within 4 hours of 73% 68.50% 41.40% 65.00% 65.80% 76.90% presentation at an urgent care facility

90% of stroke patient’s stay in hospital is on a stroke unit once confirmed diagnosis of 97.70% 87.10% 75% 83.70% 87.30% 92.90% stroke

Opportunity to receive thrombolysis at Comprehensive Stroke Centre for those 9% 6.80% 2% 4.90% 1.40% 4.50% patient who are eligible / compliance with

the Greater Manchester Stroke pathway

All appropriate stroke patients have a urinary continence plan drawn up by 100% 95.20% 95.50% 98.00% 98.10% 97.4% discharge from inpatient care

All stroke patients whose nutritional screening identifies a high risk of 89% 92% 80% 79% 66.70% 77.8% malnutrition are seen by a dietician prior to discharge

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All applicable stroke patients receive occupational therapy equivalent to 45 99.6% 86.8% 99.7% 94.1% 93.70% 90.6% minutes on 5 days per week.

All applicable stroke patients receive physiotherapy equivalent to 45 minutes on 69.10% 66.30% 83.30% 84.70% 60.60% 75.0% 5 days per week.

All applicable stroke patients receive speech and language therapy equivalent to 45 24.10% 16.40% 20.40% 23.80% 19.80% 22.6% minutes on 5 days per week.

All stroke patients presenting with new or previously diagnosed atrial fibrillation are anti-coagulated on discharge, or with a plan 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% to start, or with a documented rationale for not anti-coagulating

All stroke patients are discharged with a joint health and social care plan and a 100.0% 100.0% 98.3% 98.6% 100.0% 100.0% named contact.

All applicable Stroke patients are discharged 66.70% 67.30% 79.70% 75.70% 66.20% 73.5% to an Early Supported Discharge Team

Reporting our progress:  All our improvement projects follow an established governance structure which monitors and measures performance and progress.  The forum which will provide progress, oversight and accountability for this work stream is the Stroke Service Governance Meeting, chaired by Business Manager and Stroke Service Clinical Lead and the Better Care Together Meeting, chaired by the Director of Nursing  Externally Bolton reports to the Greater Manchester Stroke Operational Delivery Network via the following meetings:  Board  Clinical Effectiveness Group  Rehabilitation Group  Training and Education Group

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Priority three: End of Life Care

Background: Improving End of life care involves a wide range of individuals and organisations, across the health and social care, professional and public, and statutory and voluntary spectrum. In 2016/17 Bolton NHS Foundation Trust will work with colleagues and individuals across our health economy to implement and improve end of life care for patients in the last year of life. We recognise the increasing needs of patients and their families during the final year of life and the importance of anticipating their needs and forward planning of care. We also recognise that exemplary care in the final year of life requires commitment from all health and social care; it is everyone’s responsibility. Aim: We aim to ensure every patient will receive optimal holistic patient centred end of life care, encompassing their physical, spiritual and emotional needs, taking into account their wishes and preferences. Patients, families and carers will be treated with dignity and respect, and be communicated with in an open, honest and compassionate manner; and this care will be provided during the final 12 months of life and extend into bereavement. What we will do Our interventions can be grouped into the following categories:

Patient and Carer experience  Implementation of Bereavement and Care questionnaire  Monitoring of complaints and compliments, review of action logs and learning  Implementation of the Bereavement and Donor Alliance  Reduction of DNA rates for clinic  All patient to be asked about preferred place of care

Education and Training  Staff to attend Sage and Thyme.  Ward managers/team leaders /clinical leads to have attended enhanced communication training  Establishment of Palliative and End of life education group  Development of End of Life Care link/leads group, supported by End of Life university module  Attendance report on training monthly report

Documentation and Communication  Trust-wide roll out of “Record of care”

Agree and implement work plan and Measurements of KPIs  Development of End of Life Care Action plan with associated key performance indicators to track progress

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 Non-executive/lay person representative to form part of End of Life Care Steering Group  Review and approval of all end of life care polices

Measurement: Outcome measures:  All patients and families report good or outstanding care  90 % of patients on Record of care for the dying person  95% of patients on Record of care to be asked about their preferred place of care.

Other measures we will monitor include: Patient and Referrals to Specialist Palliative care team:  Hospital referrals -100% referral to the specialist palliative care team for pain and symptom control within hospital setting are seen within 24 hours  Community referral -100% referral for pain and symptom control have first contact within 72 hours Record of care of the dying person:  80% of expected deaths in hospital identified to be in the last few days of life are placed on the Record of care of the person document Bereavement Questionnaire  100% of bereaved families are sent a questionnaire two weeks after hospital death Specialist palliative care MDT  Attendance of Core members at the weekly specialist MDT is greater the 66% Education and Training of end of life care  100% of eligible nursing staff are trained to carry out nurses verification of expected death  25% of clinical staff in the trust has received 5 priorities of care of the dying person (this training is for all clinical staff and now part of the induction for all new clinical starters)

Reporting our progress: The “Record of Care for the dying person” was introduced in 2015/16, in 16/17 we are aiming to establish a baseline with the above metrics agreed as targets to be monitored and reported as below:  All our improvement projects follow an established governance structure which monitors and measures performance and progress.  The forum which will provide progress, oversight and accountability for this workstream is the End of Life Steering Group and the Better Care Together Meeting, chaired by the Director of Nursing; and is also accountable to the Clinical Governance and Quality Committee

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Statement of assurance from the board

Review of services During 2015/16 Bolton NHS Foundation Trust provided and/or sub-contracted seven regulated activities (as defined by the CQC) across 38 specialities. Bolton NHS Foundation Trust has reviewed all the data available to it on the quality of care in these NHS services. The income generated by the relevant services reviewed in 2015/16 represents 100% of the total income generated from the provision of NHS services by Bolton NHS Foundation Trust in 2015/16

Participation in Clinical Audits and Research Activity During 2015/16 41 national clinical audits and 4 national confidential enquiries covered relevant health services that Bolton NHS Foundation Trust provides.

During that period Bolton NHS Foundation Trust participated in 100% national clinical audits and 100% national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries Bolton NHS Foundation Trust was eligible to participate in during 2015/16 are as follows:

Participation Audit 2015/16

Heart Failure National Audit Project Yes

MINAP Yes

National Diabetes Foot care Audit - Diabetes (Adult) Yes

Diabetes (Paediatric) (NPDA) Yes

Emergency Use of Oxygen Yes

National Comparative Audit of Blood Transfusion programme Yes

NCA Patient Blood Management/Blood Use in Elective Surgery Yes

Transfusion sample labelling Re-audit (errors detected at the pre-testing stage) Yes

Sentinel Stroke National Audit Programme (SSNAP) Yes

National Audit of Intermediate Care Yes

UK Parkinson’s Audit (previously known as National Parkinson's Audit) Yes

Procedural Sedation Yes

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VTE risk in lower limb immobilisation in plaster cast Yes

Vital signs in Children Yes

MBRACE Maternal, new-born & infant Clinical outcome review programme Yes

WHO Baby Friendly Initiative Yes

National Diabetes In-patient Audit - Diabetes (Adult) Yes

National Diabetes Audit - Diabetes (Adult) Secondary Care Yes

Pregnancy in Diabetes (NPID) NCAPOP Yes

Paediatric Asthma BTS 2015 Yes

Neonatal Intensive and Special Care (NNAP) Yes

Pulmonary rehabilitation Audit - National COPD Audit Programme, BTS Yes

Downs Syndrome Screening + amino / cvs Yes

Lower limb amputation Yes

Diabetic foot ulcer Yes

Management of Diabetic Ketoacidosis (DKA) in adults Yes

National Joint Registry (NJR) Yes

Falls and Fragility Fractures Audit Programme (FFFAP) 3 Work streams include: Yes 1. Nation Hip Fracture Database 2. Fracture liaison service database 3. National Audit of Inpatient Falls 2015 National Comparative Audit of Lower Gastrointestinal Bleeding and the use of Yes blood (RCS BDRF ACPGBI) Major Trauma: The Trauma Audit & Research Network (TARN) Yes

National Emergency Laparotomy Audit (NELA) Yes

Rheumatoid and Early Inflammatory Arthritis Yes

ICNARC Case Mix Programme (CMP) Yes

Bowel cancer (NBOCAP) Yes

Lung cancer (NLCA) Yes

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National Prostate Cancer Audit Yes

Oesophageal- gastric cancer (NAOGC) Yes

Elective surgery (National PROMs Programme) Yes

Medical and Surgical Clinical Outcome Review Programme (NCEPOD) Yes

National Vascular Registry Yes

Diabetes Foot Care National Audit - 2015/16 Yes

Table 1: National Clinical Audits

The reports of 9 national clinical audits were reviewed by the provider in 2015/16 and Bolton NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided.

National Comparative Audit of Blood Transfusion programme Blood Transfusion competency assurance paper presented to Clinical Governance & Quality committee Staff lists to be data cleansed and the Blood Transfusion team updated accordingly. Medical Staff to be targeted on next induction. Blood Transfusion Link Nurses will be revisited for low performing clinical areas. Training dates for Link Nurses to be obtained from the Blood Transfusion team and Link Nurses to be booked onto training.

National Bowel Cancer Audit Colorectal Cancer MDT upload should move to a monthly configuration allowing all consultant colorectal surgeons to actively inspect their data in real time.

Falls and Fragility Fractures Audit Programme – National Audit of In-patient Falls - September 2015 Dementia and delirium Falls teams should work closely with dementia and delirium teams to ensure team working for these high-risk patients. Work in progress. Dementia working group currently working through action plan to improve awareness of dementia and delirium. Falls representation also involved. Use of assessment tools and care plans to be audited once established. Blood pressure – All patients aged over 65 years have a lying and standing blood pressure performed as soon as practicable, and that actions are taken if there is a substantial drop in blood pressure on standing. This is already recommended and encouraged for all patients deemed at risk of falls but practice is poor at present (though improving). Matrons to continue to encourage this and to be checked regularly via NEWS audit. Medication review – All patients aged over 65 years have a medication review, looking particularly for medications that are likely to increase risks of falling. Poorly done at present. Pharmacy staff to begin to check for medication likely to increase falls risk during medicines reconciliation and advise medical staff accordingly. Visual impairment – We recommend that all patients aged over 65 years are assessed for visual impairment and, if present, that their care plan takes this into account. This is already in the falls management plan but not routinely completed so requires further encouragement for improvement. To be checked again in next audit of falls management plan. Walking aids – We recommend that trusts and health boards develop a workable policy to ensure that all

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patients who need walking aids have access to the most appropriate walking aid from the time of admission. Regular audits should be undertaken to assess whether the policy is working and whether mobility aids are within the patient’s reach, if they are needed. There is a mechanism for accessing therapy staff out of core hours when walking equipment is needed. To ensure all staff have access to contact details for this process. To check location of mobility aids again in next audit of falls management plan. Continence care plan – We recommend that all patients aged over 65 years have a continence care plan developed if there are continence issues, and that the care plan takes into account and mitigates against the risks of falling. Pilot currently being done on B1 and G4 to encourage good continence assessment. If successful will be rolled out to other wards. Call bells – We recommend that all trusts and health boards regularly audit whether the call bell is within reach of the patient and embed change in practice if needed. Practice is generally good across the organization with this but could be further improved. This will be audited through clinical nurse walk about and intentional rounding.

MINAP National Report

Introduction of ward round to CDU to determine if any patients are for C1 or CCU care. Implementing new minimum data standards Expand MINAP coordinators role so that they are more involved and make the data collection exercise meaningful and patient centered, not a tick-box exercise. Timeliness of angiography following nSTEMI - dependent on the tertiary centre accepting patients within the timeframe.

National Lung Cancer Audit People with lung cancer have adequate tissue samples taken in a suitable form to provide a complete pathological diagnosis including tumour typing and sub-typing, and analysis of predictive markers. Service is clinically appropriate and taking into account multiple risk factors National Emergency Laparotomy Audit (NELA)

A sustained multidisciplinary effort is required to provide 24-hour interventional radiology, this is essential for units providing an EGS service. Available weekdays during daytime hours. Work continues to develop sector solution

Sentinel Stroke National Audit Programme (SSNAP)

Discuss partnership working with WWL Improve planning for annual leave and sickness cover for TIA clinic though use of ‘e-leave’ Recruitment to Consultant vacancy – geriatrician with stroke certificate Work with CCG and GP to review how and what information is currently given to patients and agree new process Seek patient feedback on satisfaction with TIA clinic booking process Revise referral form to include potential barriers to short notice access e.g. mobility/dependency Immediate feedback to referrers when referral indicates a delay between being seen and referral being sent

National COPD Audit Programme RCP/BTS Patient length of stay – hospital model work in progress. Better identification of COPD on admission. Implementation of Admission / discharge care bundles. Develop trust O2 training programme. Participation in research project by BTS & Bristol University. Medical staffing - Improve ratio of ST3+. Business plan.

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National Emergency Laparotomy Audit 24-hour interventional radiology. Available weekdays during daytime hours. Work continues to develop sector solution. Financial/staffing issues need resolving to provide this service

Table 2: National Clinical Audits: Actions to Improve Quality

Number cases Local Gap Analysis Completed Included Outcomes of published Report Mental Health N=5/5 Cases Report due mid 2016 100% Awaiting report

Acute Pancreatitis N=5/5 Cases Report due mid 2016 100%

Awaiting report

Sepsis N=5/5 Cases 21 recommendations – Are we compliant? Draft Gap Analysis Dec 2015 100% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Action Plan: 6. Nursing home trial to extend. Increase collaboration with CCG 7. As above + Liaise with NWAS 8. Ongoing discussion re vitals recorded at triage. Moving towards NEWS 10. Emphasised locally but not incorporated into guideline. Awaiting national approach. 16. Awaiting national publication of support booklet 18. Education to junior doctors completing discharge. Happens ad hoc. 19. Occurs inconsistently at departmental M&M. Plan for sepsis RCA 20. Inconsistent nationally as some coroners don’t accept diagnosis. To discuss locally. 21. National approach needed. Local work being undertaken to achieve better coding.

Gastrointestinal N=2/2 Cases 1 N N 4 5 6 7 8 9 10 Haemorrhage 100% A A Gap Analysis Nov 2015 N 12 13 14 15 16 17 18 19 20 A 21 N N 24 N N A A A A

Action Plan: 1. Formal network required through IR. 6, 12. Audit required 11, 22, 23. For professional documents 15. Business case 25, 26 For JAG Table 3: NCEPOD Confidential Enquiries Projects Participation

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Local Audits: 297 Local Audits were registered between April 2015 and March 2016.

The reports of 40 local clinical audits were reviewed by the Trust in 2015/16 and the Bolton NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided.

Title Actions Theme of change In practice Adult IBD Organisational Regular MDT meetings on a 6-8 weekly basis. Chaired by Communication Audit Nurse Consultant. The IBD nursing team meets monthly. Process Access for relapsing patients. All patients are seen within 2 weeks; IBD named coordinator. Audit required. Specialist support for young IBD patients Transition pathway in place, QI updates in progress

Acute exacerbation od Determine causes of death within this audit cohort. Re-audit COPD Re-audit deceased patients.

Metastatic Spinal Cord Improve the current inadequate information sent with Process compression Pathway referrals to our service – forward & discuss audit results review with referring agencies.

In Hospital falls Update of falls assessment tools. Local Guideline Increase awareness & use of falls assessment tools. Update Improve access to medical assessment tool – availability. Process Disseminate audit results & learning. Community Acquired Dissemination of results to Primary Care / CCG colleagues. Education Pneumonia Work towards better are for CaP in the community. Process Radiographers to prioritise chest x-rays in acute areas.

Alcohol Withdrawal Improve link nurse network for cascade training. Communication Management Increase awareness among junior doctors by formal / Training Informal training. Process Explore other options for withdrawal assessment. Update & implement new withdrawal care plan. Maintain relationships with departments within the Trust. Risk assessment during Failure to recognise risks at booking - Existing list in ANC Process antenatal, intrapartum & pathway guideline. postnatal period Lack of compliance with 3rd Trimester Antenatal Risk Standard Assessment and Mental Health Risk Assessment - ensure working all staff are aware of the importance of assessment and it is the responsibility of all staff to complete Assessment Training Improve compliance of risk assessment in ANC/ labour/ Postnatal/ community - ensure staff are aware of relevant sections

Essure Re-audit Reduction in pain score categorisation. Documentation Trial use of paracervical block & re-look at pain scores Process

High Risk / Delayed Improved documentation of negative results in the notes Documentation Results in paediatrics along with improved documentation of correspondence with colleagues and patients and families - new proforma

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from August 2015.

Puerperal Sepsis outlier Positive feedback regarding reduced SSI to all teams. (Oct Training audit – CQC 2015 2015) Re-audit Further training and awareness around diagnosis and management of sepsis with the current cohort of doctors, midwives, anaesthetic trainees, and senior doctors. (Nov 2015)

Audit to be repeated on a monthly rolling basis with smaller multidisciplinary panel. Revision of audit proforma. (Nov 2015). Diabetic Ketoacidosis in Ensure guideline states BM should be monitored hourly Process Paediatrics whilst on IV insulin. Training More clarity regarding what time the insulin infusion has been started. Revision of IV fluid prescription charts Adopt NICE guidelines and change to starting insulin at 0.05 UNITS/kg/hr.

IV fluids in children – audit Ensure U&E rechecked within 24 hrs. - Education , clear Process of prescribing indication on new I/V Rx charts Standard Replaced of old charts by the new charts - Waiting printing working to chase. Documentation Guideline to better direct choice between 24/48hrs deficit replacement. Review guidelines and if necessary update. Cow’s Milk Allergy – Clarify indications for IgE testing in new guideline - Standard Diagnosis & Management Guideline update due November 2015 working Incorporate lactose intolerance and its management in new Documentation guideline (with indications for stool testing) Introduction of separate Gastro-oesophageal reflux guideline Introduce separate Cow’s Milk Protein Allergy information leaflet - Incorporate into information leaflet work already on-going

CAMHS Record Keeping Training of staff on good record keeping standards. Training 2015/16 All have responsibility for ensuring standards. Documentation

Acute Paediatrics Record Display outline of recordkeeping standards poster to Training Keeping 2015/16 remind staff. Documentation Supervisors to monitor trainee’s documentation. 1st staff member to see patient on F5 ward to prepare clerking document with patient details labelling on all pages. Nutrition & Fasting in Hip Emphasise fasting guidelines Training Fracture Patients Nutrition assessments to be completed & risks to be highlighted to medical staff Standard Educate staff nurses regarding proper documentation in working NAT chart Encourage availability of snacks/ sociable meal times Dietician review in all patients with dementia

Pre-operative Quality & Booking 2-4weeks prior to operation Standard

Quality Report

Service Improvement – Investigation review prior to pre-op clinic working Bolton One Referral documentation with specific indication Training Nurse pre-assessment visit prior to anaesthetist Safety on discharge Embed as Routine practice Standard Document on anaesthetic chart working Recovery staff to audit practice Documentation STOP Before You Block Ensure awareness of STOP before you block Training Audit All to perform ‘STOP’ immediately prior to block. Documentation Re- design Audit form to capture if patient was awake or asleep at the time of block. Adapt how data collected for on- going audits. Bolton Pain Assessment Continue Pain Education across Trust Training Scale Encourage good attendance from Link Nurse from all wards Staff Knowledge - Pain and Departments at Quarterly Pain Link Nurse meetings Management Organise Trust wide Study days twice a year that all staff can access Develop business case to expand Acute Pain Team Pain Clinic - Patient Reduce waiting times Standard Satisfaction Survey working

5 year locoregional Audit showed a locoregional recurrence rate of 2.9% which Re-Audit recurrence following is lower than the published literature of 3-10%. breast cancer surgery High current level of treatment for our patients. No changes identified Re-audit. Consenting Practice within Breast Consent form Steering group established Communication Bolton Breast Unit for Raise awareness amongst surgical team Training Common Breast Develop consensus opinion/guideline on the necessary risks Documentation Procedures to be documented for each procedure Develop breast procedure specific consent forms Trial of sticky labels RBH ITU Tracheostomy Consent to be fully documented - patient obviously Documentation Checklist & Consent Audit incapacitated from clinical context Checklist use Fully complete forms including Timeout and/or Post- procedure Checks

Emergency case operation Improve legibility and completeness of operation notes Documentation notes Increase uptake of typed operation notes - dedicated printer installed in recovery room in theatres.

NICE CG174 fluid Fluid management an active part of all ward rounds. Standard prescription guidelines on Improved documentation working Surgical Wards Fluid management included into the induction booklet for new junior doctors to surgery. Re-audit in 3-6 months.

Re‐Audit of Consent & Feedback results of this audit to raise awareness Training Information for Blood Further discussion - Recording information given prior to Documentation Transfusion discharge (in cases where the patient could not give consent at the time of transfusion) Re-audit

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Review of pregnancy Add comments to results of high βHCG MoMs Documentation outcomes in women with Abstract at FOCUS 2016 high βHCG MoMs Transfusion Sample Disseminate presentation via email to Divisions for Training Rejection Re-Audit consideration through quality forums for further action 2015 Contact clinical leads to evaluate practice in key service- Standard user areas with above average error rates working (Paediatrics/Neonatal) Continue to monitor NPSA transfusion competency assessment compliance and report to Trust and Divisions Continue transfusion sample zero tolerance i.e. all incorrect samples are discarded (a minority of qualifying samples may be tested under concession, as per transfusion policy) Continue to evaluate implementation of positive ID system for blood samples using barcode technology (to be managed via HTC action plan) Local Re-Audit of Competency assessment to continue to be monitored and Standard Transfusion Bedside reported to the Trust via the quarterly Transfusion Metrics working Practice 2015 report Local re-audit in 2016 Present this audit at the Hospital Transfusion Committee Meeting and add any further actions to HTC action plan Present this audit at the Trust Governance and Quality Committee Meeting and add any further actions to action plan. NPSA/Training Transfusion Competency assessment non-compliance has been escalated from HTC. Body Weight Dosing of Red Agree target Hblevels to be used for the calculation Standard Cells for Patients with Amend code in red cell calculator program working Normovolaemic Anaemia: Full validation project as per Quality Management Phase 2 Validation Audit standards Implement in practice if successful validation and approved by Trust Q&G Re‐audit of cases where the calculator has been implemented

Re-Audit of Blood Re-design blood request/prescription form to improve Documentation Transfusion Consent emphasis of consent section. Gain user opinion. Change at Documentation next re-print Training structure and content to remain Training same. Update induction Power-point slides with new graphics Update e-learning programmes with new graphics

Suspected / Confirmed Develop a generic proforma to collect data Documentation Neutropenic Sepsis All out of hours Haematology patients to go via A&E rather Process than D1/D2

NICU imaging in assessing To use lower exposure factors, reduce dose creep, and use Standard line placement tighter collimation. working Continue to attempt to correctly position the infant to Process allow no rotation. Radiographers to check that all arte facts are removed prior to exposure, especially those related to ECG leads. Encourage use of markers. Encourage radiographers to magnify their images on PACs

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when verifying and to record which mobile machine was used as per IRMER. Audit to be performed on imaging for line insertion. Application of Staging No actions Re-audit System in Cancer Diagnosis Re-audit in one year time with bigger sample study to have more reliable representation of the audit result

Record Keeping and Review archiving process and identify new procedure Training Consent audit Darley All staff to attend documentation up-date training sessions Standard Court Review current practice in PT meeting and agree guidelines working to support practice MSK Therapy Out-Patients Endeavour to see patients as close to their appointment Standard Appointment time time as possible. working compliance Patient Experience Audit No actions NA Therapy Out-Patients New Joint Injection Audit injection referrals. Communication pathway from GP direct to Establish if all GP’s aware that injection appointments MSK Physiotherapy offered at RBH Discuss with injection therapists Effectiveness of the Admin staff to fill all slots each week. Strict D/C policy for Standard Hydrotherapy Group DNA’s. working Sessions Give out exercise sheets at Hydro sessions Documentation Give referral letters to all patients on completion of their sessions. Liaise with management staff and IT to establish pathways.

Participation in Clinical Research The total number of patients receiving relevant health services provided by Bolton NHS Foundation Trust that were recruited to participate in research in 2015/16 was 798. 671 of these patients were recruited into 45 open NIHR Portfolio Trials, an increase of 102 (17.9%) patients recruited from 2014/15.

Goals agreed with Commissioners: use of the CQUIN payment framework A proportion of Bolton NHS Foundation Trust income in 2015/16 was conditional on achieving quality improvement and innovation goals agreed between Bolton Foundation NHS Trust and any person or body they entered into a contract agreement or arrangement with for the provision of relevant health services, through the Commissioning for Quality and Innovation payment framework. (CQUIN)

Further details of the agreed goals for 2015/16 and for the following 12 month period are available on request via [email protected]

In 2015/16 Bolton NHS Foundation Trust achieved 85% of the £4.9m CQUIN target agreed with commissioners. In 2014/15 Bolton NHS Foundation Trust achieved 92% of its CQUIN target, and received £5.4m of its £5.9m target

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Care Quality Commission Registration Bolton NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is “registered without conditions”. The Care Quality Commission has not taken enforcement action against the Bolton NHS Foundation Trust during 2015/16. Bolton NHS Foundation Trust has not participated in any special reviews or investigations by the CQC during the reporting period. Bolton NHS Foundation Trust was inspected by CQC in March 2016 and at the time of reporting we have not yet received our inspection report. In preparation for our CQC inspection we undertook self-assessments across our services and while we identified many areas of outstanding care we did identify some areas where we felt improvement was required. At the end of our inspection week we received some high level feedback from the CQC inspection team, this was in line with our own assessment with recognition that actions are planned to address estates and IT issues and further action is required to improve flow through our A&E department. The CQC team provided welcome feedback on the overall care provided in the Trust praising us for our excellent, passionate and caring staff. We look forward to receiving the full report from the CQC inspection and will ensure the report and our response to it is made publically available.

Data Quality The Trust submitted records during 2015/16 to the Secondary Users service for inclusion in the Hospital Episode Statistics which are included in the latest published data.

The percentage of records relating to admitted patient care which include the patient’s valid NHS number

Admitted Patient Care Outpatient Care Accident and Emergency Apr 14 - Jan 15 Apr 15 - Jan 16 Apr 14 - Jan 15 Apr 15 - Jan 16 AprCare 14 - Jan 15 Apr 15 - Jan 16 Bolton 99.80% 99.80% 99.90% 99.90% 99.20% 99.10% Nationa 99.20% 99.20% 99.30% 99.40% 95.20% 95.30% l

The percentage of records relating to admitted patient care which include the patient’s General Medical Practice Code

Admitted Patient Care Outpatient Care Accident and Emergency Apr 14 - Jan 15 Apr 15 - Jan 16 Apr 14 - Jan 15 Apr 15 - Jan 16 AprCare 14 - Jan 15 Apr 15 - Jan 16 Bolton 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% Nationa 99.90% 99.90% 99.90% 99.80% 99.20% 99.10% l Apr 15 - Jan 16 data is taken from the SUS data quality dashboard based on the provisional April 2015 to January 2016 SUS data at month 10 inclusion date

Information Governance Bolton Foundation NHS Trust Information Governance Assessment Report overall score for 2015/16 was 79% and was graded green

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Clinical Coding Audit Bolton Foundation NHS Trust was not subject to the Payment by Results clinical coding audit during 2015/16 by the Audit Commission.

Action to Improve Data Quality Bolton Foundation NHS Trust will be taking the following actions to improve data quality:

A Data Quality Group has been established, with senior representation from each Division, in order to co-ordinate action to improve data quality. A set of metrics has been developed against which improvements in data quality can be measured.

Routine daily checks identify common data quality errors which are investigated and fixed. Where appropriate, further training is provided to staff.

We receive assurance on the accuracy of our data quality through an annual report on non-financial data from our internal auditors with a review of the metrics included in this report being performed by our external auditors.

Data is benchmarked nationally using the CHKS system and a number of additional external audit reports are also used where appropriate.

Never Event In 2015/16, the Bolton NHS Foundation Trust has focused on embedding learning from Never Events, and invited the Royal College of Surgeons to conduct a review of surgery as part of this, and PWC were asked to review the process around Serious Incidents. The Serious Incident process was found to be robust, and the Royal College of Surgeons made some valuable suggestions on team- working and culture. In 2015/16 there were 3 Never Events:  Retained surgical sling (this was an error from 2014 which came to light in 2015)  Retained throat swab (removed in Theatre Recovery)  Wrong site anaesthetic block None of the three Never Events in 2015/16 resulted in significant harm for those involved; however, the Trust took these events very seriously. In particular, we have reviewed the training development for staff, and strengthened the protocol for throat packs. There is also work underway on Human Factors training. In addition, a Never Event Assurance Framework has been produced to look at all potential never events, and the strength of the controls in place to prevent those from happening.

The Trust continues to seek external opinion on the investigation report where there has been a Never Event, and as part of the monthly learning slides, is reminding staff how the different Never Events are prevented.

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Duty of Candour

Whilst the Trust primarily works towards reducing harm, we endeavour to be open and honest with all incidents where a patient was harmed. Where there has been moderate harm or greater, there is a conversation with the patient or family, and a formal letter of apology sent. These incidents are investigated, and the findings sent to the patient. Over the course of 2015/16 our Quality and Assurance Scorecard demonstrates that the Trust well over the course of the year with a dip from 100% performance in August, September and October. Performance returned to 100% (number of duty of candour letters sent to patients) in November 2016. A combination of training sessions, awareness raising and an increasing confidence in staff that a duty of candour letter is an apology for harm caused (or thought to be caused). The Trust approach to the Duty of Candour is a reflection of the Trusts values (Vision, Openness, Integrity, Compassion and Excellence). Work has been undertaken across the year to ensure not only initial letters of apology have been sent, but these have been followed up with a second letter containing the findings and actions from any investigation. In 2016/17 the Trust will continue to follow up completion of both Duty of Candour letters (where the 1st has indicated only possible harm, with a continuation of monthly training. A review of complaints and claims will be undertaken to establish if the Duty of Candour process has had any impact on these processes.

Sign Up to Safety The Trust has joined the Sign-Up-To-Safety campaign, and is committed to the goals of the campaign in terms of reducing harm, and has successfully reduced significant harm incidents this year. The Trust is committed to on-going work to learn from incidents, complaints, claims and inquests, and to explore new ways to improving the effectiveness of this process.

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Reporting against core indicators

Since 2012/13 NHS foundation trusts have been required to report performance against a core set of indicators using data made available to the trust by the Health and Social Care Information Centre (HSCIC). An overview of the indicators is provided in the table. It is important to note that whilst these indicators must be included in the Quality Accounts the most recent national data available for the reporting period is not always for the most recent financial year. Where this is the case the time period used is noted underneath the indicator description. It is also not always possible to provide the national average and best and worst performers for some indicators due to the way the data is provided.

Indicator 2015/16 National Best Worst Trust Statement 2014/2015 2013/14 Average Where applicable Mortality: SHMI SHMI SHMI SHMI Bolton Foundation NHS Trust considers SHMI value SHMI value value = value = Value = Value = that this data is as described for the = 1.056 = 1.078 The value 1.04 1.056 0.685 1.211 following reasons: and banding Band 2 as Band 2 as The data has been obtained from the of the Band 2 expected expected Health & Social Care Information Centre summary Band 2 as Band 3 Band 1 (HSCIC) hospital- as expected (10/13 – (10/12 – level expecte 09/14) 09/13) Bolton Foundation NHS Trust has taken mortality d the following actions to improve this indicator indicator and so the quality of its (SHMI) for (10/14 – services by: the Trust for 09/15) 10/14 – Monthly mortality meeting chaired by 09/15 latest the Medical Director data Implementation of level one facilities for available monitoring patients within ward areas

Increase intensive care consultants within critical care

External critical care outreach. % patients 20.28% 20.45% 0.05% 43.93% Bolton Foundation NHS Trust considers 18.75% 16.83% deaths with (13/14) that this data is as described for the (12/13) (11/12) palliative following reasons: care coded The data has been obtained from the at either Health & Social Care Information Centre diagnosis or (HSCIC) specialty level for Bolton Foundation NHS Trust has (2013/14 taken the following actions to latest data improve this indicator and so the available quality of its services by:

Continually to auditing the quality of our clinically coded data for deceased patients as part of our mortality reviews to ensure it is an accurate reflection of the patient’s diagnoses and procedures

The Clinical Coding team receive weekly information on any patients who have had a palliative care or

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contact with the palliative care team, so that this can be reflected in the clinical coding

Quality of clinical coding in relation to deceased patients is discussed, with action being taken to address any queries

Our mortality review programme, which includes validation of the clinical coding for the patient’s spell of care

Indicator 2015/16 National Best Worst Trust Statement 2014/2015 2013/14 Average Where applicable Patient reported outcome scores for groin 31.4% 51.1% 100% 12.5% Bolton Foundation NHS Trust considers 47.4% 53.1% hernia that this data is as described for the surgery following reasons: 04/15 – The data has been obtained from the 03/16 latest Health & Social Care Information Centre data (HSCIC) available * provisional Bolton Foundation NHS Trust has for varicose 25.0% 54.1% 100% 14.3% taken the following actions to 46.8% 41.2% vein surgery improve this indicator and so the 04/15 – quality of its services by: 03/16 latest data Centralisation of pre-operative services available * to standardise information received. provisional for hip 90.0% 81.3% 100.0% 25.0% Bolton Foundation NHS Trust considers 89.7% 91.9% replacement that this data is as described for the surgery following reasons: 04/15 – The data has been obtained from the 03/16 latest Health & Social Care Information Centre data (HSCIC) available * provisional Bolton Foundation NHS Trust has for knee 81.8% 74.7% 100.0% 25.0% taken the following actions to 76.0% 75.3% replacement improve this indicator and so the surgery quality of its services by: 04/15 – 03/16 latest Work has commenced with the CCG in data relation to thresholds for surgery available * provisional Continue to adhere to implant best practice

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Indicator 2015/16 National Best Worst Trust Statement 2014/2015 2013/14 Average Where applicable 28 day 12.82% 9.5% 5.1% 13.58% Bolton Foundation NHS Trust considers 13.78% 14.02% readmission that this data is as described for the rate for (11/12) (11/12) (11/12) (11/12) following reasons: (10/11) (09/10) patients The data has been obtained from the aged 0 – 15 Health & Social Care Information Centre (HSCIC) 2011/12 latest data Bolton Foundation NHS Trust has available taken the following actions to improve this indicator and so the 28 day 10.04% 11.2% 8.96% 13.5% quality of its services by: 10.17% 9.74% readmission rate for (11/12) (11/12) (11/12) (11/12) Establishing a clinically led readmission (10/11) (09/10) patients group aged 16 or over Working collaboratively with the CCG to carry out a follow up audit to determine 2011/12 causes latest data available Further work is on-going around risk stratification of high risk patients with long term conditions. The latest national data for 28 day readmission rate provided above is for 2010/11. Our internally reported performance against this target for 2015/16 was 13.4% Responsiven 69.3% 68.9% 86.1% 59.1% Bolton Foundation NHS Trust considers 70.9% 68.9% ess to that this data is as described for the inpatients’ (14/15) (14/15) (14/15) (14/15) following reasons: personal The methodology follows exactly needs: the detailed guidelines determined national by the Survey Co- ordination inpatient Centre for the overall National survey score Inpatient Survey programme.

2014/15 We triangulate our staff and latest data patient survey data with that from available the CQC in-patient survey, which gives a more accurate method of identifying patient concerns. Data from other surveys including the Friends and Family test can also be used to give a clearer picture of patients’ concerns.

Bolton Foundation NHS Trust has taken the following actions to improve this indicator and so the quality of its services by: The development and implementation of the PATIENT, Family and Carer integrated experience strategy. Review and refining of the complaints process Implementation of the Bedside Booklet Analysis of patient stories

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Indicator 2015/16 National Best Worst Trust Statement 2014/2015 2013/14 Average Where applicable Percentage 73.3% 69.8% N/A N/A Bolton Foundation NHS Trust considers 63.5% 57% of staff who that this data is as described for the would following reasons: recommend the provider The methodology follows exactly to friends or the detailed guidelines determined family by the Survey Co- ordination needing care Centre for the overall National

Staff Survey programme. 2015 Staff

Survey

Bolton Foundation NHS Trust has taken the following actions to improve this indicator and so the quality of its services by:

Increased use of Friends and Family Test – available in a variety of formats Use of Staff FFT results as the basis for team development sessions Starting to correlate Staff FFT results to Patient Experience measures Communicating the process to the public Implementation of the ‘you said’ ‘we did’ process for feedback

% of 97.33% 95.7% 100% 18.3% Bolton Foundation NHS Trust considers 96.76% 96.30% admitted that this data is as described for the patients risk- following reasons: assessed for The data has been obtained from the Venous Health & Social Care Information Centre Thromboem (HSCIC) bolism

Bolton Foundation NHS Trust has taken April 15 – the following actions to improve this Dec 15 indicator and so the quality of its

services by:

Appointment of Nurse Champion Nurse-led DVT Clinic VTE database Staff Awareness campaign RCA of patients developing clots for continuous learning and improvement

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Indicator 2015/16 National Best Worst Trust Statement 2014/2015 2013/14 Average Where applicable Rate of 11.66 15.1 0.00 21.62 Bolton Foundation NHS Trust considers 8.78 17.22 C.Difficile that this data is as described for the per 100,000 following reasons: bed days The data has been obtained from the

Health Protection Agency (HPA) 15/16 latest data Bolton Foundation NHS Trust has taken available the following actions to improve this

indicator and so the quality of its services by:

Introduction of a deep cleaning programme. Hand washing basins and gel outside all wards. Weekly strategic meetings to discuss all cases Improved scrutiny of antibiotic management. Investment in estate Collaborative working across the health economy Investment in the infection control and prevention team Clear guidance and policy

Number/Rat 44.17 38.1 31.64 61.35 Bolton Foundation NHS Trust considers 38.65 36.21 e of patient (count of (count of that this data is as described for the (count of (count of safety incidents incidents following reasons: incidents incidents incidents per 4,229) 632,050) 3,658) 3,214) The data has been obtained from the 1000 National Patient Safety Agency (NPSA) admissions latest data Bolton Foundation NHS Trust has taken available the following actions to improve this Apr15 – indicator and so the quality of its Sep15 services by:

Introduction of a new risk management

strategy Rate of 0.17 0.15 0.01 0.7 Risk management training for clinical 0.12 (count 0.12 (count patient (count of (count of risk managers of incidents of incidents safety incidents incidents 11) 9) New risk management committee incidents per 17) avg 15) established 1000 Introduction of “harms” meeting to admissions review incidents and ensure appropriate that resulted actions are taken in severe External training programme for harm or managers to undertake RCA training death 04/15 Review of current electronic incident – 09/15) reporting system to ensure investigation latest data conclusion can be logged available

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Indicator 2015/16 National Best Worst Trust Statement 2014/2015 2013/14 Average Where applicable Inpatient 96% 95.77% 100% 76.3% Bolton Foundation NHS Trust considers 95.66% 78.33% Friends and that this data is as described for the Family Test following reasons: To 01/16 latest data The data has been obtained from available the Health and Social Care Information Centre (HSCIC)

Bolton Foundation NHS Trust has taken the following actions to improve this indicator and so the quality of its services by:

Increased use of Friends and Family Test – available in a variety of formats Communicating the process to the public Implementation of the ‘you said’ ‘we did’ process for feedback

Accident and 85.7% 87.55% 99.33% 60.11% 80.00% 61.75% Emergency Friends and Family Test To January 2016 –latest data available Percentage 23% 24% - - Bolton Foundation NHS Trust considers 18% 20% of staff that this data is as described for the experiencing following reasons: harassment, The methodology follows exactly the bullying or detailed guidelines determined by the abuse from Survey Co-ordination Centre for the staff in the overall National Staff Survey last 12 programme. months Bolton Foundation NHS Trust has taken 2015 Staff the following actions to improve this Survey KF26 indicator and so the quality of its services by:

Our 2015 Staff Survey Action Plan will include actions to improve the quality of Incident Reporting.

HR will continue to offer support for employees reporting such incidents.

The Trust will shortly appoint a ‘Speak Up Guardian’ on a 6-month trial basis.

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Indicator 2015/16 National Best Worst Trust Statement 2014/2015 2013/14 Average Where applicable Percentage 91% 86% - - Bolton Foundation NHS Trust considers 94% 91% of staff that this data is as described for the believing following reasons: that the trust The methodology follows exactly the provides detailed guidelines determined by the equal Survey Co-ordination Centre for the opportunitie overall National Staff Survey s for career programme. progression or promotion Bolton Foundation NHS Trust has taken the following actions to improve this 2015 Staff indicator and so the quality of its Survey KF21 services by:

Our 2015 Staff Survey Action plan includes an item to address perceived fairness & transparency around allocation & moves of Nursing staff between Wards.

We are establishing a Career Academy.

We are investigating the expansion of our numbers of Apprentices.

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Performance against Trust selected metrics

This section of the report is provided to give an overview of the quality of care across a range of indicators covering patient safety, clinical effectiveness and patient experience. We have chosen to use the same indicators as previously used in 2014/15.

Where these priorities are discussed elsewhere in the report we will refer to that data to avoid repetition.

Indicator/Measure Patient Safety Mortality Please see page 79

Infection Control Please see page 80

Pressure ulcers Please see page 114

Patient Patient Please see page 116 Experience Experience

Please see page 118 Lessons Learnt

Please see page 119 Dementia

Effectiveness Sickness Please see page 85 Management

Appraisal rates Please see page 121

Mandatory Please see page 121 Training compliance

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Pressure Ulcers Pressure ulcers occur when the skin and the tissue beneath it becomes damaged due to pressure. Pressure ulcers are a widespread and often underestimated health problem. In the UK, it is estimated that between 4% and 10% of all patients admitted to hospital will develop at least one pressure ulcer. For elderly people with mobility problems, the figure can be as high as 70%. Some patients, particularly those who are frail, sick, bed ridden or have limited mobility, are more susceptible to developing ulcers whilst in hospital without corrected intervention. Pressure ulcers are categorised following national guidance, ranging from a Category 1 pressure ulcer, which is minimal damage, to a Category 4 pressure ulcer, which would be classed as significant harm. Based on NICE guidance, Category 1 pressure ulcers are not reported in any Trust figures. Our doctors and nursing staff are being encouraged and empowered to make pressure ulcer prevention a key priority as part of the Trust’s patient safety agenda.

Pressure Ulcers by Category & year 250

210

200

150 128 135

100 81 56 38

No. of Pressure No. Pressure of Ulcers 50 19 9 0 Apr 2014 - Mar 2015 Apr 2015 - Mar 2016

Cat 2 Cat 3 Cat 4 Total

The number of pressure ulcers attributed to Bolton Foundation Trust has increased over the past 12 months; however, there has been a reduction in those which were unavoidable. Following an identified discrepancy in reporting data towards the end of this year, we invited internal auditors to review our Harm Free Care process to ensure we were following a satisfactory process to determine the outcome of pressure ulcer harms. The findings from the report indicate robust documented procedures are in place. These procedures comprise of the following:  Timely reporting of pressure ulcers  Verification of pressure ulcers undertaken by Tissue Viability Nurses  Outcomes of pressure ulcers determined and agreed at Harm Free Care panel  Accurate data reporting to Trust Board on a monthly basis

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Target for Pressure Ulcers 2016-2017

Category of Current figures Percentage reduction Target figures Pressure Ulcer 2015-2016 required 2016-2017 Category 2 135 20% 108 Category 3 56 50% 28 Category 4 19 90% 2

A pressure ulcer reduction action plan has now been developed to help in the drive to achieve the target for 2016-2017. This action plan includes the following:  Training  Policy review  Review of documentation  Evaluation and introduction of new devices to support pressure relief  Improve collaborative working by engaging the CCG and external care agencies  Reviewing themes and responding to lessons learned to be monitored and shared between divisions to ensure whole health economy is benefitting from this with the aim of reducing pressure ulcers.

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Patient Experience

2015/16 has been an active and busy year for the patient experience team. The Friends and Family Test has been rolled out across Community Services, Outpatients and Day Care. Envoy messaging were contracted to carry out the FFT surveys using text messages to mobile phones and voice messaging to land lines. Where these methodologies were not deemed appropriate a paper based FFT method was incorporated into the roll out plan. As a result of this expansion the Trust can report achievement of the 5% increase in volume of FFT responses through a wider range of services reporting. A total of 86,700 responses were received and the table below demonstrates the breakdown of the feedback. 90.28% of respondents said that they would be either extremely likely or likely to recommend our services to Family and Friends.

Response Option Responses Percentage 1 - Extremely Likely 62,101 71.63% 2 - Likely 16,167 18.65% 3 - Neither Likely nor Unlikely 3,026 3.49% 4 - Unlikely 1,577 1.82% 5 - Extremely Unlikely 2,139 2.47% 6 - Don't Know 1,690 1.95%

All service areas are provided with monthly analysis of the feedback including both positive and negative comments against which an action plan is developed within their services to build on, continually improving the patient experience.

Inpatient Friends and Family Test

Inpatient FFT was collected via paper based system throughout 2015/16 and during this period of time a new electronic solution is being piloted with an external company (Meridian). Ipads have been deployed across the Trust allowing ward based staff to undertake FFT and also patient experience surveys in real time. In 2015/16 6258 responses were received, 4766 patients reported that they would be extremely likely to recommend our services to Friends and Family with 22 patients reporting that they would be extremely unlikely to recommend. Through this approach we have been able to adapt and individualise patient experience surveys by service area. We are currently working to connect the data sources. One of the key advantages to using this new electronic solution is that we have started to look at correlations between Staff FFT results and Patient data (FFT, Complaints) at individual Ward level. Early results from this indicate that the Staff FFT Additional Question around receiving feedback & recognition from line manager has an important role in linking the quality of the

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Quality Report staff experience and the quality of the resultant patient experience; where this theme is strong within a Ward, patient satisfaction tends to be high and the number of complaints low. This relationship will be further analysed & explored through the work to use Meridian to capture integrated staff & patient feedback.

Inpatients % FFT Response by Category 2015/16

0.35

23.55

76.10

Extremely Likely Other Response Categories Extremely Unlikely

All inpatient areas are provided with a monthly report containing the data, % recommended and % not recommended. The reports also include the individual comments from patients. These are routinely published in patient facing areas on the wards.

The information from these reports are utilised in the ‘You said, We did” ward boards for Friends and Family comments.

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Lessons Learnt

In 2015/16 the Trust has continued to produce monthly learning slides sent to every employee in the organisation. These cover learning from incidents, complaints, claims, inquests, as well as the findings from Clinical Audit, and national alerts. These are reviewed annually, and in 2016/17, these will be extended to cover research and equality and diversity. The Trust also continues to send out urgent SBAR (Situation, Background, Assessment, Recommendation) alerts for single issues identified where there needs to be rapid widespread learning. The Trust is committed to continuing to improve learning across the organisation. Learning themes from the Trust Harm Free Care Panels (Pressure Ulcers, Falls, VTE) and End of Life Care incidents will be reported to the Professional Advisory Group going forward, on a monthly basis to enable dissemination of this learning to be cascaded through the organisation. The Trust recognises that the key element in learning, is the implementation of change. The implementation of actions arising from Serious Incidents, Divisional Reviews, Complaints, Claims and Inquests are monitored through a weekly meeting chaired by the Head of Governance. Going forward, the Trust will be increasing the scrutiny at the review panels for serious incidents, to assess the potential impact and effectiveness of actions in reducing the risk to future patients. This will enable us to focus resources on those actions which make the greatest difference.

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Dementia In January 2015 the Dementia Steering Group at Bolton FT was reformed and one of the first objectives was to create a business case for appointing a Dementia Nurse Specialist as a single point of contact for this subject area; as per the National Dementia Strategy (2009). This process was completed and the Lead commenced in post October 2015. Prior to this the responsibility for delivering Dementia orientated tasks sat with various different personnel who themselves had broad portfolios elsewhere, making a focused approach difficult. Encouragingly, the appointment of the new lead 6 months ago has now allowed the Trust to approach the challenges Dementia will pose both now and in the future in a centred manner. The following reflects both our achievements to date and our ambition for Dementia Care over the next two years. It is taken in part from the Trust’s first Dementia Strategy (currently in draft form). The strategy has five aims which previously existed as a draft work plan for the Dementia CNS and his colleagues but which have now been refined so that the primary objective; ‘’improving the patient and carer experience’’ within every area of Bolton FT, will be met by delivering on the other four.

Improving the Patient and Carer Experience Patients can present at any stage of their disease progression in what to them is an unfamiliar and stressful environment. It is therefore up to us to be as welcoming and nurturing as possible. Yet with such a sporadic demand on our services, and in almost any department at any time, it will take organisational change to make this happen. Delivering well on our other key aims will do much for the experience, not just of the person with dementia but carers and staff also. This is particularly relevant where reasonable adjustment is concerned for those whose dementia is further complicated by Learning Disability or sensory impairment and these areas are considered in the Dementia Steering Group’s Action Plan also. With open visiting cards having been introduced, and a system of identifying and providing for those with a Dementia Diagnosis in place we can start to improve care from admission to discharge.

Raising Awareness through Education and Training The person with dementia and their family meet a whole variety of people on their journey into hospital, from the first volunteer who gives them directions to the Consultant on the Ward Round. So broad staff engagement is essential to the quality of care people can expect from us. The Dementia CNS, in tandem with Practice Educators provides training to staff based on continuing evaluation of our patient group versus their learning needs. Training is not restricted to clinical staff but instead, is aimed broadly across our organisation to ensure Bolton adopts a Dementia Friendly approach in all areas patients interact with. This training includes regular ‘’drop ins’’ to the wards in order to workshop patients and educate staff in a person centered manner, as well as less formal Dementia Friends Training. Link Nurses have also been created to champion Dementia care in various wards and departments, and study days have been developed around Tier 2 Dementia Training and providing Enhanced Care.

Supporting Treatment & Early Diagnosis The purpose of this aim is threefold; firstly, to ensure that those who come into our organisation for whatever reason receive the appropriate treatment from a medical point of view and that medical staff are adequately supported in delivering this. This is especially pertinent where delirium or depression complicate the picture. By developing protocols to

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Ensuring Best Practice by Delivering on Standards This aim addresses the need to promote integration of services and systems to meet the needs of our clients. Ensuring joined up working across all areas as part of best practice will have a constructive impact on the patient’s journey, with the overall benefit of improving the patient and carer experience in the process. Since the appointment of the Lead, we have ensured that Bolton Dementia Support Group are included as members of the steering group, and will be regularly consulted with regarding their work and ours. We have created a flagging system for all patients with a clinical coding of Dementia (though there will be many without) who come into our organisation. On a daily basis, their length of stay and location will be emailed for the attention of the Lead, to enable support of patients and families on repeat admission. The Forget Me Not Sticker to subtly identify patients with Dementia and Getting to Know me Booklet have also been embedded in the ward BSCA accreditation program to ensure a high standard of care is delivered. The hope is that this will become a greater priority as areas are audited and become more aware of their purpose. Finally, our e-learning is in the process of being improved, and drop in training is starting to be delivered in the Elective division by their PEF with hopes that this practice can be expanded if successful.

Championing a Dementia Friendly Environment Finally, it has always been the aim of Bolton FT to have a Dementia Friendly environment to support patients in their inpatient recovery. Promoting changes to the hospital environment with a view to becoming more Dementia Friendly is also an important goal of our service and comes in line with the National Dementia Strategy (2009). Though in part this is a long term aim, the Dementia CNS is now in place to act as a single point of contact to advise on procurement, way-finding and signage panels as well as providing our project management and estates teams with valuable evidence based guidance on the best features of an environment fit for Dementia patients, but accessible for all. This aim also looks at unique projects which can enhance the patient experience regardless of their surrounds to provide welcome distraction and respite from the ward environment. It is closely linked to the fortunes of the Donate £1 for Dementia Appeal, which is running well.

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Mandatory training Throughout 2015/16, the Organisational Development Team have continued to refine and embed the e-learning training for staff which has significantly reduced the amount of time spent on classroom based attendance for annual mandatory training updates. We continue to offer a blended approach to delivery (where appropriate), with additional classroom based sessions offered to support elements of the mandatory training programme where face-to-face delivery of peer group interaction or the demonstration of physical skills i.e. moving and handling techniques is essential to further embed learning and increase understanding. This approach has also allowed us to further develop the training within our Education & Training prospectus so that we can pro-actively support service development priorities. We continue to work closely with universities and higher education institutions to ensure that our staff have access to undergraduate and postgraduate programmes of study that enhance their skills, knowledge and competence whilst keeping them abreast of advances in patient care and as a result, improving the quality of their patients’ experience. We now report separately on Mandatory and Statutory training compliance. Our statutory training rate has increased from 92.4% in April 2015 to 95% in March 2016, against a target of 95%. Our mandatory training rate has increased from 85.4% to 90.9% over the same period, against a target of 85%. The Trust Workforce Committee monitors compliance and also determines what constitutes mandatory training, which can also be role-specific.

Appraisals It is widely accepted, that there is a direct link between a satisfied and engaged workforce and the quality of care patients receive. An appraisal provides both an individual and his/her supervisor with the opportunity to reflect on how well the individual has met agreed targets and objectives over the past year, to identify any training needs and areas for personal development and to review any issues or concerns that the staff member or supervisor may have. Our completed appraisals have improved from 82.1% in April 2015 to 83.7% in March 2016 against a target of 85%. We are incorporating our new Values into our appraisal process from May 2016, and have disseminated a senior leadership appraisal and objectives roll out in line with our agreement of the 2016/17 Annual Plan.

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Achievement against the Monitor Risk Assessment Framework 2015/16

Target Apr 15 - Achieved Apr 14 - Achieved Indicator Mar 16 Mar 15

Referral to Waiting Times - incomplete 92% 95.20 99.00%

Maximum waiting time of four hours in A&E from arrival 95% 90.4% 92.55% to admission, transfer or discharge

Maximum waiting time of 62 days from urgent referral to 85% 89.6% 91.20% treatment for all cancers - from urgent GP referral to * treatment Maximum waiting time of 62 days from urgent referral to 90% 95.2% 97.40% treatment for all cancers - from consultant screening * service referral Maximum waiting time of 31 days from diagnosis to 94% 99.2% 100% treatment of all cancers - surgery *

Maximum waiting time of 31 days from diagnosis to 98% 100%* 100% treatment of all cancers – anti cancer drug treatments

All cancers 31-day wait from diagnosis to first treatment 96% 98.5% 98.3%

Cancer: two week wait from referral to first seen, all 93% 97.4% 98.80% cancers *

Cancer: two week wait from referral to first seen, 93% 98.6% 95.40% symptomatic breast patients (cancer not initially * suspected) Clostridium difficile - meeting the C. difficile objective 19 26 20

100% 100% 100% Certification against compliance with requirements regarding access to health care for people with a learning disability 50% 99% 99% Data completeness community service referral to treatment

100% Data completeness community services - referral 50% 100% information

50% 100% 100% Data completeness: community services - treatment activity information

* data available to February 2016 only

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Statement from NHS Bolton Clinical Commissioning Group (CCG) We have worked closely with Bolton FT throughout 2015/16 to gain assurances that the services provided were safe, effective and patient focused. The quality and performance of these services is monitored within a clinically led governance structure and we note that the content of the Quality Account is consistent with the information provided throughout the year. The CCG also acknowledges the progress made by the organisation which has resulted in the lifting of their FT licence breach. The CCG notes the prescriptive requirements of the Account but considered the scale and format not necessarily to be the most appropriate for a public facing document and hope this can be reflected on in future years. With the exception of the priority to reduce falls resulting in harm, the CCG noted that the FT failed to achieve the key priorities in last year’s Account. However, we do acknowledge that initiatives remain in place to address these in the coming year and we expect this will result in significant progress. The CCG is largely supportive of the three priority areas for 2016/17, although we would like to have seen greater reference to the Locality Plan throughout the Account. We note specifically that two of the priorities, namely stroke and end of life care, relate to areas which involve community and acute services and we expect a focus to be placed on the community aspect of these priorities throughout the year. The CCG is encouraged by the positive feedback provided by the CQC following their visit in March and look forward to receiving the final report in the coming months. The CCG also acknowledge the openness of the FT in continuing to extend membership of various committees to the CCG e.g. Quality Assurance Committee and Mortality Reduction Group. The clinically led collaborative approach to the development and delivery of the CQUIN schemes for last year resulted in a high level of achievement which we expect to be sustained and further improved upon in 2016/17. The CCG acknowledges the significant developments with regards to the patient safety culture within the organisation which is reflected in their current standing in the ‘Learning from Mistakes’ league and within the National Reporting and Learning System framework. We also welcome the transparency of the FT with regards to the Royal College of Surgeons review into theatre culture and with investigations in to serious incidents and never events, which all lead to improvement in services. In summary the CCG is pleased with the positive progress portrayed within the Account, but in acknowledging the significant challenges that remain, we expect the collaborative relationship developed last year to be sustained in order to optimise the further delivery of safe, effective and personalised care by Bolton FT. Michael Robinson Associate Director of Integrated Governance and Policy Bolton CCG

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Statement from Bolton NHS Foundation Trust - Trust Governors As Foundation Trust Governors we have worked closely with the Directors of the Trust and will continue to do so during 2016/17. In the last year we have received additional briefings from the Executive Directors on the performance of the Trust, this has provided us with an opportunity to seek assurance and further our understanding of the challenges facing the Trust. We welcome the publication of the Quality Report and congratulate the Trust on the results achieved particularly with regard to the reduction in falls with harm where the objective agreed last year has been achieved. We also note the progress made towards the other objectives and are assured that the agreed actions will continue. We recognise the success of the Trust in balancing the achievement of strong financial performance whilst also improving performance against a wide range of quality metrics. The range of regular reports that are presented to the Council of Governors highlight the performance and compliance of the Trust against its many performance indicators and particular areas of focus. As well as receiving strategic, performance and compliance information, Governors are invited to take part in regular safety visits and inspections which provide the opportunity for Governors and board members to visit operational areas and speak directly with patients, visitors and staff about their experiences at the Trust. We have been assured that although savings have been made this has not been at the expense of quality We were particularly concerned as A&E performance has deteriorated despite the actions taken earlier in the year with the “Perfect week”. We have been made aware of the challenges in achieving this target and the actions taken and we expect the required improvements to be made. With the devolvement of health and social care to Greater Manchester, we are also keen to ensure that the Trust plays a full part alongside Bolton CCG, Bolton Council and other stakeholders to ensure appropriate provision of care to the people of Bolton. We hope that the same effort and determination will continue in 2016/17 and look forward to continuing to support the Trust in our role as critical friend, in the coming year.

Statement from Healthwatch Bolton No statement received.

Statement from Overview and Scrutiny Committee

No statement received

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INDEPENDENT AUDITOR’S REPORT TO THE COUNCIL OF GOVERNORS OF BOLTON NHS FOUNDATION TRUST

Opinions and conclusions arising from our audit 1 Our opinion on the financial statements is unmodified We have audited the financial statements of Bolton NHS Foundation Trust for the year ended 31 March 2016. In our opinion:  the financial statements give a true and fair view of the state of the Trust’s affairs as at 31 March 2016 and of the Trust’s income and expenditure for the year then ended; and  the financial statements have been properly prepared in accordance with the NHS Foundation Trust Annual Reporting Manual 2015/16.

2 Our assessment of risks of material misstatement In arriving at our audit opinion above on the financial statements, the risk of misstatement that had the greatest effect on our audit is considered below. There have been no changes to the risks included in our report compared with the prior year. Valuation of land and buildings - £92.4 million (2014/15: £90.9 million) Refer to the Audit Committee Report within the Strategic Report section of the Trust’s Annual Report and Accounts 2015/16, sections 1.6 and 1.11 of the Trust’s accounting policies (Note 1 to the Accounts) and Property, plant and equipment financial disclosures at Note 16 to the Accounts.

The risk: Land and buildings are required to be maintained at up to date estimates of year-end market value in existing use (EUV) for non-specialised property assets in operational use, and, for specialised assets where no market value is readily ascertainable, the depreciated replacement cost of a modern equivalent asset that has the same service potential as the existing property (DRC). There is significant judgment involved in determining the appropriate basis (EUV or DRC) for each asset according to the degree of specialization, as well as over the assumptions made in arriving at the valuation. In particular the DRC basis requires an assumption as to whether the replacement asset would be situated on the existing site or, if more appropriate, on an alternative site, with a potentially significant effect on the valuation.

The Trust commissioned a full revaluation of land and buildings during 2014/15, which was conducted for the first time on an ‘alternative site’ basis. For 2015/16, the Trust did not commission a full revaluation of its land and building assets. Since there is a requirement for the year-end estimate of market valuation to be kept up to date, the Trust has undertaken investigations to ascertain whether a material change in the value of land and buildings since 31 March 2015 has occurred. This has included a calculation of movements in market values, using RICS property value indices data provided by the District Valuer, as well as a formal review of impairment indicators across the Trust’s estate. The Trust has concluded that, following completion of these procedures, there has not been a material movement in the value of its land and building assets, and therefore that a formal revaluation or impairment of these assets in its financial statements for 2015/16 is not required.

Our response: In this area our audit procedures included:

 assessing the competence, capability, objectivity and independence of the Trust’s external valuer and considering the information provided to the Trust in 2015/16, to inform its assessment of market value movements, for consistency with the requirements of the NHS Foundation Trust Annual Reporting Manual;  critically assessing the calculation of market value indices movements completed by the Trust, including a re-performance of this calculation to confirm that no material movement in the value of land and building assets is indicated;

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 agreeing the data underpinning the Trust’s calculation of market value movements to the RICS data obtained by the District Valuer and corresponding with the Trust’s external valuer to confirm that no adjustments have been made to this RICS data prior to its presentation to the Trust;  critically assessing the Trust’s formal consideration of impairment indicators within its estate, including the process undertaken and the adequacy of the formal, written decision document used in the process; and  considering the adequacy of the disclosures about the key judgements and degree of estimation involved in concluding that there has been no material movement in the value of land and buildings since 31 March 2015. 3 Our application of materiality and an overview of the scope of our audit The materiality for the financial statements was set at £4.5m (2014/15: £4.0m), determined with reference to a benchmark of total revenues (of which it represents 1.54%; 1.40% in 2014/15). We consider total income to be more stable than a surplus-related benchmark.

We report to the Audit Committee any corrected and uncorrected identified misstatements exceeding £225,000 (2014/15: £200,000), in addition to other identified misstatements that warrant reporting on qualitative grounds.

Our audit of the Trust was undertaken to the materiality level specified above and was all performed at the Trust’s Finance department at the Royal Bolton Hospital site.

4 Our opinion on other matters prescribed by the Code of Audit Practice is unmodified In our opinion:  the parts of the Remuneration and Staff Reports to be audited have been properly prepared in accordance with the NHS Foundation Trust Annual Reporting Manual 2015/16; and  the information given in the Annual Report for the financial year for which the financial statements are prepared is consistent with the financial statements. 5 We have nothing to report in respect of the following matters on which we are required to report by exception Under ISAs (UK and Ireland) we are required to report to you if, based on the knowledge we acquired during our audit, we have identified other information in the annual report that contains a material inconsistency with either that knowledge or the financial statements, a material misstatement of fact, or that is otherwise misleading. In particular, we are required to report to you if:  we have identified material inconsistencies between the knowledge we acquired during our audit and the directors’ statement that they consider that the Annual Report and Accounts taken as a whole is fair, balanced and understandable and provides the information necessary for patients, regulators and other stakeholders to assess the Trust’s performance, business model and strategy; or  the Audit Committee report, within the Annual Report, does not appropriately address matters communicated by us to the Audit Committee. Under the Code of Audit Practice we are required to report to you if in our opinion:  the Annual Governance Statement does not reflect the disclosure requirements set out in the NHS Foundation Trust Annual Reporting Manual 2015/16, is misleading or is not consistent with our knowledge of the Trust and other information of which we are aware from our audit of the financial statements.  the Trust has not made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. In addition we are required to report to you if:

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 any reports to the regulator have been made under Schedule 10(6) of the National Health Service Act 2006.  any matters have been reported in the public interest under Schedule 10(3) of the National Health Service Act 2006 in the course of, or at the end of the audit. We have nothing to report in respect of these responsibilities.

Respective responsibilities of the accounting officer and auditor As described more fully in the Statement of Accounting Officer’s Responsibilities, the accounting officer is responsible for the preparation of financial statements which give a true and fair view. Our responsibility is to audit, and express an opinion on, the financial statements in accordance with applicable law and International Standards on Auditing (UK and Ireland). Those standards require us to comply with the UK Ethical Standards for Auditors.

Scope of an audit of financial statements performed in accordance with ISAs (UK and Ireland) A description of the scope of an audit of financial statements is provided on our website at www.kpmg.com/uk/auditscopeother2014. This report is made subject to important explanations regarding our responsibilities, as published on that website, which are incorporated into this report as if set out in full and should be read to provide an understanding of the purpose of this report, the work we have undertaken and the basis of our opinions.

Respective responsibilities of the Trust and auditor in respect of arrangements for securing economy, efficiency and effectiveness in the use of resources The Trust is responsible for putting in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources, to ensure proper stewardship and governance, and to review regularly the adequacy and effectiveness of these arrangements.

Under Section 62(1) and Schedule 10 paragraph 1(d), of the National Health Service Act 2006 we have a duty to satisfy ourselves that the Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. We are not required to consider, nor have we considered, whether all aspects of the Trust’s arrangements for securing economy, efficiency and effectiveness in its use of resources are operating effectively.

Scope of the review of arrangements for securing economy, efficiency and effectiveness in the use of resources We have undertaken our review in accordance with the Code of Audit Practice, having regard to the guidance on the specified criterion issued by the Comptroller and Auditor General (C&AG), as to whether the Trust has proper arrangements to ensure it took properly informed decisions and deployed resources to achieve planned and sustainable outcomes for taxpayers and local people. The C&AG determined this criterion as necessary for us to consider under the Code of Audit Practice in satisfying ourselves whether the Trust put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2016.

We planned our work in accordance with the Code of Audit Practice. Based on our risk assessment, we undertook such work as we considered necessary to form a view on whether, in all significant respects, the Trust had put in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources.

The purpose of our audit work and to whom we owe our responsibilities This report is made solely to the Council of Governors of the Trust, as a body, in accordance with Schedule 10 of the National Health Service Act 2006. Our audit work has been undertaken so that we might state to the Council of Governors of the Trust, as a body, 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 Council of Governors of the Trust, as a body, for our audit work, for this report or for the opinions we have formed.

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Certificate of audit completion We certify that we have completed the audit of the accounts of Bolton NHS Foundation Trust in accordance with the requirements of Schedule 10 of the National Health Service Act 2006 and the Code of Audit Practice issued by the National Audit Office.

Timothy Cutler for and on behalf of KPMG LLP, Statutory Auditor Chartered Accountants 1 St Peter’s Square, Manchester, M2 3AE 26 May 2016

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INDEPENDENT AUDITOR’S REPORT TO THE COUNCIL OF GOVERNORS OF BOLTON NHS FOUNDATION TRUST ON THE QUALITY REPORT

We have been engaged by the Council of Governors of Bolton NHS Foundation Trust to perform an independent assurance engagement in respect of Bolton NHS Foundation Trust’s Quality Report for the year ended 31 March 2016 (the ‘Quality Report’) and certain performance indicators contained therein.

Scope and subject matter

The indicators for the year ended 31 March 2016 subject to limited assurance consist of the following two national priority indicators (the Indicators):

 percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the reporting period; and

 A&E: maximum waiting time of four hours from arrival to admission/transfer/discharge.

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 and supporting guidance;

 the Quality Report is not consistent in all material respects with the sources specified in the Detailed Guidance for External Assurance on Quality Reports 2015/16 (‘the Guidance’); and

 the indicator 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 supporting guidance and the six dimensions of data quality set out in the Guidance.

We read the Quality Report and consider whether it addresses the content requirements of the NHS Foundation Trust Annual Reporting Manual and supporting guidance 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 and papers for the period April 2015 to May 2016;

 papers relating to quality reported to the board over the period April 2015 to May 2016;

 feedback from commissioners (Received May 2016);

 feedback from governors (Received May 2016);

 the trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009;

 the latest national patient survey (Received May 2015);

 the latest national staff survey (Received February 2016);

 the 2015/16 Head of Internal Audit’s annual opinion over the trust’s control environment (Received May 2016); and

 the latest CQC Intelligent Monitoring Report.

The Trust has requested feedback from the Overview and Scrutiny Committee and from local Healthwatch organisations on 4th May 2016 but this has not been received.

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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.

This report, including the conclusion, has been prepared solely for the Council of Governors of Bolton NHS Foundation Trust as a body, to assist the Council of Governors in reporting the NHS Foundation Trust’s quality agenda, performance and activities. We permit the disclosure of this report within the Annual Report for the year ended 31 March 2016, to enable the Council of Governors to demonstrate they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicator. 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 Bolton NHS Foundation Trust for our work or this report, except where terms are expressly agreed and with our prior consent in writing.

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 indicator;

 making enquiries of management;

 testing key management controls;

 limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation;

 comparing the content requirements of the NHS Foundation Trust Annual Reporting Manual to the categories reported in the Quality Report; and

 reading the documents.

A limited assurance engagement is smaller in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement.

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 the non-mandated indicator, which was determined locally by Bolton NHS Foundation Trust.

Basis for qualified conclusion As set out in the Statement on Quality from the Chief Executive of the Foundation Trust within the Trust’s Quality Report, the Trust currently has concerns with the accuracy of data in respect of the percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the reporting period indicator. Our testing of this indicator identified a number of instances where incomplete pathways were reported for a period of 2-3 months after the pathway ought to have been ended as treatment had taken place, per the patient record evidence available. In some instances, this resulted in the incomplete pathways being incorrectly reported as a breach (over 18 weeks in duration) for a number of months.

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As a result of the issues described above we are unable to give limited assurance on the percentage of incomplete pathways within 18 weeks for patients on incomplete pathways indicator included in the Quality Report for the year ended 31 March 2016. Qualified conclusion Based on the results of our procedures, except for the effects of the matters described in the ‘Basis for qualified conclusion’ section above, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2016:  the Quality Report is not prepared in all material respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual and supporting guidance;

 the Quality Report is not consistent in all material respects with the sources specified in the Guidance; and

 the indicator in the Quality Report subject to limited assurance (A&E: maximum waiting time of four hours from arrival to admission/transfer/discharge) has not been reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual and supporting guidance and the six dimensions of data quality set out in the Guidance.

KPMG LLP Chartered Accountants 1 St Peter’s Square Manchester M2 3AE

26 May 2016

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BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16 FOREWORD TO THE ACCOUNTS

These accounts for the year ended 31 March 2016 have been prepared by Bolton NHS Foundation Trust under Schedule 7, sections 24 and 25, of the National Health Service Act 2006.

Dr Jackie Bene Chief Executive 26th May 2016

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BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

FOREWORD TO THE ACCOUNTS

BOLTON NHS FOUNDATION TRUST

These accounts for the year ended 31 March 2016 have been prepared by Bolton NHS Foundation Trust under Schedule 7, sections 24 and 25, of the National Health Service Act 2006.

Signed ……..…………………………………………….

J Bene Chief Executive

Date 26 May 2016 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

STATEMENT OF COMPREHENSIVE INCOME FOR THE YEAR ENDED 31 MARCH 2016

For the year For the year ended 31 ended 31 March 2016 March 2015 NOTE £000 £000 Revenue Operating income from patient care activities 4 271,537 266,791 Other operating revenue 6 21,004 24,771 Operating expenses 8 (287,918) (309,474) Operating surplus (deficit) 4,623 (17,912) Finance costs: Finance Income 13 35 41 Finance expense - financial liabilities 14 (642) (849) Finance expense - unwinding of discount on provisions (12) (122) Public dividend capital dividends payable (2,152) (2,535) NET FINANCE COSTS (2,771) (3,465)

Surplus/(Deficit) from continuing operations 1,852 (21,377)

Other comprehensive income

Revaluation gains/(losses) and impairment losses property, plant and equipment - (5,155) Total comprehensive income for the year 1,852 (26,532)

The notes on pages 6 to 43 form part of these accounts.

Page 1 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

STATEMENT OF FINANCIAL POSITION AS AT 31 MARCH 2016

For the year For the year ended 31 March ended 31 March 2016 2015 NOTE £000 £000 Non-current assets Intangible assets 17 1,290 894 Property, plant and equipment 16 108,201 104,835 Trade and other receivables 20 537 546 Total non-current assets 110,028 106,275 Current assets Inventories 19 3,010 2,599 Trade and other receivables 20 8,896 10,011 Cash and cash equivalents 21 1,470 5,265 Total current assets 13,376 17,875 Total assets 123,404 124,150

Current liabilities Trade and other payables 22 (26,392) (25,461) Borrowings 23 (1,368) (1,675) Provisions 25 (632) (1,300) Total current liabilities (28,392) (28,436)

Total assets less current liabilities 95,012 95,714

Non-current liabilities Borrowings 23 (15,867) (18,585) Provisions 25 (447) (464) Total non-current liabilities (16,314) (19,049)

Total assets employed 78,698 76,665

Financed by taxpayers' equity: Public dividend capital 26 102,271 102,090 Revaluation reserve 27 31,255 31,259 Income and expenditure reserve (54,828) (56,684) Total Taxpayers' Equity 78,698 76,665

The financial statements on pages 1 to 5 were approved by the Board on 26 May 2016 and signed on its behalf by:

Signed: ……………………………… ( Chief Executive) Date: 26/05/2016

Page 2 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

STATEMENT OF CHANGES IN TAXPAYERS' EQUITY

Public Revaluation Income & Total dividend reserve Expenditure capital reserve (PDC) £000 £000 £000 £000

Taxpayers' and others' equity at 01 April 2015 - brought forward 102,090 31,259 (56,684) 76,665

Surplus/(deficit) for the year - - 1,852 1,852 Public dividend capital received 4,281 - - 4,281 Public dividend capital repaid (4,100) - - (4,100) Transfer to retained earnings on disposal of assets - (4) 4 - Taxpayers' and others' equity at 31 March 2016 102,271 31,255 (54,828) 78,698

Page 3 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

STATEMENT OF CHANGES IN TAXPAYERS' EQUITY

Public Revaluation Income & Total dividend reserve Expenditure capital reserve (PDC) £000 £000 £000 £000

Taxpayers' and others' equity at 01 April 2014 - as previously stated 101,987 36,445 (35,338) 103,094

Surplus/(deficit) for the year - - (21,377) (21,377) Revaluations - property, plant and equipment - (5,155) - (5,155) Public dividend capital received 103 - - 103 Transfer to retained earnings on disposal of assets - (31) 31 - Balance at 31 March 2015 102,090 31,259 (56,684) 76,665

Page 4 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

STATEMENT OF CASH FLOWS FOR THE YEAR ENDED 31 MARCH 2016

For the year For the year ended 31 ended 31 March 2016 March 2015 £000 £000 Cash flows from operating activities Operating surplus/(deficit) from continuing operations 4,623 (17,912)

Non-cash income and expense: Depreciation and amortisation 5,539 5,536 Impairments - 25,259 Reversals of impairments - (3,322) (Gain)/Loss on disposal of non-current assets 1 16 Non-cash donations/grants credited to income (55) (192) (Increase)/Decrease in trade and other receivables 1,252 (96) (Increase)/Decrease in inventories (411) (985) Increase/(Decrease) in trade and other payables 1,661 7,451 Increase/(Decrease) in provisions (694) (3,453) Other movements in operating cash flows 16 (6) Net cash generated from/(used in) operations 11,932 12,296

Cash flows from investing activities Interest received 36 40 (Payments) of intangible assets (294) (252) (Payments) for property, plant and equipment (9,568) (3,564) Sales of property, plant and equipment and investment property 11 - Net cash generated from/(used in) investing activities (9,815) (3,776)

Cash flows from financing activities Loans received from the Department of Health 108 1,750 Public dividend capital received 4,281 103 Public dividend capital repaid (4,100) - Loans repaid to the Department of Health (3,118) (1,368) Interest paid (661) (804) Capital element of finance leases (680) (644) Interest element of finance lease (1) (37) PDC dividend paid (1,741) (2,663) Net cash generated from/(used in) financing activities (5,912) (3,663)

Increase/(decrease) in cash and cash equivalents (3,795) 4,857

Cash and cash equivalents at 1 April 2015 5,265 408 Cash and cash equivalents at 31 March 2016 1,470 5,265

Page 5 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES Monitor is responsible for issuing an accounts direction to NHS foundation trusts under the NHS Act 2006. Monitor has directed that the financial statements of NHS foundation trusts shall meet the accounting requirements of the FT ARM which shall be agreed with the Secretary of State. Consequently, the following financial statements have been prepared in accordance with the FT ARM 2015/16 issued by Monitor. The accounting policies contained in that manual follow IFRS and HM Treasury’s FReM to the extent that they are meaningful and appropriate to NHS foundation trusts. The accounting policies have been applied consistently in dealing with items considered material in relation to the accounts.

1.1 Accounting conventions These accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, intangible assets, inventories and certain financial assets and financial liabilities.

1.2 Going concern IAS 1 requires management to assess, as part of the accounts preparation process, the foundation trust’s ability to continue as a going concern. In the context of non-trading entities in the public sector the anticipated continuation of the provision of a service in the future is normally sufficient evidence of going concern. The financial statements should be prepared on a going concern basis unless there are plans for, or no realistic alternative other than, the dissolution of the (foundation) trust without the transfer of its services to another entity.

The Directors consider the contracts that have been agreed with commissioning bodies and an agreement with Monitor and The Department of Health for additional funding in 2015/16 is sufficient evidence that the Trust will continue as a going concern for the foreseeable future.

1.3 Acquisitions and discontinued operations Activities are considered to be 'acquired' only if they are acquired from outside the public sector. Activities are considered to be 'discontinued' only if they cease entirely. They are not considered to be 'discontinued' if they transfer from one NHS body to another.

1.4 Critical accounting judgements and key sources of estimation uncertainty In the application of the Trust accounting policies, management is required to make judgements, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical experience and other factors that are considered to be relevant. Actual results may differ from those estimates. The estimates and underlying assumptions are continually reviewed. Revisions to accounting estimates are recognised in the period in which the estimate is revised if the revision affects only that period, or in the period of the revision and future periods if the revision affects both current and future periods.

1.5 Critical judgements in applying accounting policies Critical judgements, apart from those involving estimations (see next page), management has made in the process of applying the entity’s accounting policies and that have the most significant effect on the amounts recognised in the financial statements.

Page 6 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED) 1.6 Key sources of estimation uncertainty The following are the key assumptions concerning the future, and other key sources of estimation uncertainty at the Statement of Financial Position date, that have a significant risk of causing a material adjustment to the carrying amounts of assets and liabilities within the next financial year:

Asset valuation and impairments: the valuation of the Trust’s Land and Buildings is subject to significant estimation uncertainty, since it derives from estimates provided by the Trust’s external valuers who base their estimates on local market data as well as other calculations to reflect the age and condition of the Trust’s estate. In 2014/15, the basis upon which the Modern Equivalent Asset Valuation is assessed by the external valuer was been changed from the existing site to an alternate, theoretical site.

The depreciated replacement cost of specialised buildings has been valued on a modern equivalent assets basis and, where it meets the location requirements of the service being provided, an alternative site has been used. This provides a basis for estimation uncertainty at the Trust.

Incomplete spells (see revenue recognition note at 1.7) These have been calculated as per previous years. A report is produced to show the number of patients that had been admitted but not discharged by midnight on 31st March 2016. As these patients aren’t fully coded at that stage it is not possible to assign the national Healthcare Resource Groups (HRGS) and so an estimate of the anticipated income is made using average costs based on both admitting method (Elective / Non Elective), admitting specialty and the average number of excess bed-days incurred.

Deferred income The rules around how we get paid for delivering maternity changed in 14/15, we now get paid for each stage of woman’s journey in one singular payment at the antenatal, birth and postnatal phase of pregnancy. This means we receive up to 6 months payment in advance and because some of this cost will be borne in the subsequent financial year, we have to defer some of the income we received in 15/16 to pay for it. We have used guidance produced by the Department of Health to calculate how much we need to defer into 15/16. The deferred income at 31 March 2016 for maternity pathway was £1.4m.

1.7 Revenue recognition Revenue in respect of services provided is recognised when, and to the extent that, performance occurs and is measured at the fair value of the consideration receivable. The main source of income for the Foundation Trust is contracts with commissioners in respect of healthcare services.

Where revenue is received for a specific activity which is to be delivered in the following financial year, that revenue is deferred. Under IAS 18, the Foundation Trust is entitled to recognise revenue for partially completed spells of activity at 31 March 2016. As the individual National Tariff price and procedure code is not known for partially completed spells, the Foundation Trust has based its calculation of such income on the average length of stay and the cumulative activity and price of individual specialties.

Revenue from the sale of non-current assets is recognised only when all material conditions of sale have been met, and is measured as the sums due under the sale contract.

Page 7 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

The Foundation Trust receives income under the NHS Injury Cost Recovery Scheme, designed to reclaim the cost of treating injured individuals to whom personal injury compensation has subsequently been paid e.g. by an insurer. The Foundation Trust recognises the income when it receives notification from the Department for Work and Pensions' Compensation Recovery Unit that the individual has lodged a compensation claim. The income is measured at the agreed tariff for the treatments provided to the injured individual, less a provision for unsuccessful compensation claims and doubtful debts.

1.8 Employee benefits Salaries, wages and employment related payments are recognised in the period in which the service is received from employees. The cost of annual leave entitlement earned but not taken by employees at the end of the period is recognised in the financial statements to the extent that employees are permitted to carry forward leave into the following period.

1.9 Pension costs NHS Pension Scheme Past and present employees are covered by the provisions of the NHS Pensions Scheme. The scheme is an unfunded, defined benefit scheme that covers NHS employers, general practices and other bodies, allowed under the direction of Secretary of State, in England and Wales. It is not possible for the NHS Foundation Trust to identify its share of the underlying scheme liabilities. Therefore, the scheme is accounted for as a defined contribution scheme.

Employer's pension cost contributions are charged to operating expenses as and when they become due.

Additional pension liabilities arising from early retirements are not funded by the scheme except where the retirement is due to ill-health. The full amount of the liability for the additional costs is charged to the operating expenses at the time the Foundation Trust commits itself to the retirement, regardless of the method of payment.

1.10 Expenditure on other goods and services Expenditure on goods and services is recognised when, and to the extent that they have been received, and is measured at the fair value of those goods and services. Expenditure is recognised in operating expenses except where it results in the creation of a non-current asset such as property, plant and equipment.

Page 8 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

1.11 Property, plant and equipment Recognition Property, plant and equipment is capitalised where: • it is held for use in delivering services or for administrative purposes; • it is probable that future economic benefits will flow to, or service potential be provided to, the Foundation Trust; • it is expected to be used for more than one financial year; and • the cost of the item can be measured reliably; and individually has a cost of at least £5,000; or • collectively have a cost of at least £5,000 and individually have a cost of more than £250, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or • items form part of the initial equipping and setting-up cost of a new building, ward or unit irrespective of their individual or collective cost. Where a large asset, for example a building, includes a number of components with significantly different asset lives e.g. plant and equipment, then these components are treated as separate assets and depreciated over their own useful economic lives.

Measurement Valuation All property, plant and equipment assets are measured initially at cost, representing the costs directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management. All assets are measured subsequently at fair value.

Land and buildings are stated in the statement of financial position at their revalued amounts, being the fair value at the date of revaluation less any subsequent accumulated depreciation and impairment losses. Revaluations are undertaken with sufficient regularity to ensure that the carrying amounts are not materially different to those that would be determined at the end of the reporting period.

Equipment assets are carried at fair value, with depreciated historical cost used as a proxy for fair value. The ranges of useful lives used in the Foundation Trust’s accounts are set out in note 16.3.

Subsequent expenditure Where subsequent expenditure enhances an asset beyond its original specification, the directly attributable cost is added to the asset’s carrying value. Where subsequent expenditure is simply restoring the asset to the specification assumed by its economic useful life then the expenditure is charged to operating expenses.

Page 9 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

Depreciation Freehold land, properties under construction, and assets held for sale are not depreciated.

Items of property, plant and equipment are depreciated over their remaining useful economic lives in a manner consistent with the consumption of economic or service delivery benefits. Freehold land is considered to have an infinite life and is not depreciated.

Property, plant and equipment which has been reclassified as ‘Held for Sale’ ceases to be depreciated upon the reclassification. Assets in the course of construction and residual interests in off-Statement of Financial Position PFI contract assets are not depreciated until the asset is brought into use or reverts to the Foundation Trust, respectively.

Otherwise, depreciation and amortisation are charged to write off the costs or valuation of property, plant and equipment and intangible non-current assets, less any residual value, over their estimated useful lives, in a manner that reflects the consumption of economic benefits or service potential of the assets. The estimated useful life of an asset is the period over which the Trust expects to obtain economic benefits or service potential from the asset. This is specific to the Trust and may be shorter than the physical life of the asset itself. Estimated useful lives and residual values are reviewed each year end, with the effect of any changes recognised on a prospective basis. Assets held under finance leases are depreciated over their estimated useful lives.

Revaluation Increases in asset values arising from revaluations are recognised in the revaluation reserve, except where, and to the extent that, they reverse an impairment previously recognised in operating expenses, in which case they are recognised in operating income.

Impairment In accordance with the FT ARM, impairments that are due to a loss of economic benefits or service potential in the asset are charged to operating expenses. A compensating transfer is made from the revaluation reserve to the income and expenditure reserve of an amount equal to the lower of (i) the impairment charged to operating expenses; and (ii) the balance in the revaluation reserve attributable to that asset before the impairment.

An impairment arising from a loss of economic benefit or service potential is reversed when, and to the extent that, the circumstances that gave rise to the loss is reversed. Reversals are recognised in operating income to the extent that the asset is restored to the carrying amount it would have had if the impairment had never been recognised. Any remaining reversal is recognised in the revaluation reserve. Where, at the time of the original impairment, a transfer was made from the revaluation reserve to the income and expenditure reserve, an amount is transferred back to the revaluation reserve when the impairment reversal is recognised.

Other impairments are treated as revaluation losses. Reversals of ‘other impairments’ are treated as revaluation gains.

Page 10 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

De-recognition

Assets intended for disposal are reclassified as ‘Held for Sale’ once all of the following criteria are met: • the asset is available for immediate sale in its present condition subject only to terms which are usual and customary for such sales; • the sale must be highly probable i.e.: • management are committed to a plan to sell the asset; • an active programme has begun to find a buyer and complete the sale; • the asset is being actively marketed at a reasonable price; • the sale is expected to be completed within 12 months of the date of classification as ‘Held for Sale’; and • the actions needed to complete the plan indicate it is unlikely that the plan will be dropped or significant changes made to it.

Following reclassification, the assets are measured at the lower of their existing carrying amount and their ‘fair value less costs to sell’. Depreciation ceases to be charged and the assets are not revalued, except where the ‘fair value less costs to sell’ falls below the carrying amount. Assets are de-recognised when all material sale contract conditions have been met.

Property, plant and equipment which is to be scrapped or demolished does not qualify for recognition as ‘Held for Sale’ and instead is retained as an operational asset and the asset’s economic life is adjusted. The asset is de-recognised when scrapping or demolition occurs.

1.12 Intangible assets

Recognition Intangible assets are non-monetary assets without physical substance which are capable of being sold separately from the rest of the Foundation Trust’s business or which arise from contractual or other legal rights. They are recognised only where it is probable that future economic benefits will flow to, or service potential be provided to, the Foundation Trust and where the cost of the asset can be measured reliably.

Internally generated intangible assets Internally generated goodwill, brands, mastheads, publishing titles, customer lists and similar items are not capitalised as intangible assets.

Expenditure on research is not capitalised.

Expenditure on development is capitalised only where all of the following can be demonstrated:

Page 11 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

• the project is technically feasible to the point of completion and will result in an intangible asset for sale or use; • the Foundation Trust intends to complete the asset and sell or use it; • the Foundation Trust has the ability to sell or use the asset; • how the intangible asset will generate probable future economic or service delivery benefits e.g. the presence of a market for it or its output, or where it is to be used for internal use, the usefulness of the asset; • adequate financial, technical and other resources are available to the Foundation Trust to complete the development and sell or use the asset; and • the Foundation Trust can measure reliably the expenses attributable to the asset during development.

Software Software which is integral to the operation of hardware, e.g. an operating system, is capitalised as part of the relevant item of property, plant and equipment. Software which is not integral to the operation of hardware, e.g. application software, is capitalised as an intangible asset.

Measurement Intangible assets are recognised initially at cost, comprising all directly attributable costs needed to create, produce and prepare the asset to the point that it is capable of operating in the manner intended by management.

Subsequently intangible assets are measured at current value in existing use. Where no active market exists, intangible assets are valued at the lower of depreciated replacement cost and the value in use where the asset is income generating. Revaluations gains and losses and impairments are treated in the same manner as for property, plant and equipment. An intangible asset which is surplus with no plan to bring it back into use is valued at fair value under IFRS 13, if it does not meet the requirements of IAS 40 of IFRS 5.

Intangible assets held for sale are measured at the lower of their carrying amount or ‘fair value less costs to sell’.

Amortisation Intangible assets are amortised over their expected useful economic lives in a manner consistent with the consumption of economic or service delivery benefits.

1.13 Donated assets

Donated and grant funded assets are capitalised at their fair value on receipt. The donation/grant is credited to income at the same time, unless the donor has imposed a condition that the future economic benefits embodied in the grant are to be consumed in a manner specified by the donor, in which case the donation/grant is deferred within liabilities and is carried forward to future financial years to the extent that the condition has not yet been met.

Page 12 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

The donated and grant funded assets are subsequently accounted for in the same manner as other items of property, plant and equipment.

1.14 Leases Leases are classified as finance leases when substantially all the risks and rewards of ownership are transferred to the lessee. All other leases are classified as operating leases.

Finance leases Where substantially all risks and rewards of ownership of a leased asset are borne by the NHS Foundation Trust, the asset is recorded as property, plant and equipment and a corresponding liability is recorded. The value at which both are recognised is the lower of the fair value of the asset or the present value of the minimum lease payments, discounted using the interest rate implicit in the lease. The implicit interest rate is that which produces a constant periodic rate of interest on the outstanding liability.

The asset and liability are recognised at the inception of the lease, and are de-recognised when the liability is discharged, cancelled or expires. The annual rental is split between the repayment of the liability and a finance cost. The annual finance cost is calculated by applying the implicit interest rate to the outstanding liability and is charged to Finance Costs in the Statement of Comprehensive Income.

Operating leases Other leases are regarded as operating leases and the rentals are charged to operating expenses on a straight-line basis over the term of the lease. Operating lease incentives received are added to the lease rentals and charged to operating expenses over the life of the lease.

Leases of land and buildings Where a lease is for land and buildings, the land component is separated from the building component and the classification for each is assessed separately. Leased land is treated as an operating lease.

The Foundation Trust as lessor Rental income from operating leases is recognised on a straight-line basis over the term of the lease. Initial direct costs incurred in negotiating and arranging an operating lease are added to the carrying amount of the leased asset and recognised on a straight-line basis over the lease term.

1.15 Inventories Inventories are valued at the lower of cost and net realisable value using the weighted average cost formula. This is considered to be a reasonable approximation to fair value due to the high turnover of stocks.

Page 13 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

1.16 Cash and cash equivalents Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value.

In the Statement of Cash Flows, cash and cash equivalents are shown net of bank overdrafts that are repayable on demand and that form an integral part of the Foundation Trust’s cash management.

1.17 Provisions The NHS foundation trust recognises a provision where it has a present legal or constructive obligation of uncertain timing or amount; for which it is probable that there will be a future outflow of cash or other resources; and a reliable estimate can be made of the amount. The amount recognised in the Statement of Financial Position is the best estimate of the resources required to settle the obligation. Where the effect of the time value of money is significant, the estimated risk-adjusted cash flows are discounted using the discount rates published and mandated by HM Treasury.

The HM Treasury discount rate for early retirement and injury benefit provisions is 1.37% for 2015/16 (1.3% 2014/15).

1.18 Clinical negligence costs The NHS Litigation Authority (NHSLA) operates a risk pooling scheme under which the NHS Foundation Trust pays an annual contribution to the NHSLA, which, in return, settles all clinical negligence claims. Although the NHSLA is administratively responsible for all clinical negligence cases, the legal liability remains with the NHS Foundation Trust. The total value of clinical negligence provisions carried by the NHSLA on behalf of the NHS Foundation Trust is disclosed at note 25.

1.19 Non-clinical risk pooling The NHS Foundation Trust participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the Foundation Trust pays an annual contribution to the NHS Litigation Authority and in return receives assistance with the costs of claims arising. The annual membership contributions, and any ‘excesses’ payable in respect of particular claims, are charged to operating expenses when the liability arises.

1.20 Contingent liabilities Contingent liabilities are not recognised, but are disclosed in Note 28, unless the probability of a transfer of economic benefits is remote.

Page 14 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

Contingent liabilities are defined as: • possible obligations arising from past events whose existence will be confirmed only by the occurrence of one or more uncertain future events not wholly within the entity’s control; or • present obligations arising from past events but for which it is not probable that a transfer of economic benefits will arise or for which the amount of the obligation cannot be measured with sufficient reliability.

1.21 Financial assets Financial assets are recognised on the balance sheet when the Foundation Trust becomes party to the financial instrument contract or, in the case of trade receivables, when the goods or services have been delivered. Financial assets are de-recognised when the contractual rights have expired or the asset has been transferred. Financial assets are initially recognised at fair value.

Financial assets are classified into the following categories: financial assets ‘at fair value through profit and loss’; ‘held to maturity investments’; ‘available for sale’ financial assets; and ‘loans and receivables’. The classification depends on the nature and purpose of the financial assets and is determined at the time of initial recognition.

Financial assets at fair value through profit and loss Embedded derivatives that have different risks and characteristics to their host contracts, and contracts with embedded derivatives whose separate value cannot be ascertained, are treated as financial assets at fair value through profit and loss. They are held at fair value, with any resultant gain or loss recognised in the income statement. The net gain or loss incorporates any interest earned on the financial asset.

Loans and receivables Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. After initial recognition, they are measured at amortised cost using the effective interest method, less any impairment. Interest is recognised using the effective interest method.

Fair value is determined by reference to quoted market prices where possible, otherwise by valuation techniques.

The effective interest rate is the rate that exactly discounts estimated future cash receipts through the expected life of the financial asset, to the net carrying amount of the financial asset.

At the balance sheet date, the Foundation Trust assesses whether any financial assets, other than those held at ‘fair value through profit and loss’ are impaired. Financial assets are impaired and impairment losses recognised if there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset.

Page 15 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset’s carrying amount and the present value of the revised future cash flows discounted at the asset’s original effective interest rate. The loss is recognised in the statement of comprehensive income and the carrying amount of the asset is reduced directly, or through a provision for impairment of receivables.

If, in a subsequent period, the amount of the impairment loss decreases and the decrease can be related objectively to an event occurring after the impairment was recognised, the previously recognised impairment loss is reversed through the income statement to the extent that the carrying amount of the receivable at the date of the impairment is reversed does not exceed what the amortised cost would have been had the impairment not been recognised.

The Foundation Trust’s loans and receivables comprise: cash and cash equivalents, NHS debtors, accrued income and other debtors. It excludes prepayments, VAT receivable and PDC dividend receivable.

1.22 Financial liabilities Financial liabilities are recognised on the balance sheet when the Foundation Trust becomes party to the contractual provisions of the financial instrument or, in the case of trade payables, when the goods or services have been received. Financial liabilities are de-recognised when the liability has been discharged, that is, the liability has been paid or has expired.

Loans from the Department of Health are recognised at historical cost. Otherwise, financial liabilities are initially recognised at fair value.

Financial liabilities are classified as either financial liabilities ‘at fair value through profit and loss’ or other financial liabilities.

Financial liabilities at fair value through profit and loss Embedded derivatives that have different risks and characteristics to their host contracts, and contracts with embedded derivatives whose separate value cannot be ascertained, are treated as financial liabilities at fair value through profit and loss. They are held at fair value, with any resultant gain or loss recognised in the income statement. The net gain or loss incorporates any interest earned on the financial asset.

Other financial liabilities After initial recognition, all other financial liabilities are measured at amortised cost using the effective interest method. The effective interest rate is the rate that exactly discounts estimated future cash payments through the life of the asset, to the net carrying amount of the financial liability. Interest is recognised using the effective interest method.

Page 16 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

1.23 Value Added Tax Most of the activities of the Foundation Trust are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.

1.24 Foreign exchange The functional and presentational currencies of the Foundation Trust are sterling.

A transaction which is denominated in a foreign currency is translated into the functional currency at the spot exchange rate on the date of the transaction.

Where the Foundation Trust has assets or liabilities denominated in a foreign currency at the balance sheet date:

• monetary items (other than financial instruments measured at ‘fair value through income and expenditure’) are translated at the spot exchange rate on 31 March; • non-monetary assets and liabilities measured at historical cost are translated using the spot exchange rate at the date of the transaction; and • non-monetary assets and liabilities measured at fair value are translated using the spot exchange rate at the date the fair value was determined.

Exchange gains or losses on monetary items (arising on settlement of the transaction or on re- translation at the balance sheet date) are recognised in income or expense in the period in which they arise.

Exchange gains or losses on non-monetary assets and liabilities are recognised in the same manner as other gains and losses on these items.

1.25 Third party assets Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since the NHS Foundation Trust has no beneficial interest in them. Details of third party assets are disclosed in Note 32 to the accounts.

1.26 Public dividend capital (PDC) and PDC dividend Public dividend capital (PDC) is a type of public sector equity finance based on the excess of assets over liabilities at the time of establishment of the predecessor NHS trust. HM Treasury has determined that PDC is not a financial instrument within the meaning of IAS 32.

Page 17 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

A charge, reflecting the cost of capital utilised by the NHS foundation trust, is payable as public dividend capital dividend. The charge is calculated at the rate set by HM Treasury (currently 3.5%) on the average relevant net assets of the NHS foundation trust during the financial year. Relevant net assets are calculated as the value of all assets less the value of all liabilities, except for (i) donated assets (including lottery funded assets), (ii) average daily cash balances held with the Government Banking Services (GBS) and National Loans Fund (NLF) deposits, excluding cash balances held in GBS accounts that relate to a short-term working capital facility, and (iii) any PDC dividend balance receivable or payable. In accordance with the requirements laid down by the Department of Health (as the issuer of PDC), the dividend for the year is calculated on the actual average relevant net assets as set out in the “pre-audit” version of the annual accounts.

1.27 Losses and special payments Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way each individual case is handled.

Losses and special payments are charged to the relevant functional headings in the Income and Expenditure Account on an accruals basis, including losses which would have been made good through insurance cover had NHS Foundation Trusts not been bearing their own risks (with insurance premiums then being included as normal revenue expenditure).

1.28 Accounting standards No accounting standards have been adopted early.

1.29 Corporation tax Bolton NHS Foundation Trust is regarded as a Health Service body within the meaning of the Income and Corporation Tax Act (ICTA) 1988 and accordingly is exempt from taxation on its income and capital gains within categories covered by this. There is a power for the Treasury to disapply this exemption in relation to the specified activities of a Foundation Trust. Accordingly, Bolton NHS Foundation Trust is potentially within the scope of corporation tax in respect of activities which are not related to, or ancillary to, the provision of healthcare and where the profits therefrom exceed £50,000 p.a.

There is no corporation tax liability for this financial period.

Activities such as staff and patient car parking and sales of food are considered to be ancillary to the core healthcare objectives of the Foundation Trust and therefore not subject to corporation tax.

Page 18 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

1.30 Transfers of functions from other NHS bodies

For functions that have been transferred to the trust from another [NHS / local government] body, the assets and liabilities transferred are recognised in the accounts as at the date of transfer. The assets and liabilities are not adjusted to fair value prior to recognition. The net gain corresponding to the net assets transferred is recognised within income, but not within operating activities. The net gain corresponding to the net assets transferred from Bolton PCT is recognised within the income and expenditure reserve.

For property, plant and equipment assets and intangible assets, the Cost and Accumulated Depreciation / Amortisation balances from the transferring entity's accounts are preserved on recognition in the trust's accounts. Where the transferring body recognised revaluation reserve balances attributable to the assets, the trust makes a transfer from its income and expenditure reserve to its revaluation reserve to maintain transparency within public sector accounts.

1.31 Accounting standards that have been issued but have not yet been adopted The Treasury FReM does not require the following Standards and Interpretations to be applied in 2015- 16. The application of the Standards as revised would not have a material impact on the accounts for 2015-16, were they applied in that year:

IFRS 9 Financial Instruments - Application required for accounting periods beginning on or after 1 January 2018, but not yet adopted by the FReM: early adoption is not therefore permitted.

IFRS 15 Revenue for Contracts with Customers - Application required for accounting periods beginning on or after 1 January 2017, but not yet adopted by the FReM: early adoption is not therefore permitted. IFRS 16 Leases - Application required for accounting periods beginning on or after 1 January 2019, but not yet adopted by the FReM: early adoption is not therefore permitted.

2. OPERATING SEGMENTS All activity for Bolton NHS Foundation Trust is healthcare related. As the operating segments have similar characteristics there is no requirement to report segmentally.

Whilst the Foundation Trust has a divisional structure in place the services that are provided are essentially all the same (patient care) and the majority of risks faced by each division are fundamentally the same.

3. INCOME GENERATION ACTIVITIES

The Trust undertakes income generation activities with an aim of achieving profit. The total income generation for the year ended 31 March 2016 was £72k. (£80k for the year ended 31 March 2015) This is included within other income.

Page 19 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

4. OPERATING INCOME FROM PATIENT CARE ACTIVITIES

4.1. Revenue from patient care activities - by nature 2015/16 2014/15 £000 £000 Acute Trusts Elective income 31,451 32,449 Non elective income 75,741 75,154 Outpatient income 42,110 43,514 A&E income 12,705 11,638 Other NHS clinical income 103,801 102,699

All Trusts Additional income for delivery of healthcare services* 4,100 - Private patient income 73 69 Other clinical income 1,556 1,268 Total income from activities 271,537 266,791 * The Trust has received an additional £4,100k from the Department of Health in 2015/16, received via PDC capital to revenue transfer, for the delivery of healthcare services.

4.2 Revenue from patient care activities - by source 2015/16 2014/15 Income from patient care activities received from: £000 £000

NHS Foundation Trusts 199 497 NHS Trusts 77 250 CCGs and NHS England 254,672 255,611 Local Authorities 10,450 8,538 NHS Other 411 558 Additional income for delivery of healthcare services 4,100 - Non-NHS: Private patients 73 69 Overseas patients (chargeable to patient) 171 101 NHS injury scheme (was RTA) ** 1,257 1,114 Other 127 53 271,537 266,791

** Injury cost recovery income is subject to a provision for impairment of receivables of 18.9% to reflect expected rates of collection.

4.3 COMMISSIONER AND NON COMMISSIONER REQUESTED INCOME Under the terms of its provider license, the trust is required to analyse the level of income from activities that has arisen from commissioner requested and non-commissioner requested services. Commissioner requested services are defined in the provider license and are services that commissioners believe would need to be protected in the event of provider failure. This information is provided in the table below:

Page 20 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

4.3 COMMISSIONER AND NON COMMISSIONER REQUESTED INCOME (CONTINUED)

2015/16 2014/15 £000 £000 Commissioner requested income 254,672 255,611 Non -commissioner requested income 16,865 11,180 Total income from activities 271,537 266,791

5. OVERSEAS VISITOR INCOME 2015/16 2014/15 £000 £000 Income recognised this year 171 101 Cash payments received in-year 47 31 Amounts added to provision for impairment of receivables 6 3 Amounts written off in-year - 28

6. OTHER OPERATING REVENUE 2015/16 2014/15 £000 £000 Research and development 455 408 Education, training and research 9,545 9,639 Received from NHS charities: Donation of physical assets (non- cash) 55 192 Non-patient care services to other bodies 4,687 4,560 Reversal of impairments of property, plant and equipment - 3,322 Rental revenue from operating leases 186 186 Income in respect of staff costs where accounted on gross basis 2,495 2,495 Other revenue 3,581 3,969 21,004 24,771

Other Revenue 2015/16 2014/15 £000 £000 Car parking 1,376 1,302 Estates recharges 77 204 Pharmacy sales 133 149 Staff contributions to employee benefit schemes 27 65 Staff accommodation rentals 46 30 Clinical excellence awards 421 511 Catering 923 883 Property rentals 5 23 Other 573 802 Total 3,581 3,969

7. REVENUE Revenue is almost totally from the supply of services. Revenue from the sale of goods is immaterial.

Page 21 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

8. OPERATING EXPENDITURE

8.1 Operating expenses 2015/16 2014/15 £000 £000 Services from Foundation Trusts 2,235 2,125 Services from NHS Trusts 306 361 Services from CCG's and NHS England - 3 Services from other NHS bodies 132 107 Purchase of healthcare from non-NHS bodies 903 509 Employee expense - Executive directors 1,164 1,033 Employee expense - Non-executive directors 143 140 Employee expense - Staff costs 203,766 201,829 Supplies and services - clinical (excluding drug costs) 20,588 19,975 Supplies and services - general 8,480 8,152 Establishment 3,260 3,058 Transport 138 188 Premises - business rates payable to local authorities 1,128 1,106 Premises - other 10,336 10,127 Increase/(decrease) in provision for impairment of receivables (766) 754 Change in provisions discount rate (3) 25 Inventories written down 31 26 Drug costs 6,290 5,707 Drugs inventories consumed 14,266 13,116 Rentals under operating leases 299 362 Depreciation on property, plant and equipment 5,259 5,350 Amortisation on intangible assets 280 186 Impairments of property, plant and equipment - 25,255 Impairments of intangible assets - 4 Audit fees audit services - statutory audit 59 63 other auditor remuneration (external auditor only) 10 12 Clinical negligence premium 6,881 7,062 Loss on disposal of other property, plant and equipment 1 16 Legal fees 125 253 Consultancy costs 275 1,082 Internal audit costs - (not included in employee expenses) 142 119 Training, courses and conferences 592 503 Patient travel 20 22 Redundancy - 97 Insurance 136 120 Losses, ex gratia & special payments 113 208 Other 1,329 419 287,918 309,474

Page 22 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

9. OPERATING LEASES

9.1 As lessee This note discloses income generated in operating lease agreements where Bolton NHS Foundation Trust is the lessor. Operating lease payments include £107k for leased vehicles and £192k for equipment leases. The contracts for equipment leases are taken out for between 5 and 10 years, whilst vehicle leases are taken out for 3 years.

Payments recognised as an expense 2015/16 2014/15 £000 £000

Minimum lease payments 299 362 299 362

Future minimum lease payments due: 2015/16 2014/15 £000 £000 Other - not later than one year 181 248 - later than one year and not later than five years 113 311 Total 294 559

9.2 As lessor This note discloses costs and commitments incurred in operating lease arrangements where Bolton NHS Foundation Trust FT is the lessee. Rental revenue 2015/16 2014/15 £000 £000

Contingent rent 186 186 Total rental revenue 186 186

Total future minimum lease payments receivable 2015/16 2014/15 £000 £000 Buildings - not later than one year 111 186 - later than one year and not later than five years 164 270 - later than five years - - 275 456

Total 275 456

The £186k received in rental revenue includes rentals received from WRVS for the use of rooms within the hospital for providing shops and rentals from High Meadows Nursery.

Page 23 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

10. EMPLOYEE COSTS AND NUMBERS

10.1 Employee costs 2015/16 2015/16 2015/16 2014/15 2014/15 2014/15 Total Permanent Other Total Permanent Other £000 £000 £000 £000 £000 £000 Salaries and wages 164,593 152,757 11,836 162,566 154,356 8,210 Social Security costs 12,190 11,290 900 12,184 11,589 595 Termination benefits 166 166 - - - - Pension costs - defined contribution plans Employer's contributions to NHS Pensions 18,581 18,581 - 17,744 17,744 - Agency/contract staff 9,400 - 9,400 10,465 - 10,465 Total gross staff costs 204,930 182,794 22,136 202,959 183,689 19,270

2015/16 2014/15 £000 £000 Analysed as Employee expense - Executive directors 1,164 1,033 Employee expense - Staff costs 203,766 201,829 Redundancy - 97 Total gross staff costs is comprised of: 204,930 202,959

10.2 Directors' remuneration 2015/16 2014/15 £'000 £'000 Directors' remuneration 1,307 1,173 Employer contribution to a pension scheme in respect of directors 124 99

2015/16 2014/15 Number Number The total number of directors to whom benefits are accruing under defined benefit schemes 7 8

Further details on directors' renumeration can be found in the renumeration report.

10.3 Key management remuneration Key management is defined as the executive and non-executive directors of the Foundation Trust. Further details of their remuneration can be found in the 2015/16 remuneration report published as part of the Foundation Trust's annual report.

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NOTES TO THE ACCOUNTS

11. PENSION COSTS

Past and present employees are covered by the provisions of the two NHS Pension Schemes. Details of the benefits payable and rules of the Schemes can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions. Both are unfunded defined benefit schemes that cover NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State in England and Wales. They are not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, each scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS body of participating in each scheme is taken as equal to the contributions payable to that scheme for the accounting period.

In order that the defined benefit obligations recognised in the financial statements do not differ materially from those that would be determined at the reporting date by a formal actuarial valuation, the FReM requires that “the period between formal valuations shall be four years, with approximate assessments in intervening years”. An outline of these follows:

a) Accounting valuation A valuation of scheme liability is carried out annually by the scheme actuary (currently the Government Actuary’s Department) as at the end of the reporting period. This utilises an actuarial assessment for the previous accounting period in conjunction with updated membership and financial data for the current reporting period, and are accepted as providing suitably robust figures for financial reporting purposes. The valuation of scheme liability as at 31 March 2016, is based on valuation data as 31 March 2015, updated to 31 March 2016 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS 19, relevant FReM interpretations, and the discount rate prescribed by HM Treasury have also been used.

The latest assessment of the liabilities of the scheme is contained in the scheme actuary report, which forms part of the annual NHS Pension Scheme (England and Wales) Pension Accounts. These accounts can be viewed on the NHS Pensions website and are published annually. Copies can also be obtained from The Stationery Office.

b) Full actuarial (funding) valuation The purpose of this valuation is to assess the level of liability in respect of the benefits due under the schemes (taking into account their recent demographic experience), and to recommend contribution rates payable by employees and employers.

The last published actuarial valuation undertaken for the NHS Pension Scheme was completed for the year ending 31 March 2012.

The Scheme Regulations allow for the level of contribution rates to be changed by the Secretary of State for Health, with the consent of HM Treasury, and consideration of the advice of the Scheme Actuary and appropriate employee and employer representatives as deemed appropriate.

Page 25 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

12. RETIREMENTS DUE TO ILL-HEALTH

During 2015/16 there were 6 (2014/15, 10) early retirements from the NHS Trust agreed on the grounds of ill-health. The estimated additional pension liabilities of these ill-health retirements will be £190,450 (2014/15: £918,393). The cost of these ill-health retirements will be borne by the NHS Business Services Authority - Pensions Division.

13. FINANCE INCOME Finance income represents interest received on assets and investments in the period. 2015/16 2014/15 £000 £000

Interest on bank accounts 35 41 Total 35 41

14. FINANCE COSTS - INTEREST EXPENSE Finance expenditure represents interest and other charges involved in the borrowing of money. 2015/16 2014/15 £000 £000

Capital loans from the Department of Health 640 786 Finance leases 2 37 Other - 26 Total interest expense 642 849

15. OTHER GAINS AND LOSSES 2015/16 2014/15 £000 £000

Gain/(loss) on disposal of property, plant and equipment 1 16

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16.1 PROPERTY, PLANT AND EQUIPMENT Land Buildings Dwellings Assets under Plant and Transport Information Furniture Total excluding construction machinery equipment technology & fittings 2015/16: dwellings £000 £000 £000 £000 £000 £000 £000 £000 £000

Cost or valuation at 1 April 2015 8,618 159,195 1,099 2,756 24,919 138 7,015 423 204,163 Additions purchased - 2,883 93 3,917 502 - 1,410 - 8,805 Additions leased - - - - 125 - - - 125 Additions donated - - - 7 22 - - - 29 Reclassifications - 733 - (1,603) 391 - 157 - (322) Disposals - - - - (312) - - - (312) At 31 March 2016 8,618 162,811 1,192 5,077 25,647 138 8,582 423 212,488

Depreciation at 1 April 2015 5,928 70,253 331 - 17,475 128 4,872 341 99,328 Disposals - - - - (300) - - - (300) Impairments ------Reversal of impairments credited to operating income ------Provided during the year - 3,733 - - 1,183 2 321 20 5,259 Depreciation at 31 March 2016 5,928 73,986 331 - 18,358 130 5,193 361 104,287

Net book value NBV - Owned at 31 March 2015 2,690 87,627 768 2,748 5,026 10 2,134 79 101,082 NBV - Finance lease at 31 March 2015 - - - - 1,785 - - - 1,785 NBV - Donated at 31 March 2015 - 1,315 - 8 633 - 9 3 1,968 Total at 31 March 2015 2,690 88,942 768 2,756 7,444 10 2,143 82 104,835

Net book value NBV - Owned at 31 March 2016 2,690 87,563 861 5,070 5,183 8 3,382 60 104,817 NBV - Finance lease at 31 March 2016 - - - - 1,528 - - - 1,528 NBV - Donated at 31 March 2016 - 1,262 - 7 578 - 7 2 1,856 Total at 31 March 2016 2,690 88,825 861 5,077 7,289 8 3,389 62 108,201

Page 27 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

16.2 PROPERTY, PLANT AND EQUIPMENT Land Buildings Dwellings Assets under Plant and Transport Information Furniture Total excluding construction machinery equipment technology & fittings 2014/15: dwellings £000 £000 £000 £000 £000 £000 £000 £000 £000

Cost or valuation at 1 April 2014 23,935 146,871 1,099 1,456 23,923 138 6,344 423 204,189 Additions purchased - 696 - 2,748 705 - 1,073 - 5,222 Additions leased - - - - 514 - - - 514 Additions donated - 10 - 8 174 - - - 192 Reclassifications - 1,456 - (1,456) 402 - (402) - - Revaluations (15,317) 10,162 ------(5,155) Disposals - - - - (799) - - - (799) At 31 March 2015 8,618 159,195 1,099 2,756 24,919 138 7,015 423 204,163

Depreciation at 1 April 2014 - 50,866 297 - 16,574 125 4,645 321 72,828 Disposals - - - - (783) - - - (783) Impairments 5,928 19,327 ------25,255 Reversal of impairments credited to operating income - (3,322) ------(3,322) Provided during the year - 3,382 34 - 1,684 3 227 20 5,350 Depreciation at 31 March 2015 5,928 70,253 331 - 17,475 128 4,872 341 99,328

Page 28 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

16.3 PROPERTY, PLANT AND EQUIPMENT (CONTINUED)

Assets totalling £55k have been donated by Bolton NHS Charitable Fund. These are: £'000

ECG machine 8 OCT Machine 9 BX43F Microscope Frame 26 Microscope 5 Transport Ventilator 7

Assets are depreciated evenly over the estimated life given in the table below: Life (Years)

Software Licences 2 - 6 Buildings excluding dwellings 1 - 76 Dwellings 5 - 60 Plant & Machinery 6 - 16 Transport Equipment 10 - 15 Information Technology 8 - 8 Furniture and Fittings 12-12

At 31 March 2016 no land, buildings or dwellings were valued at open market value.

The date of the latest revaluation of land and buildings was 1 January 2015. The valuation was carried out by the District Valuer, a RICS registered individual, who is external to the organisation. The valuation was completed using a "modern equivalent assets - alternate site" basis on the grounds that this was a more appropriate method of calculation. The decision to use this basis for the first time was approved by the Audit Committee on behalf of the Board in February 2015.

Page 29 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

17. INTANGIBLE ASSETS Computer software - 2015/16: purchased £000 Gross cost at 1 April 2015 2,472 Additions purchased 328 Additions - donations of physical assets (non-cash) 26 Reclassifications 322 Gross cost at 31 March 2016 3,148

Amortisation at 1 April 2015 1,578 Provided during the year 280 Amortisation at 31 March 2016 1,858

Net book value Purchased 1,248 Donated 42 Total at 31 March 2016 1,290

Prior year: Computer software - 2014/15: purchased £000 Gross cost at 1 April 2014 2,102 Additions purchased 562 Disposals (192) Gross cost at 31 March 2015 2,472

Amortisation at 1 April 2014 1,580 Provided during the year 186 Impairments charged to operating expenses 4 Disposals (192) Amortisation at 31 March 2015 1,578

Net book value Purchased 869 Donated 25 Total at 31 March 2015 894

Page 30 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

18. CAPITAL COMMITMENTS

Contracted capital commitments at 31 March not otherwise included in these financial statements:

2015/16 2014/15 £000 £000

Property, plant and equipment 1,317 192 Total 1,317 192

19. INVENTORIES

2015/16 2014/15 £000 £000

Drugs 1,042 1,001 Consumables 1,490 1,162 Energy 82 94 Other 396 342 Total 3,010 2,599 of which held at net realisable value: 3,010 2,599

The Foundation Trust does not have any non-current inventories.

19.1 INVENTORIES RECOGNISED IN EXPENSES 2015/16 2014/15 £000 £000

Drug inventories consumed 14,266 13,116 Supplies and services clinical consumed 5,201 4,269 Supplies and services non clinical consumed 1,645 1,772 Other inventories consumed - - Write-down of inventories recognised as an (31) (26) expense TOTAL Inventories recognised in expenses 21,081 19,131

Page 31 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

20. TRADE AND OTHER RECEIVABLES

20.1 Trade and other receivables Current Non-current 2015/16 2014/15 2015/16 2014/15 £000 £000 £000 £000

NHS receivables - revenue 3,146 4,626 - - Provision for the impairment of receivables (362) (1,661) (125) (127) Prepayments - other 2,627 1,768 - - Accrued income 713 2,385 - - PDC dividend receivable 81 492 - - VAT receivable 1,150 397 - - Other receivables 1,541 2,004 662 673 Total 8,896 10,011 537 546

20.2 Ageing of non-impaired receivables past their due date 2015/16 2014/15 £000 £000

0-30 days 2,171 4,525 30-60 days 377 613 60-90 days 356 242 90-180 days 589 75 180-360 days 399 193 3,892 5,648

Page 32 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

20.3 Provision for impairment of receivables 2015/16 2014/15 £000 £000

Balance at 1 April 1,788 1,113 (Increase)/decrease in receivables impaired 6 754 Amounts utilised (535) (79) Unused amounts reversed (772) - Balance at 31 March 487 1,788

Receivables impaired during the period relate to the:

movement in the provision for bad debt on the injury cost recovery scheme. movement in the provision for bad debt on trade receivables.

20.4 Ageing of impaired receivables 2015/16 2014/15 £000 £000

0-30 days - - 30-60 days 6 - 60-90 days 10 - 90-180 days 52 58 180-360 days 419 1,730 487 1,788

Page 33 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

21. CASH AND CASH EQUIVALENTS Cash and cash equivalents comprise cash at bank, in hand and cash equivalents. Cash equivalents are readily convertible investments of known value which are subject to an insignificant risk of change in value.

2015/16 2014/15 £000 £000

Balance at 1 April 5,265 408 Net change in year (3,795) 4,857 Balance at 31 March 1,470 5,265

Made up of Cash with the Government Banking Service 1,464 5,228 Commercial banks and cash in hand 6 37 Cash and cash equivalents as in statement of financial position 1,470 5,265

Third party assets held by the foundation trust Bolton NHS Foundation Trust held cash and cash equivalents which relate to monies held by the the foundation trust on behalf of patients or other parties. This has been excluded from the cash and cash equivalents figure reported in the accounts. 2015/16 2014/15 Bank balances Bank balances £000 £000

Balance at 1 April 40 47 Gross inflows 42 27 Gross outflows (48) (34) Balance at 31 March 34 40

Page 34 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

22. TRADE AND OTHER PAYABLES Current 2015/16 2014/15 £000 £000

NHS payables - revenue 2,449 1,805 Other trade payables - capital 2,042 2,771 Other trade payables - revenue 3,423 3,188 Other taxes payable 3,635 3,626 Other payables 4,807 7,480 Accruals 10,036 6,591 Total 26,392 25,461

Other payables include: Outstanding pension contributions of £2,570,909 at the 31 March 2016 (£2,478,798 at 31 March 2015).

Pension contributions are paid a month in arrears.

23. BORROWINGS Current Non-current 2015/16 2014/15 2015/16 2014/15 £000 £000 £000 £000

Capital loans from Department of Health 1,368 1,659 15,867 18,585 Finance lease liabilities - 16 - - Total 1,368 1,675 15,867 18,585

The Foundation Trust has three loans with the Department of Health which total £17,235k.

£15,567k - To fund "Making it Better" developments within Women's and Children's. The loan has a fixed rate of 3.75% and has been taken out over a 20 year term and is due to be fully repaid by October 2029.

£1,560k - To fund the purchase of land for a Car Park. The loan has a fixed rate of 1.26% and has been taken out over a 10 year term and is due to be fully repaid by December 2022.

£108k - To fund Estate Strategy. The loan is for £24,500k with £108k drawn down at 31 March 2016 the balance to be drawn down in the next 3 years. The loan has a fixed rate of 2.22% and has been taken out over a 25 year term and is due to be fully repaid by November 2040.

Page 35 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

24. FINANCE LEASE OBLIGATIONS Finance leases are for medical equipment used within the Trust. This is for a Managed Facilities Service in radiology that commenced in July 2010. The capital value of the assets provided to date under this facility is £3,006,446. The facility is for a 15 year term. As the 31 March 2016 the finance lease is a receivable balance of £539k, this is part of prepayments in note 20.1

Amounts payable under finance leases: Minimum lease Present value of minimum payments lease payments 2015/16 2014/15 2015/16 2014/15 £000 £000 £000 £000

Within one year - 18 - 18 Between one and five years - - Less future finance charges - (2) Present value of minimum lease payments - 16 - 18

Included in: Current borrowings - 16 - - Non-current borrowings - - - - - 16 - -

25. PROVISIONS Current Non-current 2015/16 2014/15 2015/16 2014/15 £000 £000 £000 £000 Pensions relating to other staff 2 2 48 51 Legal claims 121 162 399 412 Redundancy - 181 - - Other 509 955 - 1 Total 632 1,300 447 464

Page 36 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

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25. PROVISIONS (CONTINUED)

Pensions Legal Other Redundancy Total relating claims to other staff £000 £000 £000 £000 £000 At 1 April 2015 53 574 956 181 1,764 Change in the discount rate - (3) - - (3) Arising during the year - 93 61 - 154 Utilised during the year (5) (98) (159) - (262) Reversed unused - (56) (349) (181) (586) Unwinding of discount 2 10 - - 12 At 31 March 2016 50 520 509 - 1,079

Expected timing of cash flows: not later than one year 2 121 509 - 632 later than one year and not later than five 6 77 - - 83 later than five years 42 322 - - 364 TOTAL 50 520 509 - 1,079

£104,724,618 is included in the provisions of the NHS Litigation Authority at 31 March 2016 in respect of clinical negligence liabilities of the Trust (31 March 2015: £52,430,995).

Legal Claims include £100,835 for Employer's and Occupiers' Liability cases and £419,287 for Permanent Injury Benefits. The items shown for Employer's and Occupiers' Liability cases relate to cases that have more than a 50% chance of being settled. Claims that have a remote chance of being settled are classed as contingent liabilities and disclosed in note 28.

In January 2009 the Trust signed an agreement with the NHSLA that in the event of the Trust (i) choosing to leave the CNST voluntarily and (ii) in the event of insolvency, the Trust would be required to compensate the NHSLA for all outstanding clinical negligence claims i.e. lump sum liability.

Provisions for redundancy costs are for individuals that haven't yet been identified. Although individuals are not known, the reduction in staff numbers is incorporated in the annual plan and the Trust Board has signed up to these financial reductions and communicated to the staff. The Trust is committed to this expenditure and it is appropriate to provide for.

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NOTES TO THE ACCOUNTS

26. MOVEMENTS IN PUBLIC DIVIDEND CAPITAL Public dividend capital (PDC) is a type of public sector equity finance based on the excess of assets over liabilities at the time of establishment of the predecessor NHS trust. Additional PDC may also be issued to NHS foundation trusts by the Department of Health. A charge, reflecting the cost of capital utilised by the NHS foundation trust, is payable to the Department of Health as the public dividend capital dividend.

2015/16 2014/15 £000 £000 Public Dividend Capital as at 1 April 102,090 101,987 Public dividend capital received * 4,281 103 Public dividend capital repaid (4,100) - Public Dividend Capital as at 31 March 102,271 102,090

* In 2015/16 the Trust received £4,281k Public Dividend Capital, this comprised of:

£000 Convert IT loan to PDC 1,604 IT Strategy 2,219 Ultrasound scanner 24 Open eyes 434 Public dividend capital received 4,281

27. MOVEMENTS ON REVALUATION RESERVE

Increases in asset values arising from revaluations are recognised in the revaluation reserve, except where, and to the extent that, they reverse impairments previously recognised in operating expenses, in which case they are recognised in operating income. Subsequent downward movements in asset valuations are charged to the revaluation reserve to the extent that a previous gain was recognised unless the downward movement represents a clear consumption of economic benefit or a reduction in service potential.

2015/16 2014/15 £000 £000 Revaluation reserve at 1 April 31,259 36,445 Revaluations - (5,155) Asset disposal (4) (31) Revaluation reserve at 31 March 31,255 31,259

Page 38 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

28. CONTINGENT LIABILITIES 2015/16 2014/15 £000 £000 (65) (82) Other (Employer's and Occupiers' legal claims) Total (65) (82)

29. FINANCIAL INSTRUMENTS

29.1 Financial assets by category Loans and receivables £000 Trade and other receivables 6,756 Cash at bank and in hand 5,265 Total at 31 March 2015 12,021

Trade and other receivables 5,601 Cash at bank and in hand 1,470 Total at 31 March 2016 7,071

29.2 Financial liabilities by category Other £000 Trade and other payables 8,053 Finance lease obligations 16 Other borrowings 20,244 Provisions under contract 432 Total at 31 March 2015 28,745

Trade and other payables 8,183 Finance lease obligations - Other borrowings 17,235 Provisions under contract 419 Total at 31 March 2016 25,837

Page 39 BOLTON NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2015/16

NOTES TO THE ACCOUNTS

29. FINANCIAL INSTRUMENTS CONTINUED

29.3 Maturity of financial liabilities 2015/16 2014/15 £000 £000 In one year or less 9,571 9,748 In more than one year but not more than two 1,388 1,679 years In more than two years but not more than five 4,269 5,035 years In more than five years 10,609 12,283 Total at 31 March 25,837 28,745

29.4 Financial risk management

Financial Reporting Standard IFRS 7 requires disclosure of the role that financial instruments have had during the period in creating or changing the risks a body faces in undertaking its activities. Because of the continuing service provider relationship that the NHS Trust has with Clinical Commissioning Groups and the way those Clinical Commissioning Groups are financed, the NHS Trust is not exposed to the degree of financial risk faced by business entities. Also financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The NHS Trust has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the NHS Trust in undertaking its activities.

The Trust’s treasury management operations are carried out by the finance department, within parameters defined formally within the Trust’s standing financial instructions and policies agreed by the Board of Directors. Trust treasury activity is subject to review by the Trust’s internal auditors.

Currency risk The Trust is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. The Trust has no overseas operations. The Trust therefore has low exposure to currency rate fluctuations.

Interest rate risk The Trust borrows from Government for capital expenditure, subject to affordability as confirmed by Monitor. The borrowings are for 1 – 25 years, in line with the life of the associated assets, and interest is charged at the National Loans Fund rate, fixed for the life of the loan. The Trust therefore has low exposure to interest rate fluctuations.

Page 40 NOTES TO THE ACCOUNTS

29.5 Financial risk management

Credit risk Because the majority of the Trust’s income comes from contracts with other public sector bodies, the Trust has low exposure to credit risk. The maximum exposures as at 31 March 2016 are in receivables from customers, as disclosed in the Trade and other receivables note.

Liquidity risk The Trust’s operating costs are incurred under contracts with Clinical Commissioning Groups, which are financed from resources voted annually by Parliament. The Trust funds its capital expenditure from funds obtained within its prudential borrowing limit. The Trust is not, therefore, exposed to significant liquidity risks.

30. EVENTS AFTER THE REPORTING PERIOD There are no events after the reporting period.

31. RELATED PARTY TRANSACTIONS

Details of related party transactions with individuals are as follows: Receipts Payments Amounts Amounts from to Related due from owed to Related Party Related Related Party Party Party £ '000 £ '000 £ '000 £ '000 Bolton Metropolitan Borough Council - 1,167 - - McMillan Cancer - 4 - - Salford University 36 - 2 - University of Bolton - 9 - - Bolton Hospice 786 - 59 -

The Department of Health is regarded as a related party. During the period, Bolton NHS Foundation Trust has had a significant number of material transactions with the Department, and with other entities for which the Department is regarded as the parent Department. These entities are listed below: Receipts Payments Amounts Amounts from to Related due from owed to Related Party Related Related Party Party Party £ '000 £ '000 £ '000 £ '000 Department of Health 4,100 5 93 -

Bolton CCG 180,598 - 439 1,258 NHS England 29,549 3 200 105 Wigan Borough CCG 16,905 - 44 - Salford CCG 14,949 - - 101 Bury CCG 8,760 - 486 - Other CCG's & NHS England 586 3 674 126

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NOTES TO THE ACCOUNTS

31. RELATED PARTY TRANSACTIONS (CONTINUED)

Receipts Payments Amounts Amounts from to Related due from owed to Related Party Related Related Party Party Party £ '000 £ '000 £ '000 £ '000

Greater Manchester West Mental Health 1,587 75 293 74 Foundation Trust Salford Royal NHS Foundation Trust 155 661 261 259 Central Manchester University Hospitals NHS 760 1,140 305 224 Foundation Trust Wrightington, Wigan And Leigh NHS 159 634 61 242 Foundation Trust Christie Hospital NHS Foundation Trust 374 230 145 28 University Hospital Of South Manchester NHS 87 194 28 86 Foundation Trust Bridgewater Community Health Services NHS 189 3 119 3 Foundation Trust Other Foundation Trusts 263 327 91 106

Pennine Acute Hospitals NHS Trust 177 90 31 259 East Lancashire Hospital Trust 139 1 68 26 Other NHS Trusts 99 173 13 41

Health Education England 9,973 168 14 5 Public Health England 306 27 199 -

In addition, the Foundation Trust has had a number of material transactions with other Government Departments and other central and local Government bodies. Most of these transactions have been with the NHS Pension Scheme and the National Insurance Fund in respect of employee contributions. These entries are listed below: £ '000 £ '000 £ '000 £ '000 NHS Pensions Agency - 18,581 - 2,571 NHS Litigation - 6,881 - - NHS Property Services 481 2,320 272 1,104 Community Health Partnerships - 1,413 - 139

The Foundation Trust has received revenue and capital benefit from purchases made by Bolton NHS Charitable Fund. The transactions are summarised below. The separate Trustees' Report and Accounts for Bolton NHS Charitable Fund are available on request.

£ '000 Purchases made from Charitable Funds relating to capital assets transferred to the 55 Trust

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32. THIRD PARTY ASSETS The Trust held £34,219 cash and cash equivalents at 31 March 2016 (£40,037 at 31 March 2015) which relates to monies held by the NHS Trust on behalf of the SHO Induction Fund and patients. This has been excluded from the cash and cash equivalents figure reported in the accounts.

33. ANALYSIS OF INTER WHOLE OF GOVERNMENT BALANCES Current Income Current Expenditure receivables Transactions payables transactions £000 £000 £000 £000

English NHS Foundation Trusts 1,303 3,574 1,022 3,264 English NHS Trusts 112 415 326 264 Health Education England 14 9,973 5 168 Department of Health 93 4,100 1 5 NHS England and English Clinical Commissioning 1,936 255,447 1,590 3 Groups Special Health Authorities - 10 433 6,881 Public Health England 199 306 - 27 DH NDPBs 1 1 - 95 Other DH bodies 272 481 1,243 3,733 Total NHS Receivable/Payables 3,930 274,307 4,620 14,440 Other WGA bodies - Local Government 112 12,343 1,234 382 Other WGA bodies - Central Government 1,283 121 6,228 31,775 Total WGA Receivables/Payables at 31 March 2016 5,325 286,771 12,082 46,597

34. LOSSES AND SPECIAL PAYMENTS There were 42 cases of losses and special payments (2014/15: 144 cases) totalling £113k (2014/15: £285k) paid during 2015/16.

There were no cases exceeding £300,000. These amounts have been prepared on an accruals basis but exclude provisions for future losses.

35. LIMITATION ON AUDITORS' LIABILITY The limitation on auditors liability is £1,000,000, KPMG that provides for limitation of the auditors' liability. KPMG completed the review of the Trusts quality accounts, this is treated as a non-audit service.

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