Summary Annual Report and Accounts 2012/13 Central Manchester University Hospitals NHS Foundation Trust Central Manchester University Hospitals NHS Foundation Trust Annual Report and Summary Accounts – 2012/13. Presented to parliament pursuant to Schedule 7, Paragraph 25 (4) of the National Health Service Act 2006. 1 Contents Message from the Chairman & Chief Executive ..........................................................4 All about the organisation ...............................................................................6 Working with our Patients and Visitors. 8 Equality, Diversity and Human Rights. 14 Working with our Staff .................................................................................18 Carbon Reduction/Sustainability. .26 Infection Prevention and Control .......................................................................27 Research and Innovation. 28 Highlights and Developments ..........................................................................32 Viewed by Millions On TV ..............................................................................49 Activity and Performance ...............................................................................54 Quality Accounts 2012/13 .............................................................................56 Feedback from the Governors ........................................................................134 Commissioners’ Statement ...........................................................................134 Health and Wellbeing Overview and Scrutiny Committee ..............................................136 Statement of Directors’ Responsibilities in Respect of the Quality Report 2012/13 .....................137 Independent Assurance report to the Council of Governors of Central Manchester University Hospitals NHS Foundation Trust on the Annual Quality Report ..............................139 Performance against the Trusts Key Priorities for 2012/13 .............................................142 Monitor’s Regulatory Ratings. 146 Council of Governors .................................................................................148 Membership .........................................................................................168 Board of Directors ...................................................................................172 Annual Governance Statement. 180 Statement of Compliance with the NHS Foundation Trust Code of Governance ........................190 Audit Committee Annual Report. .192 The Remuneration and Nominations Committee Report ..............................................196 Statement of Chief Executive’s Responsibilities .......................................................197 Report of the Executive Director of Finance ...........................................................198 Independent Auditors Report. 200 Summary Financial Statements ......................................................................202 Mission Statement: The Trust aims to become the leading We have three key organisational integrated health, teaching, research priorities, all of which we are and innovation campus in the NHS and committed to and working to improve: to position itself on an international 1) Patient safety and clinical quality. basis alongside the major biomedical research centres, as part of the 2) Patient and staff experience. thriving city region of Manchester – 3) Productivity and efficiency. with its strong emphasis on economic regeneration, science and enterprise. 3 Message from the Chairman & Chief Executive elcome to our fifth annual report as Patient Experience, Safeguarding, Public Health and a Foundation Trust. We would like Frail and Elderly care. We were delighted that we Wto begin this report by thanking our achieved an outstanding 96% of the schemes and staff for all their hard work and dedication over in fact we are the only trust in the region delivering the year. harm free care at patient level, above and beyond the targets set by CQUIN. Another example is As a healthcare organisation we have three main that CQUINs has enabled us to increase the priorities – Patient safety and clinical quality; number of home hazard assessments for patients Patient and staff experience and productivity referred for fragility fractures to over 80%. CQUIN and efficiency. These are always at the heart of schemes enable us to really push forward on quality everything we do. initiatives and we look forward to the new schemes We pride ourselves in ensuring that we deliver the set for 2013/14. best possible care and treatment to our patients With regard to The New Health Deal for Trafford, not only as a local hospital but as a specialist centre the changes that are being proposed for hospital in so many clinical fields. services in Trafford were the subject of an This year we have seen an improvement in our extensive public consultation last summer, and the NHS Staff Survey results. We were delighted to Commissioners have now confirmed that they want see that our overall staff engagement score had us to implement the revised service model. significantly increased and is now above average The changes are aimed at ensuring that the when compared to other acute Trusts. services provided in Trafford continue to be safe, The CQUIN (Commissioning for Quality and high quality, and financially sustainable. The local Innovation) framework is a national framework for authorities in Trafford and Manchester have asked quality improvement schemes. Some CQUIN schemes the Secretary of State to review the proposals, are set nationally, but most are agreed regionally and no changes will be implemented until after or locally, allowing us to ensure that areas of work this review has been completed. Subject to that are particularly important to our patients are the outcome of the Secretary of State’s review, included. We work closely with GPs and commissioners changes could be implemented later this year. to ensure that the local CQUINs are of benefit and As an organisation we believe that research and relevance to the patients we treat here. innovation are at the heart of everything we do – In 2012/13 there were over 70 individual CQUIN from ensuring that our patients get high quality schemes, split into a number of goals such as Harm care to improving the efficiency and effectiveness Free Care, Dementia, VTE (blood clot) Prevention, of the way we work. 4 We bring together internationally renowned researchers and clinicians who take discoveries from the laboratory We are indebted into our eight hospitals, community services and beyond. We are currently taking part in over 700 to our staff, research studies. without We are proud to be a partner in the Manchester Academic Health Sciences Centre. Together with The whom our University of Manchester and our local NHS partners we continue to work to bring benefits to patients through achievements research, education and innovation. Our Ward Accreditation Scheme which was a would not have major project introduced last year to support been possible. patient experience has proved very successful. The ward accreditation scheme is the assessment and measurement of a set of locally determined criteria available which details all of our charitable activities and based on best practice and quality improvement we would like to thank all our supporters who fundraise demonstrated through a series of indicators and cross in so many different ways. Our charity events during referenced with evidence such as complaints, incidents, the year have included The Great Manchester Run; Big culture, values and patient feedback. Wards are T Break and Celebrity Grilling. May 2012 also saw the awarded either White, Bronze Silver or Gold standard opening of a new £7.5 million Ronald McDonald House based on the results. It has proved incredibly successful on site which provides accommodation for up to 60 and we intend to develop this scheme further over the families at a time supporting parents of children and coming months. babies at Royal Manchester Children’s and Saint Mary’s Hospitals. We are lead sponsors of the Manchester Health Academy. This year students and staff there celebrated There have been many more developments and big improvements in GCSE results for the third year achievements which are highlighted throughout running since the Academy opened in September 2009. the report. Our staff have celebrated a particularly successful year with many individuals and teams The results were just the latest in a string of successes receiving national recognition via various recognised for the academy. The Academy has grown hugely in award schemes, which are also detailed in the Highlights popularity and its reputation as a centre of excellence section of this report. providing outstanding opportunities and support for students has meant that it has moved into a position News and up-dates throughout the year can be found within the top 10 most popular secondary schools in on our website (www.cmft.nhs.uk) and you can also Manchester from the position of least popular occupied follow us on Facebook and Twitter. by the predecessor school. As a Foundation Trust we are directly accountable to our members, local population, communities, partners and other organisations with whom we work. As a Member of the organisation, you have a real opportunity, through your elected representatives to shape our future. It is important to remember that even in a publicly funded service such as ours, charitable funding