Annual Report and Accounts 2015 – 2016
Annual Report and Accounts 2015 – 2016
North Tees and Hartlepool NHS Foundation Trust
Annual Report and Accounts 2015 – 2016 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006. ©2016 North Tees and Hartlepool NHS Foundation Trust Contents
Page
1. Chairman’s Statement 8
2. Performance Report 10
2.1 Overview of Performance 10
2.1.1 Chief Executive’s Statement 10
2.1.2 Overview of the Trust 11
2.1.3 Business Review 13
2.1.4 Trust Strategic Direction 13
2.1.5 Development and Service Improvement 14
2.1.6 Stakeholder Relationships 25
2.1.7 Risks and Uncertainties 25
2.1.8 Going Concern 28
2.2 Performance Analysis 28
2.2.1 Performance and Development of the Trust’s Business 28
2.2.2 Performance Review 30
2.2.3 Business Planning and Linkages to Key Activities 34
2.2.4 Future Challenges to Performance Delivery 36
2.2.5 Corporate and Social Responsibility 37
2.2.6 Environment, Sustainability and Climate Change 39
3. Accountability Report 42
3.1 Directors' Report 43
3.1.1 Organisational Structure 43
3.1.2 Council of Governors 45 5 3.1.3 Board of Directors 52
3.2 Remuneration Report 65 Annual Report and Accounts 2015 – 2016 Page
3.3 Staff Report 70
3.3.1 Commitment to Staff 70
3.3.2 Keeping Staff Informed 76
3.3.3 Supporting Staff 77
3.3.4 Development and Education of Staff 79
3.3.5 Equality and Diversity 88
3.3.6 NHS Staff Survey 91
3.3.7 Staffing Analysis 93
3.4 Code of Governance 95
3.5 Regulatory Ratings 95
3.6 Statement of the Chief Executive’s responsibilities 96
3.7 Annual Governance Statement 98
4. Research and Development 108
5. Quality Report – Our Commitment to Quality 112
6. External Audit Opinion 230
7. Financial Performance 2015-16 238
7.1 Foreword to the Accounts 238
7.2 Financial Performance against Plan 2015-16 239
7.3 Income and Contract Performance 241
7.4 Capital Investment 243
7.5 Financial outlook for 2016-17 243
7.6 Summary 246
7.7 Financial Key Performance Targets 246
7.8 Annual Accounts 2015-16 including Financial Statements and Notes 247 6 8. Contact Information 289 Annual Report and Accounts 2015 – 2016 Welcome
North Tees and Hartlepool NHS Foundation Trust provides integrated hospital and community-based healthcare to around 400,000 people living in East Durham, Hartlepool, Stockton-on-Tees and surrounding areas including Sedgefield, Easington and Peterlee.
Intensive care unit nurses celebrate a joint 150 years’ service.
It provides services from two main hospitals; the University Hospital of North Tees in Stockton-on- Tees and the University Hospital of Hartlepool and provides a number of outpatient and outreach clinics at our smaller community hospital in Peterlee, and in an increasing number of community locations. The breast and bowel screening services extend further, across Teesside and parts of North Yorkshire and County Durham. The Trust also provides community dental services to the whole of Teesside and many of the other community services also reach out beyond its geographical boundaries. The Trust’s skilled staff provides a minor injuries service at One Life Hartlepool and services in other community settings. The Trust is very proud of its staff, who are passionate about providing 7 excellent care for patients and clients. Annual Report and Accounts 2015 – 2016 1 Chairman’s Statement
As chairman of North Tees and Hartlepool NHS Foundation Trust I am delighted to introduce this Annual Report which is an opportunity to place on record the enormous amount of work which has been undertaken throughout the year in the interest of patients. The Board of Directors set the direction, strategy and objectives for the Trust, working closely with the Council of Governors and our staff. It is my role as chairman to lead the board and hold the executives accountable for the Trust’s performance. Quality remains our top priority, despite being in a challenging financial climate; we are not prepared as a Trust to compromise the performance and quality our patients have come to expect. While this year has been a really tough time for everyone in the Trust; unprecedented levels of demand for emergency care for prolonged periods of time, financial pressures and challenging operational targets, the Trust has risen to the challenge and we have delivered some fantastic healthcare for our communities over the year. Our accident and emergency performance, our responsiveness and waiting times, and most importantly our patient satisfaction has been good. A great amount of hard work has been put in over the last year from our staff who are constantly making improvements in the interest of our patients, to continuously deliver high quality patient care. The unprecedented pressures we have faced this winter have been seen across the national picture and we have felt the effect just like everywhere else in the country. We plan for these additional pressures every year so that as an organisation we can respond to the increased demand for services. The Trust took part in an initiative called Kick Start January, where we looked at patient flow to ensure patients have a smooth journey through the hospital until they are ready to go home. This initiative put an intense focus on the management of discharge and involved staff at all levels. I was proud to see that it was clearly evident we have strong leadership at all levels and continue to drive the Kick Start January and Perfect Week agenda forward. Despite the increased pressures we have seen across the Trust, performance has remained high. We are not seeing many more patients attending accident and emergency, but we are seeing a higher proportion of those patients being admitted into hospital which shows the levels of frailty and illness across the population. While targets are challenging to achieve, I know the staff are doing their very best for our patients. We had the CQC inspection in July and while we were given an overall rating of ‘requires improvement’, I was very proud of our response to the visit, where we were rated as ‘good’ for safety, caring and responsiveness of our services. A number of areas were identified as good practice, including surgery, critical care, end of life care, the Trust’s simulation suite, community services and the Trust’s services at One Life Hartlepool. Throughout the Trust 65 of the 85 individual ratings were rated as good. It has become incredibly tough to meet the standards, which cannot be compared to those of 20 years ago. We gave a good account of ourselves and it was a positive experience, following which we have already addressed many of the areas 8 mentioned by the CQC, and will continue to improve going forward. We welcome them visiting again for a re-inspection in future. Annual Report and Accounts 2015 – 2016 Thanks to better care, people are surviving illnesses and living with conditions for much longer than we used to. This means that our health service needs to change in order that we can meet patient needs and future proof services for the coming generation in the communities we serve. The Trust is involved in the Better Health Programme, the programme is across County Durham and the Tees Valley and is looking at how services can be improved including changing health needs and how services need to change to meet those needs; how different parts of care services can work together more effectively; ensuring high standards are consistently delivered; having staff with the right skills and training; and making sure we have the right services available, 24 hours a day and seven days a week. Engagement with our patients and the public will be key as this programme progresses. After the disappointment of having to put the new hospital on ‘pause’, we ended 2015 on a more positive note having secured £25m from the government to carry out essential infrastructure work, to give the University Hospital of North Tees a longer life. We really welcome this much needed investment and work is expected to start in April 2016 which will help to secure the longer term future of the hospital. We have continued to invest in services, equipment and our buildings, to keep the environment and equipment up to date so that our staff have the very best facilities to work in and for our patients to receive high quality care. We saw the new electronic patient records system go live in October. There was never going to be an ideal time in the Trust to make such a major change as this, however, for many reasons, it had to be done and despite the enormity of the task, it will bring great benefits in the future. Our staff have done a fantastic job in training, support and implementation of the new system whilst also ensuring continuity of services for patients. It makes me pleased and very proud to be associated with this Trust and all the amazing people who work for us and who keep on giving first class, safe care to local people, in hospital and in the community. I am pleased to place the board’s thanks on record throughout this report, for the work our staff does to ensure the people we serve have a health service they can be proud of.
Paul Garvin QPM, DL Chairman
Staff in accident and emergency taking part in a huddle. 9 Annual Report and Accounts 2015 – 2016 2 Performance Report
2.1 Overview of Performance
2.1.1 Chief Executive’s Statement Once again this has been a successful year for the Trust. We have continued to improve quality and achieve high levels of performance during what has been a busy and challenging period. This has been achieved by excellent leadership at all levels throughout the organisation and by individual members of staff who take great pride in their work, and who are committed to providing high quality services for patients. Many challenges have been faced this year; the Trust has been stretched on many occasions, with sustained pressure particularly over the winter period in the Accident and Emergency Department, and increased admissions to the Emergency Assessment Unit of sick elderly patients with complex needs. Performance against key targets continues to be a challenge, and pressures across the whole health service have affected the delivery of services. However, the quality and depth of work going on, day in day out in this organisation, is excellent with staff going above and beyond to ensure seamless care. A significant amount of work goes unseen; no matter what job people do they are making a real difference to our patients and it is teamwork that enables the Trust to provide the very best care we can for all our patients. Financially, the expected year end deficit was £7.4m which is in line with the control total agreed with Monitor our regulator, earlier in the financial year. While we will continue to invest in our services, we know that we cannot keep doing the same things in the same way. The demand for healthcare services is ever increasing so the transformation of our services, in hospital and the community is essential to ensure we meet the future needs of the population we serve. There is much we can do locally; however, changes need to be made across wider geographical areas and across all sectors not just health. I have been selected to lead and develop a sustainability and transformation plan for the Durham, Darlington and Tees, Hambleton, Richmondshire and Whitby planning footprint. This work will bring local health and care leaders, organisations and communities together to develop local blueprints for improved health, care and finances over the next five years, to deliver the NHS Five Year Forward View. We are proud to be among six Trusts in the country to have been selected as a demonstrator site for the GS1 project, which is a national initiative aimed at individually barcoding all equipment, drugs and consumables used by NHS organisations, and will generate an electronic record for all patients to be able to individually identify what equipment has been used. This report contains details of the many developments which have improved services for our patients and provides an opportunity to gather together the many achievements which have taken place throughout the year. Even working under immense operational pressures, we continue to provide high quality services for patients and I commend our staff for their hard work and dedication. 10
Annual Report and Accounts 2015 – 2016 Alan Foster, MBE Chief Executive 2.1.2 Overview of the Trust North Tees and Hartlepool NHS Trust was formed when North Tees Health NHS Trust and Hartlepool and East Durham NHS Trust merged on 1 April 1999. North Tees and Hartlepool NHS Foundation Trust was authorised as a NHS Foundation Trust in December 2007. As a Foundation Trust now for over eight years, it provides a wide range of health and healthcare services across and beyond our catchment area. The Trust has two hospitals: • The University Hospital of Hartlepool; • The University Hospital of North Tees in Stockton-on-Tees. The Trust has been providing care for patients in the community since 2008. These services are provided in a number of community facilities across the areas supported, including Peterlee Community Hospital and the One Life Centre Hartlepool, which was the first of the integrated care centres to be created under the Momentum: pathways to healthcare programme. This programme is transforming the shape of health services in our area by providing care in clinics, sports centres, children’s centres, schools and in people’s homes. The combining of acute and community services has been a model, which has proved very successful in streamlining care for patients and working with primary care colleagues and GP practices. Community and acute palliative services are co-located, which facilitates the provision of a more cohesive care pathway for patients and their families. Other specialist services, such as the heart failure and community respiratory teams, are working more closely with acute care staff to improve patient care. Community staff have also seen benefits in having the resources of a successful acute NHS Foundation Trust to support their work. The Trust’s breast screening services cover Teesside (the local authority areas of Hartlepool, Stockton-on-Tees, Middlesbrough and Redcar and Cleveland), South Durham and parts of North Yorkshire. It is the referral centre for bowel screening for Teesside, South Durham and North Yorkshire and the laboratory test centre for the Cervical Screening programme. Community musculoskeletal services and community dental services for the whole of Teesside are also provided. Patients from a wider catchment area can, and do, choose to use the Trust’s services. The leading- edge spinal services at the University Hospital of North Tees attract patients from other parts of the country, and women who live out of the catchment area have chosen to use the midwife-led birthing centre in Hartlepool. The map below shows the extended catchment population of the Trust, reflecting the service developments around screening programmes and bariatric surgery collaboration. The general catchment population of the Trust is shown by the darker shading.
Easington Durham Wheatley Hill Peterlee
A181
Trimdon Hart A1M A179 11 Hartlepool A19 Annual Report and Accounts 2015 – 2016 Sedgefield Newton Aycliffe A689 Greatham
Billingham A1M Stockton-on-Tees Key General patient catchment area
A66 Darlington Extended patient catchment area for service developments A19 The Trust continues to provide a diverse range of services from the two hospital sites, and a range of community services which are delivered from community clinics and through integrated intermediate care services in partnership with social care to people in their own homes. Many of these services are inter-related and span across patient pathways. The following table provides an overview:
Service Profile 2015 – 16 Acute Services Community Services across Stockton, Hartlepool and Peterlee * Outpatient Services Asylum Seekers * General Surgery Cardiac Services * Breast Safeguarding Children Community Integrated Assessment ** Colorectal Team (CIAT) Community Respiratory Assessment ** Upper Gastrointestinal and Management Service (CRAMS) ** Urology Asthma & TB (Stockton) * Trauma and Orthopaedics including spinal services Continence Advisory Service * Ear Nose and Throat (visiting specialties) - outpatients Community Dental Services * Ophthalmology (visiting specialties) outpatients Diabetes Team Oral Surgery/Orthodontics (visiting specialties) Diabetic Retinopathy Screening * outpatients Service * Plastic Surgery (visiting specialties) outpatients Family Nurse Partnership * Dermatology (visiting specialties) outpatients Youth Offending * Anaesthetics (including Pain management) Hand and Wrist Surgery ** Critical Care Health Visiting ** Accident and Emergency Looked After Children Specialist Palliative Care/Macmillan ** General Medicine Nursing ** Stroke Skin/Minor Surgery ** Care of the Elderly Musculoskeletal Services ** Gastroenterology Podiatry ** Cardiology Podiatric Surgery ** Diabetic Medicine Wheelchairs ** Rheumatology School Nursing ** Respiratory Medicine Speech and Language Therapy Obstetrics and Midwifery (including Midwifery Led Unit ** Health Trainers at UHH site and community services across the area) Gynaecology inpatients at UHNT outpatient clinics, ** Stop Smoking Service PAC and EPAC on both sites Neonatal: Paediatric; Children and Young People’s ** Physiotherapy Services (including community) Cancer services including Acute Oncology team at 12 * Occupational Therapy UHNT site/Clinical Haematology * Radiology Nutrition & Dietetics Annual Report and Accounts 2015 – 2016 * Pharmacy Audiology ** General Pathology ENT * Bereavement Services Orthotics * Allied Health Professionals Teams Around the Practice (TAPS) ** Bariatric Single Point of Access (SPA) * Haematology Older Person’s Team (OPTIN) ** Vascular (Visiting specialty) Dementia Liaison Service * Oncology ** Nephrology (Visiting Specialty) * Psychiatry * Genetics (Visiting specialty) Key: *predominantly both sites ** predominantly University Hospital of North Tees GP Links and Community/Specialist Services The Trust continues to build on its good working relationships and well established positive links with local GPs, Local Authorities and Clinical Commissioning Groups (CCGs), and health and social care economy wide governance is achieved through discussion at the North of Tees Partnership Board and the local Health and Wellbeing Boards. The Trust hosts meetings with local GPs, and participates in lunch and learn sessions. A quarterly GP newsletter is sent to all local practices, and is supplemented by visits to practices to discuss specific developments and issues. The Trust continues to work with the local CCGs to transform health and healthcare services, and relationships have been well established with clinician and GP dialogue with regards to driving forward service improvements. This will be enhanced through the development of plans to implement services across health and social care under the auspices of the Better Care Fund, Better Healthcare Programme and the Sustainability and Transformation Plans. 2.1.3 Business Review This section provides an overview of the Trust’s strategic direction, activities, developments, and key risks and uncertainties. The Trust ensures that all risks are effectively managed, and ensures compliance with all regulatory targets and performance indicators. The Corporate strategy can be summarised in the triangular diagram below:
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2.1.4 Trust Strategic Direction Annual Report and Accounts 2015 – 2016 A new hospital is fundamental to the Trust’s long term strategic direction, and will afford the opportunity to navigate the challenging financial environment facing the NHS and provide the ability for the Trust to reduce infrastructure and overhead costs. However, following the Trust’s decision to pause the development of the new hospital, the continuing need and appetite for transformational service change is now of critical importance to the way in which healthcare services are delivered to the people of North Tees, Hartlepool, Sedgefield and Easington. With a constant backdrop of efficiency savings, the need for the Trust to continue to develop new models of care and integrated pathways to provide services closer to home is now greater than ever. Building on the Trust’s Clinical Services Strategy, the organisation will transform its services by putting in place effective models, practices and procedures which will bring about genuinely integrated care to provide the best possible experience for patients and their families, who will receive services that are clinically effective, safe, of the highest quality, and efficient to run. The mission and values underpinning the current strategic direction remain relevant and there is little need for major changes. In driving the strategy the aims are summarised as follows:
Aim What is it Putting Patients First To create a patient centred Organisational culture by engaging and enabling all staff to add value to the patient experience and demonstrated through patient safety, service quality and LEAN delivery. Integrated Care To develop and expand the portfolio of services to provide integrated Pathways pathways for the people of Easington, Hartlepool, Sedgefield and Stockton providing equal access to acute care and care as close to home as possible in line with Momentum: Pathways to Healthcare. Service To continually review, improve, transform and grow our healthcare Transformation services to respond to the needs of our healthcare community. In line with evidence based guidelines we will enhance quality, clinical effectiveness and patient experiences whilst improving clinical outcomes. Manage our To ensure our services, and the way we provide them, meet the needs Relationships of our patients, commissioners and other partners by proactively engaging with all appropriate stakeholders including our staff, through communications, engagement and partnership working. Maintain Compliance To maintain our performance and compliance with required standards and Performance and continually strive for excellence by good governance and operational effectiveness in all parts of our business. Health and Wellbeing To embrace the health and wellbeing of the population we serve and ensure that the health needs of the people of Easington, Hartlepool, Sedgefield and Stockton are reflected and catered for in the provision of services from the Trust
2.1.5 Development and Service Improvement Transformational Change North Tees and Hartlepool NHS Foundation Trust is a successful forward thinking provider of integrated acute and community based healthcare to people living in Hartlepool, Stockton-on-Tees and East Durham and surrounding areas including Sedgefield and Easington. It is recognised that transformational change is required to enable the Trust to continue to deliver high quality, safe and affordable services. A significant programme of change will be delivered within the next five years, streamlining services and pathways of care across both hospital sites, with the emphasis on delivering clinical pathway improvements across acute and community, enabling patients to be treated closer to home. The Trust has a proven track record of effectively planning, driving quality and safety, improving patient experience and delivering operational and financial standards, and this is reinforced with ambitious plans for the future to work with healthcare partners to transform public health and social care services under the Momentum: pathways to healthcare programme. Improving the health of the population in the area, and tackling the legacy of ill-health in an environment with high levels of deprivation is a major challenge. Whilst meeting the increasing 14 demands of an ageing population, the shape, form and type of healthcare provided to patients needs to be different to that available today, and this is reflected in the Trust’s strategic approach
Annual Report and Accounts 2015 – 2016 as a successful Foundation Trust. The focus on public health measures, health promotion and ill-health prevention needs greater emphasis whilst being accompanied by changes to the way that services are provided so that people are able to access the full continuum of services from self-care through to tertiary treatments more easily and at earlier stages in the disease cycle. Services closer to home are essential, particularly those that are planned and provided on the basis of integrated care that ensure access to hospital services only when needed. There are considerable health issues in the locations covered by the Trust which result in a subsequent level of need for health services above the national average. It is unquestionable that the local population will benefit from improvements and investment in public health and social care services in conjunction with the direction set out in the Trust’s Strategy. System-wide transformational change will be delivered within the next ten years, supported by the Better Healthcare Programme and the development of robust Sustainability and Transformation plans across the region. The Trust is fully signed up to the development of collaborative pathways across the providers of acute, primary and social care within the region. Balancing delivery of high quality services whilst also delivering a challenging cost improvement programme continues to be a high priority for the Board of Directors and this is addressed within the robust planning and the overarching governance and performance improvement and delivery framework. This will manifest through the Clinical Services Strategy and is synonymous with the public health, Joint Strategic Needs Assessment (JSNA) and commissioner plans, concentrating on a system wide approach to service delivery. The Evidence Base To ensure that the organisation develops a strong and robust direction of travel as a Foundation Trust, it will continue to use the principles, values and recommendations from the following reviews to set out its strategic approach: • The NHS Five Year Forward View; • The Dalton Review; • The Keogh Report; • The focus on quality reflecting the findings of the Francis Report; • The Planning Framework (NHSE); • Seven Day Services; • Lord Carter Review. The Trust has taken a broad and in-depth analysis of the political landscape and operational environment, including the aspirations and ambitions of our patients, stakeholders, commissioners and staff during the development of its strategy. It is important that the Trust recognises its strengths and begins to address its weaknesses, and the strategy is built upon iterations of SWOT and PESTL analyses, reviewed and enhanced during 2015 – 16, to support on-going planning. The Trust has aligned its planning and strategic visioning with Commissioner Clear and Credible Plans, Local Authority Joint Strategic Needs Assessment, as well as national policy and guidance. The Five Year Forward View highlights effective collaboration between providers and commissioners as a step towards dismantling the barriers of ‘silo’ care, and the Trust is committed to working with its strategic partners and stakeholders at a local level to bring about change across primary, community, social and acute care settings. The Trust has developed a locality based approach in developing the strategy under the three main areas served by the Trust: Stockton-on-Tees, Hartlepool, Peterlee/Durham - as well as setting out opportunities and considered options for service delivery and integration more widely. Common themes recurring throughout the discussions to date include: • Closer working with GPs and primary care to develop pathways in line with the Primary and Acute Care (PAC) model; • Tees Valley collaboration – elective Common IT platform/EPR; 15 • Fully integrated co-adjacent, urgent and emergency care provision and clinical network facility; Annual Report and Accounts 2015 – 2016 • One Stop Clinics; • Health Village to support challenges in the demographic expectations; • Centre of excellence for Frail, Elderly and Dementia care; • Increase and widen spread of outpatient acute services in peripheral localities; • Seek tendering opportunities across the whole local health economy, including East Durham; • Improved stakeholder engagement and communication; • Collaborative provision of corporate support services. This is specifically linked to the Integrated Care Pathway work on long term conditions, supporting the Health and Wellbeing agenda and local authority work, with the key theme being collaboration across the whole health and social care economy to deliver a sustainable model. Clinical Services Strategy The implementation of the Clinical Services Strategy is a pivotal feature of the organisation’s delivery as a progressive Foundation Trust, and it has been developed in tandem with the strategy. One of the major developments within this strategy, and one that features as a strategic aim for the Trust, is the development of a pathways-based approach reflected in pre-hospital, internal pathway and post-hospital pathway development and delivery. As outlined above, long term chronic conditions continue to make up the largest, and growing, share of healthcare budgets and the percentage of bed days. The Trust is therefore committed to delivering services in the most appropriate setting that demonstrates value for money. Integrated care pathways provide the opportunity for clinicians and specialist staff to develop a more systematic yet tailored approach to care which can be delivered closer to the patient’s home and within distinct communities. Linked to locality changes, the Trust has outlined the long term conditions that will be more effective and efficient, over time, with local delivery (either integrated or co-ordinated) that is patient-centred, safe and of the highest quality. The planning and delivery options for Integrated Care Pathways (ICP) for Long Term Conditions (LTC) are currently being advanced in conjunction with commissioners and key stakeholders, providing a central plateau for the continued Clinical Transformation Programme. The Integrated Care Pathways include; Frail Elderly and Dementia, End of Life, Respiratory, Cardiac, Diabetes, and Stroke Care. An infrastructure of governance is in place with commissioners and Local Authorities feeding into the North of Tees Partnership Board and linked to the Better Care Fund objectives. Other Elements of the Clinical Services Strategy The Trust continues to focus delivery of clinical services through a structured programme of development and implementation in order to prevent duplication, engage stakeholders, and to streamline processes more effectively. This approach is integrated with the Transformation Programme, Workforce Model Development and Service Improvement and Efficiency Programme (SIEP), supported by the annual business planning cycle with a 'bottom up' approach enabling clinical ownership. This includes: Planned Care – Options for optimising inpatient and day case surgical care and efficient pre and postoperative care/pathway management across: Breast services, Endocrine surgery, Bariatric Surgery, Orthopaedics, Spinal services and Urology, utilising both hospital sites to deliver planned procedures and exploring collaborative opportunities with neighbouring organisations; Unplanned Care – Network approach to the provision of emergency services in the right place, at the right time, and by the right healthcare professionals, including Urgent and Emergency care tender opportunities, collaborative approach to delivering Haematology and Chemotherapy services, and improved discharge pathways; Women’s and Children’s Services – Key deliverables for 2016 – 17 include reviewing the Midwifery led unit and the provision of 98 hour consultant presence in Obstetrics. This will build on the Royal College of Paediatric and Child Health (RCP&CH) review of Neonatal services and recommendations to improve the network provision. The option to develop a Paediatric hub will be pursued in 2016 – 17; Clinical Support Services – Deliverables include exploring collaborative provision of Pathology services with a partner provider, point of care testing and widening Radiology provision i.e. 16 community based services, networking and sustainability. Annual Report and Accounts 2015 – 2016 The following image summarises this approach: The Clinical Services Strategy – Overview
Community Based Services As much care as possible provided in local communities closer to where people live through improved service provision and new facilities in primary and community settings.
Long Term Unplanned Care Planned Care Conditions -Major A&E Department -Outpatients/Very minor -Minor injury units treatments in community -Management of LTC -More day case surgery Step Up -Avoid admission -Reduce lengths of Stay Step Down -Assist discharge Clinical Support -Alternative -Appropriate provision in therapy community/acute setting -Best use of technology
Women & Children's Services -Reprovision of current services -Consultant led -Midwife led
Acute Hospital Based Services A wide range of acute services provided in a new hospital to replace the existing hospitals.
Developing the Clinical Services Strategy The Trust has undertaken an intense review of the organisation’s clinical services during 2015 – 16, with the aim to further refine future service delivery. The work has been built around defining each service under a strategic option of investment, re-design, collaboration and divestment, based on where the specialties/sub specialties fit within the organisation’s core, outer core and discretionary service provision. The evaluation process was based on current performance across Clinical Sustainability, Patient Safety and Outcomes, Financial Sustainability, Operational Sustainability and Workforce, and supported by a dedicated group of work stream leads, which included analysing activity forecasts, performance against healthcare and quality standards, financial performance, including patient level costing data, workforce projections, productivity and operational efficiency, market share analysis, patient survey and outcomes data, SWOT and PESTL analysis. The result of this detailed work is now being used to support future planning through clinically-led 17 directorate development groups.
Stakeholder Engagement Annual Report and Accounts 2015 – 2016 The Trust has undertaken extensive engagement and discussion with a wide range of stakeholders while developing the strategy. This has included, and will include further discussion and engagement with: • Health and Wellbeing Boards; • Audit, governance and health scrutiny committees; • HealthWatch; • Patient representative groups (including the Trust's Healthcare User Group); • Governors; • Members; • GP federations; • Clinical commissioning groups. The Trust is a member of the North of Tees Partnership Board which serves as a forum of key stakeholders for the discussion and agreement of strategic changes across the local health and social care economy. The Trust is engaged in the Better Healthcare Programme (formally SeQIHS) review of locality services, which includes A&E, Acute Surgery, Acute Medicine, Critical Care, Obstetrics, Paediatrics, Neonatology, Interventional Radiology and Elective Care, with senior Clinical and Executive led representation on the working groups. Governance for each organisation remains as defined by the individual organisation’s governance structures and arrangements. The Board has been key in overseeing the delivery of service reconfigurations to date and has functioned as the local 'Unit of Planning' in relation to the implementation of the Better Care Fund. Directorate managers and individual clinicians have visited GP practices to discuss service developments and a mapping exercise will capture this activity to look at ways to make these interactions an additional forum for ‘clinician to clinician’ engagement to inform the strategy and progress key milestones. Understanding the strategic direction of commissioners is crucial to the development of the strategy. The Trust will continue to participate in public engagement events with commissioners to further overall common aims and transformational delivery. The Trust has engaged in the Hartlepool Health and Social Care Planning Programme, led by Professor Colin-Thomé. These workshops have included representation from local Councils/ HealthWatch/Mental Health/Health and Social Care and the general public, with focus groups reviewing frail and elderly services, Primary and Community based services, urgent care services, child and health and wellbeing (including maternity and early years and mental health provision). As part of the internal engagement and consultation on the development of the strategy, a Clinical Services Strategy Development Project Team has been established to support the directorates, pivotal to progress, and the Board of Directors continues to be actively engaged in the development of the Trust’s ten year strategy. Public Health Following the transfer of Public Health functions to Local Authorities, the Trust continues to work with partner organisations to contribute to the priorities identified by the Joint Strategic Needs Assessment (JSNA), such as; smoking cessation in pregnancy and increasing health visitor numbers. The Chief Executive of the Trust chairs the 'Health and Wellbeing Partnership' for Stockton and is a voting member of Stockton and Durham Health and Wellbeing Boards, and a non-voting member of the Hartlepool Health and Wellbeing Board. Out of Hospital Services Out of Hospital services have successfully delivered a robust platform for change in the delivery of care closer to home with the completion of the Community Renaissance Programme. However, the significant pressure that continues upon health and social care systems requires a constant focus upon ensuring that our services are able to respond to the challenges to deliver safe, patient- focused care close to where people live. The Five Year Forward View provides a strategic direction that requires more joined up services 18 around the needs of the individual, co-produced with users of the service, moving care systems from organisational models to system wide integration and requiring organisations to work more
Annual Report and Accounts 2015 – 2016 closely with local partners (both statutory and non-statutory) to deliver models of care. The drive for further integration between health, social care, public health and third sector services locally is underpinned by initiatives, for example the Better Care Fund, Integrated Care Pathways and, within children’s services, a change in the public health focus with funding no longer being ring fenced and a need to work in collaboration across all sectors The Out of Hospital clinical care strategy 2015 – 2020 has been refreshed in line with national policy to reflect the demands of a growing elderly frail population, increasing complexity of multiple medical conditions and a rise in the numbers of school children. This is set against a backdrop of limited resources to deliver excellent health and social care. The Trust has taken a fresh approach to delivering excellent care at the heart of the community and the strategy sets out how we will do this within a sustainable quality and financial framework. The next 1 to 5 years will be about developing models of care that aim to dissolve boundaries between community and hospital services, primary care services and local authorities, supporting the principles of a ‘community hub’ model. This will further be supported by the development of patient self-management (expert patient programmes), telehealth and telecare as well as challenging the boundaries between professions as highlighted in NHS England’s Five Year Forward View. Fundamental to the above is the review of adult nursing services using a robust approach to objectively assess population demands, review the size of the workforce required to meet the demand in a given locality, the skills of the workforce required and to deploy resources to provide the best possible health and broader care and support outcomes. This review supports the huge change in the landscape of health and social care delivery, including:- • Increasing demand for nursing care at home to ensure people can remain at home; • Pressures upon acute hospital care; • Aging population with more complex needs; • Increased prevalence of complex long term health problems; • Earlier discharge for patients with more complex needs; • Advances in healthcare techniques and technology allowing more complex interventions and support to be delivered at home; • Opportunities to develop a competency based workforce model. The vision for the new model enhances and expands the existing model of Teams Around the Practice (TAPS) and Community Integrated Assessment Team (CIAT) supported by a single point of access. The Trust will develop the roles of assistant practitioners to deliver protocol-driven care, releasing capacity in our registered workforce to deliver more complex interventions, some currently only provided within acute care. This will contribute to keeping people out of hospital and support earlier discharge.
19 Annual Report and Accounts 2015 – 2016
Masefield road district nursing team.
The review also includes enhancement of the community matron model to support more intensive brief interventions with a focus (but not exclusively so) in supporting people in residential and care homes. It is envisaged that remodelling of the workforce will provide some increased capacity and enable more support to be provided out of hours, with more proactive support of emergency care pathways. The Trust will continue to work with local authority providers and commissioners to develop an integrated single point of access supported by clinical triage, ultimately 24/7. The Single Point of Access (SPA) will be key to the coordination of both in and out of hours care as well as care coordination of the integrated care pathways. Fundamental to service change is the co-production of plans for the Better Care Fund in conjunction with social care, public health, primary care and the voluntary sector as a catalyst for a shared vision to deliver: • Improved pathways of care from in hospital to out of hospital care; • Development of a greater range of more integrated services in community settings designed around the needs of individuals; • Interventions that keep people healthy for longer, prevent ill health and reduce health inequalities underpinned by the principle that every encounter is an opportunity to influence change; • Support options for alternatives to in hospital care, preventing avoidable admissions via localised multi-agency support. This will be achieved by: • Leadership models that support working across integrated pathways; • Engagement of patients, carers and families in care delivery; • Innovative models of step down care that support the transition of patients from acute in hospital care to home enabling discharge earlier in their recovery; • Integrated, simplified and standardised care pathways/protocols; • Risk profiling and multi-agency, protocol driven universal assessment using multidisciplinary service delivery model to support service delivery options; • Enhancement of Out of Hours services that provide a rapid response to urgent needs; • Optimising the use of technology to support care delivery; • The delivery of ‘expert patient’ and self-management where appropriate; • Developing the potential to develop new partnerships with, for example the voluntary sector and primary care to deliver new service models that enhance wellbeing and independence; • Timely involvement, engagement and consultation with staff in relation to service change and new workforce models; • Shared buildings and facilities to support new ways of working; • Governance and performance metrics that support system wide performance and provide clear accountability. Seven Day Working In response to the publication of the clinical standards published in 2013 by the ‘NHS Services, Seven Days a Week Forum’, a gap analysis of all ten standards has been performed and an action plan, developed with clinical leads. In agreement with the Clinical Commissioning Group (CCG), as part of the commissioning contract, The Trust has focused on the implementation of standards: 1 – patient experience; 2 – time to first consultant review; 5 – diagnostics; 7 – mental health; and 10 – quality improvement in 2015 – 16. 20 2016 – 17 will realise the implementation of the remaining five standards: 3 – multi-disciplinary team review; 4 – shift handovers; 6 – intervention/key services; 8 – on-going review; and 9 – transfer to community, primary and community care. Annual Report and Accounts 2015 – 2016 On completion of the NHS Improving Quality (NHSIQ) whole system self-assessment tool, a gap analysis for each standard has been analysed to focus on areas for improvement, with an action plan developed with senior clinical leads. Progress is monitored monthly and reported six monthly to the Executive Team. The Trust recognises the significant resource implications attached to the delivery of the seven day working standards, including the extension of physician hours and the associated additional consultant posts required for full compliance. This is currently being reviewed within the workforce planning. Primary Engineering Infrastructure As a result of the new hospital development being put on hold, and the need for the Trust to deliver and sustain services locally, an outline business case was developed and submitted to the Department of Health to fund the replacement of the primary engineering infrastructure at the University Hospital of North Tees during 2015 – 16. Existing services are 50 years old and the resilience and reliability of these essential services could no longer be assured. The business case was approved by the Department of Health and a £25m two year investment Programme will commence in the spring of 2016. This investment will secure the support services that will provide the foundations for further clinical developments at the hospital which hitherto have been constrained by the limitation of the incoming electrical supply. Commercial Ventures As part of the Trust’s desire to generate supplementary income it has established a trading company, called ‘Optimus Health Ltd’ which is a wholly owned subsidiary company of North Tees & Hartlepool NHS Foundation Trust. The company started trading in 2014 – 15, with the setup of ‘Panacea’ a retail pharmacy located in the entrance at the University Hospital of North Tees, the retail and out patients pharmacy service has developed well over the last twelve months and is providing an invaluable service to patients and staff. Further opportunities are being explored to expand the commercial ventures of the Trust, with a view to generating income and contributing to health care services. Environmental Developments The Support Services Directorate has supported the Trust by providing a comprehensive range of services, covering all aspects of the management of the estate and facilities services, thus supporting patients and staff in both clinical and non-clinical services. During the year the estates and facilities management team has: • Completed the capital programme for the period 2015 – 16 to deliver a wide range of environmental, safety and service improvements and developments across the Trust; • Continued with the estates strategy to rationalise the Trust-wide estate, to maximise space utilisation and to improve cost efficiencies by either generating additional income or by reducing the cost of external rents. Specifically, a range of services/staff have moved onto the Hartlepool Hospital site, including community services staff, Local Authority, social services staff and a local education authority facility; • Completed the centralisation of the Sterile Services department onto the North Tees site, modernising equipment and increasing capacity and resilience of services; • Further developed clinical, environmental and equipment ‘deep cleaning’ services including the provision of pressure relief mattresses and a mattress inspection programme. Continued to provide a 24-hour rapid response domestic cleaning service and maintained the provision of ward hygienists and the utilisation of hydrogen peroxide vapour decontamination robots. In terms of capital investment, the Trust expended a total of £8m in the following areas during 2015 – 16: • Trust wide implementation of the new Electronic Patient’s Record System, TrakCare, along with a major replacement of associated ICT equipment and infrastructure; • Refurbishment of the main public thoroughfares of the Podium block; 21 • Developed a 32 bedded resilience/decant ward. This will help to accommodate increased patient admissions during winter months and, at other times of the year; it will provide a ward decant facility, thus enabling the ward decontamination programme to be implemented; Annual Report and Accounts 2015 – 2016 • Developed a new multi-purpose lecture theatre and meeting room; • Replacement of various radiology machines, scanners and ultrasound machines as well as investment in theatre tables, instruments and enhanced theatre ventilation systems. Catering Services Improvement of patient meal services has continued to be a priority for the Trust and menus have been introduced to suit differing types of patient groups i.e. the elderly, children, Critical Care and Maternity patients. These include the introduction of optional ‘light bites’ and ‘high teas’ and there is a focus on improving the nutrition and hydration of patients whilst they are in our care. Menus have been produced for display at the patient’s bedside which provides them and their relatives/visitors with information on those choices available on a daily basis, and shows the significant range of catering services available throughout each 24 hour period for both patients and staff. Patient satisfaction survey results continue to improve; this has resulted in North Tees and Hartlepool NHS Foundation Trust featuring in the upper quartile of performance figures in the National ERIC returns and annual Patient Led Assessments of the Care Environment (PLACE) Inspections for questions relating to food.
Executive chef Richard Kirton.
Catering Services have been modernised to adapt to the changing needs of each hospital, this included the creation of a ‘satellite kitchen’ at the University Hospital of Hartlepool, moving the provision of food services directly adjacent to the in-patient wards. Wilber’s, the Trust’s branded retail catering facility, continues to grow in success and popularity. The service has invested in the purchase of a purpose built ‘coffee pod’ making retail catering more accessible to both staff and visitors. • Food and cleaning ward notice boards have been installed in ward areas which display nutrition 22 and hydration information, informing patients and visitors on the availability of food and drink and what they can expect as a minimum each day; Annual Report and Accounts 2015 – 2016 • Food waste levels have reduced and patient satisfaction with the catering service has continued to improve. Central Sterile Services Department The team has completed a hugely significant year in the history of the department by completing a successful centralisation of sterile services to the North Tees site, thus creating economies of scale and ensuring the department remains efficient, effective and above all safe. Both Sterile Services and Endoscopy decontamination units continue to achieve ISO status, working to exceptionally high standards and achieving a turnaround time of 24 hours in the Sterile Services Department. Domestic Services and Ward Hygienists Team During 2015 – 16 a ‘Resilience Plan’ outlining a programme of work including Ward Hygienist and Deep Cleaning on operational wards was implemented which allowed the team to continue with its work without the availability of a decant ward. The plan was developed and agreed with the support of Infection Prevention & Control, Estates department and nursing teams prior to being supported by the Executive Team. The departments have continued to provide excellent, high quality, routine and responsive cleaning services to the Trust across both the hospital and the community setting. This has resulted in excellent standards being achieved and was reflected by favourable and positive feedback from patients in the national in- patient survey results. The team has been proactive with initiatives which contributed to the reduction of healthcare acquired infections in high risk areas. Measures to reduce the risk of cross infection include daily ‘touch point cleaning’, vacuum cleaners deep cleaned and fogged, and commodes are deep cleaned and bio decontaminated using a validated process. There have been improvements in the National In-Patient Survey for 2014 – 15 which showed that scores for cleaning had improved and we strive to continue this trend, along with the annual Patient Led Assessments of the Care Environment (PLACE) validation inspection which showed both sites above the increased national average score for cleanliness. All performance of standards of cleanliness is measured against the Trust’s stringent quality monitoring standards. Managed Mattress Service/Medical Equipment Libraries The Trust has completed a second year of operating a very successful in-house service for cleaning and the decontamination of pressure relief mattresses. Requests for replacement mattresses are fulfilled within 30 minutes and requests for specialist equipment were also met within the same timescale. The identified savings of this initiative of £150k per annum have continued to be achieved. (This is additional to savings of £100k per annum which has been achieved since the team began to decontaminate and recycle foam mattresses and covers in 2012). Patient safety being paramount, the team is committed to ensuring that the Trust’s medical devices are clean, readily available, and accessible when required. The service has resulted in an improved efficiency of service, making best utilisation of the stock of medical devices and has limited the need for additional stock, thus also providing cost efficiencies. Service Developments The Trust implemented a number of service improvements during 2015 – 16, with key examples outlined below. The Trust’s planned priorities for 2016 – 17 are reflected on page 35. Emergency Care • Expanded Rapid Assessment area to provide immediate assessment on admission; • Pilot of streaming nurse to reduce avoidable attendances by re-directing to primary care/ community services where appropriate; • GP pilot in A&E (14:00 to 22:00 weekdays, weekends and bank holidays); • 24 hour Patient Process Facilitator in place in A&E to manage patient flow. In Hospital Care 23 • Development of front of house comprehensive geriatric assessment and a Frailty Unit for frail
elderly patients; Annual Report and Accounts 2015 – 2016 • Expansion of Endobronchial Ultrasound (EBUS) in the Lung service; • Successful recruitment of two new Respiratory consultants to meet increasing demands on the service; • Development of pacing service at North Tees Hospital. Orthopaedics • Continue to excel as a Trauma Unit and provide sub specialised pathways for complex trauma management; • Following a successful pilot, the substantive appointment of discharge liaison specifically for the orthopaedic and surgical wards on the North Tees site to improve patient discharge pathway and reduce length of stay. Out of Hospital • Established specific work streams with partner organisations for the development of the Palliative Care Integrated Pathway; • Health Visiting and Family Nurse Partnership have undergone a seamless transition to the local authority; • The School Nursing service continues to be developed following the success of the tendering process; • Development of Speech and Language Therapy Service for County Durham and Darlington; • Development of Team Durham Maiden Castle, a commercial venue for the delivery of physiotherapy service to Durham University; • Provision of Audiology services for Hartlepool and Stockton-on-Tees CCG and South Tees CCG, through Any Qualified Provider (AQP) tender.
24 Lead Nurse Carol Bowler with a patient.
Annual Report and Accounts 2015 – 2016 Surgery • Improved the acute surgical pathways by developing a dedicated surgical emergency assessment area. (Implementation of Surgical Decision Unit in August 2015); • Continued to sustain Bariatric surgery by the Trust despite changes in Specialist Weight Management service (SWM) and pathway management; • Implementation of revised bed base across the directorate of surgery and orthopaedics – including flexible week day and week end resource model; • Introduction of the combined urology on call rota in collaboration with South Tees Acute Trust; • Commenced collaboration with South Tees Acute Trust in respect of breast care services. Women and Children • Expanded Obstetric clinical team to support the 98 hour delivery suite cover requirement; • Innovative approaches to education have been introduced to support women and partners through pregnancy and birth including the introduction of Hypno birthing and active birthing classes; • Small Wonders has been successfully implemented on Special Care Baby Unit (SCBU), this is to encourage, support and educate parents around the benefits of breastfeeding these vulnerable pre-term babies; • Paediatric allergy and Botox services are now well established and attracting patients from across the region with further developments planned for both services. Ultrasound is being used to support diagnosis and management within the Botox service. 2.1.6 Stakeholder relationships The Trust continues to build on its relationships with its partners, commissioners and local stakeholders, accommodating the changes in the organisational structures in the health and social care economy. It is recognised that this is a crucial element of the Corporate Strategy, for delivery of the Trust’s objectives, and meeting the needs of its patients. It is equally important to the Trust to keep the staff informed as well. Relationships with local stakeholders continue to be developed, examples being: • The North of Tees Partnership Board, whose membership includes the most senior executive team members from the constituent organisations – the Trust, Tees, Esk and Wear Valleys NHS Foundation Trust, the CCGs, the Commissioning Support Unit and Local Authorities; • Contact with the NHS England Local Area Team; • Local HealthWatch; • Local Health Overview and Scrutiny Committees who scrutinise decisions made by the Trust on behalf of the population it serves. Meetings are also held with the Chairs of the Health Scrutiny Forums on a regular basis; • GP Lunch and Learn sessions arranged by the CCGs, which provide the opportunity for GPs and Consultants working in the Trust to share good practice and improve communications across local health service providers in primary and secondary care; • The local universities (Newcastle, Northumbria, Sunderland, Durham and Teesside) who work with the Trust to provide the workforce with the knowledge and skills that enable them to provide a quality service to the patients; • Local Health and Wellbeing Boards and Partnerships; • Local community and voluntary sector organisations; • Regular attendance by the Trust at patient forums and community groups to provide updates on service developments; • Hartlepool Health and Social Care Planning Programme. As well as seeking additional opportunities to engage with local GPs, the Trust also continues to build on alliances with neighbouring Trusts to improve existing care pathways and initiate new ones; examples include Breast, Urology and Bariatric Services. 25 Strong stakeholder relationships will be key to the development and delivery of the system wide Sustainability and Transformation Plans and, as such, the Trust will continue to expand on the Annual Report and Accounts 2015 – 2016 collaborative work carried out to date to support further service reform. 2.1.7 Risk and Uncertainties The Board of Directors continues to monitor risks on operational performance, taking account of both the risks identified and any actions taken to mitigate against those risks. This contributes to the Board’s capacity to declare assurance and capability to deliver the Trust’s objectives as set out in the Annual Plan. Evolving policy continues to emerge and account has been taken of all relevant publications and documents since the passing of the Health and Social Care Act 2012, including: • Monitor’s enforcement framework; • The Provider Licence conditions; • The NHS Outcomes Framework 2015 – 16; • The recommendations from the Francis Inquiry into the Mid Staffordshire hospitals; • The Keogh report on acute care; • The NHS Five Year Forward View; • The Dalton Review; • The implementation of the Better Care Fund with its focus on transferring resources from acute care to community and social care; • Development of the Sustainability and Transformation Plans 2016 – 17. The development of the Trust’s ten year strategy includes consultation with stakeholders on the 'Strengths, Weaknesses, Opportunities and Threats' (SWOT) and 'Political, Economic, Sociological, Technological and Legislative' (PESTL) analyses. Meanwhile, the risks identified in the previous strategy remain, particularly the transformation of services, the Service Improvement and Efficiency Programme (which is key to ensuring the Trust’s financial and economic viability), local political stakeholders and technologically led changes in the way services are delivered. The commissioning and regulatory regimes continue to evolve, with the Clinical Commissioning Groups, NHS England’s Specialised Commissioning functions and Local Authorities maturing into their various commissioning roles. The overall strategic direction of the Trust remains appropriate with its ambitious programme aimed at providing the best possible healthcare for the people it serves (the Momentum: pathways to healthcare programme). The key risks continue to arise in the areas of the economic context and financial pressures, changing policy and structures in the health and social care environment, and the building and commissioning of a new hospital at the end of the current programme of service transformation to develop the new healthcare system. Each of these areas will be considered in turn: Economic Context and Financial Pressures The focus of the NHS financial situation needs to be put into context within the wider economic situation and, whilst there is suggestion that within the United Kingdom the economic situation has begun to improve, there remains a requirement to reduce public sector expenditure to tackle the national debt. In a time of severe financial constraint, the NHS is being asked to make productivity savings of £22 billion by 2020 – 21. During 2016 – 17 the NHS Trust and Foundation Trust sector will, in aggregate be required to return to financial balance. £1.8 billion of income from the 2016 – 17 Sustainability and Transformation Fund will be distributed across NHS Trust’s, calculated on a Trust by Trust basis, released on a quarterly basis dependent on achieving recovery milestones. These include reduction in deficit, achievement of all access standards and progress on transformation. To continue to deliver efficient, cost effective services to the population it serves the Trust will continue to work closely with all partners in tackling the underlying deficit through the development of robust Sustainability and Transformation Plans, focussing on the 9 ’must do’s’ for 26 2016 – 17, including contributing to the delivery of aggregate financial balance for the NHS. Despite the financial challenges the Trust has historically delivered a good performance, balancing Annual Report and Accounts 2015 – 2016 the need to deliver financial and operational performance with high quality patient care. Trusts are funded through a national tariff of prices for all of the services they deliver, the prices that the Trust receives have been deflated year on year and this, coupled with zero or marginal growth in the economic and financial environment and an increasingly ageing population, has put further pressure on the ability to maintain a healthy financial position whilst continuing to deliver high quality, safe and caring services to its patients. This has resulted in the Trust out turning at a deficit position in 2015 – 16 for the second time since becoming a Foundation Trust. The Trust with its local commissioners has agreed plans to ensure the needs of the local population can be met and this will continue into the future, however, the ever increasing demand for hospital and community services means that the local health economy and the Trust are facing a period of tight financial constraints with significant efficiency requirements to deliver the required £2.050m surplus. As part of the Sustainability and Transformation Fund, the Trust has been set a control total for 2016 – 17 of £2.050m surplus by Monitor, budget plans will reflect this requirement. However, delivery against trajectories will be challenging. The opportunity to continually deliver efficiencies over the current year has been extremely challenging, but is no different to that facing the majority of Trusts due to unprecedented pressures on services over the winter period. Many of the efficiency plans the Trust had in place have not been delivered, however, the quality of services delivered to its patients has been maintained. Transformational change is required across health and social care to enable the Trust to continue to deliver high quality, safe and affordable services. This will be supported by the implementation of the service changes agreed within the Clinical Services Strategy, utilising service redesign, increasing productivity, collaborative working and improved Information Technology and information sharing. The work will run in tangent with the recommendations of the Better Healthcare Programme and the Sustainability and Transformation planning, working towards a system wide approach to future service delivery. The North of Tees Partnership Board with Executive membership from the Trust, Tees, Esk and Wear Valleys NHS Foundation Trust, the local Clinical Commissioning Group and with the addition of Local Authorities, continues to oversee the development of integrated programmes of service change across the local health and social care economy, in particular the Momentum: pathways to healthcare programme and the implementation of the Better Care Fund (for which it provides the appropriate 'Unit of Planning'), and will encompass delivery of the Sustainability and Transformation Plans going forward. One of the key tasks of the Partnership Board is to ensure high quality clinical services are maintained whilst protecting the financial stability of the local heath economy; overseeing the delivery of capital developments, pursuing service changes associated with a single site hospital, and acting as a director-level reference group. Similar engagement is being established with the areas overseen by other commissioners, notably in the Durham, Easington and Sedgefield area. The Trust’s 'Continuity of Services 'rating was at a level 3 for the first six months of the year, however falling to a level of 2 in quarter 3. This was because the planned surplus on income and expenditure was not achieved due to the unprecedented demand on services in the last quarter of the year. The Trust has maintained the appropriate balance between the challenging financial efficiency agenda and the desire to continue to invest in improving quality, patient experience and service performance. The Trust agreed a revised control total deficit with Monitor of £7.4m, which was delivered at year end. Other matters that have impacted upon the Trust include: • Ability to recruit to posts, where expertise is in short supply for both nursing and medical professions, resulting in higher than expected locum and agency costs; • Very high demand for patient beds, particularly over the winter months, which continued into 2015 – 16 resulting in additional beds and associated staffing levels being made available over and above that planned and costed; • National and local pay, and terms and conditions of service, whilst nationally changes have been agreed, further opportunities will need to be considered locally to achieve the right balance of efficiency savings in respect of the Trust’s staffing establishment and efficient ways of working; • Centralisation/regionalisation of services to provide patients with care delivered by specialist units that are designed to treat the minimum number of patients to maintain expertise. The impact would be for the Trust to potentially lose services or become a key provider; • The technical changes to tariff whereby the costing and pricing for services could be impacted if the Trust has provided more services than the contract will pay for, therefore insufficient funding could follow core activity; 27 • Continuing to develop working relationships with a number of commissioners whilst working through the impacts that the introduction of a number of policy initiatives such as the Better Care Annual Report and Accounts 2015 – 2016 Fund and the new Care Act will have on the services the Trust offers; • The intention for commissioners to market test services to demonstrate value for money which could result in services being provided by numerous organisations challenging pathway delivery and losing economies of scale. All of the above are being considered in the light of their impact upon local and national policy, best practices and services the Trust can invest in and secure. Changing Policy and Structures As the commissioning arrangements develop – with the maturing of the Clinical Commissioning Groups, and the developing roles of Local Authorities as commissioners of some services, linked to the implementation of the Better Care Fund - the engagement and support of local political stakeholders remains crucial in transforming services to provide enhanced quality, clinical effectiveness and patient experience to the people of Easington, Hartlepool, Sedgefield and Stockton whilst improving clinical outcomes. The Trust continues to engage with and involve the local Health Scrutiny Committees, Local Authority Health and Wellbeing Boards and HealthWatch. With Public Health now the responsibility of Local Authorities, the Trust continues to develop its Public Health Strategy to complement those of the Local Authority areas that we serve. Service Transformation Plans continue to be developed to deliver further service transformations through the ten year strategy which will enable the Trust to continue to improve the quality and safety of the services it delivers, providing care closer to home and increasing quality, accessibility, integration, responsiveness and value for money across the patient pathways, linked to the wider Better Healthcare Programme and Sustainability and Transformation Plans. These will continue to progress irrespective of the decision to pause the New Hospital capital project. 2.1.8 Going Concern After making enquiries, the directors have a reasonable expectation that the North Tees and Hartlepool NHS Foundation Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts. For further comment in this regard, please see Note 1.3 to the accounts, page 253. 2.2 Performance Analysis
2.2.1 Performance and Development of the Trust’s Business During 2015 – 16 the Trust has continued to review and re-model its services to meet the needs of the population, with further work on-going to deliver Phase 3 of the organisation’s Clinical Service Strategy. The Trust’s bed base has been re-aligned to meet the increasing emergency activity coming into the organisation, providing resilience for the periods of seasonal demand and flexibility within service delivery. The elective bed base has been re-configured, providing a flexible week day and weekend resource to achieve maximum operational efficiency. The Trust has worked jointly with neighbouring organisations to ensure individual services are clinically sustainable for the local population, for example Breast, Urology and Haematology, with further collaboration planned during 2016 – 17. The Trust is committed to the continued review and improvement of patient pathways, in line with Momentum: pathways to healthcare strategy and providing care closer to home through integrated acute and community care. The planning and delivery options for the Integrated Care Pathways (ICP) for Long Term Conditions (LTC) are currently being advanced in conjunction 28 with commissioners and key stakeholders, providing a central plateau for the continued Clinical Transformation Programme. The Integrated Care Pathways include: Frail Elderly and Dementia, End of Life, Respiratory, Cardiac, Diabetes, and Stroke Care. An infrastructure of governance is in place Annual Report and Accounts 2015 – 2016 with commissioners and Local Authorities feeding into the North of Tees Partnership Board and linked to the Better Care Fund objectives. The table below outlines the Trust activity within 2015 – 16. During 2015 – 16 the Trust has seen a slight decrease in elective activity across both inpatient planned admissions and day case surgery, however the reduction in day case surgery reflects the repatriation of vascular surgery to the South Tees contract. Outpatient attendances (new and review) have shown a decrease, which is expected as the Trust reduces the number of review appointments in line with changes in clinical pathways. Ward attender activity has reported an increase against the previous year, with additional patients being treated within the ward assessment areas. 2015 – 16 has seen an increase in emergency activity through A&E with a decrease in non-elective admissions in comparison to the previous year. Despite the non-elective decrease, the Trust has been under significant operational pressure during 2015 – 16, with evidence of an increased acuity within patients admitted into the Trust, with the admissions via A&E indicating by 6.22% (n=1044) increase on last year (April – March comparative position). Of the patients coming through the emergency route the Trust continues to see, diagnose and treat a significant number of emergencies through the Ambulatory Care unit, a positive move to reducing avoidable admissions onto the in-patient base wards.
Point of Delivery 2014 – 15 2015 – 16 Variance % Variance Actual Actual 2015 – 16 against 2015 – 16 against 2014 – 15 2014 – 15 A&E Attendances 88,318 88,999 681 0.77% Day Case Admissions 37,438 36,464 -974 -2.60% Inpatient Planned Admissions 5,589 5,751 162 2.90% Inpatient Emergency 37,181 40,142 2,961 7.96% Admissions Ambulatory Care Attendances 7,949 8,129 180 2.26% Outpatient Attendances (New 215,493 207,379 -8,114 -3.77% and Review) Ward Attenders 20,422 24,000 3,578 17.52%
The current commissioning process involves regular meetings between GP Commissioners and Trust Clinical Leads to discuss and debate the commissioning intentions around quality and operational efficiencies, with a focus on reducing the number of patients who require readmission and improving acute and primary care pathway integration. The Annual Operational Plan negotiations to agree the 2016 – 17 contractual activity has involved a detailed and robust process with rigorous challenge and contest, with the requirement to agree aligned activity plans for the next financial year. The contracts with the main commissioners were agreed by the end of April 2016. In line with the NHS commissioning structure, negotiation of the 2016 – 17 contracts has involved local Clinical Commissioning Groups (CCGs), NHS England, Local Authorities and Public Health organisations. The Board of Directors and Finance Committee have been apprised of progress. The contract poses challenges to system efficiencies and pathway delivery, the detail of which will continue to be shared with the Board of Directors to enable debate and challenges as to future risk and mitigation. Service Line Management Service Line Management (SLM) is the mainstream model of working throughout all directorates. The Trust has committed to embed the principles of SLM across the organisation, equipping staff with the ability to manage and deliver efficient and quality services. The continuing difficult economic climate, with the requirement of substantial efficiency savings and with service transformation and the overall objective of delivering the clinical services strategy, has posed significant challenges on Service Lines. Clinicians are using SLM as a model to deliver operational and financial efficiencies to improve patients’ experience and enhance the quality and safety of the services we deliver. Operational, financial and quality metrics are routinely reviewed at a service line level, thus identifying inefficiencies and variance in practice to inform service 29 improvements and developments. Service Line Reporting (SLR) has been implemented utilising a patient level costing system (PLICS). Annual Report and Accounts 2015 – 2016 PLICS is discussed by service lines enabling them to analyse and compare detailed financial information from individual clinical cases to address unwarranted variation and realise financial efficiencies, whilst maintaining quality and patient experience. During 2016 – 17 the Trust will continue to advocate SLM as its model of working and continue to develop leaders, at all levels, within the organisation. The focus will be to strengthen SLM in all acute clinical, community and non-clinical services. 2.2.2 Performance Review The Trust is committed to developing and improving service efficiency. In line with the commissioning agreements in the Commissioning for Quality and Innovation (CQUIN) and Quality, Innovation, Productivity and Prevention (QIPP) programmes these concentrate on efficiency indicators aimed at improving patient pathways with care closer to home, where appropriate. Progress is reported to the Board of Directors within the corporate dashboard, together with detailed indicators incorporated into the specialty and sub specialty dashboards, to enable detailed clinical monitoring. The Trust has received the Lord Carter report from the Department of Health Team, outlining the estimated savings that can be made based on the national benchmarking exercise carried out within the review. Areas or recommendation for review include workforce, medicine optimisation, estates management and procurement. The Trust’s team have reviewed the information provided and will use the initial baselines, accepting the associated assumptions may require further work, to support further review of operational efficiencies. The areas that have been highlighted as having potential opportunities for savings include Obstetrics and Gynaecology, Surgery and Urology, Trauma and Orthopaedics and Paediatrics, which will be further reviewed through the Trust’s Patient Level Costing system alongside the Lord Carter findings. Effective surge management remains a priority within the emergency preparedness agenda, and as such the Trust has a well-developed flexible capacity plan to accommodate surges in demand, which has been effective in managing the significant challenges posed by the seasonal pressures of 2015 – 16. The current economic climate with the requirement of substantial efficiency savings, pose more challenging requirements in 2016 – 17 with penalties applied against locally agreed performance standards and Quality, Innovation, Productivity and Prevention (QIPP), to drive improvements in efficiency. The Trust endeavours to continue with its success in managing service improvements to deliver the operational efficiencies through projects identified and implemented using LEAN methodology to diagnose and drive change in patient pathway management. The Trust has implemented a number of initiatives to support the delivery of the efficiency agenda with particular improvements noted within emergency readmission rates, new to review ratios and pre operative stays in comparison to the previous year. These include: • Increased booking of clinics to reduce inefficiencies; • Increased non-face-to-face follow up appointments; • Enhanced recovery in elective surgery reducing the need to stay in hospital longer than necessary; • Opening of a Surgical Decision Unit to reduce inappropriate emergency admissions and usage of inpatient base wards; • Theatre access lounge to reduce the need for pre-operative stays; • Review of readmissions to identify lessons learnt and establish if these could have been avoidable; • Increased number of day case and outpatient procedures; 30 • Reviewed accountabilities within the discharge liaison team (DLT) to facilitate early referral to rehabilitation and social care reducing time to discharge.
Annual Report and Accounts 2015 – 2016 Further work is being carried out within the Outpatient service with a dedicated Transformation project to review operational efficiencies across patient pathway management, estates management, booking processes, workforce models and Information Technology. Care Quality Commission Rating The Trust has continued to comply with the Care Quality Commission (CQC) registration without conditions, which is a reflection of the safe, high quality levels of care provided in the organisation and continues to deliver against key standards. When the new Health and Social Care Regulations were published in November 2014; two of the regulations were to be applied to NHS bodies from 27 November; these were the Duty of Candour and Fit and Proper Persons (Directors). The requirements for both of these regulations have been reviewed by the Trust and implemented in line with guidance received from the CQC. The CQC undertook a formal inspection of the Trust 7 – 10 July 2015 with a final report published in February 2016. The Trust felt the inspection went well and was positive regarding the care provided to patients across the Trust and complimentary of the staff despite a number of recommendations. The CQC inspection was split into five domains for reviewing services; • Safe; • Caring; • Responsive; • Effective; • Well-led. Each domain is rated as either inadequate, requiring improvement, good or outstanding. The inspectors rated the University Hospital of Hartlepool ‘good’ for safe, caring and responsive and ‘requiring improvement’ for effectiveness and well-led care. The CQC stipulates that if a Trust is rated with two or more ‘requiring improvements’ out of five results, then the overall rating will result in ‘requiring improvement’. The inspectors rated the University Hospital of North Tees as ‘good’ for caring and responsive services but ‘requiring improvement’ for safe, effective and well- led services. This resulted in an overall rating of ‘requiring improvement’. It must be noted that out of 85 individual ratings, the Trust was rated as good for 65, with many areas of good practice commended. Overall Ratings for the Trust
Overall rating for the Trust Requires improvement Are services at this Trust safe? Good Are services at this Trust effective? Requires improvement Are services at this Trust caring? Good Are services at this Trust responsive? Good Are services at this Trust well-led? Requires improvement
The full inspection report can be found on the CQC website: www.cqc.org.uk/provider/RVW Key Performance Standards The Trust has continued to strive to deliver against the key performance standards throughout the year, however has reported outside the required target in year for a number of standards. The key areas of pressure include: • C-Difficile; • Emergency 4 hour standard; • Cancer 62 urgent referral to treatment standard; • Cancer 2 week referral to first appointment standard. Delivery against the C-Difficile standard was recognised as challenging for 2015 – 16, due to the significant reduction in the Trust’s annual objective, set at 13 cases. The Trust has achieved substantial year on year reductions since the introduction of the standard in 2007 – 08, reducing 31 from 210 cases to 20 cases in 2014 – 15. As such, achievement of the reduced objective was declared at risk by the Board in the 2015 – 16 annual planning submission. Work has continued Annual Report and Accounts 2015 – 2016 within the organisation to address the number of C-Difficile cases reported, with detailed action plans in place, including peer review work to support best practice. There has been a drop in performance against the Emergency 4 hour standard during 2015 – 16, due to both surges in demand and the complexity and acuity of patients attending the organisation. This is reflective of the national pressures across A&E and emergency care delivery. The Trust has undertaken detailed reviews of emergency pathway management during 2015 – 16, including ‘Perfect Week’ and ‘Kick Start January’ initiatives, with two intense 7 day programmes of work taking place to support emergency service delivery. Subsequent lessons learnt and recommendations have been taken forward to support on-going improved pathway delivery. The provision of access against the cancer standards is a key priority of the Trust; however consistent delivery continues to be difficult due to a number of influences, some of which are outside the Trust’s control. The impact of increased referrals due to cancer awareness campaigns, complexity of patient pathways, patients requiring multiple diagnostic tests, and patient choice to delay diagnosis and treatment are some of the key pressures influencing under-achievement against the set standards. The Trust has implemented a cancer recovery plan to support pathway management, achieving all cancer standards by the end of Quarter 3, however recognising that a system-wide approach to the delivery of cancer pathways is required to influence on-going delivery. The Risk Assessment Framework forms the basis on which the Trust’s Annual Plan and in-year reports are presented to the Board of Directors. Regulation and proportionate management remain paramount in the Trust to ensure patient safety is considered in all aspects of operational performance and efficiency delivery. End of year performance against the Risk Assessment Framework targets and key commissioner targets are displayed in the table below with comparisons to the previous year.
32 Annual Report and Accounts 2015 – 2016 Lead Cancer Nurse, Jan Harley with members of the Cancer Patient Group. Monitor Compliance Framework 2015-16 2015-16 2014-15 Achieved Indicators Target Performance Performance (cumulative) Clostridium Difficile – meeting the C.Diff 13 36 20 ✘ objective MRSA - meeting the MRSA objective 0 2 0 ✘ Cancer 31 day wait for second or 94% 100.00% 97.47% ✔ subsequent treatment – surgery * (Qtr 4 provisional) Cancer 31 day wait for second or 98% 100% 99.84% ✔ subsequent treatment – anti cancer drug treatments * (Qtr 4 provisional) Cancer 31 day wait for second or 94% N/A N/A N/A subsequent treatment – radiotherapy Cancer 62 Day Waits for first treatment 85% 82.19% 84.23% ✘ (urgent GP referral for suspected cancer) * (Qtr 4 provisional) Cancer 62 Day Waits for first treatment 90% 96.43% 96.70% ✔ (from NHS cancer screening service referral) * (Qtr 4 provisional) Cancer 31 day wait from diagnosis to first 96% 99.04% 98.85% ✔ treatment * (Qtr 4 provisional) Cancer 2 week wait from referral to date 93% 93.03% 93.75% ✔ first seen, all urgent referrals (cancer suspected) * (Qtr 4 provisional) Cancer 2 week wait from referral to date 93% 93.61% 93.89% ✔ first seen, symptomatic breast patients (cancer not initially suspected) (Qtr4 provisional) Maximum time of 18 weeks from point 79.25% 91.83% of referral to treatment in aggregate, admitted patients (Feb 16) Maximum time of 18 weeks from point of 97.19% 98.21% referral to treatment in aggregate, non- admitted patients (Feb 16) Maximum time of 18 weeks from point of 92% 92.21% 96.77% ✔ referral to treatment in aggregate, patients on incomplete pathways Mar 16) A&E: maximum waiting time of 4 hours 95% 94.60% 95.16% ✘ from arrival to admission/transfer/discharge (Apr 15 – Mar 16) Community care data completeness 50% 95.38% 93.55% ✔ - referral to treatment information completeness (Feb 16) 33 Community care data completeness - 50% 93.40% 92.61% ✔ referral information completeness (Feb 16) Annual Report and Accounts 2015 – 2016 Community care data completeness - 50% 93.66% 72.51% ✔ activity information completeness (Feb 16) Community care data completeness - 50% 93.66% ✔ patient identifier information completeness (Shadow Monitoring) (Feb 16) Community care data completeness - End 50% 88.64% ✔ of life patients deaths at home information completeness (Shadow Monitoring) (Feb 16) Compliance with access to healthcare for 100% Full Full ✔ patients with learning disabilities compliance compliance Other National and Contract Indicators 2015-16 2015-16 2014-15 Achieved Target Performance Performance Cancelled Procedures for non-medical 0.80% 0.44% 0.41% ✔ reasons on the day of op (Apr 15 – Mar 16) Cancelled Procedures reappointed within 100% 96.91% 100% ✘ 28 days (Apr 15 – Mar 16) Eliminating Mixed Sex Accommodation Zero 0 0 ✔ (Apr 15 – Mar 16) cases A&E Trolley waits > 12 hours Zero 0 ✔ cases Choose and Book slot issues <4% No data 3.53% Stroke - 90% of time on dedicated Stroke 80% 87% 91.91% ✔ unit Stroke - TIA assessment within 24 hours 75% 82% 88.24% ✔ Delayed transfers of care (Apr 15 – Mar 16) <3.5% 1.63% 2.65% ✔ Breast Feeding at Delivery (Apr – Sep 15) >=50% 49.36% 51.22% ✘ Number of Diagnostic waiters over 6 weeks 99% 99.65% 99.30% ✔ (Apr 15 – Mar 16) Retinal Screening - offered an appointment 95% 92.91% 92.86% ✘ within 48 hours (Mar 16) VTE Risk Assessment (Apr – Dec 15) 95% 95.57% 95.94% ✔ Health Visitor Numbers (March 16) 73.49 68.49 61.39 ✘
* Retinal Screening can have more than 1 offer per patient; therefore can be greater than 100% 2.2.3 Business Planning and Linkages to Key Activities The Trust continues to operate within the context of the economic downturn, more stringent efficiency requirements, a measurable quality drive and new ways of delivering NHS services, as evidenced in the requirements of NHS Five Year Forward View. The Business Planning process takes into account the strategic requirements at operational level, year on year. The Trust has a robust business planning cycle which commences in Quarter 2 each year, with completion of a Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis. Plans for the forthcoming year are submitted in December, allowing initial relevant information to be shared between services. In addition, the timely development and focus afforded to directorates and departments through early planning enables a robust and structured approach to contract negotiation. Each business plan is accompanied by pre-full business case proformas, each of which are progressed through the governance route of the Trust, and ultimately presented to the Capital and Service Development Group for consideration as to alignment with strategic priorities, investment potential and lifecycle payback. Where appropriate, agreed service developments are shared with commissioners if supporting funding streams are required. The Trust continues to re-profile services and flex capacity to accommodate changes in service 34 demand, disease profile and patient needs. The resilience in capacity management will continue into the future, especially in the face of limited public spending and further cost improvements
Annual Report and Accounts 2015 – 2016 and, more specifically, given the planning assumptions expected on growth and efficiency. In 2015 – 16 the key elements of the strategic vision were: • Continued delivery of quality care pathways; • Improved and streamlined care, both in hospital and out of hospital; • New and existing community facilities utilised to help deliver care closer to home; • Development of the Clinical Service Strategy for future services. The Trust will continue to build on the service changes that have been delivered during 2015 – 16, taking into consideration the lessons learnt through the implementation of these transformations, thus ensuring the introduction of future developments are both planned and implemented via the most appropriate routes. The Trust is assessing the viability of provision of the following new services in 2016 – 17 in contributing to the improved safe provision of efficient and cost effective services. Planned Service Development Priorities for 2016 – 17 include: Emergency Care/EAU and Ambulatory Care • Extended Consultant cover until 22:00 and increase to five consultants at weekends, with Advanced Nurse Practitioners to compliment the medical rota; • Continuation of GP in A&E; • Patient Flow/Discharge Liaison Team Model; • Excellence in Practice Scheme – Teesside University. In Hospital Care • Expand Diabetes service to support transition into adult care; • Developing liver specialist nurse service; • Expansion of GI/Endoscopy services and endoscopic ultrasound Service; • Re-design of rheumatology services – including an additional Rheumatology consultant, collaborative working with supporting teams and specialist nurse review; • Recruitment of further elderly care consultants/specialist nurses to facilitate Frailty Unit; • Development of a Day Unit incorporating medical patients; • Growth in cardiology through implantable device services and cardiac MRI; • Implement Community Acquired Pneumonia Specialist Nurse role. Out of Hospital Care • Fully implement Integrated Care Pathways for Palliative Care, Diabetes Care, Respiratory Enhanced Care, Frail Elderly/Dementia , Rheumatology and Long Term Neurological Conditions; • Review of Step Down model: Fully nurse/therapy led supported by the Planned & Responsive Care @home Team outlined in the Community Strategy. Surgery and Orthopaedics • Develop own Specialist Weight Management (SWM) service to support the Bariatric service; • Develop a Tees wide breast care service, in conjunction with radiology, with the Trust being the HUB for both radiology and surgery; • Further develop Urology collaboration; • Introduce 7 day therapy routine work on surgical wards. Trauma and Orthopaedics • Work in conjunction with the MSK service to support the CCG requirements for all orthopaedic referrals to be directed initially through the MSK service. Adapt the secondary care service model accordingly once the impact on the initiative is fully reviewed; • Redesign the secondary care provision for Spinal services within the Trust; • Further expand the foot and ankle service based upon increased market share demonstrated in 2015 – 16; • Further expand the elbow and shoulder service; 35 • Review the further expansion of the hand trauma service to incorporate the North of Tees Trusts
(Sunderland, County Durham and Darlington). Annual Report and Accounts 2015 – 2016 Women and Children • Develop 7 day Early Pregnancy Assessment service; • Develop 24 Hour Obstetric Assessment service; • Fully implement Birth Rate Plus. 2.2.4 Future Challenges to Performance Delivery NHS England’s Everyone Counts: Planning for Patients 2014-15 to 2018-19 outlines the performance expectations for providers. This includes: • NHS Services 7 days a week; • More transparency; • More choice; • Patient participation and improved customer service; • Improved outcomes; • Higher standards and safer care; • Better data to inform commissioning; • Continuous achievement of elective and emergency access standards, alongside patient choice, complex pathway management and other complex variables outside of the control of the Trust; • Continuous achievement of the cancer standards, namely two week wait and 62 day referral to treatment within the context of system pressures. The overall aim is to develop an integrated approach to healthcare delivery across the whole health economy. These key priorities are reflected within the Trust’s business plans. Improving access, quality, patient safety and experience remains high on the performance agenda, and this is further supported through the NHS Outcomes Framework. The national performance measures fall into five domains of delivery that continue to be given particular attention: • Preventing people from dying prematurely; • Enhancing quality of life for people with long term conditions; • Helping people to recover from episodes of ill health or following injury; • Ensuring that people have a positive experience of care; • Treating and caring for people in a safe environment and protecting them from avoid-able harm. The National focus for Referral to Treatment (RTT) is now one measure of success, the reduction in ‘incomplete pathways’, with the supporting indicator of zero tolerance for RTT non adjusted waits of 52 weeks or over. The operational performance section highlights the success of the Trust in managing the RTT standards. In addition to the RTT access measures the following key performance indicators will be monitored closely to ensure the Trust fully complies with all the required domains: • Reducing Diagnostic waiting times; • Further reduction in number of cases of C-Difficile; • Reduction in MSSA and E-Coli cases; • Reduction in HSMR and SHMI mortality rates; • Total time in A&E supported by the shadow monitoring of the A&E Quality Outcome Standards, including: --arrival to discharge, 36 --arrival to treatment, --arrival to assessment for ambulance admissions/attendances, Annual Report and Accounts 2015 – 2016 --left without being seen, --unplanned re-attendance within 7 day; • Reduction in new to review ratios; • Risk assessment of hospital related Venous Thromboembolism (VTE); • Reduction in emergency readmissions within 30 days; • Reducing avoidable hospital admissions for acute conditions; • Managing increasing emergency pressures; • Achieve operational efficiencies in line with the Lord Carter review and recommendations; • Friends and Family test for admitted, A&E, maternity services, outpatients, diagnostic and staff cohorts. Effective surge management remains a priority within the emergency preparedness, response and resilience agenda, and as such the Trust has well developed escalation and capacity management plans. The Trust has once again responded well to this year’s winter pressures, with a relatively small number of elective procedures cancelled due to a lack of beds and the junior doctor’s industrial action. The Trust has reported minimal ambulance diverts and zero 12 hour trolley waits. This is despite peaks in activity, compounded with periods of ward closures due to outbreaks of diarrhoea and vomiting. Each year the Trust’s resilience plans are reviewed following debrief and reflection. The Trust is striving to ensure it continues to manage surges in activity as effectively as possible, and to this end is engaged in working with partner agencies to develop and further refine pathways to explore means of admissions avoidance and effective and timely discharge.
Staff on ward 31 taking part in Kick-Start January.
The Infection Prevention and Control Team continue to work closely with clinical teams and estates colleagues, to ensure that all staff are aware of the measures needed to reduce the risk of C-Difficile and maintain high standards of environmental cleanliness. These teams are also ensuring that those patients who do become symptomatic are managed appropriately, to result in best patient outcomes and optimum patient safety. 2.2.5 Corporate and Social Responsibility North Tees and Hartlepool NHS Foundation Trust is committed to being a Good Corporate Citizen (GCC). During the year it worked hard to strengthen its corporate responsibility programme. Corporate social responsibility touches all areas of the Trust’s activities, including the way in which it trains and develops its workforce, the way it purchases goods and services, how it uses energy 37 and how it conducts its relationships with patients, carers, and members of staff, governors and members of the public. The Trust continues to improve its GCC rating on an annual basis and is Annual Report and Accounts 2015 – 2016 positioned well above the national average. During 2015-16, the Trust completed the initial phase of its Carbon Management Plan, having achieved the target savings within the 5 year programme. In its aim for continual improvement, the Trust has set a target of a further 2% reduction in carbon emissions per year. The Combined Heat and Power units (CHPs) on both sites continue to provide site electricity whilst contributing to heat generation from free waste-heat energy. Due to the quality of units we continue to be exempt from the Climate Change Levy on all Gas imports through a scheme operated by the Department of Energy and Climate Change. The system at North Tees has traditionally provided approximately 40% of the hospital steam requirements by recovering heat energy from the engine exhaust, but developments, made possible through funding of our Carbon Management Programme, have enabled further recovery of this free waste-heat so that it now provides 75% of the site’s hot water demand, and approximately 20% towards the heating demand. The Trust has introduced a free inter-hospital shuttle service for patients, visitors and staff. The service has proven very popular and as well as improving access for the public has contributed to an organisational reduction in expenditure for travelling expenses in excess of 20% since the introduction of the service. Some examples of good practice include: Dementia Friend More than 40 staff in the pharmacy team have made a pledge to be a dementia friend, helping raise awareness about dementia. The Trust’s dementia team regularly holds dementia friend sessions for staff.
Pharmacy staff celebrates as they become dementia friends.
Celebrating our armed forces staff Many of our staff have or still do serve in the armed forces, including consultant in emergency medicine Kay Adeboye and A&E healthcare assistant Ben Baino who are both members of reserve forces. Kay is a wing commander in the 612 (County of Aberdeen) Squadron RAF, where he has been for 17 years, whilst Ben is a private in the 201 Field Hospital who have barracks in Norton. Chief Executive Alan Foster is the field hospital’s honorary colonel.
38 Annual Report and Accounts 2015 – 2016
Healthcare Assistant, Ben Baino. Consultant in emergency medicine, Kay Adeboye. Record number of care makers The Trust now has more care makers than any other Trust in the country with over 120 out of the national figure of 1,200. The latest group of staff to volunteer to be care makers were presented with certificates in the lecture theatre in the Middlefield Centre at the University Hospital of North Tees. Colleagues apply to become caremakers because they are passionate about making a difference to patients, families and colleagues and act as ambassadors for the 6Cs.
There are now more care makers here than any other Trust in the country after more staff signed up.
Trust says thank you to its army of volunteers at its annual event Once again the Trust said thank you to people from the community who do voluntary work in the Trust at its annual volunteer thank you event. Staff formed a choir to entertain the volunteers for the evening.
39 Annual Report and Accounts 2015 – 2016
Volunteer event 2015.
2.2.6 Environment, Sustainability and Climate Change The Trust endorses the views of Saving Carbon, Improving Health (2008) and the aims of the NHS Sustainable Development Unit to reduce the Carbon Footprint of the NHS and to be a good ‘Corporate Citizen’. The NHS is now responsible for emissions exceeding 20 million tonnes of carbon dioxide per annum and is one of the largest public sector emitters in the world. It has economic and ethical obligations to reduce its impact on the environment not only for public health, but also for its own health and long-term survival. The reports conclude that a low carbon NHS is a more efficient NHS and, if the service is to provide the best quality of healthcare in the future, it must build on both its efforts to mitigate climate change and its resilience to that change. This will require further investment in the future. Climate change is regarded as the greatest global health threat of the 21st century. The NHS carbon footprint of 20 million tonnes CO2 per year comprises energy (22%), travel (18%) and procurement (60%). Despite increased efficiency, the NHS has increased its carbon footprint by over 40% since 1990. To meet the Climate Change Act (2008), the government has set itself carbon targets of 34% reduction by 2020 and 80% by 2050, which is deemed a huge challenge, and the NHS will have to play its part in supporting the government’s target. The Trust initially aimed to reduce its 2007 carbon footprint by 10% by 2015, which required it to curb the level of growth in emissions and reverse the trend in absolute emissions. An Environmental, Sustainable & Carbon Governance Committee was established to focus resources into deliverable short, medium and long-term goals. The Trust, through the Committee, supported the implementation of the Carbon Management Plan with the following aims: • To work towards a low carbon environment across its services that include transport,service delivery and community engagement; • To reduce carbon emission from energy, waste, procurement and transport; • To realise financial savings. Of the initial 25 projects defined and accepted within the plan, it has not been technically possible to complete five of them at this time. However, the other 20 have been completed and extended due to their success. The Trust has now, through participation in the ‘Good Corporate Citizen Assessment’ model developed by the Sustainable Development Commission and the continued efforts of the multi- disciplinary team, achieved the target reductions of 17% since the start of the programme and 20% on the 2007 benchmark figure. These successful carbon reductions, together with continued good management of the two combined heat & power units, have also achieved cost avoidance of over £1 million in utilities revenue and tax.
Carbon Value at Stake 18,000
) 16,000 2 14,000 12,000 10,000 8000 6000 4000 Carbon Emissions (Tonne CO Carbon Emissions (Tonne 2000 0 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 Actual BAU Target
40 Financial Value at Stake 4,500,000
Annual Report and Accounts 2015 – 2016 4,000,000 3,500,000 3,000,000 2,500,000 £ 2,000,000 1,500,000 1,000,000 500,000 0 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 Actual BAU Target Carbon Governance Arrangements The Environment, Sustainable Carbon Governance Committee oversees performance and governance issues. A comprehensive range of measures has been implemented and is monitored and reported upon annually with summaries including: • Benchmark of peer performance using the Department of Health Premises Assurance Model of space, efficiency and effectiveness; • Good Corporate Citizen Assessment Model ratings and improvements; • Reduction in single car journeys through the application of a Trust travel plan; • Progression through Carbon Trust NHS Carbon Management Programme; • Energy performance ratings utilising Display Energy Certificate methodology; • Utilities consumption and carbon emissions utilising NHS Estates Returns Information; • Reduced the level of waste to landfill from the hospital to zero and re-cycling levels.
Alan Foster, MBE Chief Executive Date: 27 May 2016
Staff testing the new cardiac scanner at the University Hospital of North Tees. 41 Annual Report and Accounts 2015 – 2016 3 Accountability Report
The previous section provides a comprehensive overview of the Trust’s performance, incorporating a review of its business, a summary of its strategy, and a description of the principal risks and uncertainties it faces.
A new group of medical trainees were welcomed into the Trust.
The Accountability Report provides further information on the Trust’s performance and services, with particular reference to: • How the Trust is organised, with description of the structure, membership and functions of the Board of Directors, Council of Governors and various Committees (section 3.1); • A detailed remuneration report (section 3.2); • The Trust’s commitment to its staff, including details on staff engagement, support, training and development, management of equality and diversity, absence management, findings from and action plan to address the issues raised in the Staff Survey 2015 and staffing analysis (section 3.3); • The NHS Foundation Trust Code of Governance (section 3.4); • Regulatory performance and ratings (section 3.5); and 42 • The Annual Governance Statement which includes the arrangements in place for quality governance in the Trust (section 3.7). Annual Report and Accounts 2015 – 2016 3.1 Directors’ Report
Statement of Directors’ Responsibilities Under the NHS Act 2006, Monitor has directed North Tees and Hartlepool 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 Directors are responsible for preparing the accounts on an accrual basis, which gives a true and fair view of the state of affairs of North Tees and Hartlepool 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 Directors are required to comply with the requirements of Monitor’s Foundation Trust Annual Reporting Manual 2015 – 16 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 Directors are 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 Directors are 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. The Directors consider the annual report and accounts, taken as a whole, to be fair, balanced and understandable and provide the information necessary for patients, regulators and stakeholders to assess the NHS Foundation Trust’s performance, business model and strategy. 3.1.1 Organisational Structure The Trust is a Foundation Trust, which requires specific statutory duties to be met. These include the composition of the Council of Governors and Board of Directors. The Trust values the contribution, which the Council of Governors and Board of Directors provide, their engagement in reviewing and assessing Trust services, patient safety and quality is invaluable to enable the Trust to both grow and enhance its healthcare reputation. The Trust has during 2015 – 16 provided development for both the Council of Governors and Board of Directors in a range of services and activities. This section provides an overview of the structures and responsibilities which the Council of Governors, Board of Directors and Executive Management Team undertake. It also provides an overview of key Committees of the Trust and how they work in partnership with the Board, Council of Governors and Executive Management Team. The Trust was authorised as a Foundation Trust in December 2007; it is led by a Board of Directors who are responsible for exercising the powers of the Trust and is a body that sets the strategic direction, allocates the Trust’s resources and monitors its performance. It also has responsibility for ensuring the highest standards of corporate governance, patient safety and quality are maintained, 43 and that the Trust operates within a framework of prudent and effective controls, which enables risk to be assessed and managed. Annual Report and Accounts 2015 – 2016 The responsibilities of the Board of Directors and the Council of Governors are set out in the Trust’s constitution, which was updated to include changes required by the Health and Social Care Act 2012, and further updated in 2015 to include regulations in respect to the ‘fit and proper person’ test and new model rules for elections. Responsibilities are also presented in the approved Standing Orders and Scheme of Delegation, which sets out the powers reserved to the Board of Directors, and those powers delegated to individuals. The Board of Directors composition and its meeting structures are described on page 52. The Council of Governors are responsible for representing the interests of NHS Foundation Trust members, patients, carers, members of the public and stakeholder organisations in the governance of the Trust. They exercise statutory powers, as laid down in Monitor’s NHS Foundation Trust Code of Governance, which include the appointment and terms and conditions of the Chairman and Non-Executive Directors, ratification of the appointment of the Chief Executive and approval of the appointment of the Trust’s External Auditors. They also receive the Annual Report and Accounts and hold to account the Board of Directors for its management and leadership of the Trust, the performance of the Trust, and ensure the Trust does not breach its terms of authorisation. Working Together – the Board of Directors and Council of Governors The Board of Directors and Council of Governors engage regularly, there are four Council of Governor meetings each year, and the Board of Directors’ attend these meetings. The Council of Governors meeting is held in two parts. The formal meeting takes place, following which the Trust hosts a development and information session, where the Council of Governors and Board of Directors come together to learn and develop ideas to support the work of the Trust. At these sessions, insight was provided on priority areas and key issues of interest, which allowed Governors an opportunity to provide valuable feedback and suggestions regarding work being undertaken, whilst also ensuring they were fully aware of both the challenges being faced by the Trust, and the valuable improvements being made to patient care, including service transformation plans. The range of development and information sessions held during 2015 – 16 focussed on the following key themes: • CQC Inspection preparation and readiness; • Update on National Recommendations from Freedom to Speak, Morecambe Bay and Savile Reports; • Overseas Visitor requirements; • Strategy Session: Local and national context; current thoughts and priorities for service delivery and the challenge of developing services fit for the future; • Clinical Services Strategy – Implementation; • Clinical Services Strategy – Infrastructure and Estates Reconfiguration. Over the last year Governors and Non-Executive Directors have continued to participate and provide invaluable independent input into the Staff, Patient Experience and Quality Standards (SPEQS) reviews. These reviews enable Governors to speak directly to patients and staff and provide assurance that standards are aligned with information reported. Panels are held across the full range of areas of the Trust, with reports from SPEQs reviews provided to the Board of Directors and Council of Governors. Governors, as part of this process, support the Trust by ensuring focus is kept on the care of patients whilst also supporting frontline staff to fulfil their roles to deliver safe, high quality care and good patient experiences. The Board of Directors has overall responsibility for the day to day operations of the Trust, ensuring they are effective, economical and efficient, and that all areas of identified risk are managed appropriately. The Council of Governors receive regular reports and updates from the Board of Directors covering all aspects of Trust business, thus ensuring statutory requirements are achieved and monitored. Members of the Board also attend various Sub-committees of the Council of Governors, and therefore engage with Governors on specific issues. There is a Senior Independent Director, who is available to Governors and members for contact and communication in the event of any concerns or difficulties. 44 The Governors meet informally three times per year in between their formal meetings and during 2015 – 16 Non-Executive Directors and Executive Directors have attended these informal gatherings to share the work they undertake as Board Directors. Also, key clinical leads have attended to Annual Report and Accounts 2015 – 2016 provide updates on topical issues, enabling more detail to be understood and debate to be had. These informal gatherings have proved very successful to aid the understanding of both the Board and Governors and will continue during 2016 – 17. The Senior Independent Director and Company Secretary attend these informal gatherings. The Board of Directors approve the directions and decisions agreed. The Council of Governors receive the decisions and directions made by the Board of Directors, and hold the Board to account and seek justification of its decisions. Such examples include: • Patient safety and quality developments/initiatives; • Changes to service configurations; • Development of the Clinical Services Strategy • Service Improvement and Efficiency Programme (SIEP); • Reconfiguration of the estate; • Financial performance; • Quality report. The Board of Directors and the Council of Governors ensure application and compliance with the NHS Foundation Trust Code of Governance. There is a requirement, within the Code of Governance, for a mechanism to be in place for the resolution of any disagreement between the Board of Directors and the Council of Governors. In the first instance, it is the responsibility of the Chairman, as leader of both forums to attempt to reach a consensus. Failing that, the next formal step would be for the Chairman to receive formal representation from the designated Lead Governor, who is currently Pat Upton, Elected Governor for Stockton, and seek to arrive at a mutually agreeable position. In 2015 – 16, the Trust has not needed to have recourse to such action. 3.1.2 Council of Governors The Council of Governors forms an integral part of the governance structure within the Trust and is the ‘voice’ of local people, setting the direction for the future of our services based on the views of members. The Governors are very committed to support and serve: the Trust; its members, both public and staff; patients and their carers. The Trust values the contribution of its Governors and the perspectives they bring to the Trust’s development of services. In particular, members of the Council of Governors have engaged with the Trust’s Staff, Patient Experience and Quality Standards monthly panels, these are described in section 5, and this enables Governors to meet staff, patients and carers, and assess the quality of the services the Trust delivers. The Council of Governors working group established to review the Quality Report, has provided a third party declaration and this has also been endorsed by the Council of Governors, and can be found in section 5.
45 Annual Report and Accounts 2015 – 2016
Chief operating officer/deputy chief executive presents at the council of governors. Role and Composition The Council of Governors comprises 34 Governors who represent the Trust’s public and staff constituencies and those stakeholder organisations who are entitled to appoint Governors under the terms of the Trust’s Constitution. This is as follows: • 11 public Governors from Stockton; • 6 public Governors from Hartlepool; • 1 public Governor from Sedgefield; • 3 public Governors from Easington; • 1 public Governor from other areas; • 6 Appointed members; • 6 Staff Governors. The Council of Governors has five Sub-committees, which are described on page 47. During 2015 – 16 the Trust continued to develop opportunities for Governors to meet on a more informal basis and have time to discuss any relevant topics/issues; three such meetings have occurred. The Governors also had the opportunity to regularly meet the Chairman in an informal setting. Elections – Public and Staff Governors Public and staff members are elected to the Council of Governors from the Trust’s membership. Governors for both public and staff are elected to office normally for three years and may seek re- election for up to a maximum of three further terms (nine years). Elections are held on an annual basis for Governors. However, some Governors may be elected for a shorter term of office, as they could be filling a vacancy arising from a resignation. The last round of elections were held in the autumn of 2015, and were conducted by Electoral Reform Services (ERS) ballot services who were satisfied they were held in accordance with good electoral practice and constitutional requirements. ERS managed the whole process, from seeking nominations from members, to producing the election sheets, receiving the votes and announcing the results. The Trust was required to fill the following vacancies at its elections to take effect from 1 December 2015: • 3 public Governors – Hartlepool; • 5 public Governors – Stockton; • 1 public Governor – Easington (vacancy unfilled); • 3 staff Governors. The outcomes of elections are detailed in the table below:
Date of Election Constituency Number of Votes Turnout % Number of Cast Eligible Voters 20 November 2015 Hartlepool 342 21.2% 1,614 46 20 November 2015 Stockton 611 23.8% 2,563 20 November 2015 Easington No Nomination Annual Report and Accounts 2015 – 2016 20 November 2015 Staff 119 2.3% 5,195
Meetings of the Council of Governors The Council of Governors meetings are public meetings, four were held during 2015 – 16. The meetings comprise a formal Council of Governor meeting in the morning, followed by a closed development session in the afternoon, both of which are also attended by the Board of Directors. The Trust values the contribution, experience and skills of the Governors and, in addition to the formal meetings, there are a number of Sub-committees which Governors engage in. Each of the Sub-committees is aligned to a specific director, reflecting the applicable spheres of interest and where possible, the Governors sought to canvass views from representative members of their constituency. These focus on specific areas: Strategy and Service Development Committee – its aim is to advise on the direction of the Trust, and to receive, review and update information relating to: patient treatment pathways; service performance; compliance; patient experience, involvement and environment; Membership Strategy Committee – its aim is to raise awareness of the Trust, to enable greater engagement with current members and also develop and implement a strategy to increase the membership of patients and carers to the Trust; Travel and Transport Group – its aim being to draft and implement a travel and transport strategy for the Trust; External Audit Working Group – its aim being to appoint and/or remove the external auditors of the Trust. The Council of Governors has the statutory responsibility for the appointment of the external auditors. The external audit service was last tendered during 2010 – 11; the outcome being an initial three year contract from the financial year 2011 – 12, with a further two year extension of the arrangement, up until the audit and completion of the 2015 – 16 accounts. The External Audit Working Group met in February 2016 to commence the process to appoint external auditors for the financial year 2016 – 17, with a tendering exercise and process agreed to secure services going forward. This process will be concluded early in 2016 – 17, with a recommendation being presented to the Council of Governors for formal ratification. Nominations Committee The Nominations Committee is responsible for the recruitment, appointment, retention and removal of the Chairman and Non-Executive Directors, including matters of remuneration and conditions of appointment. The Committee has oversight of the appraisal system for the Chairman and Non-Executive Directors. During 2015, the Nominations Committee, approved by the Council of Governors, agreed to extend the term of office of Rita Taylor, Non-Executive Director/Senior Independent Director for the period of one year, whose tenure would otherwise have ceased in December 2015, and to approve a further 3 year term of office for the Chairman, Paul Garvin, commencing on 1 November 2015. In line with their statutory duties, the Council of Governors is responsible for appointment of Non- Executive Directors, and the Nominations Committee, oversaw the shortlisting, interviewing and appointment process for two new Non-Executive Directors. A recommendation was made to the Council of Governors meeting in July 2015 that Jonathan Erskine and Kevin Robinson be appointed with effect from 1 August 2015 for a term of office of 3 years. The Senior Independent Director led the appraisal review of the Chairman; this was achieved by asking all members of the Council of Governors and Board Directors to complete a questionnaire relating to the Chairman’s performance. The results were assessed with the outcome being reported to the Nominations Committee, who subsequently took their decision to the Council of Governors for ratification. The Senior Independent Director shared the analysis of responses with the Chairman and agreed any actions. There were no increases to the Chairman’s or Non-Executive Directors’ remuneration or allowances in 2015 – 16.
Name Total Number of Meetings Attended Total Number of Meetings Held 47 Paul Garvin 3 3
Tom Lennard 2 3 Annual Report and Accounts 2015 – 2016 Pat Upton 3 3 Tony Horrocks 3 3 Maureen Rogers 1 3 Wendy Gill 2 3 Carol Alexander 2 3 Barbara Bright1 2 3
1 Attends to advise the Committee Who’s Who – Council of Governors
Public Constituency Appointment Year Total Total Member of Governors term number number Committee of of of (see key) office meetings meetings ends attended held Beverley Hartlepool 3 years from 2014 2017 0 1 Hart1 Roger Hartlepool 2 years from 2007 2015 2 3 TTG, MSC Morrow2 re-elected for 3 years 2009 & 2012 Chander Hartlepool 3 years from 2012 2015 1 3 SSDC Parkash3 Pauline Hartlepool 3 years from 2013 2016 3 4 MSC Robson Maureen Hartlepool 1 year from 2007 2017 3 4 NC, MSC Rogers re-elected for 3 years 2008, 2011 & 2014 Thomas Sant Hartlepool 3 years from 2010 2016 3 4 SSDC, TTG re-elected for 3 years 2013 Alan Smith Hartlepool 3 years from 2015 2018 1 1 SSDC George Lee Hartlepool 3 years from 2015 2018 1 1 TTG Roger Hartlepool 3 years from 2015 2018 1 1 EAWG Campbell Janet Atkins Stockton 3 years from 2009 2018 4 4 SSDC, re-elected for EAWG, MSC 3 years 2012 & 2015 Ann Cains Stockton 3 years from 2011 2017 4 4 MSC, TTG re-elected for 3 years 2014 Chris Stockton 3 years from 2012 2015 2 3 SSDC, EAWG Clough4 Margaret Stockton 3 years from 2013 2016 2 4 SSDC Docherty Carol Ellis5 Stockton 3 years from 2010 2016 1 2 MSC re-elected for 3 years 2013 Mark White Stockton 3 years from 2015 2018 0 1 SSDC, EAWG 48 Val Scollen Stockton 1 year from 2015 2016 1 1 MSC Tony Stockton 3 years from 2014 2017 4 4 SSDC, NC Horrocks Annual Report and Accounts 2015 – 2016 Mary Stockton 3 years from 2007 2016 3 4 SSDC, MSC Morgan re-elected for 3 years 2010 & 2013 James Stockton 2 years from 2007 2018 3 4 SSDC Newton re-elected for 3 years 2009, 2012 & 2015 John Stockton 3 years from 2014 2017 4 4 SSDC Edwards Pat Upton Stockton 1 year from 2007 2017 4 4 SSDC, NC, re-elected for 3 EAWG years 2008, 2011 & 2014 Public Constituency Appointment Year Total Total Member of Governors term number number Committee of of of (see key) office meetings meetings ends attended held Kate Wilson Stockton 3 years from 2009 2018 4 4 SSDC re-elected for 3 years 2012 & 2015 Mary King Easington 3 years from 2010 2016 3 4 MSC re-elected for 3 years 2013 Denise Easington 1 year from 2011 2015 1 1 SSDC Rowland re-elected for 3 MBE6 years 2012 Keith Blakey Easington 3 years from 2014 2017 3 4 SSDC, EAWG Wendy Gill Sedgefield 3 years from 2010 2016 4 4 SSDC, MSC, re-elected for 3 NC, EAWG years 2013 Alison Non-core 3 years from 2014 2017 3 4 SSDC, MSC McDonough public
Staff Representing Appointment Year Total Total Member of Governors term number number Committee of of of (see key) office meetings meetings ends attended held Carol Staff 3 years from 2011 2017 4 4 MSC, NC Alexander Re-elected for 3 years 2014 Nina Staff 1 year from 2011 2015 0 0 MSC Bedding7 re-elected for 3 years 2012 Deborah Staff 3 years from 2010 2016 3 4 - Gardner re-elected for 3 years 2013 Manuf Staff 3 years from 2012 2018 2 4 - Kassem re-elected for 3 years 2015 Matthew Staff 2 years from 2011 2016 3 4 TTG Wynne re-elected for 3 years 2013 Gary Wright Staff 2 years from 2015 2017 1 1 SSDC Steven Yull Staff 3 years from 2015 2018 1 1 SSDC 49 Annual Report and Accounts 2015 – 2016 Appointed Representing Total Total Member of Members number of number of Committee meetings meetings (see key) attended held Jim Beall Stockton-on-Tees Borough Council 2 4 - Gerard Hall Hartlepool Borough Council 0 4 - Morris Nicholls Durham County Council 1 4 - Simon Forrest8 University of Durham 1 2 - Tom Lennard University of Newcastle Upon Tyne 0 4 SSDC, NC Liz Holey9 University of Teesside 1 2 Angela Warnes10 University of Teesside 0 1 NC
The cost of Council of Governors meetings and expenses, including travel and subsistence, for 2015 – 16 were £6296.21
Key: EAWG – External Audit Working Group 1 – Beverley Hart resigned on 12 June 2015 MSC – Membership Strategy Committee 2 – Roger Morrow, appointment ended 30 November 2015 NC – Nominations Committee 3 – Chander Parkash appointment ended 30 November 2015 SSDC – Strategy and Service Development Committee 4 – Chris Clough, appointment ended 30 November 2015 TTG – Travel and Transport Group 5 – Carol Ellis resigned on 26 August 2015 6 – Denise Rowland resigned on 2 July 2015 7 – Nina Bedding resigned on 1 February 2015 8 – Dr Simon Forrest appointment from 31 July 2015 9 – Professor Liz Holey appointment ended 31 August 2015 10 – Angela Warnes appointment from 18 December 2015 Register of Interests – Governors A register of Governors’ interests that may conflict with their responsibilities at the Trust is maintained and available for inspection by members of the public. If anyone wishes to inspect the Register they can view it by contacting: The Company Secretary, North Tees and Hartlepool NHS Foundation Trust, University Hospital of North Tees, Hardwick, Stockton, TS19 8PE or email: [email protected]. Membership of Our Trust Public and staff are invited to participate in NHS Foundation Trust status by becoming members. Membership brings the important benefits of being able to stand for and vote in the elections for our Governors. As the Trust continues to develop, members can expect to participate more fully 50 and help to shape the delivery of services. The Trust has some 11,057 members, which comprise of 5,855 public members and 5,202 staff members: Annual Report and Accounts 2015 – 2016 Constituency Number of Members Percentage of membership Hartlepool 1,650 28.2% Stockton 2,240 38.25% Easington 1,136 19.4% Sedgefield 553 9.45% Non-Core 276 4.7% Core Public members – are those aged 16 years and above that reside in the Trust’s core constituent areas of Hartlepool, Stockton-on-Tees, Peterlee, Easington and Sedgefield. Non-core Public members – these can be people aged 16 years and above who reside outside of the Trust’s core constituent areas, covering the whole of England. Staff members – employees of the Trust who hold an employment contract with the Trust of at least one year. In addition, staff who are based at the Trust but work for a partner organisation. Members that meet these requirements are automatic members within the staff constituency unless they choose to inform the Trust that they do not wish to be a member. This is outlined in detail within the Trust's constitution. The Trust met its target of maintaining approximately 6,000 members during 2015 – 16. The Trust's Membership Strategy provides for: engagement with members; opportunities to contact Governors; increasing and maintaining membership and ensuring it reflects the population it serves; communication with members (for example Anthem magazine) and providing benefits for members. Examples are provided below in relation to these strategic aims. Members are sent a copy of our Trust magazine ‘Anthem’, where we have produced a separate member’s page, which includes special notices, social media sites, and member events of which we held three during 2015 – 16. These events provide opportunities for members to receive and discuss information relating to our services, and included: • Nutrition and Hydration • Community Services including Community Integrated Assessment Team • Children’s Ear Nose and Throat Services • Adult Safeguarding
51
Member event. Annual Report and Accounts 2015 – 2016
The member events are also attended by our Governors, and provide an opportunity for members to raise any issues or ask questions. In addition, the Trust has continued its good practice of communicating with members by email, and enabling members to communicate with the Trust using this medium. Members can send emails to their elected Governor through the email account [email protected], emails sent to this address are passed on through the Trust’s private office, the contact address is provided in section 8, page 247. The Trust recognises the benefits members bring to the work and activity of the Trust, many of whom are volunteers and supporters. Members are provided with a membership card, which on presentation entitles them to the same benefits as staff for catering. It also enables them access to external discount facilities negotiated by the NHS. 3.1.3 Board of Directors The NHS Foundation Trust Code of Governance was published by Monitor and updated in 2014. It is based upon the combined Code of Corporate Governance and its purpose is to further the development of corporate governance in individual Foundation Trusts by making Governors and Directors aware of the principles of good governance and how to develop best practise in their applications.
Director of nursing Cath Siddle, ward matron Jane Corbey and chairman Paul Garvin celebrate nurses day.
The Trust is committed to high standards of corporate governance as set out in the NHS Foundation Trust Code of Governance and ensures compliance through the arrangements it puts in place for its governance structures, policies and processes and how it keeps them under review. These arrangements are set out in documents that include; the constitution; standing orders; standing financial instructions; schemes of delegation and decisions reserved to the Board of Directors; terms of reference of Board of Directors and Council of Governors’ Sub-committees; and codes of conduct. The Board of Directors is accountable nationally to the Foundation Trust independent regulator Monitor and to the health quality regulator, the Care Quality Commission, and locally to the Council of Governors and members. It has responsibility for ensuring compliance with the terms of authorisation, with mandatory guidance issued by Monitor, and with relevant statutory requirements and contractual obligations. The role of the Board of Directors is to exercise all powers when managing the Trust by providing effective and proactive leadership through setting the overall strategic direction of the Trust, 52 regular monitoring of performance against objectives, ensuring the integrity of financial control and planning, and the quality of patient care and safety through clinical governance. The Board will monitor any required action plans and/or improvements required to address performance issues in Annual Report and Accounts 2015 – 2016 order to ensure standards are achieved. The Board ensures it meets all its obligations as set out in the Code of Governance. The Board of Directors comprises: a Non-Executive Chairman, five Non-Executive Directors (NED), all of whom are independent; five voting Executive Directors and two non-voting Executive Directors. The general duty of the Board of Directors and of each director individually, is to act with a view to promoting the success of the Trust so as to maximise the benefits for the members as a whole and for the public. All directors have a responsibility to take decisions objectively in the interests of the NHS Foundation Trust and all members of the Board have joint responsibility for every decision regardless of their individual skills or status. Membership of the Board of Directors and biographical details of Board Members are displayed on pages 60-63. The Trust recognises the need for balance, completeness and appropriateness with regard to its Board Members and believes this is provided and shown in the Directors’ experience section pages 60-63. The test of independence for Non-Executive Directors is made both at interview and again annually at appraisal meetings. The Trust can confirm the full independence of the Chairman and Non- Executive Directors. The Chief Executive on behalf of all Board Directors can confirm that each Director has confirmed: • 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 steps to make themselves aware of any relevant audit information and ensured that the Trust’s auditor is aware of that information. The Trust Directors have taken all reasonable steps to ensure that the auditors have been provided with all information required and have executed reasonable care, skill and diligence. The Board of Directors can confirm, it has met the requirement of Section 43(2A) of the NHS Act 2006 (as amended by the Health and Social Care Act 2012) in that income from the provision of goods and services for the purposes of health services is greater than its income from the provision of goods and services for any other purposes. Income disclosures are included in notes 3 and 4 of the accounts. Internal Control The Board of Directors is responsible for the Trust’s system of internal control and for reviewing its effectiveness, which is designed to manage risk to achieve the Trust’s objectives. It provides reasonable but not absolute assurance against material misstatement or loss. The Board has established a process which is demonstrated in the Trust’s Risk Management Policy that covers identification, evaluation and management of significant risks the Trust may encounter. Further details of the Trust’s risk management process can be found within the Annual Governance Statement section 3.7, page 98. Development and Performance The Board recognises the benefits of development and taking the time to debate and discuss the impact of governance and legislation matters. A board development event was held in 2015 which enabled members of the Board to work as a collective entity in developing governance capability in preparation for the future challenges that face the Trust from both a national and local perspective. A rigorous evaluation of the Board’s performance and that of its Directors was also undertaken, following which a development plan for 2015 – 16 was produced. During 2015 – 16 all Board Directors had an appraisal and all Executive Directors had two appraisals; one relating to their board role which was undertaken jointly by the Chairman and Chief Executive, and a second relating to their operational role in the Trust by the Chief Executive. The Trust can confirm that there are no significant development gaps, and the plan produced enables on-going learning and improved practices for the Board and ultimately the Trust. The Board of Directors has an annual schedule of business which ensures it focuses on its responsibilities and the long-term strategic direction of the Trust. The Board held nine seminars, all of which provided the opportunity for detailed debate and discussion regarding Trust services and developments. The Board also held fourteen formal meetings during 2015 – 16 comprising six public and eight in Committee meetings. In addition, the Trust held one joint meeting with the Trust Directors Group and two joint meetings with the local Clinical Commissioning Groups (CCGs). The agendas and papers for the public meetings are published on the Trust’s website together with dates of future 53 meetings. Annual Report and Accounts 2015 – 2016 Board of Directors Attendance
Name Total No. of Total No. of Notes meetings attended meetings held Paul Garvin 14 14 Brian Dinsdale 12 14 Deputy Chair Rita Taylor 12 14 Senior Independent Director Stephen Hall 14 14 Kevin Robinson 10 10 Appointed 1 August 2015 Jonathan Erskine 10 10 Appointed 1 August 2015 Michael Bretherick 2 4 Left the Trust 31 May 2015 Alan Foster 12 14 Julie Gillon 14 14 David Emerton 14 14 Lynne Hodgson 14 14 Caroline Trevena 1 1 Appointed 15 February 2016 Cath Siddle 6 6 Julie Lane 8 8 Appointed 1 October 2015 Ann Burrell 14 14 Neil Atkinson 11 11 Left the Trust 13 February 2016 Barbara Bright 14 14
The Non-Executive Directors are appointed by the Governors for terms of office of three years, which can be renewed subject to satisfactory performance. The appointment and reviewing of performance is undertaken by the Nominations Committee. In the event that the Council of Governors felt the Chairman or a Non-Executive Director’s position was untenable and should be removed from position, the Trust would follow the provisions as set out in the Trust’s Constitution. The Nominations Committee would consider such situations and would make proposals to take to a general meeting of the Council of Governors of which 75% shall be in agreement. The performance evaluation of the Board, its activities and Committees is presented throughout this section, and assurance is provided in section 3.7, page 98. In addition, the Non-Executive Directors all undertake an annual appraisal, the outcomes of which are presented to the Nominations Committee.
54 Annual Report and Accounts 2015 – 2016
Stephen Hall talking about the Physicall system. Board Sub-Committees and Membership
Committee Name Membership In attendance Board In-Committee Paul Garvin (Chairman) including all members of the Board of Directors Remuneration Paul Garvin (Chair), Rita Taylor, Committee Michael Bretherick1, Stephen Hall, Kevin Robinson2 Audit Committee Brian Dinsdale (Chair), Stephen Hall, Lynne Hodgson/Janet Michael Bretherick1, Rita Taylor, Jonathan Erskine3 Alderton/Internal Audit/External Audit Finance Committee Brian Dinsdale (Chair), Michael Bretherick1, Steve Hall, Kevin Robinson2, Lynne Hodgson, Caroline Trevena Investment Committee Brian Dinsdale (Chair), Paul Garvin, Kevin Robinson2, Jonathan Erskine3, Lynne Hodgson, Caroline Trevena Charitable Funds Brian Dinsdale (Chair), Paul Garvin, Rita Taylor, Committee Jonathan Erskine3, Alan Foster, Lynne Hodgson Patient Safety and Rita Taylor (Chair)4, Stephen Hall5, Janet Alderton Quality Standards Kevin Robinson2, David Emerton, Cath Siddle, Committee Julie Lane Performance, Planning Kevin Robinson (Chair), Julie Gillon, Ann Burrell Lynne Taylor, Lynn and Compliance Kirby Committee Transformation Stephen Hall (Chair), Brian Dinsdale, Committee Jonathan Erskine, Alan Foster, Ann Burrell, Julie Gillon
1 Appointment on Committee ended 31 May 2015. 2 Appointment on Committee commenced 1 August 2015. 3 Appointment on Committee commenced 1 August 2015. 4 Appointment as Chair commenced 1 September 2015. 5 Appointment as Chair ended 31 August 2015. Trust Committee Structure Remuneration Committee The Remuneration Committee considers and approves the pay and allowances and other terms and conditions of service of the Chief Executive and Executive Directors. The Committee meets annually and the membership is reflected below, and it is chaired by the Trust’s Chairman. Name Total Number of meetings attended Total number of meetings held Paul Garvin 1 1 Rita Taylor 1 1 55 Michael Bretherick1 - -
Stephen Hall 1 1 Annual Report and Accounts 2015 – 2016 Kevin Robinson2 1 1 Barbara Bright Provided reports which the Remuneration Committee considered to enable decisions to be made
1 Appointment on Committee ended 31 May 2015 2 Appointment on Committee commenced 1 August 2015 The Committee took account of the overall performance of the Trust, and although recognised that all achievements had been met, due to the current economic climate and taking account of national pay restraints agreed that no cost of living pay awards or bonuses would be paid during 2015 – 16. Audit Committee The Audit Committee is authorised by the Board of Directors and provides the Board with an independent and objective review of financial and corporate governance risk management in the Trust. The Chair is Brian Dinsdale who is a chartered accountant. The Committee provides independent assurance for external and internal audit, ensuring the standards are set and compliance is monitored for all financial, non-financial and non-clinical areas, and activities of the Trust. The Audit Committee receives its assurance on clinical risk through the interface provided by the responsible Non-Executive Director on the Patient Safety and Quality Standards Committee and independent assurance carried out by internal audit. Stephen Hall and from 1 August 2015, Rita Taylor, provides a report to the Audit Committee summarising the business of the Patient Safety and Quality Standards Committee to ensure the Audit Committee is sighted on potential risks and the actions being taken to mitigate these. The Audit Committee investigates any activity within its terms of reference and seeks information, as required, from any member of staff of the Trust. In discharging these responsibilities the Committee approves internal and external audit work plans, their final reports and seeks assurance from the Trust that outcomes were implemented. The Audit Committee met five times during the year to assess and critically review the key risks facing the Trust and to ensure that the key financial controls were in place and operating effectively. The Assistant Director of Clinical Governance attended meetings and briefed members on significant corporate risks and the overall level of risk, including mitigating actions, from the risk register. These include operational, clinical and financial risks. Internal audit progress reports were reviewed at meetings throughout the year, with a focus on any high level recommendations. Directors and managers attended meetings to provide assurance, as required. Update reports were received from the local counter fraud service throughout the year. The Audit Committee has regularly reviewed the losses and compensation report, statement of debtors over three months old and £5,000 and single tender actions. These documents in conjunction with assurance from internal and external audit enable the Audit Committee to ascertain that key financial controls are in place and are operating effectively. The Audit Committee reviewed significant risks in year which have included: • Management override of controls; • Fraud in revenue recognition; • Valuation of property, plant and equipment; • Going concern – financial standing. These have been considered through the presentation of the external audit plan and discussions with our external auditors, PricewaterhouseCoopers LLP and have been included in the Audit Report on page 230. Documents presented included the annual plans for external audit, internal audit and the local counter fraud service, annual reports for internal audit and the local counter fraud service, annual quality account 2014 – 15, external assurance on the quality report 2014 – 15, annual accounts for 2014 – 15, external audit report on the 2015 audit, Trust annual report and accounts and the 56 annual governance statement. The board assurance framework and the compliance report to Monitor were presented quarterly.
Annual Report and Accounts 2015 – 2016 The Audit Committee reviewed the terms of reference and the following additional reports were presented: • Annual assessment of effectiveness of internal • Anti-fraud policy; audit; • Report on findings of other significant • Overdue policies; assurance functions for the Trust’s financial ledger; • IM & T Strategy Group minutes; • Assurance framework benchmarking report • Review of the statement of Trust compliance 2015; policies; • Review of external audit performance; • Payment of tariff external assurance report; • Protocol for liaison between internal and • Report relating to gifts and hospitality; external audit. • Audit Committee self and peer assessment; Name Total Number of meetings attended Total number of meetings held Brian Dinsdale (Chair) 5 5 Stephen Hall 3 5 Michael Bretherick1 1 1 Rita Taylor 3 5 Jonathan Erskine2 2 2
1 Appointment on Committee ended 31 May 2015 2 Appointment on Committee commenced 1 August 2015 Finance Committee The Finance Committee ensures that the Trust’s resources are managed efficiently and effectively. The Finance Committee met eight times during the year to review the financial affairs of the Trust; the long term financial strategy; granular level-directorate cost improvement action plans; fundamental business appraisal project and the monthly finance report to the Board of Directors, with attendance by senior managers to inform and provide assurance in relation to financial control. Draft revenue and capital budgets for 2016 – 17 were reviewed and evaluated by the Finance Committee. The going concern report was received and agreed by the Finance Committee. Progress against the Service Improvement and Efficiency Programme (SIEP) was reported at each meeting and a detailed financial forecast was presented. The forecast was used to agree control totals with the directorates to ensure the organisation would deliver the financial target agreed with Monitor. The minutes of the SIEP Board were received by the Committee. Investment Committee The Investment Committee met once during the year to consider the loan agreement to Optimus Health Ltd and consider other feasibility studies from Optimus Health Ltd. Charitable Funds Committee The Charitable Funds Committee met twice during the year to monitor arrangements for the control and management of the Trust’s charitable funds and to make decisions involving the sound investment of charitable funds in a way that both preserved their capital value and produced a proper return, consistent with cautious and sensible investment. The charitable funds accounts were approved and were submitted to the Charity Commission. The Committee has also monitored the consolidation of smaller restricted funds to better utilise donated funds in furtherance of the aims of the Charity. The Charitable Funds Committee have agreed actions in relation to increasing appropriate fundraising and a number of activities have commenced in year. The Charitable Funds Committee considered the recommendations from the Savile Inquiry and how this would be monitored going forward. Patient Safety and Quality Standards Committee The Patient Safety and Quality Standards Committee, is a statutory Sub-committee of the Board of Directors and focuses on gaining assurance in relation to quality and safety throughout the Trust to ensure they are of the highest possible standard. 57 The Committee meets on a monthly basis and is chaired by a Non-Executive Director. The quorum of the Committee also requires at least one Director and two clinicians to be in attendance. Over Annual Report and Accounts 2015 – 2016 the last year the agenda of the Committee has been adapted to reflect the domains of the Care Quality Commission: • Are services safe? • Are services responsive to the needs of our patients? • Are services caring? • Are services effective? • Are services well-led? The Committee minutes are received by the Board of Directors and a quarterly summary of activity is provided to the Audit Committee. When necessary, where there are concerns identified, these are escalated to the Board of Directors for appropriate action by the chairperson or an alternative Director. Regular reports are requested by the Committee across a wide range of services in order to gain assurance in relation to quality, safety, governance and risk management activity. The Committee receives such reports, not only to challenge and question, but also to provide support to staff and clinical teams in the delivery of safe, patient-centred, high quality care. External reports from national bodies, as a result of peer reviews or inspections are reviewed by the relevant department, with recommendations and actions implemented as required by the Trust. The Committee are provided with an analysis of any gaps identified where services may need to be reviewed in order to maintain safety and quality. Updates in relation to progress and evaluation of changes are received within agreed timescales following this. The Committee is responsible for overseeing the investigation of serious incidents and details of these investigations are reported on a monthly basis. The Director of Nursing, Patient Safety and Quality and Medical Director provide an overview of lessons learned and actions taken as a result. Evidence from clinical staff, in relation to gaining positive assurance of improvements following serious incidents, is regularly requested for presentation to the Committee. In order to ensure an active governance structure covering Ward to Board the Committee receives the minutes of a number of operational Committees and groups across a wide range of spectrums. Each of these are provided to the Committee members with a short summary of key points, identifying areas of good practice and also any areas of concern that need to be considered by the members for further action and support. This also allows members of the Committee to request details for any areas in the minutes for clarity or further action. In order to ensure all agreed actions are addressed and completed the Committee have, this year, introduced a forward programme of work that includes target timescales for agreed actions. This programme is updated following each meeting and shared across all departments. Performance, Planning and Compliance Committee The Board of Directors established the Performance, Planning and Compliance Committee in 2015 – 16 in line with the Trust’s strategic aim ‘Maintain Compliance and Performance’. The Committee is chaired by a Non-Executive Director and has representation from key stakeholders in the Trust. It takes responsibility to oversee the delivery of the Trust’s performance on a regular basis, with the aim to provide assurance to the Board of Directors that the governance processes are in place to deliver on-going compliance against the key regulatory standards and service performance standards including operational efficiencies. During the course of the year, the Committee requested reports and positive assurance from Assistant/Associate Directors and Managers on the overall arrangements for governance, risk management and internal control of performance standards and planning objectives. In addition, the Committee reviewed the work of other groups within the Trust whose work can provide relevant assurance to the Performance, Planning and Compliance Committee. These included the Cancer Strategy Group, Internal Emergency Care Collaborative and Business Performance, Planning and Delivery Group. Transformation Committee The Transformation Committee was established in 2015 – 16 by the Board of Directors to support the Trust's Assurance Framework through the establishment, monitoring and delivery of the transformation programme. The Committee, chaired by a Non–Executive director provides assurance that initiatives that have been implemented, are being achieved in line with plan and that any proposed initiatives are implemented and have robust deliverable plans in place. In respect 58 of monitoring progress, the Committee provides guidance on priorities and will have responsibility for providing all the necessary Executive support to ensure the transformation programme
Annual Report and Accounts 2015 – 2016 succeeds. During the course of the year, the Committee monitored the development and delivery of the transformation programme; monitored actual performance and implementation of the transformation agenda; monitored and sought assurance on the financial performance of programmes; reviewed risks and actions in place to manage those risks and reported regularly to the Board of Directors. Executive Team The Executive Team consists of the Executive Directors, the Company Secretary, and the Associate Director of Estates and Facilities. Other senior managers are invited to the meetings as and when required. Meetings are held on a weekly basis throughout the year. The role of the Executive Team is to monitor the management of risk, which includes the agreement of any action plans or resources and reviews, and agree detailed business plans and performance contracts. The Team contributes to the development of the Trust’s corporate and operational strategy and monitors the delivery of both, including financial objectives. It also develops and monitors the implementation of plans to improve the efficiency, effectiveness and equality of the Trust’s services. Trust Directors Group The Trust Directors Group’s membership includes members of the Executive Team, Clinical Directors, and Associate Medical Directors. The Group discuss Trust and clinical developments and have responsibility towards the achievement of corporate objectives identified by the Board of Directors. Register of Interests – Board of Directors A Register of Directors’ Interests that may conflict with their responsibilities at the Trust is maintained and available for inspection by members of the public. If anyone would like to inspect the Register they can view it on the Trust’s website: www.nth.nhs.uk or by contacting the: Company Secretary, North Tees and Hartlepool NHS Foundation Trust, University Hospital of North Tees, Hardwick, Stockton, TS19 8PE or email: [email protected].
59 Annual Report and Accounts 2015 – 2016 Director of human resources and education Ann Burrell joins a huddle on ward 25 Board of Directors – Who's Who 1. Paul Garvin QPM, DL, Chairman Appointed as Chairman from 1 November 2009, Acting Chairman from 26 November 2008. Appointed as Non-Executive Director on 1 January 2006. Term of office as Chairman concludes on 31 October 2018. Current commitments include: Deputy Lord Lieutenant for County Durham, Chair Durham Association of Clubs for Young People. Former positions: Chief Constable of Durham Constabulary, Chair County Durham Strategic Partnership, Chair Victim Support County Durham, Non-Executive Director Police Information Technology Organisation (NDPB), Member Home Office Police Appeals Tribunals...... 2. Brian Dinsdale OBE, Non-Executive Director/Deputy Chairman Appointed 30 November 2007, Deputy Chairman from 9 March 2010. Term of office as NED until 30 November 2017. Current commitments include: Chair of The Erimus Housing Association, Board Member of the Thirteen Housing Group. Former positions: Chief Executive for Hartlepool Borough Council from 1988, Chief Executive for Hartlepool (unitary) Council from 1996, Chief Executive for Middlesbrough Council from 2003, Efficiency Adviser for ‘Office of Government Commerce’ 2005 – 2007, Four interim Chief Executive positions for other Councils throughout UK 2006 – 2011, Chief Executive of Yorkshire Purchasing Organisations 2009, Former Non-Executive Director of Government North East and Clerk to Cleveland Fire Authority, Member of Chartered Institute of Public Finance and Accountancy, Bachelor of Arts – Social Sciences...... 3. Rita Taylor, Non-Executive Director/Senior Independent Director Appointed 1 January 2006. Term of office until 31 December 2016. Former positions: Chair of Mordon Parish Council, Non-Executive Director of Durham and Tees Valley Strategic Health Authority, Sedgefield Town Councillor 26 years, 60 Head of Darlington Youth Offending Service, Former teacher in Durham and Tees schools, colleges and prison service.
Annual Report and Accounts 2015 – 2016 ...... 4. Stephen Hall JP, Non-Executive Director Appointed 1 March 2007. Term of office until 1 March 2017. Current commitments include: Justice of the Peace (JP), Director of Optimus, Business Advisor, School Governor. Former positions: Director within the Compass Group and Managing Director Hallmark Catering Management, Fellow of Royal Society of Public Health (FRSPH)...... 5. Michael Bretherick, Non-Executive Director Appointed 1 August 2010. Term of office until 31 July 2016* Current commitments included: Non-Executive Director, Gus Robinson Developments Ltd, Chief Executive, Gus Robinson Foundation, Member, Extol Academy, Hartlepool. Former Positions: Principal and Chief Executive, Hartlepool College of Further Education, Senior roles in Further Education. *Resigned with effect 31 May 2015...... 6. Jonathan Erskine, Non-Executive Director Appointed 1 August 2015. Term of office until 31 July 2018. Current commitments include: Research Fellow, Centre for Public Policy and Health, School of Medicine, Pharmacy and Health, Durham University, Executive Director, European Health Property Network, Governor, Governing Body of the Links Primary School, Stockton-on-Tees. Former Positions: Research Associate, Centre for Public Policy and Health, School of Medicine, Pharmacy and Health, Durham University, Research Associate, Centre for Clinical Management Development, School of Medicine, Pharmacy and Health, Durham University, Voluntary work with the Citizen’s Advice Bureau/Alzheimer’s Society, Director of Information Technology, Escolas Cambridge Lda, Portugal...... 7. Kevin Robinson, Non-Executive Director Appointed 1 August 2015. Term of office until 31 July 2018. Current commitments include: Trustee of Abbeyfield supported housing Darlington, Member of the Darlington Rotary Club Former Positions: Chief Executive and Board Chair of Cumbria and Lancashire Community Rehabilitation Company, Carlisle. Chief Executive of Lancashire Probation Trust, Preston. Director of Partnership and Development, Northumbria Probation Trust. National Performance Improvement Manger for National Offender Management Service. Senior roles within the Probation Service including Northamptonshire, North Yorkshire and Teesside. 61 ......
8. Alan Foster MBE, Chief Executive Annual Report and Accounts 2015 – 2016 Date of commencement as Chief Executive 1 April 2007. Current commitments include: Honorary Colonel 201 Field Hospital (Volunteers). Former positions: NHS and Strategic Health Authority positions as Director of Finance and first Chief Executive of a Foundation Trust to integrate Acute and Community Services. Member of the Chartered Institute of Public Finance and Accountancy. Awarded an MBE in January 2013 honours list...... 9. Julie Gillon, Chief Operating Officer/Deputy Chief Executive Extensive NHS experience at regional and acute level. Lead on a range of complex portfolios, which have included: compliance; quality; governance; strategy; financial and operational performance. Former positions: Held a range of nursing and senior management positions including Registered General Nurse; Senior Sister; Senior Nurse; Assistant Director and Head of Strategic Planning. Registered Nurse, Diploma in Nursing Practice, BSc Nursing; MSc Research & Statistics, Post Graduate Certificate in NHS Management. Date of commencement 10 June 2008...... 10. Lynne Hodgson, Director of Finance, ICT and Support Services* Extensive experience in NHS finance from both a provider and commissioning perspective and has worked at Board level within the NHS since April 2007 at both Gateshead NHS FT, and NHS North of Tyne. Current commitments include: Member of the Chartered Institute of Management Accountants. Date of commencement 26 March 2012. * Resigned with effect from 30 April 2016...... 11. David Emerton, Medical Director Appointed to Medical Director position on 15 February 2010. Consultant in Accident and Emergency. Former positions: Clinical Director in Accident and Emergency, Associate Medical Director for Clinical Governance. MBChB (LEEDS), D.R.C.O.G, F.R.C.S. (Glasg), F.R.C.S, Ed (A & E), F.C.E.M...... 12. Cath Siddle, Director of Nursing, Patient Safety and Quality Extensive NHS experience of nursing with a strong background in clinical nursing. Has led a number of innovations to improve patient care through lean working. Has worked at local and regional level in accrediting centres of nursing excellence and sat on several national working groups on complaints handling, nurse staffing and workload management. Has sat as Vice-Chair of Cleveland Nursing Forum. Was instrumental in developing the Trust’s workload methodology. 62 Former positions: Deputy Director of Nursing, Lead Nurse in the Directorate of Medicine and
Annual Report and Accounts 2015 – 2016 Specialty General Manager within the Trust and its predecessor. MSc in Health Sciences (Nursing); BSc(Hons) in Nursing; Diploma in Nursing Services; RN. Date of commencement 5 November 2013...... 13. Ann Burrell, Director of Human Resources and Education Extensive experience in human resource management, organisational design and development in both public and private sectors. Has worked at Board level in private sector. Former positions: Director of Human Resources at: Department of Work and Pensions; Child Support Agency; Moores Furniture Group and held other senior positions in the private sector. Chartered Member of the Chartered Institute of Personnel and Development (CIPD). Date of commencement 10 March 2014...... 14. Neil Atkinson, Transformation Change Director* Extensive NHS experience across a range of finance functions. Member of the Chartered Institute of Public Finance and Accountancy. Former positions: Deputy Director of Finance and Information and other senior finance positions in the NHS Date of commencement 1 January 2015. * Resigned with effect from 13 February 2016...... 15. Julie Lane, Acting Director of Nursing, Patient Safety & Quality Experienced Nurse and Midwife having held a number of clinical and senior nurse posts. Led implementation of IT systems in clinical practice in a previous organisation prior to attaining General Manager role and latterly Deputy Director of Nursing role at the Trust. Former positions: Deputy Director of Nursing, Quality and Clinical Governance, General Manager – Women’s and Children’s Services, Senior Nurse - City Hospitals Sunderland, Midwifery Core Team Leader - City Hospitals Sunderland. BSc(Hons); Advanced Diploma in Midwifery, PGD in Transformational Leadership, Registered Nurse. Date of commencement 1 October 2015...... 16. Caroline Trevena, Acting Director of Finance and Procurement Held a range of senior finance roles across the health sector, working at regional and local level in Foundation Trusts, NHS Trusts, acute hospital in Australia, PCTS and Strategic Health Authorities. Experience includes working with Trusts in turnaround, merging and de-merging provider organisations and performance management of NHS organisations. 63 Former Positions:
Deputy Director of Finance at North Tees and Hartlepool NHS Foundation Trust Annual Report and Accounts 2015 – 2016 Deputy Director of Finance at Lewisham and Greenwich NHS Trust Chartered Management Accountant (ACMA) MBA (Durham). Date of commencement 15 February 2016......
Annual Report and Accounts 2015 – 2016 64 3.2 Remuneration Report
This report sets out the salaries, allowances and pension entitlements of the Chief Executive and Executive Directors (senior managers) of the Trust. In addition, the remuneration and expenses of the Chairman and Non-Executive Directors will also be presented. For the purposes of this report those persons in senior positions have authority or responsibility for directing or controlling the major activities of the Trust. 3.2.1 Annual Statement on remuneration The following information is the unaudited part of the Remuneration Report. The process the Trust uses for assessing performance of its Chief Executive and Executive Directors is determined by the Remuneration Committee and is reviewed annually to ensure it is fit for purpose and meets current good practice for Board Directors. The Trust's policy on pay is that it will, for all staff groups, endorse any national proposals for pay, subject to the Trust being able to afford to pay any changes/increases. The Trust, for its Directors and Chief Executive, recognises the need to pay in the upper quartile to ensure it both attracts and retains staff as it proceeds with its development of the Clinical Services Strategy and transformational change agenda. Due regard is also given to the diversity and complexity of the roles undertaken by the Directors when reviewing and benchmarking pay against comparators. Any pay changes/increases will always be subject to formal review of both the individual Directors performance and also the Trust's performance, taking cognisance of the national framework for pay. The Remuneration Committee consider the key business objectives as set out in the Trust’s Corporate Strategy and business objectives allocated to each Executive Director through the appraisal process, and receive a report of the individual's progress against those objectives. Performance is closely monitored and discussed through both an annual and on-going appraisal process. All senior managers’ remuneration is subject to satisfactory performance. The Chief Executive takes the lead on the evaluation of Directors and the Chairman takes the lead on the Chief Executive’s performance. During 2015 – 16 the Chief Executive and Chairman continued to hold joint appraisals with each Executive Director in relation to their Board role, and the Chief Executive held a separate appraisal in relation to the Executive Director’s operational role. On an individual basis targets are set against the Trust’s strategy and aligned to Directors by a number of agreed objectives at appraisal meetings. The Remuneration Committee always consider the pay and terms and conditions of service of all Trust employees when making any decisions relating to the Executive Directors’ pay and conditions, and reference pay surveys conducted by Income Data Services (IDS) and NHS Providers, as well as a local survey conducted between North East Trusts. The Trust Chairman was re-appointed to a further 3 year term of office by the Nomination Committee in 2015 – 16 and one of the Non-Executive Directors was re-appointed to a further 1 year term of office. Following the resignation of two Non-Executive Directors, recruitment was undertaken in 2015 – 16 in accordance with the NHS Foundation Trust Code of Governance and the Trust Constitution with appointments made from 1 August 2015. A number of changes at Executive Director level took place during 2015 – 16, in February 2016, the Transformation Change Director was successful in gaining a post with Leeds Teaching Hospital NHS Trust, the Director of HR and Education has assumed responsibility for the function of Transformation. The Director of Finance, ICT and Support Services was successful in gaining a post with the North East Ambulance Service and will leave the Trust on 30 April 2016, in the interim and 65 to support a transitional period, an Acting Director of Finance was appointed from February 2016. The Medical Director will be stepping down from his role and returning to clinical practice in 2016, Annual Report and Accounts 2015 – 2016 as a statutory position of the Board of Directors, a replacement has been appointed who will take up position formally in June 2016, although is working in a transitional capacity at present. The Remuneration Committee reviewed the post of the Company Secretary in 2015 – 16 with agreement that the post would be brought in line with other very senior managers in the Trust with the contractual status changing from agenda for change terms and conditions to a director (VSM) contract and remuneration on a spot salary. 3.2.2 Senior managers’ remuneration policy The Remuneration Committee considered its policies on remuneration and performance in order to satisfy itself that the level of remuneration paid above the threshold of £142,500 to some members of the senior team was justifiable and reasonable; given the diversity and complexity of portfolios, the Remuneration Committee confirmed that the salaries were appropriate. Given the current economic climate, the Remuneration Committee agreed there should be no cost of living rise for the Chief Executive or any Executive Director in 2015 – 16. Details of Directors’ remuneration and pension entitlements for the year ending 31 March 2016 are published in this Remuneration Report and the Annual Accounts section which is section 7, page 238. There have been no awards made to past senior managers. The dates of commencement of the Executive Directors in their current posts can be found in section 3.1.3, pages 60-63. This has been subject to audit review. There are no components to senior manager salaries other than those disclosed within the tables on pages 67-69 and no component of performance-related pay. Total remuneration includes salary, non – consolidated performance-related pay and benefits–in–kind. It does not include severance payments, employer pension contributions and the cash equivalent transfer value of pensions. The Medical Directors salary is in accordance with the terms and conditions of the National Health Service Consultant Contract plus a responsibility allowance payable for the duration of office. This has been subject to audit review. Expenses paid to directors in the year have been £10,755 (2014 – 15: £10,379), and for governors £631 (2014 – 15: £855). Expenses are in relation to travel and subsistence necessarily incurred in the performance of their duties in accordance with Trust policies and in compliance with HMRC regulations or other legislation. As at 31 March 2016 there are 14 (2014 – 15: 12) directors in office, and 11 (2014 – 15: 10) of these have received expenses in the 2015 – 16 year. As at 31 March 2016 there are 33 (2014 – 15: 31) governors in office, with 10 (2014 – 15: 8) of these having received reimbursement in the form of expenses. There have been no special contractual compensation provisions attached to the early termination of a senior manager’s contract of employment and there has been no payment for compensation for loss of office paid or receivable under the terms of an approved compensation scheme. Early termination by reason of redundancy is in accordance with the provision of the NHS redundancy arrangements and in accordance with the NHS pension scheme. Employees above the minimum retirement age that request termination by reason of early retirement are subject to the normal provisions of the NHS pension scheme. 3.2.3 Annual report on remuneration The Trust’s Remuneration Committee membership and roles are reflected in section 3.1.3, page 55, this Committee has responsibility for setting the salaries, allowances and terms and conditions for the Chief Executive and Executive Directors. The Trust’s Nomination Committee sets the remuneration and expenses for the Chairman and Non- Executive Directors. Details of the Nomination Committee can be found in section 3.1.2, page 47. The remuneration and expenses remained unchanged in 2015 – 16. Members of the Executive Team, with the exception of the Medical Director, are appointed on permanent contracts with a notice period of three months for them to serve and a period of six months for the Trust to serve. The Medical Director is appointed for a term of office of three years. The Trust is required to disclose the median remuneration of the Trust's staff and the ratio between this and the mid-point of the banded remuneration of the highest paid Director. The calculation is based on full-time equivalent staff of the reporting entity at the reporting year end date on an annual basis. The median remuneration of all Trust staff is £24,410 (2014 – 15: £23,684) and the ratio between this and the mid-point of the banded remuneration of the highest paid director is a ratio of 9.3 (2014 – 15: 9.6) to the highest paid Director being £225k – £230k (2014 – 15: £225K – £230K). In 2015 – 16, one employee (2014 – 15: nil) received remuneration in excess of the highest paid director, remuneration ranged from £255k – £260K (2014 – 15: n/a). This has been subject to 66 audit review. The only non-cash element of senior managers’ remuneration packages are pension-related benefits, Annual Report and Accounts 2015 – 2016 accrued under the NHS Pensions Scheme. Contributions are made by the Trust and the employee in accordance with the rules of the national scheme which applies to all NHS staff in the scheme. In the event of any matters of concern the Trust’s normal investigation and disciplinary policies apply to senior managers.
Alan Foster MBE Chief Executive 27 May 2016 This table has been subject to audit review.
To 31 March 2016 All Taxable Benefits
Name & Title (incl. performance related bonuses) related bonuses) Pension Related (incl. long-term Remuneration Remuneration Remuneration Salary & Fees performance Benefits Other Other Total
(bands of Rounded to (bands of (bands of (bands of (bands of £5,000) the nearest £5,000) £5,000) £2,500) £5,000) £000 £100 £000 £000 £000 £000 Mr Paul Garvin 50 - 55 - - - - 50 - 55 Chairman
Mr Alan Foster 225 - 230 - - - - 225 - 230 Chief Executive Ms Julie Ann Gillon Chief Operating Officer/Deputy Chief 145 - 150 7.4 - - 30 - 32.5 180 - 185 Executive
Ms Lynne Hodgson 145 - 150 0.8 - - 22.5 - 25 165 - 170 Director of Finance, ICT & Support Services
Mr David Glatton Charles Emerton 90 - 95 - 75 - 80 - - 170 - 175 Medical Director Mrs Catherine Siddle Director of Nursing, Patient Safety and 110 - 115 6.7 - - - 120 - 125 Quality
Mrs Ann Burrell 105 - 110 - - - 25 - 27.5 135 - 140 Director of Human Resource and Education
Mrs Barbara Bright 95 - 100 - - - 70 - 72.5 165 - 170 Company Secretary
Mr Neil Atkinson 100 - 105 3.6 - - 37.5 - 40 140 - 145 Transformation Change Director
Miss Caroline Trevena 10 - 15 - - - - 10 - 15 Acting Director of Finance Mrs Julie Lane Acting Director of Nursing, Patient Safety and 40 - 45 0.7 - - 45 - 47.5 90 - 95 Quality
Mr Stephen Hall 15 - 20 - - - - 15 - 20 Non-Executive
Mrs Rita Taylor 15 - 20 - - - - 15 - 20 Non-Executive
Mr Brian Dinsdale 15 - 20 - - - - 15 - 20 Non-Executive
Mr Michael Bretherick 0 - 5 - - - - 0 - 5 Non-Executive
Mr Jonathan Erskine 10 - 15 - - - - 10 - 15 Non-Executive 67 Mr Kevin Robinson 10 - 15 - - - 10 - 15 Non-Executive Annual Report and Accounts 2015 – 2016 NOTES: 1. All taxable benefits relate to cars and are expressed in £000's. The 7. Mr Kevin Robinson, Non Executive, joined the Trust on 1 August 2015. method of calculating benefits in kind is based upon HMRC guidance 8. Ms Julie Lane took up the post of Acting Director of Nursing, Patient and uses the CO2 emissions rate of the vehicle and the type of fuel Safety and Quality on 1 October 2015. used. 9. Ms Caroline Trevena took up the post of Acting Director of Finance 2. Remuneration in relation to the Medical Director includes payment on 15 February 2016. for clinical sessions as follows: Mr David Glatton Charles Emerton. 10. Mr Alan Foster, Chief Executive has not made contributions into the 3. The amount reported in salary and fees for Mr David Glatton Charles NHS pension scheme this financial year and has been entitled to claim Emerton relates purely to his basic pay and the other salary category pension in year. includes allowances in connection with medical duties. 2014/15 has 11. Mrs Catherine Siddle, Director of Nursing, Patient Safety and been restated on this basis. Quality has not made contributions into the NHS pension scheme this 4. Mr Neil Atkinson, Transformation Change Director left the Trust on financial year and has been entitled to claim pension in year. She has 13 February 2016. been absent due to sickness since 20 August 2015. 5. Mr Michael Bretherick, Non Executive, left the Trust on 31 May 12. Pension - Related Benefits have been calculated in line with the 2015. 2015 – 16 Monitor ARM guidance and have been determined in 6. Mr Jonathan Erskine, Non Executive, joined the Trust on 1 August accordance with the HMRC method of calculating less the amounts 2015. paid by employees. For comparison purposes the 2014 – 15 pension related benefits have been restated on the same basis. This table has been subject to audit review.
To 31 March 2015 (Restated for pension related benefits calculation) (incl. performance
Name & Title related bonuses) related bonuses) Pension Related (incl. long-term Remuneration Remuneration Remuneration Salary & Fees performance All Taxable Benefits Benefits Other Other Total
(bands of Rounded to (bands of (bands of (bands of (bands of £5,000) the nearest £5,000) £5,000) £2,500) £5,000) £000 £100 £000 £000 £000 £000 Mr Paul Garvin 50 - 55 - - - - 50 - 55 Chairman Mr Alan Foster 225 - 230 - - - - 225 - 230 Chief Executive Ms Julie Ann Gillon Chief Operating Officer/Deputy 140 - 145 6.1 0 - 5 - 5 - 7.5 155 - 160 Chief Executive Ms Lynne Hodgson Director of Finance, ICT & 140 - 145 - 5 - 10 - 102.5 - 105 250 - 255 Support Services Mr David Glatton Charles Emerton 100 - 105 - 95 - 100 - 30 - 32.5 230 - 235 Medical Director Mrs Catherine Siddle Director of Nursing, Patient 115 - 120 7.3 - - - 125 - 130 Safety and Quality Mrs Ann Burrell Director of Human Resource 105 - 110 - - - 20 - 22.5 130 - 135 and Education Mrs Barbara Bright 90 - 95 - - - - 90 - 95 Company Secretary Mr Neil Atkinson Transformation Change 25 - 30 1.1 - - 32.5 - 35 60 - 65 Director Mr Stephen Hall 15 - 20 - - - - 15 - 20 Non-Executive Mrs Rita Taylor 15 - 20 - - - - 15 - 20 Non-Executive Mr Brian Dinsdale 15 - 20 - - - - 15 - 20 Non-Executive Mr Michael Bretherick 10 - 15 - - - - 10 - 15 Non-Executive Mr Ken Lupton 5 - 10 - - - - 5 - 10 Non-Executive
NOTES: 1. All taxable benefits relate to cars and are expressed in £000's. The 4. Mr Neil Atkinson was appointed Transformation Change Director on 68 method of calculating benefits in kind is based upon HMRC guidance 1 January 2015. and uses the CO2 emissions rate of the vehicle and the type of fuel 5. Mr Ken Lupton, Non Executive, left the Trust on 31 October 2014. used. The figures shown, therefore, reflect the taxable benefit. 6. Mr Alan Foster, Chief Executive has not made contributions into the Annual Report and Accounts 2015 – 2016 2. Remuneration in relation to the Medical Director includes payment NHS pension scheme this financial year and has been entitled to claim for clinical sessions as follows: Mr David Glatton Charles Emerton. pension in year. 3. The amount reported in salary and fees for Mr David Glatton Charles 7. Mrs Catherine Siddle, Director of Nursing, Patient Safety and Quality Emerton relates purely to his basic pay and the other salary category has not made contributions into the NHS pension scheme this financial includes allowances in connection with medical duties. 2014/15 has year and has been entitled to claim pension in year. been restated on this basis. This table has been subject to audit review.
Salary and Pension Entitlements of Senior Managers - B) Pension Benefits Name & Title Real Total Cash Cash Real Increase Employers increase in accrued Equivalent Equivalent in Cash Contribution pension and pension and Transfer Transfer Equivalent to Stake- related lump related lump Value at 31 Value at 31 Transfer holder sum at age sum at age 60 March 2016 March 2015 Value Pension 60 at 31 March 2015 (bands of (bands of £000 £000 £000 0 £2,500) £5,000) £000 £000
Mr Alan Foster+ - - 1,718 1,718 - - Chief Executive Ms Julie Ann Gillon Chief Operating Officer/ 7.5 - 10 235 - 240 1,037 975 50 21 Deputy Chief Executive Ms. Lynne Hodgson Director of Finance, ICT & 10 - 12.5 230 - 235 1,046 973 62 21 Support Services Mr David Glatton Charles Emerton* - 220 - 225 - 1,359 - 13 Medical Director Mrs Catherine Siddle+ Director of Nursing, Patient ------Safety and Quality Mrs Ann Burrell Director of Human Resource 0 - 2.5 0 - 5 49 25 23 15 and Education Mrs Barbara Bright 10 - 12.5 130 - 135 577 511 59 14 Company Secretary Mr Neil Atkinson (left the Trust 13/02/2016) 2.5 - 5 80 - 85 336 304 29 14 Transformation Change Director Miss Caroline Trevena (from 15/02/2016) ------Acting Director of Finance Mrs Julie Ann Lane (from 01/10/2015) 7.5 - 10 115 - 120 542 - 46 5 Acting Director of Nursing, Patient Safety and Quality
As Non-Executive members do not receive pensionable remuneration, It takes account of the increase in accrued pension due to inflation there will be no entries in respect of pensions for Non-Executive and uses common market valuation factors for the start and end of the members. period. A Cash Equivalent Transfer Value (CETV) is the actuarially assessed On 16 March 2016, the Chancellor of the Exchequer announced capital value of the pension scheme benefits accrued by a member a change in the Superannuation Contributions Adjusted for Past at a particular point in time. The benefits valued are the member's Experience (SCAPE) discount rate from 3.0% to 2.8%. This rate affects accrued benefits and any contingent spouse's pension payable from the calculation of CETV figures in this report. Due to the lead time 69 the scheme. A CETV is a payment made by a pension scheme, or required to perform calculations and prepare annual reports, the arrangement to secure pension benefits in another pension scheme CETV figures quoted in this report for members of the NHS Pension or arrangement when the member leaves a scheme and chooses to scheme are based on the previous discount rate and have not been Annual Report and Accounts 2015 – 2016 transfer the benefits accrued in their former scheme. The pension recalculated. figures shown relate to the benefits that the individual has accrued as * Mr David Glatton Charles Emerton is over the Normal Retirement a consequence of their total membership of the pension scheme, not Age in the existing scheme and therefore a CETV calculation is not just their service in a senior capacity to which the disclosure applies. applicable and he no longer contributes to the scheme. The CETV figures, and from 2004-05 the other pension details, include + Mrs Catherine Siddle, Director of Nursing, Patient Safety & Quality the value of any pension benefits in another scheme or arrangement and Mr Alan Foster, Chief Executive have not made contributions into which the individual has transferred to the NHS pension scheme. They the NHS pension scheme this financial year and been entitled to claim also include any additional pension benefit accrued to the member as pension in year. a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines - Miss Caroline Trevena - Acting Director of Finance has not made and framework prescribed by the Institute and Faculty of Actuaries. contributions into the NHS pension scheme this financial year. Real Increase in CETV - This reflects the increase in CETV effectively The above tables form part of the audited statements. funded by the employer.
Chief Executive ...... Date: 27 May 2016 3.3 Staff Report
North Tees and Hartlepool NHS Foundation Trust is a vibrant and successful provider of hospital and community based health care services. It can only achieve this success with its most valuable and important resource, staff, the value of which cannot be over-emphasised. During 2015 – 16 the Directorate of Human Resources and Education aligned itself more closely to the corporate strategy, principally by putting workforce planning at the centre of what it does to ensure it has the right staff with the right skills in the right place at the right time. To this end we have strengthened the teams in workforce planning, resourcing, management information, education and organisation development. This integration of service will allow the Directorate to respond quickly and effectively to the requirements of service transformation and assist in the development and realisation of the 10 year strategy. 3.3.1 Commitment to Staff The Trust is committed to its staff and recognises that the organisation’s aspirations can only be delivered via its workforce. Day in day out our people provide excellent and compassionate care and this year staff have been under significant pressure due to much increased demand for services. The Trust prides itself on its people-focused approach and we place strong emphasis on engagement with our staff through a range of mechanisms that enable them to have a voice in the future development of the organisation. Harnessing the expertise and enthusiasm of our workforce is the key to success in achieving improvements in both our performance and the overall wellbeing of our staff, which, in turn, delivers excellent quality of care for our service users. The Trust is proud of the achievements of its staff which can be seen in the Awards and Accolades section of this report. The Trust recognises the need to attract, retain, reward and develop its current and future workforce. It provides substantial opportunities for staff to acquire the skills to do their jobs and, with its continuing leadership development programme, recognise the importance of leadership and management. The Trust’s appraisal and development processes are essential tools to both support and develop staff and it recognises that every member of staff should receive an annual appraisal. The Trust continues to perform well in mandatory training, achieving all our targets. During 2015 – 16 the Trust took part in the annual NHS Staff Survey. The results detailed in the report are used to inform improvements in working conditions and practices, provide evidence for self-assessments and sense check future development in those areas, and enable us to celebrate success in areas where the Trust has scored well. There are a number of events throughout the year where staff’s contribution to the Trust and their achievements can be recognised. Our Annual Shining Stars awards showcase the amazing achievements of the staff, whether as individuals or in teams. Following feedback from staff through a variety of engagement forums the Trust is to introduce a number of recognition schemes including employee of the month and recognising long service. The Trust recognises the need to reward staff for their contribution to making North Tees and Hartlepool NHS Foundation Trust an excellent place to receive care, delivering the Trust vision and people first values. The following pages reflect some of the achievements for our staff during 2015 – 16. 70 Awards and Accolades The Trust supports its staff in seeking both internal and external recognition for its excellent Annual Report and Accounts 2015 – 2016 work. The awards and accolades achieved in 2015 – 16 recognised the hard work, commitment and contribution staff make to enable North Tees and Hartlepool NHS Foundation Trust to be a successful provider of healthcare services. The Trust celebrates its ‘Shining Stars’ Awards The Trust held its fifth recognition event in 2015 – 16, the Shining Stars Awards, which enabled the Trust to recognise and acknowledge the staff and volunteers who go above and beyond the call of duty to help patients. The annual event allows staff, including volunteers, to be recognised by their colleagues for the contribution they have made to their work, and that of the Trust in putting patients at the forefront of everything we do. Ann Burrell Director of Human Resources and Education said: “Our philosophy of rewarding and recognising our staff is vital to ensuring that staff feel valued and supported in all they do. We want to ensure that quality, value and recognition are the themes which will run through all our activities to enable us to attract, retain, reward and develop our current and future staff. I would like to congratulate everyone who was nominated for an award. It’s great to have the opportunity to celebrate some of the excellent work and achievements in the Trust.”
All nominees of each category were put forward by staff and volunteers of the Trust. There were 12 awards and the winners are identified below: • Developing excellent services – Hospital Play Specialists • Learner of the year – Sarah Hodgson • Working behind the scenes – The Security Team and Point of Care Testing team (joint winners) • Student of the year – Karabo Willis • Unsung hero – Diane Jones • Healthcare worker of the year – Roger Barrett • Outstanding contribution to volunteering – David Charlton • Dedication to quality improvement – The nursing team, critical care • Working in partnership with other agencies – Senior nurses for practice placements • Leadership award – Gary Wright • Patient focused care – Paediatric nurse practitioners • Team of the year – The Portering Service The event was a great success, with very positive feedback from staff.
71 Annual Report and Accounts 2015 – 2016
Staff were recognised in the Trust’s annual Shining Stars Awards. Celebrating the best of health Congratulations to all of our staff who picked up awards or who were shortlisted at the Hartlepool Mail Best of Health awards. They were:
Midwife of the year – Hospital team of the year – Karen Pearson won the award with the Stockton Ward 4 (Elective Care) won the award with the community midwife team shortlisted. Nursing team, chemotherapy department, Main outpatient team, Day Case unit and Assisted Unsung hero award – reproduction unit all shortlisted. Community dental service won this award. Hospital doctor of the year – Pharmacist of the year – Anil Agarwal won the award with Manuf Kassem Peter Burrell who works with the chemotherapy and R W Dennis shortlisted. team won this award. Nurse of the year – Careworker of the year – Gill Roberts, infection control nurse, Craig McCarthy, physiotherapist PCH was won this award. shortlisted. Long term achievement award – Sue Moore, Senior Clinical Matron (Out of Hours) won this award. World-wide recognition for research doctors Research fellow Amit Chattree won the support of five international judges in a Dragon’s Den competition for his proposal to extend the regional network which supports health professionals looking after patients with complex polyps (growths in the bowel). Research fellow Ed Derbyshire was awarded funding for future research from United European Gastroenterology Week. Ed’s research was a national study into perforations of the bowel. He questioned health professionals from across the country to look at the outcomes for patients whose bowel had been accidentally damaged during a bowel examination.
72 Annual Report and Accounts 2015 – 2016 Fellowship award Professor Jane Metcalf was awarded fellowship of the Academy of Medical Educators (AoME).
Passed with flying colours A group of foundation doctors have passed with flying colours following an annual review of their progress. The foundation programme team carried out a week long annual review of competence progression (ARCP) process for 87 foundation doctors in the Trust.
During the review, the group consider whether the foundation doctors have met the requirements for satisfactory completion of F1 or F2 years. A 100% pass rate was achieved. Queen’s nurses honoured District nurses Moraig Orpen 73 and Debbie Royal received
Queen’s Nurse Awards for Annual Report and Accounts 2015 – 2016 their commitment to caring for patients in the community. Both attended a ceremony in London to be presented with awards for commitment to nursing and for work mentoring junior nurses. Shine a Light Awards Commendation Hospital mortuary manager nominated for top honour Clinical specialist speech and language therapist Susan Stewart was highly commended at an The Trust’s mortuary and bereavement service awards ceremony in London as part of her role manager Michelle Lancaster was announced as working in County Durham’s Youth Offending a finalist in the Good Funeral Awards. Michelle Service. Susan was singled out at the Shine was a finalist in the Mortuary Assistant (APT) a Light Awards for effectively responding to Team or Individual category, after being selected young people with speech, language and from hundreds of nominees to go through to communication needs. the final stages of this year’s awards ceremony at the University of Winchester.
Healthcare assistants’ vital role recognised A nationally recognised workbook for healthcare assistants and health support workers has been rolled out. The Care Certificate is a national initiative developed jointly by Skills for Care, Health Education England and Skills for Health. It follows a national independent government report into healthcare assistants and support workers in the NHS, known as the Cavendish Review. The review concluded the public image of these staff was out-dated and the levels of responsibility needed for this role has increased. Staff in the stroke unit at the University Hospital of North Tees were the first to take part, before it is reviewed and then rolled out across the Trust.
74 Annual Report and Accounts 2015 – 2016 Top awards for apprentices Talented young NHS estates apprentices from across the region were recognised for their efforts at the annual Northern and Yorkshire NHS Assessment Centre’s estates apprenticeship programme awards. All apprentices were presented with certificates, including several from the Trust.
Congratulations to graduates Critical care ward matron Sonya Wilkinson, organisation development lead Janet Varga and organisation development practitioner Louise Samuel who completed their masters MSc in service improvement at Teesside University.
Glowing student feedback for orthopaedic outpatients 75 Orthopaedic outpatients at the University Hospital of Hartlepool Annual Report and Accounts 2015 – 2016 were awarded with a certificate as an excellent practice placement by student nurses at Teesside University. Developing more leaders Another group of staff have completed the Trust’s leadership and management development programme. The programme, run in partnership with Teesside University, teaches staff a range of skills over a number of study days before finally taking part in a poster presentation to the Board of Directors and senior managers.
Wards score top marks after SPEQS visits The Staff and Patient Experience and Quality Standards panel (SPEQS) are held in different areas in hospital and community settings. Wards and departments awarded 100% by a standards panel were thanked with flowers and a certificate. Every month a panel of staff and patients rates each area at North Tees and Hartlepool NHS Foundation Trust.
76 Annual Report and Accounts 2015 – 2016 3.3.2 Keeping Staff Informed To ensure we provide patients, carers and their families with the best possible service, care and outcomes, it is vital that the people we employ feel valued, motivated and committed to the Trust so they can carry out their duties to the highest level. The people we employ continue to be our most valuable asset and they are the cornerstone of our future success. We recognise and acknowledge the correlation between high quality human resources (HR) practices and improved patient outcomes and safety. It is important that we continuously seek, measure and act on opinion in relation to how we communicate and engage with the people we employ. The Trust takes part in the NHS annual staff survey and we seek feedback on a quarterly basis through the staff friends and family test. Opinions and feedback are also sought and encouraged by other means such as staff engagement events, directorate listening events and feedback from staff in relation to organisational change. The Trust has a range of communication channels designed to keep staff informed and to support two-way dialogue and engagement. The Chief Executive briefing is issued to all staff on a monthly basis. Managers have the opportunity to discuss this with their workforce and ensure that all staff are properly informed of developments, quality, operational and financial performance and plans. Staff are given the opportunity to discuss and debate these issues and raise questions. Staff are also sent weekly news round-up, and the Trust's Anthem magazine is issued quarterly. At a local level staff are kept informed about matters affecting them at a departmental level via Directorate, departmental and team meetings. There is recognition that the strategic aims of the organisation are delivered by its people and the success relies on the right, positive organisational culture being established and maintained. This can only be achieved through continuous engagement of all our staff. Working towards understanding and changing the Trust's culture is not a one off task but an on- going continuous process. The Trust is actively engaged in many different activities to measure understanding and transform its culture, including: • Analysis of National Staff survey results; • Establishment of Improving Working Lives (IWL) group; • Specific staff engagement events; • Collaborative working with local University on subject of culture; • Development of Trust Triangle and People First Values; • Organisation Development interventions, specifically the implementation of lean methodologies; • Investment in initiatives such as the rollout of Local Improvement System & 6Cs; • Comprehensive leadership development programme for wide range of Trust staff. The Trust recognises that engaging with and listening to our staff is crucial as we aim to achieve excellence. The Trust has in place robust partnership working with our staff side via a Joint Forum. For medical staff we have the Local Medical and Medical Staff Committees. Building on the success of the sessions on Your Part in Our Future in 2013, a continuation of planned engagement events commenced in 2015 – 16 and will continue into the new financial year. These covered areas in relation to Reward and Recognition, Flu Vaccination Programme, Violence and Aggression, the Trusts 10 Year Strategy and Making a Difference to Patients. The purpose of the events is to give staff the opportunity to share their views and ideas about important issues facing us all, as individuals and as a Trust and have been very well received. The engagement sessions have also proved useful in providing staff with the opportunity to learn how the Trust has been performing, gain an understanding of the health care and business requirements of the organisation as well learning about future plans. Staff also have the opportunity to give their views on these and any other matters that are important to them. 3.3.3 Supporting Staff The Trust is fully committed to supporting and improving the health and wellbeing of its employees. This is achieved through providing various support options to assist with their physical and mental well-being and help them to maintain work-life balance. This helps staff reach their full potential, be energised, motivated and fully committed to their work. All of which contributes to staff being able to deliver high quality patient care. The Trust’s ‘Our People Strategy’ clearly articulates the need to provide a working environment 77 that will enable employees to meet their full potential both in and out of the workplace; this is evidenced as having a positive impact upon patient care. Annual Report and Accounts 2015 – 2016 The Trust has in place a number of policies offering support to staff throughout their employment. The Work Life Balance Policy covers flexible working, career breaks, time off for domestic emergencies, bereavement leave, and the promotion of good mental health and the management of stress policy. The Trust also recognises that, at times staff may experience situations or incidents that are traumatic. The Procedure for Supporting Staff involved In Traumatic/Stressful Incidents, Complaints and Claims is in place to ensure staff are provided with appropriate support prior, during and following the event, as required. There is also support from occupational health during such cases; from a debriefing perspective. The Trust adopts a zero tolerance approach to violence and aggression and the bullying and harassment of staff, whether this being from patients, relatives, visitors or staff. The Trust’s Prevention of Bullying and Harassment policy addresses this and encourages employees to develop self-awareness about their own behaviour and the effect this can have on others. The Trust has committed to the provision of regular training to all managers in leadership and managerial positions on how to address and proactively prevent bullying behaviour from staff. In February 2015 Sir Robert Francis published his report on the Freedom to Speak up Review. His report sets out principles and actions which aim to create the right conditions for NHS staff to speak up, share what works well across the NHS, get all organisations up to the standard of the best and redress when things go wrong in the future. Work continued throughout the year in response to these recommendations including: • A review of the existing Trust Policy ‘Disclosure of Concerns (Whistle Blowing) - HR27’, in response to these principles; • Rita Taylor, Non-Executive Director confirmed as the Freedom to Speak Up Guardian for the Trust; • Enhancing the provision of planned training to include how to address and prevent bullying, how to raise concerns and how to deal with concerns once raised. The Trust has in place a First Stop Contact Officer (FSCO) scheme which enables easy and immediate access to informal and confidential support to staff that may have concerns. The scheme allows staff to discuss any issues and concerns they may have in confidence and the FSCOs are then able to direct them to the correct source for support. There is also a full mediation service accessible to all Trust staff that may require support in dealing with concerns regarding working relationships. These take place in a confidential and safe environment, allowing staff to feel confident that the process (where both parties are agreeable) provides them with the opportunity to reach a mutually agreeable resolution, without the need for this to be influenced by formal policy. External mediation is also available to staff where there is a concern that the context of the case may need an external party to be involved. The Occupational Health and Wellbeing Service supports staff through early intervention and facilitates rapid access to services such as physiotherapy and counselling, providing prevention and rehabilitation advice and guidance for staff improving their health and wellbeing. In addition to this there are health promotion events as well as specific services that provide help and support in relation to stress, weight loss, smoking cessation. The Corporate Health & Safety and Non Clinical Risk (CH&S/NCR) team continue to monitor and audit Trust compliance against legislative and Department of Health requirements. Continually developing and reviewing risk assessments, providing advice and guidance to managers and staff, developing and delivering health and safety training, reporting and investigating incidents are the key services we provide to ensure compliance. The CH&S/NCR Annual Report provides assurances to the Board of Directors that the Trust provides a safe and secure environment for patients, visitors and staff. The Trust has an established anti-fraud policy, reviewed and approved at the Trust’s Audit Committee, which aims to minimise the risk of fraud or corruption, together with a code of conduct and disclosure of concerns policy to be followed in the event of any suspected wrong- doing or claims/concerns being reported. The policies and related materials are available on the 78 Trust’s intranet and counter-fraud information is prominently displayed both on the Trust’s intranet and throughout the Trust’s premises.
Annual Report and Accounts 2015 – 2016 The Trust’s Local Counter-Fraud Specialist (LCFS) reports to the Audit Committee and performs a programme of work designed to provide assurance to the Board of Directors with regard to fraud and corruption. The LCFS provides fraud awareness sessions and induction packs to the Trust’s staff, investigates any concerns reported by staff and liaises with NHS Protect and the police as appropriate. If any issues are substantiated, the Trust takes appropriate criminal, civil or disciplinary measures. The Trust has well established forums that assist in taking forward the health and wellbeing strategy. The Trust has established a Culture Group and aspect of this group involves reviewing, implementing and monitoring initiatives aimed at improving the health and well- being of employees. The Culture Group plays a central role in setting the Trust strategic direction and consists of representatives from across the Trust. It reviews and reacts to key reports and activities from a national, regional and local perspective that relate to improving working lives, the annual staff survey and health and wellbeing at work agenda. In order to formulate a structured plan the group obtained the views of staff as to how they felt the Trust could assist in maintaining and improving their wellbeing. The feedback from staff indicated that they were keen for more social and physical activities to be promoted in the workplace. The health and wellbeing staff group meets regularly to organise staff events to raise money to fund such activities. The group has also been responsible for setting up and running a reading group, singing group, relaxation sessions and chess group. Managing Absence The Health and Wellbeing of our staff is crucial in ensuring the provision of high quality patient care. Regular attendance of staff at work is essential in order to be able to provide a consistent level of care. In order to be able to maximise the level of resources available, the Trust continuously strives to reduce absence levels and promote a culture of attendance. The Head of HR Business Services oversees absence management within the organisation and is involved in formulating strategic direction. The Trust has a responsibility to monitor and manage levels of staff absence. Effective management should help increase staff health and morale as well as reduce the financial burden of sickness absence and also deliver improvements in patient care. Absence monitoring information, including a range of key indicators are provided to the Board of Directors on a quarterly basis through the Human Resources and Education report. The Trust has seen a slight decrease in overall absence in 2015 – 16 when compared to 2014 – 15. The average rate in 2015 – 16 was 4.46% compared to 4.56% in 2014 – 15. The table below reflects the relevant nationally published figures:
Figures converted by DH to best estimates of Statistics Published by HSCIC from required data items ESR Data Warehouse Average FTE 2015 Adjusted FTE days lost to FTE-Days FTE-Days Average Cabinet Office definitions Available recorded Annual Sick Sickness Days per Absence FTE 4,555 46,684 1,657,082 75,731 10.3
Source: HSCIC – Sickness Absence and Workforce Publications – based on data from the ESR Warehouse for the period January to December 2015. The revised Attendance Management Policy which was introduced October 2014 assists managers in adopting a more proactive approach to managing staff absenteeism. This includes an enhanced reporting mechanism which is designed to provide a transparent review of trends. This allows the Trust’s executive team to identify and understand hotspots and trends and provide strategic support for Trust wide initiatives to help tackle these issues and reduce absenteeism. As a direct result of absences due to Anxiety/Stress/Depression, which have constantly been the number one reason for sickness in the last two years (between 23 – 30%), there are plans to introduce a newly created role of Mental Health Advisor within the Occupational Health Department. Managers and HR representatives continue to have regular discussions in relation to management 79 of sickness absence both in terms of long term absences and also for employees who hit ‘triggers’ as defined within the Trust’s Attendance Management policy. This helps to ensure that the appropriate action is taken and that the policy is applied consistently across the organisation. Annual Report and Accounts 2015 – 2016 There are also Attendance Clinics/Task & Finish meetings for individual areas where OH, HR and line/ senior management all attend to discuss individual cases. 3.3.4 Development and Education of Staff The Trust recognises the importance of high quality education and development for all our staff. The directorate have continued to contribute to the Trust’s strategic aims by offering high quality education and training, which is available to all. Leadership Development Building leadership capacity at all levels of the organisation remains a priority for the Trust. The Trust remains committed to ensuring that effective leadership is in place to support the delivery of its strategic aims and continue to recognise the importance of developing leaders and managers at all levels of the organisation to deliver high quality patient care. The Directorate continues to support this approach and continues to invest resources to build leadership and management capacity across the organisation. Over recent years, the Trust has invested significant resources into developing leaders at all levels of the organisation by working with a wide range of stakeholders to offer comprehensive leadership development programmes. In addition, the Trust offers a range of opportunities via its links with the North East Leadership Academy (NELA). In response to feedback, an internal programme has been developed to support managers with the practical skills required to manage and lead day to day. The practical skills for managers programme is not intended to replace the range of leadership programmes offered, but to complement them. The programme is also designed to link to Talent Management and the implementation of the Local Improvement System (LIS) as part of the wider service improvement and transformation agenda.
Chief executive Alan Foster attends a stand on leadership and management development.
As we continue to transform our services we need people who can manage the processes and people, i.e. change management, dealing with potential conflict, as well as issues such as attendance management. The aim is to ensure that our staff are best equipped to deal with the situations that inevitably arise when significant change takes place. This programme equips individuals to have the right skills and knowledge and the ability to deploy them in practice. It also consolidates and strengthens their understanding of change management, giving them enhanced confidence to deal with their role. The Directorate are working collaboratively with the Territorial Army (TA) to develop a leadership programme for ward manager level nurses. The Trust worked with representatives from 201 field hospital where Chief Executive, Alan Foster is Honorary Colonel to develop a programme based 80 upon the military ‘seven questions’ model: 1. What is the adversary doing and why and/or what situation do I face and why, and what effect Annual Report and Accounts 2015 – 2016 do they have on me? 2. What have I been told to do and why? 3. What effects do I need to have on the situation, and what direction must I give to develop the plan? 4. Where can I best accomplish each action or effect? 5. What resources do I need to accomplish each action or effect? 6. When and where do the actions take place in relation to each other? 7. What control measures do I need to impose? On completion of the programme, participants: • Develop an understanding of how military decision-making has evolved. • Understand the concept of the Estimate Process and how the 7Qs apply in practice. • Are able to apply the Estimate Process to address current challenges faced in the NHS. Initial feedback from the first cohort appears to be extremely positive. E&OD are now in the process of officially evaluating the course and further detail will be available in 2016 – 17. Cohorts 2 and 3 are planned for April and September 2016. Organisation Culture There is recognition that the strategic aims of the organisation are delivered by its people and success relies on the right, positive organisational culture being established and maintained. This can only be achieved through continuous engagement of all our staff. Acknowledging the importance of this subject matter and recognition that many work streams influence the organisational culture, the culture group has expanded to incorporate reward and recognition, Improving Working Lives (IWL) and staff survey work. Following a presentation at the Executive Team strategic session, it has been agreed that the four priority areas the culture group will focus upon will be: 1. Ensure all staff know how they do/can make a positive impact on patient care; 2. Building productive and effective relationships between individuals/teams and managers; 3. Recognise and celebrate good practice; 4. Communicate strategic vision and how individuals contribute. The culture group continues to meet regularly and has recently expanded to incorporate the work of the Improving Working Lives group as well as overseeing the distribution and analysis of the National Staff survey. Performance and Behaviour Framework It is widely recognised that performance reviews/appraisals are essential for the effective management and evaluation of staff that help develop individuals, improve organisational performance, and impact on patient care. The new Performance and Behaviour Framework has been developed based on a range of existing performance review and talent management models, and best practice used in the NHS and private industry. The framework is comprised of two key components: 1. Performance/behaviour Conversation - A fundamental component of using the framework is for a manager and individual to hold and engage in an open and honest conversation. 2. 9 Box Grid - based on talent management best practice and aims to compliment the performance review conversation and provide managers and individuals with a framework to assess an individual’s performance, behaviours/values, and how these meet the expectations of the organisation for the individual’s role. Following the successful implementation of the framework to senior managers, plans are underway to rollout the new system to a wider audience. The performance and behaviour framework is designed to provide a robust and transparent process that aligns individual’s objectives to the strategic aims of the organisation. The framework is designed to give equal weighting to 81 performance and behaviours, focusing on the values expected by the Trust.
In addition, the framework aims to act as a talent management/succession planning tool that helps Annual Report and Accounts 2015 – 2016 develop the leaders of the future. Mandatory Training There continues to be significant effort to ensure that all Trust staff have the appropriate level of training to do their jobs efficiently, effectively and safely. To help achieve compliance with mandatory training across the organisation whilst recognising the clinical pressures the Directorate continues to look at ways to widen access to training. This includes investing in technology such as e-learning. In order to ensure that Trust staff have the right skills to perform their duties in a competent and safe manner, the Trust has a comprehensive and robust process for developing, implementing and monitoring mandatory training topics. The continued investment in technology allows the Trust to disseminate a wide range of information to our staff at a time that meets the individuals and service’s needs. In addition, challenges the existing culture of face to face and paper based training which can be resource intensive. e-learning is now an established method of training with over 30% of all training undertaken this way. To further enhance this, work is underway to develop the use of mobile technology. The directorate has successfully implemented e-induction. Utilising the technology available from the e-learning system, e-induction allows a newly appointed member of staff to be welcomed to the Trust, complete essential training and have access to vital information before their first working day. This system is currently only available for non clinical staff, however, work is underway to look at the possibility to expanding to clinical staff where appropriate. E-induction reduces the time away from the workplace and ensures new staff have the relevant skills to perform their role. The overall Trust compliance remains at 95% despite winter pressures and high levels of clinical pressure the Trust has faced; the Education Delivery team having worked closely with Directorates to increase compliance. Clinical Simulation The Trust remains committed to the investment in clinical simulation as a way of improving skill and improving patient safety. Regular simulation is delivered to nursing staff (including nurse preceptorship course, midwives and nurses from acute areas of A&E and EAU/ambulatory care), doctors in training and medical students, receiving excellent verbal and written feedback. Simulation in situ continues to run across the Trust including paediatric and neonatal departments, and the sepsis EAU simulations are now an established part of the simulation training agenda. The team has organised a further Introduction to Simulation course to train additional medical faculty to ensure continued operation of these sessions. Both the simulation suite and simulation in situ have been used to target key areas of patient safety such as sepsis and Acute Kidney Injury (AKI), and continue to use Serious untoward Incidents (SUIs) and other patient incidents as the basis for new simulation. All nurses from A&E and EAU/ ambulatory care have attended the sepsis simulation training, and AKI training is currently in development. Responding to a patient incident, the team are developing a training package around management of diabetic emergencies. The use of the newly established community suite continues to grow with regular use for technical skills training for Community Health Care Assistants. The team have established strong links with the District Nursing team and have begun to roll out new training on the care and use of Hickman lines in conjunction with the new orthopaedic home antibiotic pathway. The team have continued to promote the simulation suite and its staff as a centre for excellence in simulation education to the Universities and Colleges in the region, as well as more widely via social media.
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Simulation team. Relocation and development of the laparoscopy suite is complete and a number of internal and external events have been successfully hosted. Installation of a Scotia medical observation and training system (SMOT) camera system is complete. The system gives the capability of point of care simulation being recorded and viewed live from any other location in the Trust including the new community suite. Local Improvement System (LIS) The Trust remains committed to ensuring resources are used in an efficient and effective manner. The North Tees and Hartlepool NHS FT Local Improvement System (LIS) is now well established and acts as a brand for the improvement work underway within the Trust whilst providing systematic ways of delivering high quality, safe, reliable care to patients across the organisation. LIS provides a practical approach that educates staff to streamline and standardise their work and look at ways to eliminate waste in their own areas. By empowering front line staff to redesign their own processes it enabled them to spend more time with their patients resulting in improved outcomes and experience. LIS enables the Trust to build upon the good work already undertaken following the introduction of LEAN principles and the Productive Ward initiative. LIS helps to create standard operating procedures (SOPs) enabling patients to be cared for the in the best way. In addition, it allows the identification of best practice from each area and establishes the ‘best way’ of working together as a team by eliminating waste in the patients’ journey whilst creating an organised working environment allowing staff to save time and reduce errors by effective use of visual controls. The team has continued to support the Trust in a number of high profile projects including: • 6C training and Insights awareness – Local Improvement System (LIS) team continue to deliver mandatory training sessions combining 6Cs and Insight discovery to the midwifery, paediatric and neonate teams. They have delivered ten training sessions to date and have further dates planned in the diary to ensure everyone has been included; • Organisation Culture – In order to raise awareness on how Trust members contribute to making a positive impact on patient care, the LIS team hosted a road show and visited wards and departments to ask all staff; “How do you contribute to patient care?” Answers were written onto a speech bubble and the staff member/teams had their picture taken. Nearly 300 people participated and their photographs will be shown on a portable display board in the near future; • Team Days – The LIS team are currently continuing their work within directorates by delivering bespoke team days in order to build productive and effective relationships between individuals/ teams and managers. The teams involved are Speech and Language, Women and Children’s Services (Senior Midwives and Paediatrics), CSSD and Pathology; • Lean Leader Course – The LIS team redesigned the previous Certified Lean Leader training into a five half day course where the theory and practical application of Lean methodologies are examined. After completion of the programme, each candidate will now be required to implement a Lean intervention in their workplace and present a poster presentation recording its result; • Training Video – The LIS team, Medical Director and theatre staff have been developing/making a training video to expedite the introduction of the Trust’s amended WHO checklist. Quality The Trust has had six Quality Assurance visits during 2015 – 16 for medical training, the GP 83 Vocational Training Scheme the Schools of Obstetrics & Gynaecology and, as well as the annual Joint Schools and Annual Dean’s Quality Monitoring visits and an informal visit by the new Head of the School of Paediatrics (18 December 2015). The Trust received positive feedback with no issues Annual Report and Accounts 2015 – 2016 highlighted for action. The response rate for the 2015 Your School Your Say (YSYS) Foundation School survey was 100% (third year running), with the Trust featuring eight times in the Top 10 Trusts in the United Kingdom for clinical supervision out of hours, adequate experience, overall satisfaction, educational supervision and feedback at F1 level and feedback, adequate experience and access to educational resources at F2 level. The GMC response rate for the 2015 National Trainee survey was 97.8%. The Trust achieved 33 green positive outliers and 5 negative red outliers, all of which have either been addressed or have an action plan to address the issue. The Quality Team now facilitate the HR & Education Quality Group to ensure uniformity in the quality agenda across the directorate and provide the admin support for medical appraisal and revalidation. Workforce Planning Systems & Resourcing Following the re-alignment of Workforce Planning, Systems and Resourcing from the previous financial year, this year has seen workforce planning at the heart of the Directorate’s core business through which all workforce activity is driven and has enhanced links with the Resourcing team and supported by workforce information and effective utilisation of workforce systems. Workforce Planning Earlier in the year the Workforce Planning team undertook training with Skills for Health to understand the effectiveness of workforce planning and the impact it can have on the Trust. This involved work around designing the future workforce, by understanding, influencing and ensuring that workforce considerations combine with service and financial planning; developing the future workforce with clear integration with education commissioning, staff development, and recruitment and retention processes; and delivering the future workforce to ensure plans are delivered, processes are effective, clinicians are engaged and best practice is shared. The workshop provided training on local tools and techniques available including the NHS Benchmarking Tool and other competence search tools, roles directories and learning needs analysis tools. In particular the team have become an active user of the NHS Benchmarking Tool and have used it to assist with identifying and understanding models of best practice with regards to alternative workforces. Throughout 2015 – 16 there has been a strong focus on the development and refinement of workforce plans and projections to 2020 – 21; however it has been with a more robust approach than in previous years. This has been driven by the principles outlined in the Five-Year Forward View including the need to provide seven day, sustainable services for the future with a focus on patient safety, clinical effectiveness and patient experience. As a result, the key focus for the Workforce Planning team has been the development of a Clinical Services Strategy. This work has involved a significant resource as well as collaborative working with General Managers, Senior Clinical Matrons, Consultants and representatives from the Performance and Finance teams. The team have supported the development of each directorate’s clinical services strategy through undertaking intensive research into alternative workforce models based around the introduction of new roles and technology. The strategies have been underpinned by commissioning intentions where known, and have provided the conduit through which the workforce planning process has been strengthened and improved, with clinical engagement from the outset. Following the completion of the directorate specific strategies in which preferred future states were outlined, a series of workshops were held with key players from each directorate in order to align the relevant workforce to these preferred options. This then led to the creation of a workforce plan for each directorate which summarised the current state and then modelled out the future state through five year workforce projections with narrative outlining the associated risks and challenges. A summary of the proposed changes was submitted to Board of Directors for consideration in January 2016. Work is now focussing on developing a suitable workforce model for an urgent care centre, in 84 preparation for invitations to tender for the service. As a consequence, the current workforce plans for all directorates are being reviewed with a view to including any impact or interdependencies this development may have. Annual Report and Accounts 2015 – 2016 Further work is also beginning on reviewing maternity services following the recent assessment of maternity care by NHS England and also to support the transformation of the Outpatients Department. The next few months will see the Clinical Services Strategies move into the next phase, namely, implementation. Resourcing Following the integration of the Resourcing Team with Workforce Planning, this link has been strengthened by the appointment of a Workforce Planning Lead in September 2015 who operationally leads the Resourcing Team. Further appointments were also made to the Workforce Planning team with a view to increasing its presence in the Trust in order to ensure successful integration with services and financial planning. There were a number of key achievements in the year involving the Resourcing team including the introduction of new systems which has reduced the need for duplication and improved processes across a number of activities. Opportunities to improve the recruitment process were identified as part of a Rapid Process Improvement Workshop (RPIW) which led to a series of developments being implemented in order to streamline the service, improve customer satisfaction and reduce waste. Training days were held with the team including visits from NHS Jobs regarding its improvements in functionality and also from the UK Visa and Immigration Service in relation to regulated identification documents. Three key internal audits were undertaken during 2015 – 16; Pre Employment Checks, Overseas Recruitment Checks and Registration Authority. The audits were an opportunity to ensure compliance with recruitment functions and processes. In particular the Pre Employment Check audit led to a number of improvements made to the recruitment checklist in order to ensure it complies with the NHS Employment Check Standards. This led to further work ensuring that associated policies, procedures and templates were updated accordingly. Work is currently underway to develop a recruitment and retention strategy for the Trust with the aim of promoting the Trust as the employer of choice. The strategy will include a number of new ways of attracting high calibre applicants together with the key performance indicators with which recruitment activity will be measured. Some of these new ways of attracting these applicants include social media recruitment, the development of a recruitment app, undertaking a return to practice nurse campaign, overseas recruitment and attendance at local job fair events. Options have been explored for improved storage of personal files including devolving files into the directorates and also the scanning of new and existing files into an electronic file system. Such a system will make the storage and retrieval of files more accessible and free up much required space within the department. Work is continuing with regards to expanding the Trust’s use of social media to attract potential applicants. Evidence suggests that the increasing use of social media such as LinkedIn and Facebook helps to attract a higher percentage of quality applicants, increases awareness of the NHS Jobs website and the jobs available and attracts applicants of all backgrounds. Social media helps potential, quality employees to find job opportunities that suit them, by targeting individuals and groups of people with relevant information based on the Trust’s workforce plan. Work has begun on the development of a recruitment app which it is hoped that candidates can download to monitor their progress through the recruitment and selection process and access other such information which may be relevant to them as a new starter to the Trust. It is hoped that this will 'go live' in the early part of the new financial year. Preliminary work has begun with regards to organising a campaign to encourage nurses no longer practicing to return either substantively or via NHSP. An open day is to be arranged later in 2016 with a view to promoting the Trust as an attractive place to work and encouraging those nurses considering starting the Return to Practice course in September 2016. The use of the aforementioned social media along with more traditional methods of advertising will be used to reach this group of professionals.
85 Annual Report and Accounts 2015 – 2016
The local improvement system (LIS) team. Workforce Information The Workforce Information Team utilise a number of information systems to provide a broad range of information to support the management of the workforce. This includes performance dashboards, attendance management data, bank and agency usage, mandatory training compliance reports and workforce profiling. Mandatory training compliance reports were updated at the start of the year to incorporate targeted training subjects for 2015 – 16 such as Palliative Care Training, Risk Assessment and Falls, Prevention of Pressure Sores, Acute Kidney Injury, Sepsis, and Anticoagulants. The report was also revised to incorporate the new appraisal system introduced Agenda for change staff on Band 8 and above, this included linking appraisal dates with increment and performance review dates. In addition to this, maternity-specific subjects were revised to incorporate new subjects and revisions to renewal periods for some existing subjects. As part of the preparation for the Care Quality Commission visit, the Team assisted in the completion of Provider Information Requests which was a significant piece of work. They also produced a number of workforce profiles and reports to assist in the development of workforce plans which feed into the Clinical Services Strategy. The Management Information Team worked closely with Medical Education and the Trust Doctor Tutor to design and develop a database, which enables users to view all Trust Doctors, their clinical and educational supervisors, and identify where they are working, from one central point. Allowing the Trust Doctor Tutor to identify all Trust Doctors, will allow regular meetings to be arranged to discuss career aspirations. This gives the Tutor the opportunity to discuss appraisal, revalidation and appropriate continual professional development opportunities. For those Trust Doctors who do not have a portfolio this option will also be discussed. This will ensure they have their input into the organisation and training, create and maintain a portfolio and get the most from study leave. The purpose of this process is to ensure that they all receive support from the organisation, feel included and valued. During this time the two teams identified ways of combining multiple spread sheets into one database to ensure that relevant information is contained centrally. In addition to this as much data as possible is imported from the Electronic Staff Record to minimise data entry and duplication. The database is currently being piloted. Workforce Information Systems To support the management of its workforce the Trust continues to invest in and utilise a number of information systems, providing managers with tools for the management of staff, as a basis for decision-making and to inform future workforce plans and needs. These systems have supported the adoption of the new agency rules implemented by Monitor and the Trust Development Authority in October 2015, which also saw the introduction of hourly pay caps for agency staff. HealthRoster continues to be used by the Trust primarily for the rostering and daily management of nursing staff, providing the flexibility to be able to move staff to where they are most needed to ensure safe staffing levels are maintained. Following a successful pilot for rostering of Junior Doctors, and on-call for Consultants and Middle Grades in Medicine, the team are now starting implementation for Junior Doctors within Accident & Emergency with the anticipated go-live date to be in time for August 2016 doctor rotations. To assist in reducing agency spend for the medical workforce the Trust implemented STAFFflow during 2015 – 16. STAFFflow is a direct engagement model offered by Liaison and Price Waterhouse & Coopers (PwC), enabling the Trust to make reductions in agency spend without reducing the number of staff required to operate efficiently. The solution involves the Trust recruiting individuals 86 on short fixed-term temporary employment contracts, or directly contracting with those workers who provide their services through a limited company. Savings are made through reduced VAT, process costs and price control. The system also provides insight to the reasons for booking agency Annual Report and Accounts 2015 – 2016 staff and transparency in costs so that improvements can be made. The financial savings realised by reducing the VAT liability through the direct engagement model was £30k at the end of January 2016, with further estimated savings expected from current bookings. The system prevents users from booking temporary workers from non-framework agencies, assisting the Trust in meeting requirements and providing assurance. Utilisation is currently at 100% with all medical locum bookings being made through the system. Systems such as eRota and eJob Planning continue to be utilised to manage the activities of Senior and Junior medical staff, balancing service and training needs whilst allowing for a healthy work life balance. Job Planning is a contractual agreement for senior medical staff which requires annual review; the Trust invested in eJobPlan software to support this process. eRota/eMonitor is used to design, manage and monitor Junior Doctor rotas to ensure compliance with contractual obligations and the working time regulations. This provides rota managers with the tools to design efficient, safe and compliant rotas. Both systems have a nominated clinical Lead assigned by the Medical Director. Throughout 2015 – 16 the Trust has continued to work in partnership with NHS Professionals to promote the bank and grow its own flexible trained workforce, which is responsive to service demands. The system has a tiered arrangement which allows the shifts to be filled by bank staff before being released to agency staff. It provides the Trust with the functionality to be able to restrict agency usage to those on frameworks and within agreed pricing. Reporting functionality provides insight into the reasons for booking agency staff and transparency in costs so that improvements can be made. The Electronic Staff Record (ESR) remains the primary workforce management and information system, with the ability to report on workforce information such as staff turnover, workforce profile and attendance to support the Trust in understanding their current workforce and identifying workforce trends, gaps and projections. The Trust plans to work collaboratively with IBM over the coming year to maximise the potential benefits from future enhancements to the ESR system. Interfaces such as NHS Jobs and the e-DBS system are used to reduce the amount of data inputting. Information from all systems is triangulated to visualise the current workforce, identify areas of risk and highlight good practice for shared learning. Each system contributes to the management of the workforce to create a responsive team which can meet the changes and challenges ahead. This information feeds into the workforce plans as part of skill-mix reviews, role redesign and plans of new ways of working. The utilisation of workforce systems is continually monitored to ensure benefits from current and future functionality are maximised. Key Achievements during 2015 – 16 • Following the Overseas Recruitment audit, all recommendations were completed on schedule. With regards to the Registration Authority audit, (in which the CIS forms part of this process) one recommendation remains outstanding in relation to the implementation of the RA/ESR interface and is scheduled for completion at the end of October 2016; • Work has commenced on a project to further utilise the functionality with the Care Identity Service, the system used for the creation of Smartcards and to manage access to Trust systems. This includes working with Directorates to ensure that there are sufficient sponsors available and trained within each area to assist in the management of smartcards. The team are also planning for the implementation of the ESR interface through the use of position based access controls (PBACs), which will allow for a more streamlined process for the creation and amendment to access rights provided by the CIS system. The ESR interface links to the Care Identity Service system by associating an employee’s job role to the specific access required to Trust systems. When an employee moves role within the Trust or leaves the organisation, system access is then automatically granted or removed, dependent on their role. This will lead to improved governance within the system and will also alleviate pressure on the resourcing team who currently do this as a manual process; • The electronic Disclosure and Barring Service (e-DBS) system was implemented in the Trust in April 2015. This has led to a significant impact on the pre-employment check stage of the recruitment process with a satisfactory certificate being returned, upon average, within five days as opposed to, on average, 6+ weeks as per the previous paper system; • Additional NHS Jobs functionality has also meant more processes previously undertaken through a paper based system, can now be done online including short-listing, invite to interviews and a text reminder service for interviews. Occupational Health pre-screening questionnaires and mandatory training are both electronic links for candidates to upload and complete, again 87 reducing the paper trail required;
• The national shortage of registered nurses led to the Trust seeking to recruit from overseas. Annual Report and Accounts 2015 – 2016 A successful recruitment campaign was held in the Philippines during July 2015 from which 35 registered nurses were given conditional offers of employment. The first cohort of fifteen nurses arrived in the UK in March and will commence work within the Trust after a short period of adjustment. The remaining 20 nurses are expected to arrive in the UK in mid-late April. Due to the success of the campaign a further visit to the Philippines is in the process of being arranged which it is hoped will take place during September 2016; • A recruitment process for registered nurses was also held in November 2015 in Romania. Thirteen nurses were appointed and arrived in the UK on the 9 February 2016. Whilst the nurses will work within the Trust, they will be employed by NHS Professionals for the first 12 months of their contract, at which point they will be offered substantive posts with the Trust. The success of this recruitment campaign will be evaluated early in 2016 – 17, at which point consideration will be given to a second recruitment exercise from Romania. • Members of the Resourcing and Workforce Planning teams attended a jobs fair in Redcar for ex SSI employees. The event was extremely well attended with delegates receiving information regarding current Trust vacancies as well as general information regarding the Trust itself. The Trust has offered to participate in future job fairs as a measure of continued support for the local community. The Resourcing Team also plan to be part of local schools events with a view to raising the profile of professions in the NHS other than those traditional posts of nurses and medics. • Attendance management reports were developed to provide secondary absence reasons and individual absence rates as well as Directorate and Trust level rates providing more meaningful data with which managers can monitor and manage attendance of staff. • Performance dashboards were further developed to include corporate areas and to provide additional granularity by producing reports by specialty area. • Processes have been put into place to support the new agency rules introduced by Monitor and Trust Development Authority in 2015, including weekly reports of any exceptions. • STAFFflow was implemented in September 2015 for the booking of agency locum medical staff providing increased transparency and improved controls, together with the ability to reduce costs relating to Medical Locums. • A ‘Sub to Bank’ process has been implemented for nursing staff including care support workers and midwifery staff to allow multi-post holders who terminate their employment with the Trust to continue to work on the bank via NHS Professionals (NHSP) for a period of three months whilst they transfer to become a bank only worker. • An exercise to encourage staff to sign up with NHS Professionals was undertaken during 2015 – 16 together with letters of thanks to all staff who worked additional shifts through the bank in order to support the Trust in meeting seasonal pressures and reducing spend on agency workers. • Implementation of the Care Support Worker Development Programme via NHS Professionals was implemented providing successful applicants with the opportunity to become a care support worker. • As part of the Trust’s initiatives to increase the number of substantive staff who are also bank workers, a new process was implemented by the Resourcing Team, aimed at actively encouraging new substantive starters to join the bank by incorporating the opportunity to sign up for the bank into the pre-employment process. Future developments include implementation of an auto registration process where new nurses, midwives and health care assistants are automatically registered with the bank but have the option to opt out. 3.3.5 Equality and Diversity The Trust is committed to the practices of equality, diversity and human rights, and aims to ensure that these practices are maintained within the organisation and embedded within all aspects of service provision and employment. The main focus within the organisation is on ensuring that the provision of health care and employment practice takes into account the individual needs of patients and staff by promoting equality of opportunities and recognising and embracing diversity. This is achieved by having robust systems in place to prevent discrimination through recruitment, employment practices, procurement service design and the delivery of healthcare pathways. 88 Tackling inequality and removing barriers in respect of equality, diversity and human rights through employment and the services provided remains a key strategic focus for the Trust.
Annual Report and Accounts 2015 – 2016 The Equality and Diversity Working Group, under the guidance of the Steering Group, have undertaken a variety of the projects which have helped to improve service provision for patients, carers and their families. Underpinning a majority of the initiatives has been the criteria for child and adult safeguarding and the care of vulnerable adults. The Trust continues to recognise and promote equality and diversity through identification of improvement initiatives, engagement and education. In line with national guidance there is continuous monitoring relating to the Workforce Race Equality Standard (WRES). In relation to the workforce the focus has been on monitoring equality practices in terms of equality of opportunity as well as allegations of discrimination and then aiming to remove any barriers that would prevent an individual from being able to fulfil their role. The Trust’s Executive lead for Equality, Diversity and Human Rights Ann Burrell, Director of Human Resources and Education is supported by the Equality and Diversity Steering Group and Working Group in implementing the E&D agenda. These groups have representation from across the organisation to include; Human Resources, Occupational Health, Senior Medical Staffing, Nursing Staff, Management as well as patient services representatives. Representatives from each directorate are invited to these meetings to provide an update on equality improvements or areas for improvement pertinent to their area. The Trust is an active member of the Regional Equality, Diversity and Human Rights Group that meets bimonthly, therefore ensuring any regional and/or national initiatives are fed directly from this group to the Trust Working and Steering Groups. The principles of Equality and Diversity have been incorporated throughout the Trust from inclusion within business plans to carrying out impact assessments, right through to the implementation of services/practices/policies. The Trust seeks to: • Eliminate unlawful discrimination, harassment and victimisation; • Advance equality of opportunity between different groups; • Foster good relations between different groups; • Seek to improve existing practices and embed new initiatives and enhance our equality and diversity activity. The Trust is continuing to develop and strengthen links with external stakeholders. Feedback is obtained from patients, their families and carers through a variety of means, including patient experience surveys and through patient representatives participating in various groups. These include HealthWatch groups from Stockton, Hartlepool and County Durham and members of the Healthcare User Groups (HUG) also work closely with the Trust by carrying out visits to departments within the organisation and reporting back on any issues that need addressing. These visits can also help identify any issues or concerns, as well as positive experiences, in relation to practices of equality and diversity issues. Engagement with staff has also been a priority and this has been carried out through various forums. Recent staff engagement focus groups have enabled staff from a range of professional groups and grades to share their views and opinions about a number of issues facing or affecting the Trust including such thing as improving communication, dealing with bullying and harassment and making a difference to patients. The views of staff and service users has also been obtained through promotional events, the annual staff survey, quarterly staff friends and family test and though feedback from Directorates. This provides both qualitative and quantitative data as well as benchmark data to allow the Trust to look at areas including adult safeguarding, audit, specifically disability audits and accessibility of services and facilities or patients. A significant amount of work has been undertaken to engage with all stakeholders and this still remains one of the key priorities during the coming year. Addressing any inequalities that have been identified through the various information sharing routes is crucial. Some of this information has been obtained through patient experience surveys, general feedback, comments and concerns raised, all of which should assist in improving patient experience 89 and creating a more favourable working
environment for employees. The Trust can Annual Report and Accounts 2015 – 2016 proactively put measures in place to avoid the inequality in relation to the protected characteristics as identified by the Equality Act 2010 and these measures are also extended to other underrepresented groups within the local community. Examples of these practices are detailed within the Equality and Diversity annual report. This year the Trust annual Equality and Diversity event took the form of an awareness session which was run by an external well established Quality Assurance Nurse, Sue Leather helped highlight the training company - Deafeating Barriers. services available to people with impaired hearing or vision during Deafblind Awareness Week. The session was fully interactive and focused on inequalities in accessing health care as well as ways in which to remove these obstacles. Some of the other initiatives that have taken place during the course of the year included: • the introduction of mealtime companions within the Trust; • increasing the number of care makers so that patients receive appropriate care and support; • the launch of 'Small Wonders' – a new initiative within the Neonatal unit aimed at helping parents play a bigger part in the care of their tiny/sick child; • pastoral support via the Chaplaincy for patients of all faiths; • hospital tours/visits for those patients experiencing anxiety about coming into hospital; • continued developments in adult safeguarding, including advances in the care of patients suffering from dementia; • 'Time to Talk' – resources, services aimed at supporting the wellbeing of staff; • empowering patients with a palliative diagnosis to a greater say regarding their care especially in terms of selecting aids and equipment to assist them with mobility and daily life; • raising awareness of sensory loss. Further initiatives and events will take place in the future and will form part of our annual calendar of events. Feedback from these indicates that they have an extremely positive effect both for staff and patients in terms of the quality and level of care being provided. The results of the 2015 staff survey will be used to identify any particular areas of care/employment or any general issues in relation to practices of equality and diversity that need addressing. The figures for those reporting of discrimination, bullying and harassment and raising grievances have remained consistent with previous years. However, this does not indicate a sense of complacency, with the Trust taking forward the objective of reducing levels across the organisation. Information obtained from the staff friends and family test has also helped the organisation as a whole and also particular services focus on employment practices and healthcare provision to ensure that we are meeting the needs of all those we employ and our service users. The Trust’s Equality and Diversity groups have clear measurable objectives to ensure further expansion and full implementation of EDS2. All of the initiatives are complemented by the Trust’s existing Equality Objectives which have been identified in accordance with the Public Sector Equality Duty (PSED) The Trust’s four Equality Objectives are as follows: • To engage with patients, local community and stakeholders, in line with the requirements of EDS2, to ensure effective provision of services; • To enable staff to work alongside patients and carers to determine realistic, reasonable adjustments to deliver safe, effective care to people with literacy problems, learning difficulties and dementia; • To develop a robust system to capture data of employees from all key characteristics to enable effective monitoring of equality; 90 • To explore and reduce discrimination experienced by staff as identified via the staff survey through the development of proactive measures and support mechanisms to be implemented Trust-wide. Annual Report and Accounts 2015 – 2016 The staff census is currently underway to ensure that all staff update their personal data so that the information we have in relation to the protected characteristics is correct. Tackling inequality in respect of equality, diversity and human rights through employment and the services provided remains a key strategic focus for the Trust. The Trust continues to hold its’ ‘two ticks’ employer status; which recognises the commitment of the Trust to removing inequality and ensuring fairness and equity in relation to recruitment and employment processes. Trust policies and practices stipulate the requirement to ensure that processes are fair and consistent, in relation to service provision and employment practices regardless of protected characteristic. Equality impact assessments are carried out for all policies, processes and projects to ensure that they are fair and equitable for all. There is a new Equality and Diversity e-learning package designed specifically for the Trust. This supplements both the national training package and the workbooks. Bespoke training continues to be provided for individuals, groups or departments that require specific training or have concerns/issues in terms of acceptable behaviour that need addressing. All recruiting managers are provided with training to raise awareness of best practice in relation to recruitment and selection protocols. Workforce statistics relating to recruitment and retention of staff are monitored by protected characteristic to ensure that the recruitment process is transparent and fair and that appointments are made purely on qualifications, knowledge, skills and experience. All the training provided fully recognises the Equality Act 2010 and is supported via the Trust Equal Opportunities and Diversity Policy which makes it clear that the Trust is committed to maintaining an environment which is conducive to the health and welfare of all staff, patients and service users. The Equality and Diversity Annual Report 2014 – 15 was published in May 2015 and highlighted the good practice that is on-going across the organisation. This report incorporated case studies in relation to employment practices and patient services. The Trust reports annually on progress made in relation to meeting the Public Sector Equality Duty (PSED) which includes reporting on workforce statistics. This information can be accessed via the Trust website www.nth.nhs.uk or in other formats upon request. 3.3.6 NHS Staff Survey The national staff survey was published in February 2016. The staff response rate for the Trust was 45% for 2015 – 16 which showed an increase from the previous year. The results are used to help make improvements in working conditions and practices and highlight successes in areas where the Trust has scored well. The Care Quality Commission will also use the results as a measure of performance, whilst the Department of Health and other national bodies will assess the effectiveness of national NHS staff policies. The staff survey compliments the on-going engagement agenda across the Trust; which includes engaging with our people in relation to culture and values through the culture toolkit and the schedule of focused engagement events each month which are led at Director level; addressing key subjects across the organisation from violence and aggression to making a difference to patients. The Trust response rate in the 2015 staff survey was above average when compared with other acute Trusts.
2014 2015 Trust deterioration/ improvement Trust National Trust National average average Response rate 43% 43% 45% 43% +2% (improvement)
The Trust remained constant in relation to most of the key findings when compared to the 2014 results. In relation to two key findings the Trust has shown improvements where staff experience has improved which is detailed below;
2014 2015 Trust Improvement/ Deterioration Staff motivation at work 3.78 3.88 +0.10 (improvement) 91 Staff recommendation of the organisation as 3.52 3.66 +0.14 (improvement)
a place to work or receive treatment Annual Report and Accounts 2015 – 2016
However one key finding detailed below has shown an increase in staff responses;
2014 2015 Trust Improvement/ Deterioration Percentage of staff experiencing harassment, 21% 26% +5% (deterioration) bullying or abuse from staff in last 12 months The Trust’s top five ranked scores in the 2015 staff survey, when compared to other acute Trusts in England were:
2014 2015 Trust Improvement/ Deterioration Top five ranked scores Trust National Trust National Average Average Percentage of staff 63% 71% 66% 72% +3% (deterioration) working extra hours (lower better) Percentage of staff/ 54% 52% 67% 52% +13% (improvement) colleagues reporting most recent experience of violence (higher better) Percentage of staff 9% 11% 7% 10% -2% (improvement) experiencing discrimination at work in last 12 months (lower better) Percentage of staff 89% 87% 90% 87% +1% (improvement) believing that the organisation provides equal opportunities for career progression or promotion (higher better) Percentage of staff 29% 30% 34% 30% +5% (improvement) reporting good communication between senior management and staff (higher better)
The Trust’s bottom five ranked scores in the 2015 staff survey, when compared to other acute Trusts in England were:
2014 2015 Trust Improvement/ Deterioration Bottom five ranked scores Trust National Trust National Average Average Percentage of staff feeling 63% 56% 69% 58% +6% (deterioration) pressure in last 3 months to attend work when feeling unwell (lower better) Percentage of staff 82% 85% 79% 86% -4% (deterioration) appraised in last 12 months (higher better) 92 Quality of appraisals Not Not 2.92 3.03 Not comparable comparable comparable Annual Report and Accounts 2015 – 2016 Percentage of staff 88% 91% 89% 91% +1% (improvement) agreeing that their role makes a difference to patients/service users (higher better) Staff motivation at work 3.78 3.88 3.88 3.92 +0.10 (improvement) Overall the survey has provided some good results but we will continue to work on relevant areas for improvement. Emerging themes from the 2015 staff survey suggest that we need to focus on: • Leadership; • Communication; • Raising concerns; • Ensuing appraisals take place and are of a high quality.* *It is important to note the number of staff reporting that they have had an appraisal in the last 12 months contradicts slightly with the Trusts RAG report figures for appraisals. The areas of focus identified via the staff survey fit well with the already established culture agenda going forward. As a result work-streams are already established that will address many of these areas; such as the implementation of the ‘I make a difference to patients’ campaign, introduction of appraisal evaluation, rolling out the performance and behaviour framework Trust wide for all staff on Agenda for Change terms and conditions. These priority areas will be built into a wider engagement plan, and will focus on specific areas of development identified in the survey over a rolling 12 month period. Directorate leads across the Trust will be taking forward actions identified locally. Progress made will be monitored through the Trust culture and values group; comprising representation from across the Trust including the Board. Along with the NHS annual staff survey the Staff Friends and Family test enables the Trust to gauge the views of staff regarding the Trust as a healthcare provider and employer. The test provides an opportunity to monitor and gather feedback from staff and report on findings, ensuring any appropriate action is being taken to address any concerns. The results for the Staff Friends and Family Test for quarter 1, 2 and 3 in 2015 – 16 were as follows: How likely are you to recommend the Trust to friends and family if they need care or treatment?
Extremely Likely Neither Unlikely Extremely Don’t know likely unlikely Q1 39% 42% 9% 5% 4% 1% Q2 35% 42% 16% 4% 2% 1% Q3 18% 44% 27% 9% 3% 0%
(Q3 figures add up to 101% - as figures have been rounded up) How likely are you to recommend the Trust to friends and family as a place to work?
Extremely Likely Neither Unlikely Extremely Don’t know likely unlikely Q1 36% 37% 13% 7% 6% 1% Q2 29% 43% 15% 7% 5% 1% Q3 16% 41% 27% 11% 5% 0% The data for quarter 3 were taken from the 2015 staff survey. 93 3.3.7 Staffing analysis The Trust employs over 5,000 staff and the table below shows staff numbers at 31 March 2016. Annual Report and Accounts 2015 – 2016
Headcount WTE Male Female Male Female Directors (inc non execs and chairman) 7 7 7 7 Senior Managers 56 108 55 100.11 Employees 928 4,393 847.43 3,589.26 Grand Total 991 4,508 909.43 3,696.37 Average number of employees This information has been subject to audit review.
2015-16 2014-15 Permanent Other Total Total Medical and dental 366 143 509 496 Ambulance staff - - - - Administration and estates 809 111 920 1,028 Healthcare assistants and other 436 139 575 891 support staff Nursing, midwifery and health 1,968 47 2,015 1,445 visiting staff Nursing, midwifery and health - - - - visiting learners Scientific, therapeutic and technical 704 1 705 675 staff Healthcare science staff 90 - 90 85 Social care staff - - - - Agency and contract staff - - - - Bank staff - - - - Other - - - - Total average numbers 4,373 441 4,814 4,620 Of which: Number of employees (WTE) - - - - engaged on capital projects
Expenditure on consultancy The Trust, in 2015 – 16, spent a total of £324,000 on services provided by external consultancies. Staff exit packages The amounts agreed are highlighted below and have been subject to audit review:
Exit package Number of Number Total Number of Number Total cost band compulsory of other number compulsory of other number redundancies departures of exit redundancies departures of exit 2015-16 agreed packages 2014-15 agreed packages 2015-16 2015-16 2014-15 2014-15 <£10,000 2 - 2 14 - 14 £10,001 - 16 - 16 19 - 19 £25,000 £25,001 - 9 - 9 5 - 5 94 £50,000 £50,001 - 5 - 5 3 - 3 £100,000 Annual Report and Accounts 2015 – 2016 £100,001 - 3 - 3 1 - 1 £150,000 £150,001 ------£200,000 >£200,000 ------Total number 35 - 35 42 - 42 of exit packages by type Total resource £1,333,000 £0 £1,333,000 £891,188 £0 £891,188 cost (£) The Trust had no non-compulsory departure payments in 2015 – 16, or 2014 – 15. Off-payroll arrangements The Trust, as of 31 March 2016, had no off-payroll engagements for more than £220 per day and that lasted for longer than six months. The Trust had no new off-payroll engagements, or those that reached six months in duration, between 1 April 2015 and 31 March 2016, for more than £220 per day and that lasted longer than six months. The Trust had no off-payroll engagements of board members, and/or senior officials with significant financial responsibility, between 1 April 2015 and 31 March 2016.
Number of engagements 2015-16 Number of off-payroll engagements of board members, and/or, senior - officials with significant financial responsibility, during the financial year. Number of individuals that have been deemed "board members and/ 17 or senior officials with significant financial responsibility". This figure should include both off-payroll and on-payroll engagements.
3.4 Code of Governance
The Board of Directors and the Council of Governors of the Trust are committed to the principles of good corporate governance as detailed in the NHS Foundation Trust Code of Governance. North Tees and Hartlepool NHS Foundation Trust has applied the principles of the NHS Foundation Trust Code of Governance on 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. 3.5 Regulatory Ratings
The Trust has continued to strive to achieve clinical and financial success during 2015 – 16, which has resulted in overall adherence to the Monitor Licence Conditions. The quarter 4 position has yet to be released by Monitor (expected mid May), however Table 1 and 2 below provides an analysis of actual quarterly rating performance compared with the expectation in the Annual Plan 2015 – 16, together with a comparison of the previous year’s (2014 – 15) rating performance. In reviewing the current and future position the Board of Directors has considered the impact of an acute focused resilience requirement, the impact on the financial position and the economic and subsequent contract risks to compliance. Balancing this with a strong historical performance, further radical solutions remain necessary to assure quality, safety and delivery of key healthcare standards. During the Quarter 2 period of 2015 – 16 the Trust experienced significant pressures in the delivery of the cancer standards, with Cancer 2 week standard and Cancer 62 day urgent referral to 95 treatment standard reporting below the required standards. The Trust further reviewed the agreed actions within its cancer recovery plan, evaluating all elements of cancer management including, Annual Report and Accounts 2015 – 2016 governance, pathway management, escalation procedures, tracking processes, Multi-disciplinary Team (MDT) management and capacity and demand. The Trust achieved compliance against all the cancer standards by the end of Quarter 3 2015 – 16. However, as outlined in the Performance section, the key pressures have continued, including significant increases in referrals associated with the national cancer awareness campaigns, complexity of pathways, and the continued uptake of patient choice. The Trust is working alongside GPs and CCG leads to review how a system wide approach to the review of cancer pathways, including pre referral triage, can be implemented to support robust delivery of cancer standards. Disappointingly, despite the significant on-going work to manage and deliver against all the cancer standards the Trust under-achieved against the Cancer 62 day urgent referral to treatment standard in Quarter 4. Additional pressures have also been evident across delivery of the Emergency 4 hour standard during 2015 – 16, with the standard under-achieved in Quarter 3 and 4. The published weekly Department of Health reports indicate the Trust is reporting above the regional and national averages, despite the significant emergency pressures experienced. The Trust has also experienced difficulties against the C-Difficile target during 2015 – 16, with 36 cases reported against the tolerance of 13 cases. Despite the increase in cases during 2015 – 16, the Trust has still delivered an 83% (n-174) reduction in C-Difficile cases since the introduction of the standard in 2007 – 08. Based on the Department of Health methodology, this significant reduction resulted in the 2015 – 16 objectives being set at 13 cases, a rate of 6.8 per 100,000 bed days, significantly below the national average of 12.5. The objective for 2016 – 17 remains at 13 cases. The Trust continues to invest in measures to improve cleanliness, including the creation of a decant facility, available from April 2016, activities to raise awareness of and improve adherence to hand hygiene practices, and work around improving antimicrobial stewardship. These actions are in place to reduce the risk of further infections and maintain safe care for our patients The Trust has, in the main, consistently delivered against the core standards historically, with robust operational plans in place to mitigate against the risk of under-achievement with regard to variables, within its control, however it recognises external influences can impact on the delivery against the key indicators i.e. Cancer standards, A&E 4 hour standard, C-Difficile and as such identifies the risk to delivery for 2016 – 17.
Risk Assessment Framework Monitoring Annual Plan Q1 Q2 Q3 Q4 2015-16 2015-16 2015-16 2015-16 2015-16 Finance Risk Rating/Continuity 3 3 2 2 2* of Services Risk Rating Governance Risk Rating Green Green Green Green Green*
* This information is subject to confirmation by Monitor.
Risk Assessment Framework Monitoring Annual Plan Q1 Q2 Q3 Q4 2014-15 2014-15 2014-15 2014-15 2014-15 Finance Risk Rating/Continuity 4 4 4 4 3 of Services Risk Rating Governance Risk Rating Green Green Green Green Green
3.6 Statement of the Chief Executive Officer
Statement of the chief executive’s responsibilities as the accounting officer of North Tees and Hartlepool 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 96 proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by Monitor.
Annual Report and Accounts 2015 – 2016 Under the NHS Act 2006, Monitor has directed North Tees and Hartlepool 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 North Tees and Hartlepool 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 Office 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.
Alan Foster MBE Chief Executive Date: 27 May 2016
97 Annual Report and Accounts 2015 – 2016
Chief executive Alan Foster receives his flu jab. 3.7 Annual Governance statement
1. Scope of Responsibility As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS Foundation Trust’s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the NHS Foundation Trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum. 2. The Purpose of the System of Internal Control The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an on-going process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of North Tees and Hartlepool 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 North Tees and Hartlepool NHS Foundation Trust for the year ended 31 March 2016 and up to the date of approval of the annual report and accounts. 3. Capacity to Handle Risk During 2015 – 16, the Trust has refocused its attention on the management of strategic risks, with the introduction of a revised Risk Management Strategy and a reframed Board Assurance Framework driving the Board’s agenda. Board Sub-committees and other high-level groups who have defined responsibilities and accountabilities for risk management are in place for the escalation of risks from the front line, through governance channels, to the Board of Directors. Overall decisions in relation to prioritisation of corporate risk issues and resource allocation are taken by the Board of Directors, with delegation of decisions relating to specific risks to sub- Committees or the Executive Team as appropriate. This features highly in the planning round to deliver the Annual Operational Plan and the Board of Directors ability to self-certify. The Board of Directors provides leadership on the overall governance agenda, whilst the Chief Executive has overall accountability for risk management within the organisation, and discharges that duty through the Executive Team who have responsibility for the delivery of a robust risk management and governance process in both their functional and corporate roles. By embracing the well led principles, it enables the Trust to support the delivery of sustainable high quality person-centred care, support learning and innovation, and promote an open and fair culture. The Director of Nursing, Patient Safety and Quality together with the Medical Director are given delegated responsibility to lead the Trust’s risk management and governance processes. All Executive Directors have responsibility for the delivery of a robust risk management and governance process in both their functional and corporate roles. The Senior Information Risk Owner at Board level is the Director of Finance, ICT and Support Services. In strengthening its risk management processes, the Trust, using service line management principles, has devolved responsibility and leadership at directorate level in order to build capacity to enable clearer lines of accountability to risks to quality and safety. Senior clinical leaders are in place throughout each directorate, they are responsible for driving improvements to quality and safety and actively support staff in the identification and management of identified risks. Clinical 98 Directorates are supported through highly skilled and competent staff within the Corporate and Support Service functions that are a central resource for training, advice and guidance on all areas
Annual Report and Accounts 2015 – 2016 of risk management. All members of staff have responsibility for participation in the risk/patient safety management system through: • Understanding of work place risk assessments, and requirements to comply with any control measures introduced by these risk assessments; • Compliance with all professional standards relevant to their role; • Understanding and compliance with all Trust policies and procedures particularly risk management and incident reporting policies which are available to all staff electronically through the intranet; • Reporting all incidents and near-misses via the appropriate reporting systems; • Compliance with mandatory training and other requirements appropriate to their role; • Awareness of the Trust Risk Management Strategy and processes within their area of work to manage risk; and • Seeking necessary support and advice, when required. The Board of Directors regularly scans the horizon for emergent opportunities or threats, and considers the nature and timing of the response required in order to ensure risk is kept under prudent control at all times. The Board of Directors participate in an annual review of skills and competence to undertake the challenges of interpreting strategy into delivery and this is accompanied by regular training, networking and attendance at nationally led events. This enables the Board to contribute to the whole Trust agenda and in particular safety and quality at a strategic level whilst challenging the delivery of performance and scrutinising the impact of risks. A Senior Independent Director at Non- Executive Board level who holds regular meetings with Governors provides a conduit for Governors to raise concerns on an informal basis. During 2015 – 16, focus has been on risk management arrangements and the Board of Directors have supplemented their understanding of this area with a range of seminars and training sessions, at times provided with external facilitation. The Board of Directors undergoes regular self- assessment to test skills and capabilities at Board ‘away days’ and seminars, which resulted in the production of a development plan for 2015 – 16. Staff have access to training in areas such as information governance, risk management, reporting systems and guidance on how to understand the processes for managing risks, which are appropriate to their authority and duties. With the introduction of the revised Risk Management Strategy particular focus has been paid to the development and roll out of training in respect to risk management and risk registers to ensure consistency and standardisation of application and process. Staff of all grades can access this training in areas such as risk assessment, risk management and the use of the Trusts Risk reporting system. The training opportunities include a variety of direct training sessions, a paper based work book and also an e-learning package. Following review of the Trusts risk policy, a summary guidance document has been prepared to support risk handlers in the day to day processes for managing risks. The Trust benefits from good practice through a range of mechanisms, including: • Policies to support staff in operating an open and honest incident reporting and risk management culture; • Robust investigation processes; • Peer reviews; • Clinical audits; • Professional and personal development; and • Application of evidence based practice. All learning from good practices and training is shared appropriately across the Trust, this is described further under ‘The Risk and Control Framework’ below. 4. The Risk and Control Framework The Board is committed to leadership of the risk management and governance functions in the Trust. Each Executive Director has within their portfolio a responsibility for some aspect of risk management and governance; this also includes Non-Executive Directors chairing Board Sub- Committees, i.e. Audit, Finance and Patient Safety and Quality Standards. The Risk Management Strategy sets out the strategic direction for risk management in the Trust 99 and was updated in 2015 to comply with legal and statutory requirements, assist in compliance
with national standards, promote proactive risk management and improve the safety and quality Annual Report and Accounts 2015 – 2016 of patient care. In line with the Risk Management Strategy, a wider review is being undertaken in respect to operational risk management processes to ensure a robust system is in place for the identification, recording and action planning of risks. The risk register and associated processes have been reviewed and simplified to ensure consistent application across the Trust; this is being supported by a comprehensive programme of education. As part of its drive to improve quality governance, during 2015 – 16 the Board thoroughly reviewed how it manages strategic risks and reframed the Board Assurance Framework (BAF). The Board engaged the services of an external consultant to initially lead on this work, but ensured that long term sustainability and continual improvement of the BAF and strategic risk management would be achievable through embedding processes into business as usual. As part of supporting the development and embedding of the Trust’s revised Board Assurance Framework, a series of seminar events were held during the year with the Board of Directors. This involved working through the risk management process, monitoring and Committee structure, reviewing risk controls and assurance, whilst considering risk appetite. This work was supported by internal audit and further sessions will be held in 2016 – 17 to firmly embed the process within the wider risk management strategy of the organisation. To promote the sharing of good practice the Trust uses an integrated approach to the identification and management of risk. Risks are identified through a variety of processes including formal risk assessments in line with Health and Safety requirements, also in response to trends linked to incident reports, complaints and litigation claims. The Risk Register provides the key focus for this; information relating to the register is scrutinised on a regular basis by the appropriate sub- Committees of the Board and quarterly by the Audit Committee supported by internal and external audit. The Board of Directors has, in line with the Risk Management Strategy; initiated planning for a Risk Management Committee. This Committee will be introduced and embedded during 2016 – 17. To ensure risk management is embedded in all Trust activities care is taken to ensure that Directorate Business Plans and projects introduced to support the organisation’s strategic objectives; are informed by reference to the Trust’s Risk Assessment process and where necessary included into the Risk Register. In order to ensure service changes are reviewed effectively the Trust has continued to utilise Quality Impact Assessments (QIA’s). This tool is used during early planning stages to support the introduction of change within services, allowing assessment of: • Patient Safety; • Clinical Effectiveness; • Patient Experience; • Equality and Diversity. All QIAs are reviewed and approved by the Director of Nursing, Patient Safety and Quality and the Medical Director prior to implementation. Initially QIA’s were introduced to support the planning of changes within the service improvement and efficiency programme, however, it was recognised this assessment could be utilised across all areas of service improvement, transformation and change. An integral part of this process is to identify what measures will be used to assess the maintenance or improvement of quality as the change is implemented. The Trust is currently evaluating this process for effectiveness and will be initiating changes as needed. The system of quality governance is designed to ensure there is an integration of systems, structures and processes from Ward to Board level. In this way appropriate actions are taken to ensure required standards are achieved; any variance or risks associated with these can be identified early; investigated and appropriate action introduced. This on-going process of quality assessment can improve planning and supports the drive for continuous improvement. The Trusts Committee and governance structure provides for direct escalation to Board and Executive level if required. To comply with the governance conditions of the NHS Provider Licence, the Trust is required to provide a governance statement to Monitor that sets out any risks to compliance with the governance conditions and the actions taken or being taken to maintain future compliance. The statement sets out a number of key questions essential for quality governance, with evidence gathered through self-assessment or review. The Board of Directors certifies on-going compliance with the governance condition, via the Corporate Governance Statement, using performance against governance indicators, financial 100 performance, exception reports and third party information to test the certification. The Board of Directors effectively planned and assessed risks for 2015 – 16, recognising the delivery of the
Annual Report and Accounts 2015 – 2016 C-Difficle standard against the threshold would be difficult and declared non-compliance in the Operational Plan submitted to Monitor. In addition, the risk of underachievement against access and cancer standards was anticipated by the Board of Directors and acknowledged in the returns to Monitor via the Annual Plan. The Care Quality Commission (CQC) undertook an announced inspection on 7 – 10 July 2015. Following the inspection a report was received which gave an overall rating of Requires Improvement based on an assessment of core services and corporate functions under the five domains. A number of ‘must do’ and ‘should do’ recommendations was made by the CQC and following a quality summit in February 2016, an action plan was developed and agreed by the CQC, which includes further development and enhancement of the Board Assurance Framework and risk management processes. Appropriate governance structures are in place to manage implementation of all actions; monitoring of progress is through a CQC Project Board led by the Director of Nursing, Patient Safety and Quality who provides assurance to the Board of Directors. A significant number of the recommendations have already been completed with further work progressing in quarter 1 2016 – 17. The full inspection reports for the Trust are available to the public on the CQC website: www.cqc.org.uk/provider/RVW. The Board of Directors is committed to, and actively promotes the identification, sharing and delivery of best practice; this includes identification and managing current risks to the quality of care; as well as scoping for any future issues that may impact on this. The internal control mechanisms support the management of risk to a reasonable level rather than to eliminate all risk of failure to achieve patient’s safety and quality; the infrastructure of support therefore provides reasonable and not absolute assurance of effectiveness. The Patient Safety and Quality Standards Committee receive reports and updates from appropriate departments in relation to any external assurance visits undertaken to assess compliance with national standards. An example of this has been the feedback from a recent visit by the Human Tissue Authority. The overall assurance from the visit was very positive with all standards being achieved and some areas of best practice being identified; there were a small number of minor improvements suggested that have already been actioned. The Patient Safety and Quality Standards Committee also request reviews of published national reports to establish if there are any identified gaps in service provision in the organisation as a result of findings and recommendations made. The Trust has a policy advising on the process of follow up of external reports and inspections to ensure agreed actions are implemented accordingly. Three Non-Executive Directors are members of the Patient Safety and Quality Standards Committee, one of whom chairs the meeting. The Board understands and promotes staff empowerment in relation to quality. This ensures all staff, including front line staff, are involved and therefore, empowered to implement Trust practices and behaviours and where appropriate challenge colleagues who have not followed Trust procedures. A non punitive approach is taken in relation to incident reporting, the organisation actively promotes a culture of safety and encourages incident reporting from all staff. The CQC Report has recently provided the Board with further assurance that this is occurring. Examination of any human factors that are linked with incidents permits actions to be implemented in order to mitigate against recurrence where possible. If, following investigations of any incident, it is shown that professional or clinical standards have been breached then an appropriate investigation will be initiated. All serious incidents are scrutinised and monitored on behalf of the Board of Directors by the Patient Safety and Quality Standards Committee supported by a robust governance process. Internal communications feature regular quality initiatives and improvements, and bulletins and on- going training to enable staff to review lessons learnt from risk management processes. Quality outcomes are made public and accessible regularly involving the Hospital Users Group (HUG) and the Quality Standards Steering Group with patient representatives and Health watch representatives. Reports of any national patient and staff surveys are all presented to the Patient Safety and Quality Standards Committee; and also other linked Committees or groups. Information obtained through the Friends and Family Test (FFT) for both patients and staff is analysed and reviewed on a regular basis. The national Staff Survey results are analysed and examined to identify where issues have been identified so that initiatives can be introduced in order to support improvements; the Board of Directors is actively involved in this planning. Patient stories, both positive and negative are regularly used throughout the organisation in order to promote the impact of issues that are raised and remind all staff that behind each complaint or incident is a patient and their family. Information on quality of care is provided on a regular basis through the Nursing Dashboard and is displayed on each clinical area and updated each month. The level of detail has been enhanced over 2015 – 16, however, it is recognised that further work is required in terms of widening 101 the scope and reviewing the overarching governance process for reporting and monitoring requirements. Details of the analysis of this information are provided within the Quality Report (Section 5). Annual Report and Accounts 2015 – 2016 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. Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with. The Trust is committed to practices of equality, diversity and human rights and aims to ensure that these practices are maintained within the organisation and embedded within all aspects of service provision and employment. This is achieved by having robust systems in place to deter discrimination through recruitment, employment, procurement service design and the delivery of health care services. The Trust has also adopted an equality impact assessment process that is used for assessing all Trust policies, procedures and practices. The 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. 5. Review of economy, efficiency and effectiveness of the use of resources The Trust has robust arrangements in place for setting objectives and targets on a strategic and annual basis. These arrangements include ensuring that the financial strategy is aligned to the service strategy and is affordable. Savings plans are scrutinised to ensure achievement and compliance with terms of authorisation. Individual objectives are co-ordinated with corporate objectives as identified in the Annual Plan, to ensure the aims of the Trust are delivered. The following processes and mechanisms are in place: • Agreeing a one year operational plan, which sits within the context of the Trust’s overarching strategy, with appropriate financial and operational detail to evidence the resilience and sustainability of the Trust and highlighting potential risks and challenges ahead; • Given the economic and financial environment of the Trust, the Board is refreshing the clinical services strategy and refocusing on a 5 – 10 year strategy which will clearly set out the ambitions and direction of travel into the future; • A rigorous process of setting annual budgets with underpinning service improvement and efficiency programmes presented and approved by the Board or a delegated Sub-committee of the Board prior to the start of the financial year; • Robust performance management arrangements supported by an explicit Performance Improvement Framework; • Daily, weekly and monthly cash flow monitoring and a rolling 18 month cash flow projection in accordance with the approved Treasury Management Policy; • Regular review of Standing Orders, Standing Financial Instructions and Scheme of Delegation; • Development of service line reporting/management and patient level information and costing system (PLICs) to support directorates to better understand and manage their relative efficiency and profitability, and to make informed business decisions; • New joint collaborative procurement arrangements put in place to ensure best value through purchasing contracts; • Estate rationalisation, workforce skill mix review and staffing reviews linked to Key Performance Indicators (KPIs) and key strategic objectives. The Board delegates responsibility for reviewing the economy, efficiency and effectiveness of the use of resources to the Audit Committee and Finance Committee, this is supported throughout the year with: • Agreeing and approving the Annual Plan; • Detailed monthly review of financial performance, financial risk and monitoring the delivery of the service improvement and efficiency programme; • Reviewing and agreeing all plans for major capital investment and disinvestment. The Board also gains assurance from: • Internal audit reports, including value for money audits; 102 • External audit reports; • The Care Quality Commission inspection report; Annual Report and Accounts 2015 – 2016 • Ad-hoc service reviews; • Benchmarking; • Various other external accreditation bodies. The Trust continues to pursue its vision of achieving fully-integrated healthcare, as described in section 2.1.4, page 13. The Board of Directors has reviewed in detail the services delivered and the impact of activity and demand on the Trust between now and 2020 to inform the Clinical Services Strategy and set the direction of travel for the Trust, as a result of the new hospital being put on ‘pause’ and has revisited the Momentum: pathways to healthcare programme. It has worked in partnership with the wider Durham and Tees Valley Health and Social Care stakeholders to consider the opportunities to align services through the Better HealthCare Programme, recognising there is not sufficient resources to stabilise and sustain services going forward to maintain the high level of quality and financial and performance levels we have historically achieved, without radically changing the way the services are delivered to meet the complex health needs of the population served. There is recognition that there is little financial flexibility to support transition between present and desired service models unless the wider health and social care system work together to understand how such a transition will be managed for the benefits of the patients we serve. The Sustainability and Transformation Plan being developed for the wider Durham and Tees Valley footprint will set the foundations for the future direction of travel. A refocused strategy is under development covering a 5 – 10 year period taking into consideration; • Continuing development of integrated patient care pathways, across hospital and community services and incorporating social care services where possible, taking a locality based focus on the delivery of services; • Appropriate investment in hospital estate to improve the quality of services; • Transfer of services into community settings where this is economically feasible or provides significant strategic advantage; • Development of new clinical roles and service models (supporting workforce and financial models); • Achievement of the demanding and on‐going efficiency targets; • Key strategic enablers; • Communication and engagement; • New models of care with local partners to best manage the demographic, socio economic and disease profile challenges of the population served. No such strategy can be developed and delivered in isolation. In developing the strategy, the Trust is working with a number of stakeholders including but not exclusive to: clinicians and staff; commissioners; Local Authority providers; GP federations and individual practices and GPs; Health and Wellbeing Boards; local scrutiny functions; Public Health departments; and patient representatives, including local HealthWatch organisations; NHS England local area team, and Foundation Trust providers. 6. Information governance The confidentiality and security of information regarding our patients and staff is monitored and maintained though the implementation of the Trust governance framework which encompasses the elements of law and policy from which applicable information governance (IG) standards are derived. Personal information is increasingly held electronically within secure IT systems. It is inevitable that in complex NHS organisations especially where there is a continued reliance upon manual paper records during a transitional phase to paperless or a paper-light environment, that a level of data security incidents can occur. Any incident involving loss or damage to personal data is comprehensively investigated by the Trust and graded in line with the Health and Social Care Information Centre (HSCIC) and Department of Health (DoH) guidelines on incident reporting and as required reported accordingly to the Information Commissioner’s Office (ICO). Incidents assessed using the HSCIC risk scoring matrix deemed to be a Serious Untoward Incident at Level 2 or above are reportable to the ICO. The Trust has significantly reduced the number of incidents at Level 2 and above from 13 in 2014 – 15 to 2 during 2015 – 16, these are shown in the table below: 103
Category Information Governance Breach Type Total Level 2 or above Annual Report and Accounts 2015 – 2016 A Corruption or inability to recover electronic data 0 B Disclosed in error 2 C Lost in transit 0 D Lost or stolen hardware 0 E Lost or stolen paperwork 0 F Non secure disposal – hardware 0 G Non secure disposal – paperwork 0 H Uploaded to website in error 0 I Technical security failing (including hacking) 0 J Unauthorised access/disclosure 0 K Other 0 In order to further strengthen existing Trust policy in areas where incidents have occurred during 2015 – 16 the following key actions were undertaken: • Review of IG policies to ensure that they reflect the specific needs and practicalities of each internal department; • Reviewed Trust policy on the provision of patient correspondence including the requirement to redact or minimise personal data contained in correspondence removed from the Trust wherever possible; • Implemented a programme of comprehensive quality assurance and spot checks to ensure all departments are complying with Trust polices relating to the protection of personal data; • Implemented additional technical and organisational measures to ensure the ‘clinical administration standard operating procedure’ is being strictly adhered to by all staff dealing with patient correspondence; • Implemented an electronic solution for letter creation to reduce the element of human error in typing; • Published new data breach procedures and policy to deal specifically with containment and recovery solutions.
The Trusts Information Governance Toolkit submission for 2015 – 16 was again graded as ‘satisfactory’ with an overall score of 77%, the minimum expected level of compliance was achieved against all Toolkit standards and higher level compliance achieved against 14 requirements. The Toolkit was also subject to external audit and again the Trust was awarded ‘significant assurance’ with no remedial actions. The Trust has identified the following key areas to focus on in 2016 – 17 to further increase the toolkit score: • Review of information assets and data flows; • Awareness of cyber security and information security; • Business continuity for information assets; • Information sharing with health and social care providers; • Increase staff awareness of the importance of information security.
7. Annual Quality Report The Board of 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. The following steps have been implemented to provide assurance to the Board that the Quality Report presents a balanced view and that there are appropriate controls in place to ensure the accuracy of data: • The draft Quality Report/Account was issued to key stakeholders in April 2016 with the Third Party Declarations being received by 30 April 2016. An easy read version of the Quality Accounts will be 104 published alongside the full accounts; • Stakeholders were consulted throughout the year starting in September 2015 and concluding in
Annual Report and Accounts 2015 – 2016 March 2016; the Stakeholders requested to review the Quality Accounts document and comment on whether they felt it accurately reflected their understanding of the Trust position in relation to quality; • The quality reporting structure is fully embedded within the organisation with the quality dashboard and alternative sources of benchmarking data and assurance (NEQOS, HSCIC and HED) used to validate conclusions and recommendations. The Council of Governors was asked to review the document as a key stakeholder: • Governors attended a Market Place event on 9 December 2015 in order to review the showcase for 2015 – 16 and provide feedback on priorities for 2016 – 17; • A working group of the Council of Governors reviewed the Quality Report on 7 March 2016 with an agreed Third Party Declaration being received on 28 April 2016 (section 5, page 112); • Third-party narratives have been received from commissioners and key stakeholders and these are included in the Quality Account and Quality Report; • The External Auditors reviewed the Quality Report/Account in May 2016 and their report is contained on page 223. The external auditors have provided a signed limited assurance report on the content of the quality report and mandated indicators in the annual report. The report includes a disclaimer on the conclusion regarding the percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the reporting period indicator. The Trust confirmed with the external auditors that the data as reported to the Board and Monitor was an accurate reflection of the patient record system at the time the data was run, which is reflective of the current ‘at the time’ waiting list and RTT incomplete pathway position. As a result of on-going validation, the underlying data can change with the passage of time meaning that an audit at the end of the reporting period will inevitably identify changes to pathways which would affect the position previously reported. The Trust has acknowledged the issues flagged in the limited assurance report and that the end of year cumulative RTT position validity is a national issue. In relation to the percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the reporting period indicator the following actions will be put in place during the forthcoming year: • The Information team will develop the report with additional checks built in, including, as now, a monthly spot check validity audit and quarterly cumulative waiting list and RTT sign off through the current performance improvement governance process. 8. 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 Directors and clinical leads within the NHS Foundation Trust who have responsibility for the development and maintenance of the internal control framework. I have drawn on the content of the quality report attached to this Annual Report and other performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the board, the Audit Committee and Patient Safety and Quality Standards Committee and a plan to address weaknesses and ensure continuous improvement of the system is in place. The Assurance Framework is well established and is designed to meet the requirements of the 2015 – 16. Annual Governance Statement and provide reasonable assurance that there is an effective system of internal control to manage the principle risks identified by the organisation. A plan to address the weaknesses and ensure continuous improvement of the system is in place. The process that has been applied in maintaining and reviewing the effectiveness of the system of internal control is outlined within the Terms of Reference of the Board Committees which are reflected in section 3.1.3, page 52 and include: • The Board of Directors – has overall accountability for delivery of patient care, statutory functions and Department of Health/Monitor requirements; • The Audit Committee – oversees the maintenance of an effective system of internal control and assurance for the Board on the Statement of Internal Control; • The Finance Committee – ensures that the Trust’s resources are being managed efficiently and 105 effectively;
• The Patient Safety and Quality Standards Committee – ensures the highest possible standards of Annual Report and Accounts 2015 – 2016 clinical practice within the Trust. To ensure the Trust has in place the systems and the processes to support individuals, teams and corporate accountability for the delivery of safe, patient-centred, high-quality care. To ensure the Quality Report/Accounts are discharged and that lessons learned and disseminated to all professionals within the Trust and to ensure patient outcomes do not demonstrate the Trust as an outlier; • The Planning, Performance and Compliance Committee - assesses the service performance, planning and service operational efficiency and monitors compliance with a view to a level of assurance with regard to self certification; • The Audit and Clinical Effectiveness Committee – oversees the application of effective clinical guidance and best practice evidence; also the monitoring of compliance against these requirements; • The Trust Directors Group – has responsibility for achieving the corporate objectives identified by the Board. Key Review Bodies: Internal Audit – provides an independent, objective assurance and consulting activity designed to add value, and improve the Trust’s operations. Through an active audit programme, it assists the Trust to accomplish its objectives by bringing a systematic, disciplined approach to evaluate and improve the effectiveness of risk management, control and governance processes. The Head of Audit, as part of his requirements, provides me with an annual opinion based upon all internal audit work undertaken during the year and the arrangements for gaining assurance via the Assurance Framework. For 2015 – 16, it is his overall opinion that ‘significant assurance’ can be given that there is a generally sound system of internal control, designed to meet the organisation’s objectives, and that controls are generally being applied consistently. However, some weaknesses in the design and inconsistent application of controls put the achievement of particular objectives at risk. Where this is the case, the Executive team has agreed to implement internal audit recommendations to mitigate these risks and ensure appropriate monitoring of progress at a senior level. It is also the Head of Audit’s opinion that there are no significant control issues which he would wish to bring to my attention for potential disclosure/inclusion within this statement. In addition to this, the Trust’s Executive Directors have reviewed the finding of all internal audit work throughout the year and have not identified any significant control weaknesses for disclosure. External Audit – provides an independent opinion on the review of resources and the financial aspects of corporate governance as set out in their Code of Audit Practice. The external auditors of the Trust undertook non-audit work in relation to VAT services for the Trust’s subsidiary company, Optimus Health Limited. Care Quality Commission – In 2015 the CQC published guidance regarding how they expect NHS Bodies to comply with the Fundamental Standards identified in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The CQC inspection regime ensures the Trust is compliant with these Fundamental Standards. The Trust continued to comply with the CQC registration without conditions and continued to deliver against key standards. Clinical Commissioning Group – The local Clinical Commissioning Groups (CCGs) have undertaken assurance visits during 2015 – 16. Reports have been provided for all visits and any recommendations made have either been acted on immediately at the time of the visits, or action plans have been initiated. However, none of the assurance visits have raised any significant concern about safety or quality within the Trust’s services. The Trusts Commissioners develop Local Quality Requirements in conjunction with the Trust, in order to monitor quality across a wide range of areas; these are monitored alongside the national quality indicators. Review and assurance mechanisms are in place but continue to be developed and ensure that: • All managers including the Board regularly review the risks and controls for which they are responsible; • All reviews are monitored, documented and reported to the next level of management; • Any changes to priorities or controls are documented and appropriately referred or actioned; • Lessons which can be learned from both successes and failures are identified and promulgated to those who can gain from them, both within and outwith the organisation. 106 An appropriate level of independent assurance is provided on the whole process of risk identification, evaluation and control.
Annual Report and Accounts 2015 – 2016 In conclusion, there are no significant internal control issues that have been identified that would prevent me from giving assurance. 9. Conclusion The Board have considered the Annual Governance Statement and I can confirm that there are no significant internal control issues within the Trust.
Alan Foster MBE Chief Executive Date: 27 May 2016 107 Annual Report and Accounts 2015 – 2016
Porter David Wilson (pictured with associate chief pharmacist) worked with pharmacy to ensure discharge prescriptions and medications were taken to wards as soon as possible during kick-start January. 4 Research and Development
The Research and Development (R&D) department continues to embed research into the culture of the Trust. The Government wishes to see a dramatic and sustained improvement in the performance of providers of NHS services in initiating and delivering clinical research. The aim is to increase the number of patients who have the opportunity to participate in research and to enhance the nation’s attractiveness as a host for research by faster approvals and delivering to time and target. Performance Data Total year on year recruitment into National Institute for Health Research (NIHR) portfolio research is shown below:
2,000 1,800 1,666 1,600 1,400 1,200 1,147 1,144 956 908 1,000 800 600 Patient Recruitment Patient 412 458 400 200 159 0 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 Total Recruitment
*Data from Research and Development Department Nationally there has been a decrease in the overall total numbers of patients being recruited as there are fewer of the large observational studies. Within NTHFT we have seen an increase in the number of more complex interventional and commercial studies at the expense of larger, simpler observational studies. So whilst our overall recruitment figures are slightly lower, the trials we are participating in are more complex and we are accruing year on year additional follow-up burden for patients in existing trials. For 2015 – 16 of the patients recruited so far, 81% were recruited into interventional studies with just 19% recruited into observational studies. 2015 – 16 Study participation – number of studies The National Institute of Health Research Clinical Research Network (NIHR CRN) portfolio is a database of clinical research studies that are supported by the NIHR CRN in England. Adoption on to the portfolio is dependent on a study meeting eligibility criteria. The Clinical Research Network provides infrastructure support including NHS Service Support costs (SSCs) and access to R&D 108 support. Research studies are reviewed for inclusion in the NIHR CRN Portfolio in parallel with the NHS Ethics review and R&D governance process. A non-portfolio study is a research study without
Annual Report and Accounts 2015 – 2016 the above support that has not been adopted onto the portfolio. Study participation – number of studies open
Study Type Number of Actively recruiting In follow-up Studies patients NIHR portfolio Observational 53 100 42 Interventional 89 Non-portfolio Observational 26 46 1 Interventional 5 Total Observational 79 Interventional 94 The number of studies currently active within the Trust has increased on last year. Last year the Trust had 165 studies open but 173 this year which further illustrates that despite the overall numbers decreasing we are actually running more trials than in previous years. The number of patients receiving relevant health services provided or subcontracted by North Tees and Hartlepool NHS Foundation Trust in 2015-16 that were recruited during that period to participate in research approved by a research ethics committee was 862 (portfolio and non- portfolio studies). National position/ranking
Year Overall national position Ranking in “medium sized acute Trusts” category 2012-13 101st out of 394 organisations* 7th out of 48 Trusts 2013-14 157th out of 454 organisations 25th out of 47 Trusts 2014-15 141st out of 445 organisations 26th out of 47 Trusts 2015-16 Not available Not available
2015-16 information not available at the time of print
*In 2012-13 we had two exceptionally large recruiting observational studies which led to our much higher ranking in the league tables and the recruitment spike seen in the first two graphs on the previous page. Also the number of “organisations” was less (394 vs 454 in the following year) Performance in Initiation and Delivery of research (PID data) From 2013, government funding for research to our Trust has become conditional on meeting national benchmarks. The Trust reports quarterly to the Department of Health on the following performance measures. Latest figures relate to our quarter 3 submission. For non-commercial interventional studies: meeting a 70-day benchmark to recruit first patients for trials.
70 day benchmark met No of Studies Reason Yes 7 No 5 1 NHS delay 2 Sponsor delay 2 Neither – no eligible patients seen/consented
For commercial interventional studies: Recruitment to time and target stated in clinical trial agreement.
Time and target met No of Studies Reason Yes 5 No 7 4 closed early – competitive recruitment meant national target was met before we reached our local target 1 change in PI* at site – delay in replacement PI* impacted on our recruitment 109 2 lack of suitable patients seen – v tight inclusion/ exclusion criteria Annual Report and Accounts 2015 – 2016 Still on-going 6
*Principal Investigator (PI) Failure to provide acceptable explanation for poor performance over two consecutive quarters may result in financial penalties. The Trust has provided extensive narrative to support why sometimes these metrics haven’t been met; the Research and Development team meet monthly to review the data and work with teams to highlight when benchmarks are in danger of not being met and develop an action plan. Once submitted to the DH, we have to post this information in a publically accessible area of the Trust’s website. Commercially Sponsored Studies The Trust continues to increase our participation in commercially sponsored studies and now have 16 commercially sponsored studies active within the Trust in this year (12 last year) within Respiratory Medicine, Paediatrics, Neonates and Cardiology and more recently Gastroenterology and Orthopaedics. The respiratory and cardiology research teams are developing their reputation as a 'preferred site' for commercially sponsored research studies with the Cardiology research team recently visited by the global representatives from the commercial company to learn lessons from their very successful recruitment strategies for the RELAX-2 study. Staffing There are 65 members of staff acting as principal investigators/local collaborators in research approved by a research ethics committee within the Trust, some of whom have up to ten studies in their research portfolio. There are 26 clinical research network funded research staff within the Trust (nurses, midwifes, data assistants, team leader and Pharmacy technician) and two nurses/ research practitioners funded from commercial income. Currently 133 members of staff have valid Good Clinical Practice (GCP) training The Trust has appointed a part-time band 7 Research Team Leader to assist with staff oversight, revalidation, appraisal and mentoring as well being a first contact advisor and mentor for new grant applications for potential Chief Investigators R&D Incentive Fund The Research and Development (R&D) Team continue to work with departments across the Trust to promote the importance of healthcare professionals being involved in research. Through the Trust’s provision of an R&D Incentive fund of £50,000, it has been able to help to develop staff knowledge and skills to enable them to lead and/or be involved in research studies. Four members of R&D delivery staff have been supported with course fees for research related MSc fees and two individuals (Neonatal and Gastroenterology) have received part-funding of their MD/PhDs. Two members of staff (Pathology and Respiratory Medicine) have received sessional support to enable them to complete a research grant application.
110 Annual Report and Accounts 2015 – 2016
Research and development team at a research and development dinner.
Trust initiated Studies Two research ideas will be progressed for external grant applications to the NIHR Research for Patient Benefit (RfPB) funding stream in March 2016 from Gastroenterology and Respiratory Medicine and a further two potential Chief Investigator led studies to work up with the relevant investigators in Pathology and Surgery. Professor Samir Gupta has successfully completed the pilot phase of his £3m HTA funded research study and has now received permission to commence the multi-centre study. The study aims to determine whether or not an echocardiographically confirmed large Patent Ductus Arteriosus (PDA) in extremely premature babies should be treated with ibuprofen within 72 hours of birth. The multi-centre study will recruit 730 babies over 30 recruiting centres Expansion of research activity Most specialisms and all directorates are now participating in research to a greater or lesser degree. The few exceptional areas where activity is non-existent are in active discussion with the R&D department to identify potential studies that might be relevant. The Trust has seen exceptional increases in the involvement in research from the out of hospital (community) directorate notably from the Podiatry team who over recruited on the 'REFORM' study (a randomised trial of a multifaceted podiatry intervention for fall prevention in patients over 65 years of age). They were set an initial target of 20 patients to recruit and actually recruited 161 patients. Four nominations were submitted to the regional NIHR awards event in March and the Trust has been informed that our Podiatry team has been successful in winning the 'Community research engagement' category. The R&D department nominated a number of teams and individuals to recognise their continued performance and dedication to the research endeavour in the Trust. Another area that hadn’t traditionally been research active that has engaged with research within the last year has been the Occupational Health Service who recruited very well to the SCIN trial (a cluster randomised controlled trial of a behavioural change package to prevent hand dermatitis in nurses working in the National Health Service). They recruited 49 patients against a target of 40 and are keen to be involved in further projects. Achievements and accolades Our bi-monthly research nurses working group continues to be well attended and provides professional support and mentorship as well as assisting national research initiatives such as raising the profile of research with patients, involving patients in meaningful PPI (patient and public involvement), developing training packages for research nurses and training nurses for commercial studies. Four nominations were shortlisted for members of the research team in different categories for the Trust’s Annual Shining Stars awards; despite not winning this was an encouraging recognition of the contribution research staff make to the Trust. The Trust met 4 of the 6 Local Clinical Research Network Continuous Improvement Objectives which resulted in additional funding of £20,000 being secured. The Trust were also successful in being awarded funding for a half time trainee research nurse through a competitive funding round with the research network. The Trust has been the first UK site to trial a new contactless patient monitoring system that aims to prevent patient deteriorations, falls and pressure sores. The 'Early Sense' monitors were installed on two wards in November 2015. The project has been overseen by the R&D manager. A research project will take place during 2016 to determine their impact and obtain data on outcomes before a decision is made as to their long term patient benefit and financial viability. The R&D department are also exploring external business development opportunities to develop a clinical trials facility on the North Tees site. 111 Annual Report and Accounts 2015 – 2016 5 Quality Report – Annual Quality Report 2015-16 ANNUAL QUALITY REPORT (Quality Accounts) 2015 – 16
Contents
Part 1 Statement on quality from the Chief Executive Page 113 Part 2 2a 2015 – 16 quality improvement priorities Page 116 2b 2016 – 17 quality priorities for improvement Page 157 2c Statement of assurance from the Board of Directors Page 163 2d Core set of Quality Indicators Page 185 Part 3 3a Additional quality performance measures during 2015 – 16 Page 197 3b Performance from key national priorities from the Department Page 213 of Health Operating Framework, Appendix B of the Compliance Framework Annex’s Annex A Third party declarations Page 215 Annex B Statement of Directors’ responsibilities in respect of the Quality Page 222 Account Annex C Independent Auditors Limited Assurance Report to the Council of Page 223 Governors of North Tees and Hartlepool NHS Foundation Trust on the Annual Quality Account. Annex D Quality Accounts Feedback Form Page 226 Glossary Glossary Definition of some of the terms used within this document Page 227
112 Annual Report and Accounts 2015 – 2016 Part 1: Statement on quality from the Chief Executive Our approach to Quality: An Introduction to this Annual Quality Account from the Chief Executive
I am pleased to introduce the North Tees and Hartlepool NHS Foundation Trust Quality Accounts for 2015 – 16 which demonstrates our continued commitment to strive for excellence and high performance in order to deliver care of the highest quality. The report focuses on our performance over the last year as well as our key priorities for 2015 – 16. 2015 – 16 has again proven to be a very busy and challenging year where we continued to achieve high performance and good outcomes for patients across the Trust. As always we continue to appreciate the excellence of our staff, and this reporting period our staff have been particularly recognised for their achievements throughout the year, having been nominated for a number of awards. It is not only our staff that deserve recognition for their hard work, but also all of our volunteers, members, governors and other partners and stakeholders. The main challenge for 2015 – 16 relates to our Hospital Standardised Mortality Ratio (HSMR) and summary hospital-level mortality indicator (SHMI) mortality values, ensuring that the values reduce closer to the national mean. The Trust has instigated numerous actions in relation to this, all overseen by a mortality clinical lead. The Trust has recently seen a decrease in the HSMR and SHMI values and would like to thank all staff members for hard in aiding in this reduction, whilst maintaining high standards of care. The Trust continually works with external bodies to ensure as an organisation we have third party assurance on the work we are undertaking. Following the July 2015 inspection from the Care Quality Commission (CQC) The Trust was rated overall as ‘requiring improvement’ but achieved a good rating for safe, caring and responsive care, Of the 85 individual ratings, 65 were rated as good. A number of areas were identified as good practice, including surgery, critical care, end-of-life care, the Trust’s simulation suite, community services and the Trust’s services at One Life Hartlepool. The Trust held its second annual Quality Accounts Marketplace on 9 December 2015 at the North Tees site; this event was well received and attended by our stakeholders. This event produced our quality strategy and Quality Accounts priorities for 2016 – 17. The priorities have been developed with patients, carers, staff, governors, commissioners and with key stakeholders including health scrutiny committees, local involvement networks (HealthWatch) and Healthcare User Group (HUG). The Trust undertook a major change to the Patient Administration System (PAS), implementing a brand new Electronic Patient Record (EPR) system across both sites. This was a challenge and came with some technical and data quality issues, but the Trust will benefit in the long term from the new systems. The Trust continues to receive regular comments and reviews from patients, carers and family members on NHS Choices; the two sites are currently rated at: University Hospital of North Tees is rated at 4.5 out of 5 star services on NHS choices and University Hospital of Hartlepool is rated at 5.0 out of 5. We continue to believe and commit to Putting Patients First by making patient safety and patient 113 experience our number one priority every day. To the best of my knowledge the information contained in this document is an accurate reflection Annual Report and Accounts 2015 – 2016 of outcome and achievement.
Alan Foster MBE Chief Executive What is a Quality Report/Accounts?
Quality Accounts are annual reports to the public from us about the quality of healthcare services that we provide. They are both retrospective and forward looking as they look back on the previous year’s data, explaining our outcomes and, crucially, look forward to define our priorities for the next year to indicate how we plan to achieve these and quantify their outcomes.
Our quality pledge In 2012, our Board of Directors and our staff pledged patient safety and experience as their number one priority supported by our corporate strategy. Our continued commitment to improving the quality of our care and service quality for our patients remains our number one priority. It is prevalent at every level of our organisation and is generating excellent performance results. Our Board of Directors receive and discuss quality, performance and finance at every Board meeting. We use our Patient Safety and Quality Standards (PS & QS) Committee and our Audit Committee to assess and review our systems of internal control and to provide assurance in relation to patient safety, effectiveness of service, quality of patient experience and to ensure compliance with legal duties and requirements. The PS & QS and Audit Committees are each chaired by non-executive directors with recent and relevant experience, these in turn report directly to the Board of Directors. The Board of Directors seek assurance on the Trust’s performance at all times and recognise that there is no better way to do this than by talking to patients and staff at every opportunity. Quality standards and goals The Trust greatly values the contributions made by all members of our organisation to ensure we can achieve the challenging standards and goals which we set ourselves in respect of delivering high quality patient care. The Trust also works closely with commissioners of the services we provide to set challenging quality targets. Achievement of these standards, goals and targets form part of the Trust’s four strategic quality aims. Listening to patients and meeting their needs We recognise the importance of understanding patients’ needs and reflecting these in our values and goals. Our patients want and deserve excellent clinical care delivered with dignity, compassion, and professionalism and these remain our key quality goals. Over the last year we have spoken with over 30,000 patients in a variety of settings including, in their own homes, community clinics, and our inpatient and outpatient hospital wards as well as departments. We always ask patients how we are doing and what we could do better. We understand from patients that great healthcare is defined in the way that we treat patients, family members, carers and staff. As a result of this we continue to promote our RESPECT nursing and midwifery strategy which was developed by staff, patients, governors and stakeholders using the 6Cs vision. Compassion in Practice is the three year vision and strategy for nursing, midwifery and care staff drawn up by the Chief Nursing Officer for England. 114 Unconditional CQC Registration During 2015 – 16 the Trust met all standards required for successful and unconditional registration
Annual Report and Accounts 2015 – 2016 with the Care Quality Commission (CQC) for services across all of our community and hospital services. CQC 2015 – 16 Rating Also during 2015 – 16 the Trust was inspected by the CQC and was rated as ‘requiring improvement’, the CQC section within this report provides greater detail of the visit and outcomes. In a total out of the 85 individual ratings, 65 were rated as good. A number of areas were identified as good practice, including surgery, critical care, end-of-life care, the Trust’s simulation suite, community services and the Trust’s services at One Life Hartlepool. Achievements 2015 – 16
Congratulations to all of our staff who picked up awards or who were shortlisted at the Hartlepool Mail Best of Health awards. They were: Midwife of the year Stockton community midwife team Karen Pearson Unsung hero award Community dental service for the way they deal with a wide range of patients with kindness, understanding and compassion, calming even the most nervous people. Pharmacist of the year Peter Burrell who works with the chemotherapy team Careworker of the year Craig McCarthy, physiotherapist (nominated by a grateful patient who had a knee replacement) Hospital team of the year Ward 4 (elective care unit) Hospital doctor of the year Anil Agarwal Nurse of the year Gill Roberts, infection control nurse, for her support to residential and nursing care homes in Hartlepool Long term achievement award Sue Moore, Senior Clinical Matron Out-of-Hours (SCMOoH) started her career aged 17 as a student nurse in 1972 and qualified as an enrolled nurse at St Hilda’s Hospital in 1975. She worked in accident and emergency and later in orthopaedics becoming a modern matron. The nomination says Sue is a fantastic role model, a true professional and a huge influence. Shining stars
Developing excellent services Hospital play specialists Learner of the year Sarah Hodgson, education, learning and development Working behind the scenes The security team and Point of care testing team Student of the year Karabo Willis, student midwife Working in partnership Senior nurses for practice placements Unsung hero Sister Diane Jones, accident and emergency department 115 Healthcare worker of the year Annual Report and Accounts 2015 – 2016 Roger Barrett, lung health Outstanding contribution to volunteering David Charlton, health care worker caremaker Dedication to quality improvement The nursing team, critical care Leadership award Gary Wright, head of education and organisation development Team of the year The portering service Part 2a: 2015 – 16 quality improvement priorities
Part 2 of the Quality Account provides an opportunity for the Trust to report on progress against quality priorities that were agreed with external stakeholders in 2014 – 15. We are very pleased to be able to report some significant achievements during the course of the year. Consideration has also been given to feedback received from patients, staff and the public. Presentations have been provided at various staff groups with the opportunity for staff to comment on and a feedback form is provided for patients views. Progress is described in this section for each of the 2015 – 16 priorities. Stakeholder priorities 2015 – 16 The quality indicators that our external stakeholders said they would like to see reported in the 2015 – 16 Quality Accounts were:
Patient Safety Effectiveness of Care Patient Experience Mortality Discharge Processes Care For the Dying Patient Information (CFDP) & Family’s Voice Dementia Discharge Processes Is our care good? (Patient Medication Experience Surveys) Safeguarding Adults Nursing Dashboard Friends and Family (Learning Disabilities) recommendation
“I have found that this hospital is very caring. Dealt with wonderfully. My 1st visit would not hesitate to recommend this hospital to anyone.“ [sic]
116 Annual Report and Accounts 2015 – 2016 Priority 1: Patient Safety 1. Mortality
Rationale: To reduce avoidable deaths within the Trust by reviewing all available mortality indicators. Overview of how we said we would do it We will use Healthcare Evaluation Data (HED) benchmarking tool to monitor and interrogate the data to determine areas that require improvement. We will also review/improve existing processes involving palliative care, documentation and coding process. And finally, we will continue to work closely with the North East Quality Observatory System (NEQOS) for third party assurance. Overview of how we said we would measure it • We will monitor mortality within the Trust using the two national measures: • HSMR (Hospital Standardised Mortality Ratio) • SHMI (Summary Hospital-level Mortality Indicator) • Utilise nationally/regionally agreed tools to assist in assessing levels of clinical care. Overview of how we said we would report it • Report to Board of Directors • Report quarterly to the commissioners • Report to Keogh Operational Group Completed and reported? • Reported to Board of Directors • Reported to Commissioners • Reported to Keogh Delivery Group The Trust Board of Directors is aware and has an understanding of the higher than expected values of both Hospital Standardised Mortality Ratio (HSMR) and Summary Hospital-level Mortality Indicator (SHMI) and as a priority objective the emphasis is on demonstrable progress to reducing avoidable deaths in and (where possible influencing progress) out of hospital. In reflecting on the progress within mortality performance and governance and on the renewed national emphasis, the Trust continues to run the well-established Keogh Delivery Group to address a root and branch review of Professor Sir Keogh’s eight recommendations/indicators, which in turn impact on mortality levels. The Trust has assigned a dedicated professional lead, whose main responsibility is to improve processes that will aid in the reduction or mortality in the Trust. The Trust continues to undertake weekly centralised mortality reviews and as of January 2016 this has now been adapted to twice weekly reviews. It was agreed by commissioners in early 2015 that from April 2015 the Trust would be allowed to 117 include the ambulatory care patients. Previously to April 2015, the ambulatory care patients were excluded from our national data. By including them it will provide a more accurate picture of the Annual Report and Accounts 2015 – 2016 types of patients admitted and discharges to the Trust and in turn will aid in the mortality indicator reductions. The Trust, while using national mortality measures as a warning sign, is investigating more broadly and deeply the quality of care and treatment provided. Further progress this year will be supported by the following: • Continuing to play a key role in the Community Acquired Pneumonia Project and from April 2015 the Trust has been involved in the Serious Infection Project Collaborative, focussing on SEPSIS, support for this project is also provided by Clarity; • Ensuring a continued close working relationship with North East Quality Observatory (NEQOS) who provide an independent review of a number of indicators and also provide a quarterly mortality report; • To aid in collaborative thinking the Trust remains part of the Regional Mortality Group, this group has representation from all eight North East Trusts where all key mortality issues are discussed; • To obtain additional external assurance, the Trust requested that Advancing Quality Alliance (AQuA) come into the Trust in February 2016 to review the process for SEPSIS and Acute Kidney Injury (AKI), the results from this review are still pending; • The Trust will continue to work with partner GPs and the CCGs to examine patient pathways into and out of hospital to tackle overall improvements in end of life pathway delivery and safe discharge processes. The following data is from the two nationally recognised mortality indicators of Hospital Standardised Mortality Ratio (HSMR) and Summary Hospital-level Mortality Indicator (SHMI). Hospital Standardised Mortality Ratio (HSMR) March 2015 to February 2016 Healthcare Evaluation Data (HED) reporting period of March 2015 to February 2016 – Hospital Standardised Mortality Ratio (HSMR) measures the Trust as 111.94 against a national mean of 100.
150.00
100.00
50.00
0.00
Trust1 NTHFT Trust 3 Trust4 Trust5 Trust6 Trust7 Trust8
HSMR National Mean
The above HSMR graph demonstrates the Trusts 12 month HSMR value throughout the reporting period of March 2015 to February 2016, benchmarked against the other North East Trusts. The Trusts 12-month average for HSMR is currently 111.94, which remains above the national mean of 100.
HSMR 118 National Mean 100 Trust 1 127.23
Annual Report and Accounts 2015 – 2016 North Tees and Hartlepool NHS Foundation Trust 111.94 Trust 3 111.67 Trust 4 108.81 Trust 5 106.70 Trust 6 104.52 Trust 7 102.76 Trust 8 98.19
*Data obtained from the Healthcare Evaluation Data (HED) HSMR Improvement As the following table and chart demonstrates, the Trust has made great strides in reducing the HSMR value to 111.94 from the peak of 127.10 for the 12 month rolling period of April 2014 to March 2015.
12 Month period HSMR National Mean Dec 2013 to Nov 2014 121.37 100.00 Jan 2014 to Dec 2014 121.90 100.00 Feb 2014 to Jan 2015 127.08 100.00 Mar 2014 to Feb 2015 125.70 100.00 Apr 2014 to Mar 2015 127.10 100.00 May 2014 to Apr 2015 126.25 100.00 Jun 2014 to May 2015 126.10 100.00 Jul 2014 to Jun 2015 125.43 100.00 Aug 2014 to Jul 2015 124.12 100.00 Sep 2014 to Aug 2015 122.05 100.00 Oct 2014 to Sep 2015 120.33 100.00 Nov 2014 to Oct 2015 118.47 100.00 Dec 2014 to Nov 2015 118.90 100.00 Jan 2015 to Dec 2015 118.00 100.00 Feb 2015 to Jan 2016 113.03 100.00 Mar 2015 to Feb 2016 111.94 100.00
HSMR Trend (12 Month Values) 150
120
90
Aug '12 - Jul '13 Feb '13 - Jan '14 Aug '13 - Jul '14 Feb '14 - Jan '15 Aug '14 - Jul '15 Nov '12 - Oct '13 May '13 - Apr '14 Nov '13 - Oct '14 May '14 - Apr '15 Nov '14 - Oct '15 Mar '15 - Feb '16 HSMR National Mean 119 Palliative Care
HSMR is influenced by the coding of specialist palliative care. The Trust instigated a number of Annual Report and Accounts 2015 – 2016 changes to the palliative care process and team during 2015 – 16, to improve patient experience and quality of care. The first change was recruiting an End-of-Life Co-ordinator in May 2015 who works alongside the Specialist Palliative Care team, this post has ensured that a larger proportion of patients are being seen with the added level of support care given to those patients at the end of their life. The following table demonstrates the year on year comparison between 2014 – 15 and 2015 – 16 for number of contacts made and total number of patients seen by the Specialist Palliative Care Team.
Reporting Period Total contacts Total patients 2014 – 15 2,186 604 2015 – 16 2,724 1,081 The following table shows the month on month trend from April 2014 to the latest data available at the time of print. The End-of-Life Co-ordinator was recruited in May 2015.
Month Total contacts Total patients Apr-14 208 45 May-14 153 40 Jun-14 138 46 Jul-14 153 48 Aug-14 159 45 Sep-14 143 36 Oct-14 197 51 Nov-14 198 49 Dec-14 228 63 Jan-15 208 61 Feb-15 167 52 Mar-15 234 68 Apr-15 201 63 *May-15 227 104 Jun-15 297 103 Jul-15 259 93 Aug-15 219 82 Sep-15 294 113 Oct-15 294 88 Nov-15 250 107 Dec-15 216 108 Jan-16 205 94 Feb-16 145 74 Mar-16 117 52
The second change has been to provide a recognised Trust training programme for consultants who carry out Palliative Care. The training is provided by the Specialist Palliative Care Team and to date 21 consultants have gone through this programme.
120 Annual Report and Accounts 2015 – 2016 Summary Hospital-level Mortality Indicator (SHMI) October 2014 to September 2015 The SHMI indicator provides an indication on whether the mortality ratio of a provider is as expected, higher than expected or lower than expected when compared to the national baseline in England. SHMI includes deaths up to 30 days after discharge and does not take into consideration palliative care. The Trust SHMI is reporting as ‘higher than expected’ with a value of 117.74. The following chart and table demonstrate the Trust current SHMI position utilising the latest time period of October 2014 to September 2015, the other North East Trusts have been anonymised.
140.00 120.00 100.00 80.00 60.00 40.00 20.00 0.00
NTHFT Trust1 Trust5 Trust4 Trust7 Trust3 Trust6 Trust8 HSMR National Mean
SHMI National Mean 100 North Tees and Hartlepool NHS Foundation Trust 117.74 Trust 1 114.79 Trust 3 107.75 Trust 5 104.19 Trust 4 100.68 Trust 6 100.60 Trust 7 98.52 Trust 8 98.22
*Data obtained from the Healthcare Evaluation Data (HED)
121 Annual Report and Accounts 2015 – 2016 Priority 1: Patient safety 2. Dementia - Improving care for people with dementia
Rationale: There are currently approximately 14,000 people with a diagnosis of dementia across County Durham & Darlington and Tees. NHS Hartlepool/Stockton on Tees has the highest projected increase of dementia across the North East by 2025. All stakeholders identified dementia as a key priority. Currently, the Trusts 77.70% (actual vs. estimated) diagnosis rate, places the Trust 2nd nationally in identifying patients with the diagnosis of dementia. All hospital patients with dementia have a named advocate and an individualised plan of care. Overview of how we said we would do it • We will use the Stirling Environmental Tool to adapt and audit the impact on our hospital environment • We will ensure that all patients over 65 receive an Abbreviated Mental Test (AMT) and are, where appropriate referred for further assessment. • Patients with Dementia will be appropriately assessed and referred on to specialist services Overview of how we said we would measure it • The Stirling Environmental audit assessment tool will be used to monitor the difference pre and post environmental adaptation. • The percentage of patients who receive the AMT and, where appropriate, further assessment will be reported monthly via UNIFY. • We will audit the number of patients over 65 admitted as an emergency that are reported as having a known diagnosis of dementia, or have been asked the dementia case finding questions. • National Audit for dementia round 3 to commence in 2015. Overview of how we said we would report it • Dementia Strategy Group quarterly • Integrated Professional Nursing and Midwifery Board (IPNMB) • Monthly UNIFY Completed and reported? • Reported to the Dementia and Strategy Group • Reported to IPNMB • Reported through Commissioning for quality and innovation (CQUIN) measures
“I am the patient’s daughter. My mother has dementia. We have had excellent care and have greatly appreciated 122 the special nurses attendance when a family member has
Annual Report and Accounts 2015 – 2016 not been here. Thank you.“ [sic] How has the organisation focused on patient safety?
2015 – 16 – two national audits completed relating to the older persons and falls, both highlighted aspect of management requiring improvement. Both the aspects focused on the dementia delirium outcomes for the older persons and falls. Datix (Trust reporting system) information has now been further developed to include additional fields when undertaking an investigation specific to environment and dementia. Continued monitoring occurs and a further National Audit for Dementia round 3 is due to commence April 2016.
+75 Screening How? All patients aged 75+ are captured via the monthly UNIFY data; this has demonstrated compliance with the first 72 hours of screening for those fitting the inclusive criteria within the Trust. This highlights the need to refer to memory services and for delirium management support from the Trusts mental health provider Tees Esk Wear Valley. Quarter 3 saw the submission for community urgent referrals commence. The screening process supports the North of Tees approach to early diagnosis enabling the person to be informed and the family of to enable decision and consideration for life planning whilst capacity is still evident. Why? The new draft guidance is available on the NHS England website providing a future direction for supported early diagnosis and intervention to engage the person whilst they are able to engage and retain information. This is to be part of the 2016 – 17 proposed dementia collaborative work stream. Carers Support • Carers information packs are reviewed and updated annually; • This aims to reduce risk of carer breakdown, and information on how they can access individual carer’s assessment; • Informs carers what services they have access to; • Increases information on how they can access individual carer’s assessment; • Both Local authorities gave detailed directory of services to support the low level interventions required for people in their own homes; • If carers feel more supported, there is less risk of admission of the people they care for; • Supports financial and social benefit. Training How? 123 The Trust provides training determined by Health Education England (HEE) and national guidance.
The training is based on the specific needs of the department and can be delivered at the time and Annual Report and Accounts 2015 – 2016 location as a structured approach via the dementia champions work group. To date the first dementia champion’s course has just come to an end and the outcomes from the attendees has been excellent. The champions are multi-professional and directorate based. The programme incorporated a number of national strands set out by leading authorities nationally. The number of trained staff within the Trust is over and above the nationally required target. In addition to this the community dementia service have delivered and supported a number of external organisations in relation to tier 1 dementia friends training, i.e. Hartlepool Hospice and Gretton Court have a number of training sessions for all employees trained. Part of the training now covers the physical aspects i.e. improvement to nutrition and communication. Review of dementia training brought it in line with HEE funding. Why? • To highlight the importance of good quality, trained staff to improve patient experience and patient safety; • 6Cs initiative; • Dementia friends. Patients admitted with a diagnosis of Dementia/Delirium The Trusts appointment of a dementia nurse specialist in 2014 – 15 has continued to reap benefits, which enhances the patient experience and support to carers. To demonstrate the challenges that Dementia/Delirium poses on the general healthcare economy, the following tables trend the number of patient’s admitted to the Trust since April 2013.
Patients admitted with a diagnosis of Dementia/Delirium
2600 2,475 2400 2,217 2250 2100 1,833 1950 1800 1650 1500 1350 1200 1050 900 750 600 450 300 150 0 2013-2014 2014-2015 2015-2016
*Data from Information Management Department Since April 2013 the Trust has admitted 6,525 patients with a diagnosis of Dementia/Delirium of which 60.63% (3,956) are females and 39.37% (2,569) are males.
Patients (by gender) admitted with a diagnosis of Dementia/Delirium 2000
1600 1,461 1,339 124 1400 1,156 1200 Annual Report and Accounts 2015 – 2016 1,014 1000 878 800 677 600 400 200 0 Male Female 2013-2014 2014-2015 2015-2016
*Data from Information Management Department Community Dementia Liaison Service (CDLS) • 2.0 Whole time equivalents (wte) within the Hartlepool locality; • Reablement and admission avoidance; • Educational function across all agencies; • Nil complaints since commencement; • Crisis intervention; • Support whole pathway journey; • Close working relationships with Tees, Esk and Wear Valleys (TEWV) Trust; • Supported discharge process; • Close liaison with GPs; • Integrated approach with the Hartlepool local authority staff; • They are to be relocated to UHH floor 1 in this supported role. Better Care Fund (BCF) Stockton Borough Council have their own work stream to develop a number of actions to support the early diagnosed person. The focus for this client group is around admission and admission avoidance. Hartlepool has stronger links with health and this is provided through the commissioned health component and their own re-enablement team working closely with the community service. • 1 to 1 support workers; • Criteria developed; • Roles and responsibilities; • Standard Operating Procedure; • Detailed training programme; • 1 year funded pilot with evaluation re-outcomes. “My husband has dementia and the care given to him was excellent. Cleanliness and food were good and staff very helpful to patient and visitors.“ [sic]
125 Annual Report and Accounts 2015 – 2016 Dementia Screening – Monthly Data Collection – April 2015 – March 2016 The prevalence study identified a number of measures which are reported in the table below:
Question a: Number of patients 75 and above admitted as emergency inpatients, reported as having been asked the dementia case finding question within 72 hours of admission to hospital or who have a clinical diagnosis of delirium on initial assessment or known diagnosis of dementia. Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar 409 402 392 300 386 411 437 480 478 443 414 559 Question b: Number of patients aged 75 and above, admitted as emergency inpatients, minus exclusions. Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar 409 412 392 300 406 411 480 487 479 446 428 564 Question c: % of all patients aged 75 and above admitted as emergency inpatients who are asked the dementia case finding question within 72 hours of admission or who have a clinical diagnosis of delirium on initial assessment or known diagnosis of dementia. Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar 100% 97.60% 100% 100% 95.10% 100% 91% 98.60% 99.80% 99.30% 96.70% 99.10% Question d: Number of admissions of patients aged 75 and above admitted as emergency, inpatients who have scored positively on the case finding question or who have a clinical diagnosis of delirium reported as having had a dementia diagnostic assessment including investigations. Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar 40 41 47 21 45 27 45 43 30 23 86 72 Question e: Number of patients aged 75 and above admitted as emergency inpatients who have scored positively on the case finding question or who have a clinical diagnosis of delirium. Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar 40 41 47 21 45 27 45 43 30 23 86 72 Question f: % of all patients aged 75 and above admitted as emergency inpatients who have scored positively on the case finding question, or who have a clinical diagnosis of delirium and who do not fall into the exemption categories reported as having had a dementia diagnostic assessment including investigations. Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Dementia Training by Staff Group
Training levels: Tier 1 - Dementia Awareness Raising This is mandatory to the entire workforce in health and care, involving the completion of ‘Essential Dementia Workbooks’ at the appropriate level according to job role. The team also provide a 1.5 hour face to face training session on request. Within this we have an element of ‘Barbara’s Story’ which involves short films focussing on different aspects of Barbara’s 126 journey through the healthcare system. Also when this face to face training is complete you have the choice whether you would like to be a Dementia Friend as this training has been accredited by the Alzheimer’s Society to be able to do this. Annual Report and Accounts 2015 – 2016 Tier 2 – Knowledge, skills and attitudes for roles that have regular contact with people living with dementia This is the level ‘Dementia Champions’ are set. To support this level of training we have commenced a Dementia Champion programme which runs every month (3 hours) for 11 months. The purpose of the Dementia Champions is to create an individual with a high level of knowledge of dementia. The six stages of ‘Barbara’s Story’ is used and discussed. This training involves support from other multi-disciplinary teams as guest speakers. On dementia SharePoint a timetable is available to view and establish what the programme entails. Tier 3 – Enhancing knowledge, skills and attitudes for key staff in a leadership role The dementia team do not deliver this but this is relevant to staff working intensively with people affected by dementia; for example, university modules/bespoke study days in relation to dementia care. Dementia Level Training by Quarter
Q1 Q2 Q3 Q4 Dementia Tier 1 96% 97% 97% 97% Dementia Tier 2 91% 93% 94% 94% Dementia Tier 3 87% 89% 88% 89% *Data obtained from the Trust dementia training Priority 1: Patient safety
Safeguarding Safeguarding Adults with Learning Disabilities (LD) All patients with a learning disability admitted to hospital will have a named advocate and an individualised plan of care. Rationale: The Trust and Commissioners believe that people with LD should not be in hospital unless absolutely necessary. When it is necessary to admit patients with LD, they will have an individualised plan of care and a named advocate. Overview of how we said we would do it • All patients with LD will be referred on admission to the LD specialist nurse • The LD Specialist nurse will act as the named advocate and will ensure that an individualised plan of care is in place and reasonable adjustments documented Overview of how we said we would measure it • Audits will be carried out and results reported Overview of how we said we would report it • Audit results and action plans to be reported to Adult Safeguarding Group quarterly Completed and reported? • Audit plans and results presented to Adult Safeguarding Group quarterly • Learning Disabilities steering group Adult Safeguarding Throughout 2015 Adult Safeguarding has continued to make positive strides towards its objectives. The aim of PREVENT is to stop people from becoming terrorists or supporting terrorism. Three national objectives have been identified for the PREVENT strategy: • Objective 1: respond to the ideological challenge of terrorism and the threat we face from those who promote it; • Objective 2: prevent people from being drawn into terrorism and ensure that they are given appropriate advice and support; • Objective 3: work with sectors and institutions where there are risks of radicalisation which we 127 need to address.
PREVENT has continued to be addressed within the adult safeguarding portfolio. We currently Annual Report and Accounts 2015 – 2016 have 18 PREVENT trainers across the Trust who delivers the nationally agreed Workshop to Raise Awareness of PREVENT (WRAP). Global events in Syria have continued to ensure the principles of counter terrorism outlined below remain in the NHS workforce agenda. An e-learning package has also been developed for staff to complete. Safeguarding adults North Tees and Hartlepool NHS Foundation Trust continues to work to enhance and develop standards for safeguarding adults across the hospitals and community services. Provision of specialist advice relating to implementation of The Mental Capacity Act (MCA), Deprivation of Liberty Safeguards (DoLS) and the Human Rights Act provides added assurance that the Trust remains compliant with legislation. In 2015 – 16 the team have seen as significant increase in DoLS 688. The Safeguarding team processed 166 Deprivation of Liberty Safeguard applications in 2014 – 15. The Trust is currently hosting a post via Public Health to respond to Domestic abuse. The Charity Harbour provides a Domestic abuse Health Link Worker who works alongside the adult safeguarding team. April 2015 saw the launch of a Trust Policy addressing the issues of Domestic Abuse. A Domestic Abuse Policy has been agreed and is now in place. During 2015 – 16 a high profile campaign raising awareness was undertaken in relation to this area of adult safeguarding. Safeguarding awareness week was carried out in June, to raise awareness on the wards; these sessions were carried out in the tower block, west wing and Hartlepool site. The safeguarding team have carried out safeguarding champions days to give key staff more intensive training, to date we have trained 82 champions. Training activity 2015 – 16 Tees-wide multi agency training is undertaken at level one via a workbook which is distributed through induction and following completion is marked and discussed with the line manager before being signed off. The target audience for level 1 was widened this year. Compliance with the level one training across the Trust is 94%. Compliance with the level two workbook and compliance across the Trust is 91%, the three members of staff who are not compliant will be by the end of quarter 1 2016 – 17. Trust Reporting For each quarter the Trust produces an Adult Safeguarding report. The purpose of this report is to provide the North Tees and Hartlepool NHS Foundation Trust Safeguarding Vulnerable Adults Steering Group members an overview of quarterly safeguarding activity within the previous quarter, with the objective that information relevant to their areas of representation may be disseminated through respective clinical governance frameworks. Additionally, the importance of two way communications are recognised as vital to ensure safeguarding adult activity is embedded within practice across adult health and social care. Therefore this report will subsequently highlight areas of good practice within all service areas requiring development as well as providing actions agreed from discussion within the group. The data contained in the report breaks down the following key themes: • Alerts raised by Local Authority; • Number of referrals; • Alerts raised by age and gender; • Number of alerts raised by Trust role; • Number of alerts raised by location; • Number of alerts raised by theme; • Incidents raised by type of abuse, Trust role and outcome; • Number and type of incident by age (18 – 60); • Number and type of incident by age (61 – 80); 128 • Number and type of incident by age (81+);
Annual Report and Accounts 2015 – 2016 The report is presented internally and shared with our commissioners. Location (Local Authority) In the 2014 – 15 reporting year, there were 240 adult safeguarding alerts raised across the Local Authorities of Durham, Hartlepool and Stockton. The Trust continues to use and develop further an in-house developed adult safeguarding database. This tool helps to collate, trend and theme the data. The data produced is governed through the quarterly Safeguarding Vulnerable Adults Steering Group to Patient Safety & Quality Standards Committee (PS & QS) Since April 2015 there have been 241 Adult Safeguarding incidents across the Local Authorities of Durham, Hartlepool and Stockton. Please see the following breakdown:
Number of Referrals Durham Hartlepool Stockton Q1 April 15 3 8 10 May 15 2 4 13 June 15 0 6 19 Q2 July 15 2 9 14 August 15 1 8 13 September 15 2 4 14 Q3 October 15 0 4 10 November 15 0 7 15 December 15 0 7 10 Q4 January 16 2 7 10 February 16 0 3 13 March 16 1 6 14 Total 13 73 155 *Data from the Trusts Adult Safeguarding database The following table details the allegation types raised per month for all Local Authorities. It is important to note, that there can be multiple allegation types per referral. Allegation types raised per month for all Local Authorities
Q1 Q2 Q3 Q4 Total Discriminatory 1 0 0 0 1 Emotional 7 7 6 6 26 Financial 6 5 3 4 18 Institutional 1 1 1 1 4 Modern Day Slavery 0 0 0 1 1 Neglect 48 51 39 42 180 Physical 18 19 12 15 64 Sexual 2 1 2 1 6 Total 83 84 63 70 300 *Data from the Trusts Adult Safeguarding database The following two tables are the allegation types raised per month for all Local Authorities by gender. Male: 129 Q1 Q2 Q3 Q4 Total
Discriminatory 1 0 0 0 1 Annual Report and Accounts 2015 – 2016 Emotional 1 3 0 1 5 Financial 0 2 1 2 5 Institutional 1 0 0 1 2 Modern Day Slavery 0 0 0 0 0 Neglect 22 21 11 21 75 Physical 6 5 4 4 19 Sexual 0 0 1 0 1 Total 31 31 17 29 108 *Data from the Trusts Adult Safeguarding database Female:
Q1 Q2 Q3 Q4 Total Discriminatory 0 0 0 0 0 Emotional 6 4 6 5 21 Financial 6 3 2 2 13 Institutional 0 1 1 0 2 Modern Day Slavery 0 0 0 1 1 Neglect 26 30 28 21 105 Physical 12 14 8 11 45 Sexual 2 1 1 1 5 Total 52 53 46 41 192 *Data from the Trusts Adult Safeguarding database The following tables detail the allegation types raised across all three Local Authorities, it is important to note that there can be multiple allegation types per referral. The 2015 – 16 data in the following tables is split down per local authority and is also benchmarked against the previous years (2014 – 15) data. Durham Local Authority
Allegation Type 2014-15 Durham 2015-16 Durham Discriminatory 0 0 Emotional 3 3 Financial 2 1 Institutional 0 0 Modern Day Slavery 0 0 Neglect 8 10 Physical 8 4 Sexual 1 0 Total 22 18 *Data from the Trusts Adult Safeguarding database Hartlepool Local Authority
Allegation Type 2014-15 Hartlepool 2015-16 Hartlepool Discriminatory 0 1 Emotional 12 7 Financial 9 2 Institutional 3 2 130 Modern Day Slavery 0 0 Neglect 43 56
Annual Report and Accounts 2015 – 2016 Physical 18 12 Sexual 0 2 Total 85 82 *Data from the Trusts Adult Safeguarding database Stockton Local Authority
Allegation Type 2014-15 Stockton 2015-16 Stockton Discriminatory 1 0 Emotional 28 16 Financial 13 15 Institutional 2 2 Modern Day Slavery 0 0 Neglect 122 114 Physical 60 48 Sexual 2 4 Total 228 199 *Data from the Trusts Adult Safeguarding database Trust Adult Safeguarding Governance Arrangements The Director of Nursing, Quality and Patient Safety is the executive lead for safeguarding adults along with the Deputy Director of Nursing who has operational responsibility for safeguarding adults through the directorate leads. Directorate management teams are responsible for practices within their own teams and individual clinicians are responsible for their own practice. The Trust Adult Safeguarding Committee has been revised and includes representatives from key Trust clinical and non-clinical directorates and partners from Local Authority and Harbour who are experts in domestic abuse. The Trust Adult Safeguarding Committee reports to Patient Safety and Quality Standards Committee (PS & QS). Attendance and participation in adult safeguarding activity remains positive. The Trust is represented at both Hartlepool and Stockton Local Authority Adult Safeguarding Boards and maintains strong links with Durham; the Trust is also represented at the Tees wide Adult Safeguarding Board. The Trust Strategy groups for adult safeguarding and learning disability all have reciprocal standard agenda items and membership. This supports sharing of information and lessons learnt so that they can be incorporated into relevant work streams relating to the most vulnerable groups. Safeguarding Adult Achievements The Trust has implemented a Single Point of Contact system (SPOC) as well as a reporting system for internal and external safeguarding alerts. Each alert is added to a central database and progress of the vulnerable adult can be tracked and managed towards an acceptable outcome. This has been extended to include a separate equivalent system for people with Learning Disabilities and the main system now includes domestic abuse cases. These systems enable The Trust to provide a robust process for developing reports on a regular basis across the Trust. The Adult Safeguarding Steering group now receives the report in respect of activity data each quarter and disseminates the lessons learnt to improve practice. Communication issues within discharge have been a focus of alerts across Hartlepool and Stockton. 131 The Trust continues to further develop its National reputation within adult safeguarding, hosting an event for the National Learning Disability network in 2015. It also contributed to the post House of Annual Report and Accounts 2015 – 2016 Lords review of The MCA through the National MCA DoLS Reference group. To date, the Trust has had 0 PREVENT referrals during 2015 – 16. Looking ahead/key challenges The key challenges for Adult Safeguarding in 2015 – 16 were: • Reviewing and enhancing vulnerable patient’s experience of safe discharge; • Developing understanding of professional accountability within adult safeguarding; • Increased visibility of the safeguarding team within the Trust; • Improving links between practice and effective clinical supervision; • Policy on DoLS and Adult Safeguarding have been updated, in line with Tees-wide procedures and the Care Act 2014; • Enhance the clinical documentation of Best Interest decisions by undertaking further audits using the recently Tees-wide adopted audit tool; • Implement the principles of Deciding Right into practice; • Significant progress is reported in terms of PREVENT. An event saw 18 plus staff trained as trainers WRAP 3 trainers. They will go onto deliver the health wrap course to their Directorates. A newly developed regional network for trainers is developed and our trainers will have access to this forum. We have strong links with this group. E-learning with regards to Prevent awareness was rolled out and so far over 800 staff have received training; • Improving Community pathways for people with learning disabilities in line with CQUIN requirements. Our Trust will take part in a national work stream which combines The Mental Capacity Act and young People with learning Disabilities; • Our Trust anticipates that work undertaken with Public Health Commissioners and Harbour will lead to the pilot of working with an independent domestic violence worker within the Trust. Children’s safeguarding A child/young person is defined as anyone who has not yet reached their 18th birthday. North Tees and Hartlepool NHS Foundation Trust has a duty in accordance with the Children Act 1989 and Section 11 of the Children Act 2004 to ensure that its functions are discharged with regard to the need to safeguard and promote the welfare of children and young people. The Trust recognises the importance of partnership working between children/young people, parents/ carers and other agencies to prevent child abuse, as outlined in Working Together to Safeguard Children and their Families, 2015. In addition arrangements to safeguard and promote the welfare of children must also achieve recommendations set out by the Care Quality Commission Review of Safeguarding: A review of arrangements in the NHS for safeguarding children, 2009 and give assurance as outlined in the National Service Framework for Children, Young people and Maternity Services, 2004 (Standard 5). The Trust continues to demonstrate robust arrangements for safeguarding and promoting the welfare of children. The Trust continues to deliver on all local performance indicators relating to children’s safeguarding and in 2014 – 15 underwent a review of Health Services for Children Looked After and Safeguarding in Stockton on Tees by the Care Quality Commission (CQC) and a single agency OFSTED review in Hartlepool. The action plan developed from this is continually monitored and fed back through the Trust's safeguarding children steering group. The CQC have recently reviewed Hartlepool’s Health Services for Looked After Children and Safeguarding in January 2016 and are awaiting the final report. 132 The Trust is represented on three Local Safeguarding Children’s Boards (LSCBs) – Hartlepool, Stockton-On-Tees and County Durham and their respective sub groups and continues to provide Annual Report and Accounts 2015 – 2016 assurance via completion of Section 11 that duties in relation to this are being discharged. There are a number of examples of excellent developments which have been undertaken. A new policy ’Children Not Brought for Appointments by Parents/Carers’ has been developed and has been launched Trust-wide. This is in response to a local Serious Case Review which identified that missed health appointments are an early indicator of neglect and the importance of responding to and assessing those children who may be at risk. Work is on-going around how The Trust can identify children whose appointments are frequently rescheduled by parents/carers alongside this. The Safeguarding Supervision policy has been revised and updated to ensure that The Trust's staff understand and are supported in their responsibility under current legislation to safeguard and promote the welfare of children, and to enable the Trust to meet its statutory duties in this regard. The changes also encourage a move away from a Senior Nurse ‘case management’ approach and towards a more reflective and autonomous approach which empowers and enables the practitioner to transfer the reflective thinking from their supervision to other cases within their caseload. Regular meetings have been established between the named Nurse and staff within the Human Resources (HR) department to improve communication and referrals to the Local Authority Designated Officer (LADO). It has subsequently been identified that the Human Resource leads would benefit from additional Safeguarding Training at level 3 and their training needs have been adjusted accordingly. Additional safeguarding training has been delivered to the Trust's senior managers to increase their awareness of adult risky behaviours that may require safeguarding intervention when supporting staff during sickness/absence or capability issues. Safeguarding children practice clinics delivered by the Safeguarding Team have continued and have been well received. These forums provide key opportunities to engage with frontline staff to deliver key learning outcomes from Serious Case Review or changes to procedures. Work has continued in accessing electronic records in the Accident and Emergency department and staff now have a generic email account and read only access to Systm1 to ensure effective information sharing between community staff and other agencies when there is a safeguarding concern. Audit of the Quality and Healthcare records is now embedded in children’s services. This includes an internal audit process that incorporates a quarterly deep dive audit where the General Manager for Nursing and Professional Standards and Deputy Director of nursing attend. The quality of assessment, planning and outcomes for children who are at risk of significant harm are measured, and areas of good practice and lessons to be learnt are identified and fed back to front-line practitioners. A report is produced bi-annually on the findings and common themes Multi-agency case file audits are undertaken with Hartlepool and Stockton Local Safeguarding Children Boards to identify learning across wider agencies. A SharePoint page has been developed and is now live on the Trust's intranet which identifies members of the safeguarding Children team, their contact details and useful resources including training courses and dates. Child Sexual Exploitation (CSE) continues to be a growing concern; The Trust is represented at the Tees Strategic Meeting and the Vulnerable Exploited Missing and Trafficked (VEMT) multi-agency operation group. This identifies those children and young people at risk, allows for the sharing of information between practitioners and helps to put safety measures in place to attempt to reduce risk. Leading on from this, the Trust's awareness of E-Safety has been a priority which has resulted in the development of the E-Safety agreement (this is an agreement that parents and children are asked to sign up to when a child becomes an inpatient). In essence parents and children are asked to follow some basic rules to ensure safe use of electronic/smart equipment within hospital premises. This is complimented by E-Safety awareness posters in relevant children’s areas throughout the Trust. The Named Nurses are involved in line with statutory responsibility with partner agencies in identifying and compiling learning lessons reviews and serious case reviews, the learning of which is disseminated to front-line practitioners and actions implemented to improve practice. To assist staff within the Trust to raise and take forward child protection concerns, standard processes in relation to escalation of cases have been developed which compliments the local Tees procedures. Flow charts have been developed to represent these standards. Safeguarding Children Senior nurses attend Multi Agency Risk Assessment Conferences (MARAC) where high risk victims of domestic abuse are identified and safety plans put in place. More recently staff from both the safeguarding children and adults team have worked together on the 133 development of the Domestic Abuse policy which has been ratified.
Safeguarding Medical Champions have been identified from each Directorate throughout the Annual Report and Accounts 2015 – 2016 Trust to support and drive forward the safeguarding children agenda. It is planned to roll this out to identify safeguarding nursing champions within each directorate. The Named Doctors for safeguarding children hold a peer review monthly meeting to discuss cases and share practice issues and experiences. An annual evaluation report is produced by one of the Named doctors. Safeguarding Children Training Programme Throughout 2015 into 2016 the Trust’s in-house Safeguarding Children Training Programme has continued to provide mandatory foundation and update single agency training for all staff employed within the organisation. The training is in-line with the requirements of Safeguarding Children and Young people: roles and competences for health care staff; Intercollegiate Document (2014) and the Trust’s Safeguarding Children Training Policy. High levels of compliance and standards have been maintained. Level 1 – All non-clinical staff working in health care settings. For example, receptionists, administrative, porters Level 2 – All clinical staff who have any contact with children, young people and/or parents/carers. This includes health care students, clinical laboratory staff, pharmacists, adult physicians, surgeons, anaesthetists, radiologists, nurses working in adult acute/community services, allied health care practitioners and all other adult orientated secondary care health care professionals, including technicians Level 3 – All clinical staff working with children, young people and/or their parents/carers who could potentially contribute to assessing, planning, intervening and evaluating the needs of a child or young person and parenting capacity where there are safeguarding/child protection concern. This includes paediatric allied health professionals, all hospital paediatric nurses, hospital based midwives, accident and emergency/minor injuries unit staff, obstetricians, paediatric radiologists, paediatric surgeons, children’s/paediatric anaesthetists, and paediatric dentists. Where appropriate staff are required and supported to attend multi-agency training provided by the LSCB and other external providers and this is a mandatory requirement for those staff groups identified as requiring Level 3 plus competencies. Bespoke training is developed and provided and mandatory in-house training is continually updated and reviewed in response to learning identified in practice, during supervision, appraisals, Datix themes, Learning Lessons Reviews, Serious Case Reviews, and new and changing national guidance and legislation. The bespoke training sessions on ‘Professional Challenge’ previously provided to identified staff groups have now been incorporated into the Trust Safeguarding Children core training rolling programme and are open to all staff. It has also been agreed that this training will be incorporated into the SLSCB and HLSCB Multiagency Training Programme facilitated by the Trusts Safeguarding Children Trainers. In response to the Domestic Violence and Abuse: Multiagency Working (NICE 2014) and development of the Trusts policy, Domestic Abuse training has continued to be provided to Health Visitors within the Trust and in 2016 this will extend to School Nurses, Midwives and A&E staff. The Senior Nurses for Safeguarding Children continue to co-facilitate the information sharing training in partnership with Stockton and Hartlepool Safeguarding Children Board. The Safeguarding Children Trainers have jointly developed a core foundation multiagency training course with Hartlepool and Stockton LSCB and co-facilitates the course with the LSCB Trainers. The Safeguarding Children Trainer and Named Drs also jointly facilitate Safeguarding Babies training for Stockton LSCB. Hartlepool and Stockton LSCB are participating in a pilot in partnership with the National Society for the Prevention of Cruelty to Children (NSPCC) Graded Care Profile 2 Tool. The safeguarding 134 children trainers are working with Early Help leads to roll out the required training and in providing support and advice to staff members. The Named nurse and trainers are contributing members of
Annual Report and Accounts 2015 – 2016 the Steering Group taking this forward. In addition the trainers and senior nurses have been identified as practice leads to support the implementation of the Signs of Safety tool across the area. The Tool has now been launched and will be used during all Child Protection Strategies and Case Conferences. To support the recent developments and demands on resources one of the safeguarding children posts have increased by 0.4WTE until February 2017. Overall Trust Compliance for Safeguarding Children Training
Month Level 1 Level 2 Level 3 Apr-15 100% 98% 92% May-15 100% 97% 92% Jun-15 100% 98% 91% Jul-15 99% 97% 94% Aug-15 99% 97% 94% Sep-15 99% 97% 96% Oct-15 99% 97% 98% Nov-15 99% 97% 97% Dec-15 99% 97% 95% Jan-16 99% 98% 95% Feb-16 98% 97% 95% Mar-16 98% 97% 96%
Sensory Loss The Equality Act became law in October 2010 and is aimed to improve and strengthen patient’s experiences by ensuring all service providers take steps or make reasonable adjustments in order to avoid putting a disabled person at a disadvantage when compared to a person who is not 135 disabled and/or has some degree of sensory loss or impairment. Annual Report and Accounts 2015 – 2016 The Trust continues to make improvements to the care provided to patients with sensory loss, these include: Identifying Patients with Sensory loss Significant changes have been made to Core Admission Documentation to identify more clearly patients who have a sensory loss/impairment. The planning of care has also been improved to include documenting the reasonable adjustments required to support the patient during their hospital stay, with the associated care plans put into place and reviewed as part of daily intentional rounding processes. Patient Experience After listening to patient’s comments, the mobile phone service has been reinstated as part of the Patient Experience Team support process to allow texting as a form of communication for deaf/hard of hearing patients. Quarterly meetings are held with the current provider of Interpretation and Translation services, Specialist Mental Health Nurse for patients with sensory loss and Hartlepool Deaf Centre to work together on issues raised by patients and thus support service development. Specialist Equipment An audit of fixed hearing loop provision throughout the Trust was performed, the results highlighted which equipment required maintenance and re-siting of equipment to maximise its use in addition to raising awareness amongst staff of the equipment in their clinical areas. The audit of portable hearing loops highlighted gaps in staff awareness and accessibility of these systems by staff. The portable hearing loops were then removed from the wards and stored in the medical equipment library so they are available to all when needed on a 24 hour basis. A portable hearing loop is also kept in the resilience offices on both sites for emergency use. Celebrating deaf/blind week On an annual basis charities and local partner agencies hold information stalls at both hospital sites to raise awareness of sensory loss and celebrate the work taking place to support patients and their families. Groups involved over the course of the week include Health watch, Hartlepool Deaf Centre, Action on Hearing Loss, Guide Dogs for the Blind and local authority partners. In addition to having stalls and displays some of the restaurant food menus were presented in Braille during the week. The Accessible Information Standard A new information standard has recently been launched by NHS England which will improve healthcare for millions of people with sensory loss and other disabilities. The Accessible Information Standard directs and defines a specific, consistent approach to identifying, recording, flagging, sharing and meeting the information and communication support needs of patient’s, service users, carers and parents where their needs relate to a disability, impairment or sensory loss. The Accessible Information Standard requires all NHS and adult social care organisations to meet the communication needs of people with a disability, impairment or sensory loss by 31 July 2016. Currently the Trust is working with colleagues to meet the key milestones of the implementation plan to ensure compliance and achievement of the Standard. Priority 2: Effectiveness of Care
Discharge processes – Rationale: Although quality of discharge information has improved considerably over the years, this remains a priority with further improvements recommended by stakeholders. Overview of how we said we would do it • Undertake an audit of discharges Overview of how we said we would measure it • Audit a number of patient discharges for the following information: 1. Reason for admission/presenting symptoms? 2. Mode of admission? 136 3. Diagnosis for this episode? 4. Was this diagnosis correct (for cases with a documented diagnosis)? Annual Report and Accounts 2015 – 2016 5. Procedures/operations recorded? 6. Were these correct (for cases with a documented procedure/operation)? 7. Medication changes? 8. Were these correct (for cases with a documented medication change)? 9. Reasons for all changes (for cases with a documented medication change)? 10. If patient has MRSA or C.Diff was this documented? 11. Are results pending 12. Immediate post discharge plan for primary healthcare team? 13. Was this correct (for cases with a documented plan)? 14. Issue of a sickness certificate? Overview of how we said we would report it • To the Audit and Clinical Effectiveness (ACE) Committee Completed and reported? • Reported to ACE Committee
The audit consisted of 120 discharges and was undertaken during quarter 1 of 2015 – 16. The 120 discharges were split into the following; 30 surgery, 30 orthopaedics, 30 medicine and Elderly Care and 30 obstetrics and gynaecology.
Were the following clearly documented on the discharge summary? 2013-14 2015-16 1. Reason for admission/presenting symptoms? 99% 98% 2. Mode of admission? 63% 64% 3a. Diagnosis for this episode? 97% 98% 3b. Was this diagnosis correct (for cases with a documented diagnosis)? 99% 99% 4a. Procedures/operations recorded? 81% 58% 4b. Were these correct (for cases with a documented procedure/ 100% 100% operation)? 5a. Medication changes? 69% 58% 5b. Were these correct (for cases with a documented medication change)? 94% 100% 137 5c. Reasons for all changes (for cases with a documented medication 62% 86% Annual Report and Accounts 2015 – 2016 change)? 6. If patient has MRSA or C.Diff was this documented? 2% N/A Are results pending 1% N/A 7a. Immediate post discharge plan for primary healthcare team? 80% 84% 7b. Was this correct (for cases with a documented plan)? 100% 100% 8. Issue of a sickness certificate? 6% N/A *Data obtained from the Trust wide Discharge Audit
“Swift, professional, caring and expert treatment. Discharge was quick and co-ordinated. Excellent, thank you.” [sic] Priority 2: Effectiveness of Care
15. Discharge processes – Medication Rationale: The latest national patient experience survey identified that the Trusts still have work to do with regards to medication discharge processes. Overview of how we said we would do it • All patients will receive information about medication side-effects to watch out for at home. Overview of how we said we would measure it • Via national and local patient surveys Overview of how we said we would report it • Local audit reports reported to Drug and Therapeutic Committee • National inpatient survey report to PS & QS Completed and reported? • Reported to PS & QS • Reported to the Drug and Therapeutic Committee “Nurses are very friendly and helped me with all medication and answered all my questions for me.” [sic]
The National In-patient and Out-patients Surveys are undertaken and include questions about medicines, including one for patients receiving information regarding which medication side-effects to watch out for at home. Medicines are dispensed mainly as Original Packs to ensure patients will receive information leaflets to inform them of any possible side effects that the medication may cause. Medicines are also dispensed with green sheets to show what medication has been dispensed and a web link to access further information. The Trust has shown an increase in the number of medication errors being reported. 554 incidents were reported in 2014 – 15 as originating with the Trust. During 2015 – 16 the figure was 609 which is a 10% increase on the previous year’s total figure. This shows an improvement in awareness of the importance of reporting incidents which allow incidents to be investigated and actions taken to improve safe practice. Medicines Safety In 2014 – 15 there were 624 medicines related incidents reported via our internal reporting database (Datix), of which 554 originated within the Trust. In 2015 – 16 there were 692 medicines related incidents reported via our internal reporting database (Datix), of which 609 originated within the Trust.
Type of incidents 2013-14 2014-15 2015-16 138 Prescribing 124 147 224 Administration 256 314 321 Annual Report and Accounts 2015 – 2016 Dispensing 41 43 48 Other 56 50 16 Total 477 554 609 *Data from the Trusts Pharmacy Department Optimising Safe Medication Practices Group • Medications Safety Officer appointed; • Analyse and theme incidents; • Introduce system changes to reduce errors; • Engage with users. As a Trust we are using technology to improve safety and reduce delays in medication administration. One example is electronic medicine cupboards (Omnicells) with biometric access which have been introduced in a number of areas. This has improved services through: • Keys no longer necessary; • Increased access to pre-labelled medicines outside of pharmacy hours; • Guiding lights improves safety and reduces time searching for items; • Stock controlled by pharmacy allowing nurses to spend more time with patients and reduces waste through appropriate stock levels. Automated Cupboards Omnicell Cupboards reduce administration through: • Fingerprint access means staff no longer having to search for keys; • Cupboards reduce delayed discharges by allowing increased access to pre-labelled medicine outside of pharmacy hours; • Organisation and Guiding Lights improves safety and reduces time searching cupboards; Other associated technology • Pharmacy Intranet Resource; • Updated Ascribe programme for: • Decision Support System; --Drug Interactions --Dose/Age --Dose/Weight • Patient Leaflets; • Planned improvements to electronic prescribing; • Planned Computer Tablets. The Pharmacy department has increased the level of support available to staff by taking pharmacy to the wards. Pharmacy intranet resource and pharmacy discharge teams mean that: • More pharmacist prescribers support with writing of discharge prescriptions; • Amendments to prescriptions and supply of medicines can be made at ward level; • Counselling can be provided by pharmacy staff to the patient at the point of discharge identifying any potential issues. Support • Increasing outreach of pharmacy support reducing delays; • Amendments can be made to prescription at point of supply reducing time spent contacting the Doctor; • Discharge prescriptions can be written by a pharmacist; • Pharmacy discharge teams; 139 • Supply can be made at ward level reducing need to send to hospital dispensary; Annual Report and Accounts 2015 – 2016 • Discharge team can provide counselling on discharge medications, identifying any potential issues; • Medicines discharge check list developed to reduce errors/omissions at point for discharge. Post Graduate Training The pharmacy department staff are involved in postgraduate and undergraduate training for staff. Links with the education department and analysis of medication errors means that we can provide the training that a safer workforce needs. This training can be delivered through classroom, workbook and e-learning packages. We also work with our local universities influencing curricula and are involved with inter-professional learning. Priority 2: Effectiveness of Care
16. Nursing Dashboard Rationale: The nursing dashboard will support close monitoring of nurse sensitive patient indicators on a day-to-day basis. It will support sharing of best practice and speedy review of any potential areas of concern. Overview of how we said we would do it • Training will be completed and each department will evidence that their results have been disseminated and acted upon • Ward matrons will present their analysis on a public area of the ward for patients and staff to see. The results will be discussed and minutes taken Overview of how we said we would measure it • Senior Clinical Matrons (SCMs) will monitor ward areas to ensure that data is up to date, accurate and displayed in a public area Overview of how we said we would report it • Monthly dashboard analysis to the Director of Nursing • Monthly to Senior Matron and to IPNMB Completed and reported? • Dashboard analysis report presented to Director of Nursing on a monthly basis. • Reported to IPNMB and SCM quarterly. Nursing and Midwifery Dashboard From April 2014 the Trust rolled out a modified Nursing and Midwifery Dashboard to all in-patient ward areas. This was also made available to all ward matrons, managers and Directors of the Trust. The dashboard consists of the following indicators: • Patient Falls; • Pressure Ulcers; • Compliments and Formal Complaints; • Infections; • Staff, Patient Experience and Quality Standards (SPEQS); • Unannounced Hand Hygiene; • Friends and Family Test. The purpose of the dashboard is for the Trust to have an overview of what is going on at ward level and to identify any issues/trends identified by having all of the data located in one place. The dashboard data is presented in numerous meetings highlighting any issues or wards that are outliers, thus ensuring that the Senior Clinical Matrons/Ward Matrons in charge of the wards can act upon the issues quickly, or at least provide a response to the Director of Nursing, Quality and 140 Patient Safety as to why they are outliers. Annual Report and Accounts 2015 – 2016 The dashboard data is use to populate the Nursing and Midwifery board in all in-patient areas for public viewing.
Priority 3: Patient Experience Care For the Dying Patient (formerly End of Life Pathway) and Family’s Voice
3. Care For the Dying Patient and Family’s Voice Rationale: The Trust used the Care For the Dying Patient (CFDP) and Family’s Voice. Stakeholders and the Trust believe that this needs to remain a priority in 2014 – 15 both in hospital and in the community. The review of the Liverpool Care Pathway (LCP) was commissioned by Care and Support Minister Norman Lamb in January 2013, because of serious concerns arising from reports that patients were wrongly being denied nutrition and hydration whilst being placed on the Pathway. The Care For the Dying Patient document has now been established within the Trust to consider the contents of the Independent Review of the Liverpool Care Pathway led by Professor Julia Neuberger. Overview of how we said we would do it 141 • We will continue to use the Family’s Voice in hospital and continue to roll its use out in the community Annual Report and Accounts 2015 – 2016 Overview of how we said we would measure it • We will evaluate feedback in relation to pain, nausea, breathlessness restlessness, care for the patient and care for the family Overview of how we said we would report it • Quarterly to IPNMB • Annually to PS & QS Completed and reported? • Reported to IPNMB and quarterly Reported to PS & QS annually “As always everybody does the very best in all care and support they give to us. As always very good. Nurses done an excellent job as every day.” [sic]
The Family’s Voice The Family’s Voice diary continues to be given out to relatives within the Trust and the community. Between April 2015 and March 2016, the Trust has handed out 154 diaries; this is an increase of 23 from the previous reporting year, currently the average score has fallen to 20.90 from the previous average of 21.10. It has been a very busy year with unprecedented pressure, more deaths and with increased acuity on wards; the Trust has employed a large number of agency nurses who have had little experience of the diaries use or the philosophy behind it. From an internal audit of the diary, there appears to be a drop in the actual written engagement of relatives attending dying relatives. Friends and relatives are not writing in as many comments; some explanation behind this may be around the clarity of explanation of the diaries use by staff. A full report of the last four years of usage is due at the end of March 2016 and this will help staff become more engaged. There is also still a sense of the loss of the NICE status to any guidance of end of life care; this state continues to have an impact on End of Life Care. The following are results since April 2011; these results demonstrate that a high standard of care continues to be provided by the Trust.
Reporting Period Number of Patients Average Daily Score (Max 24.00) April 2011 to March 2012 193 20.80 April 2012 to March 2013 242 21.10 April 2013 to March 2014 170 21.60 April 2014 to March 2015 131 21.10 April 2015 to March 2016 154 20.90 *Data obtained from the Trusts Family’s Voice database Educational Strategy for Palliative Care North Tees and Hartlepool NHS Foundation Trust recognises the importance of giving the best possible care to palliative patients and patients in the last days of life. The Trust has developed a document to outline the care needed by patients and their families from diagnosis until after death. This is entitled: “End of Life Care Guidance for Health and Social Care Professionals: A Framework for Supporting Adults with Progressive, Life Limiting Illnesses”. It is acknowledged that appropriate training and education is needed to support health care professionals in providing high quality care throughout the patient journey. Good communication skills are essential and underpin the care given. Health care professionals caring for all patients need to be trained in communication skills. However the importance of good communication becomes even more pronounced when caring for palliative patients and patients in 142 the last days of life due to the sensitive nature of discussions. An understanding of the importance of a holistic assessment is essential. It is important that a patient’s physical, psychological, spiritual Annual Report and Accounts 2015 – 2016 and social needs are addressed and that the family and carers are well supported. Health care professionals need to be aware of appropriate medication prescribing in palliative patients and to follow guidance on advance care planning and the management of palliative emergencies. Aims: 1. For staff to have increased knowledge and skills whilst caring for palliative and dying patients and their families. 2. For staff to feel more confident in providing care for palliative patients and their families. 3. For staff to feel more confident in providing care for dying patients and their families. 4. To improve the care of palliative patients and their families provided by staff employed by the North Tees and Hartlepool NHS Foundation Trust. 5. To improve the care of dying patients and their families provided by staff employed by the North Tees and Hartlepool NHS Foundation Trust. 6. To comply with national standards for training and education around caring for palliative patients and patients in the last days of life. Training The Trust recognises that it is important for all health care professionals caring for palliative patients or patients in the last days of life to receive training. In line with the North of England Palliative and End of Life Care Education Strategy (2012 – 2016) staff will be divided into four groups and the training needs of these groups identified and training planned accordingly. One of the commonest complaints related to care in general is poor communication. With a palliative care focus Sage and Thyme communication skills training initiative is being introduced to the Trust. This is a nationally recognised level one communication skill qualification. The Trust now has three Trust based facilitators. This process now forms part of the preceptorship programme and aims to provide all nurses with a level one communication skill. In 2015 the Trust ran two courses: • February 2015 – 17 attendees • October 2015 – 44 attendees Monitoring palliative care patients in the last year of life A palliative care section was introduced to the electronic discharge summary at the end of July 2013. This has enabled the Trust to identify patients and through the summary establish a palliative care register. The Electronic Discharge Summary for Palliative Care Patients has identified 1,437 palliative care patients and suggested to GPs that they should be placed on their palliative care register. The key information from the register is that there were 1,437 recommendations to be added to the GP register because they were identified as palliative. During the two years 985 have died of which 98% died within the year. 35% (503) died within the Acute Trust 65% (934) died in their own homes, hospice or nursing home. The average length of time between being identified as palliative and death was 68 days. Since the end of October 2015, the Trust using Trakcare continues to identify and monitor patients in the last year of life. The Trust has a palliative care register, two virtual palliative care wards and an end of life virtual ward. In any hospital bed in England at any one time 33% of the patients are likely to be in their last year of life and we aim to differentiate this group of patients from others. The Trust has developed a process of monitoring those palliative patients we suspect are in the 143 last year of life. We inform the GP by discharge letter and request that they place them on their
palliative care register. We are explaining to patients that they are probably in the last year of their Annual Report and Accounts 2015 – 2016 life and are currently agreeing a letter that is given to patients which states that they have become palliative and what support and services are available to them. Quotes from family members/carers for the dying patient “All of the staff have been really helpful and cared for dad and myself. Nothing is too much trouble. Thank You.”[sic]
“Staff on ward 42 are fantastic. They have given all the care and support my granddad and family need.” [sic]
“From day one he has had the very best of care. My sister and myself have been well looked after too. Thank you all for your help. We can’t thank the staff enough for making jimmy’s final week comfortable.”[sic]
Placements with specialist palliative care team in the community Over the last couple of years the clinical nurse specialists within the specialist palliative care team on both sites have been offering a week’s placement with the team for new starters to the community. The scheme has been well supported by community service managers who release the nurses from normal duties for a week at a time. The scheme has proved popular with the community nurses and they receive an introduction to palliative care working in the community and how the service links into other services across the Trust such as chaplaincy, chemotherapy and psychological services. The nurses on placement have an opportunity to see how the team work and ensure a holistic, multidisciplinary approach to each individuals care. They experience the role the team can have in coordinating care across multiple disciplines. The nurses have an opportunity to shadow the various members of the team and are asked to write a reflective piece at the end of the placement demonstrating their learning outcomes. The feedback has been positive and in the future the team would like to offer hospital staff similar opportunities. The team are in the process of evaluating the work with the findings being published. Spiritual and emotional care of patients at the end of their life In November 2011, the National Institute of Health and Clinical Excellence (NICE) published guidance describing the importance of spiritual and religious support to patients approaching end of life. The guidance specifically referred to the role of chaplains in end of life care. We were very pleased to read the guidance because it promotes the approach that our Trust has taken since July 2009 to meet the needs of patients and families when faced with the knowledge that end of life is near.
144 Annual Report and Accounts 2015 – 2016 Actions taken by the Trust: Since July 2009, the Trust has routinely referred patients on the end of life care pathway to the chaplaincy team. During 2015 – 16, 437 patients were referred by our staff to this pioneering service provided by the Trust chaplains. They provide spiritual, pastoral and emotional support to patients, families and staff. Only 3 patients declined support during the reporting year. 274 patients welcomed and received multiple visits. This service offers added value to the quality of overall care provided to patients and their loved ones and has highlighted the importance of this aspect of support to the dying patient. The Trust continues to address the spiritual and pastoral needs of patients in the community. Initially, this was for patients on or near the end of life, but practice has indicated that the service needs to be offered to patients earlier in the palliative care stage, in order to build up a relationship with the patient and offer a meaningful service. Perhaps because of management restructuring in the community, referrals have been less frequent than in the Acute Trust, but they are now beginning to gather momentum. When this service is allied to the use of the Family’s Voice (carers diary), we believe that our philosophy of care results in a better experience for patients, relatives and carers as well as better job satisfaction for clinical staff and chaplains. Please see the following chart and table for additional detail: Chaplain Referrals, Received more than 1 visit and Declined Support
Referrals Received more than 1 visit Declined Support Apr-15 52 34 0 May-15 38 26 0 Jun-15 40 24 0 Jul-15 31 17 2 Aug-15 39 27 0 Sep-15 59 51 0 Oct-15 26 15 0 Nov-15 34 18 0 Dec-15 27 19 0 Jan-16 39 26 0 Feb-16 29 17 0 Mar-16 23 17 1 Total 437 274 3
The following table demonstrates a year-on-year comparison:
2013-14 2014-15 2015-16 Referrals 397 424 437 Received more than 1 visit 233 272 274 Declined Support 3 1 3 145 *Data from the Trusts chaplain service Annual Report and Accounts 2015 – 2016 Multi Faith The Trust holds a directory of all the local faith groups in the area, with a list of contacts. If someone from a different faith group wants to talk with the chaplains we would do this for all people of faith or no faith. If they request from the chaplains the Imam (Muslim) or the Hindu Priest, Buddhist or any other faith, the chaplains would contact our link person and arrange a visit. Priority 2: Effectiveness of Care Is our care good?
Is our care good? (Patient Experience) Rationale: Trust and key stakeholders believe that it is important to ask this question through internal and external reviews. Overview of how we said we would do it • We will ask the question to every patient interviewed in the Staff & Patient Experience and Quality Standards (SPEQS) visits • We will ask the question in all Trust patient experience surveys • We will monitor patient feedback from national surveys Overview of how we said we would measure it • We will analyse feedback from SPEQS and patient experience/national surveys Overview of how we said we would report it • Reports to Board of Directors Completed and reported? • Reported to Board of Directors “Friendly Staff, pleasant and tried to do more than what was expected. Clean Ward and always some-one cleaning. Hand fed the Patient which was really kind.” [sic]
Patient Experience Surveys Below are a list of the surveys that the Trust carried out between April 2015 and March 2016. The ‘Number of patients surveyed’ column shows out of how many patients were eligible to take part.
Survey Month Survey Number of Patients Surveyed published National Cancer Patient Experience Survey 2015 Jul 2016 419 (70%) response rate CQC National Inpatient Survey 2015 Jun 2016 545 patients (45.26%) response rate CQC National Maternity Survey 2015 Dec 2015 116 patients CQC National Children’s inpatient & day case Jul 2015 101 patients/parents/guardians Survey 2015 National Parkinson’s Disease Survey 2015 Spring 2016 23 patients Friends and Family Test 2015/16 2015/2016 IP A&E OP Community 14,687 4,461 15,562 3,529 146 Total 38,239 patients Local Assisted Reproduction Unit – Client Survey Jan – Dec 2015 113 clients
Annual Report and Accounts 2015 – 2016 Local Endoscopy Patient Survey May 2016 216 patients Local Acute Oncology Survey 2015 Mar 2016 30 patients (still on-going) Local Children’s and Young People’s Survey 2015 Jun – Nov 15 11 patients Local Bariatric Surgery Survey Apr – Nov 2015 46 patients Local Upper GI Cancer Survey Mar 2016 35 patients Local Breast Screening Survey Aug 2015 593 patients Local IBD Survey Cycle I Aug 2015 21 patients Local IBD Survey Cycle II May 2016 14 patients (fieldwork phase) Local Acupuncture treatment under the pain Mar 2016 23 patients service Local Angiography Survey May 2016 100 patients Local Dementia Survey Local CQUIN survey Apr 2016 10 patients (fieldwork phase) “The staff on the ward have been fantastic from start to finish. Everyone has been really caring, friendly and approachable. I’ve been so well looked after from the moment I came into hospital. I can’t sing the praises of this ward enough – fantastic!” [sic]
National Surveys CQC National Inpatient Survey data for 2015 This survey is a Care Quality Commission (CQC) requirement for all Acute NHS Trusts. Each Trust randomly selected adult inpatient admissions during August 2015 (age over 16 years). There were 545 responses from the patients that received a survey, this equates to a response rate of 45.26%.
Survey Period Number of patients Surveyed Number of patients eligible Response Rate to be Surveyed 2010 369 823 44.84% 2011 438 832 52.64% 2012 381 794 47.98% 2013 373 803 46.45% 2014 387 818 47.31% 2015 545 1,204 45.26%
National Cancer Patient Experience Programme 2015 National Survey Fieldwork closed at the end of March 2016. To date we have a 70% response rate against the current national response rate of 66%. The survey was conducted with patients with a primary diagnosis of cancer who had an inpatient or day case attendance who were discharged during April, May and June 2015. As the survey results are not expected to be published until summer 2016 here is a sample of the type of comments the Trust received in regards to cancer treatment taken from the previous National Cancer Patient Experience Programme 2014. “All of my care was amazing, at such a horrible time all the doctors, nurses and care assistants were so caring and sensitive with my care.” [sic]
“It is nice that the various people involved in my case all know your name without looking at your file, it makes you 147 feel less like a number.” [sic] Annual Report and Accounts 2015 – 2016
“The treatment was excellent from beginning to end.” [sic] National Maternity Survey 2015 The survey was conducted in spring 2015 sampling women who gave birth in January and February. The following is a sample of questions that were asked in the survey, scored out of 10.
Questions 2013 2015 Being treated with respect and dignity during labour 9.30 9.60 Having confidence and trust in the staff caring for 8.90 9.20 them during labour and birth 8.20 Feeling their stay in hospital was the right amount 6.60 (significantly better of time score) 8.50 Feeling they were given the information and 7.60 (significantly better explanations they needed after the birth score) Feeling they were treated with kindness and 8.40 9.00 understanding by staff after birth
148 Annual Report and Accounts 2015 – 2016 Priority 3: Patient Experience Friends and Family recommendation
Friends and Family recommendation Rationale: The Department of Health require Trusts to ask the Friends and Family recommendation questions from April 2013. Stakeholders agreed that this remains being reported in the 2015 – 16 Quality Account. The Friends Overview of how we said we would do it and Family Test • We continue to ask the Friends and Family question in the SPEQS and patient surveys • We ask patients to complete a questionnaire on discharge from hospital Overview of how we said we would measure it • We analyse feedback from SPEQS and patient surveys and discharge questionnaires Overview of how we said we would report it • Report to Improving Patient Safety and Experience (IPSE) group • Report to Board of Directors Completed and reported? • Reported to Improving Patient Safety and Experience (IPSE) meeting • Report to Board of Directors The Friends and Family Test (FFT) is a single question survey which asks patients whether they would recommend the NHS service they have received to friends and family who need similar treatment or care. It is initially for providers of NHS funded acute services for inpatients (including independent sector organisations that provide acute NHS services) and patients discharged from A&E/MIU (type 1 & 2) from April 2013. The Friends and family data can be found at: www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and- family-test-data/ North Tees and Hartlepool NHS Foundation Trust – Returns for April 2015 to March 2016
How likely.... recommend? In-patients A & E MIU 1 Extremely likely 8,696 888 752 2 Likely 1,838 275 164 3 Neither 207 48 14 149 4 Unlikely 50 31 7
5 Extremely unlikely 57 44 3 Annual Report and Accounts 2015 – 2016 6 Don’t know 121 28 4 Blank 0 0 0 *Data from Trusts Friends and Family database - April 2015 to March 2016
Would recommend Wouldn’t recommend In-patients 96.03% 0.98% A & E 88.51% 5.71% MIU 97.03% 1.06% *Data from Trusts Friends and Family database - April 2015 to March 2016 Year on Year comparison
In-patients In-patients A&E A&E 2014-15 2015-16 2014-15 2015-16 Would recommend 95.30% 96.03% 89.45% 88.51% Wouldn’t recommend 1.14% 0.98% 5.30% 5.71%
The Trust has experienced a dramatic drop in A&E returns; this is due to the national guidance removing the options for the use of tokens, replacing them with the standard paper questionnaires. How ‘would recommend’ and ‘wouldn’t recommend’ % is calculated Would recommend Extremely likely + likely x 100 Extremely likely + likely+neither+extremely unlikely+don’t know
Wouldn’t recommend Extremely unlikely + unlikely x 100 Extremely likely + likely+neither+extremely unlikely+don’t know The Trust continuously monitors the positive and negative comments on a weekly basis to ensure that any similar issues or concerns can be acted upon by the ward matrons. This helps in reducing the reoccurrence of similar issues in the future. Emergency Care Themes – Positive (green), Negative (red) and Neutral (blue):
Theme Comment Total Theme Comment Total Type Comments Type Comments
Staff (general) Positive 413 Timeliness/Wait Times Negative 77 Timeliness/Wait Times Positive 385 Staffing levels Negative 9 Service/Customer Service/ Positive 369 Treatment Negative 9 Management Friendliness Positive 251 Location Specific Negative 8 Comment Help/Support Positive 245 Staff (general) Negative 8 Care/Compassion Positive 156 Miscellaneous Negative 7 Efficiency Positive 138 Service/Customer Service/ Negative 7 Management Treatment Positive 114 Admin and reception staff Negative 6 Qs Answered/Info/Advice/ Positive 90 Disposition of staff Negative 4 Explanations Politeness Positive 61 Nursing/Care staff Negative 4 Professionalism Positive 55 Care/Compassion Negative 3 150 Attentiveness Positive 40 Communication Negative 3 Location Specific Positive 39 Previous experience Negative 3
Annual Report and Accounts 2015 – 2016 Comment Nursing/Care staff Positive 39 Comfort Negative 2 Convenience Positive 38 Efficiency Negative 2 Clinicians/Specialists etc. Positive 32 Environment Negative 2 Staff Named Positive 26 Medication Negative 2 Child Friendly Positive 23 NHS - general comment Negative 2 Admin and reception staff Positive 21 Parking Negative 2 Reassured/Put at ease Positive 20 Sedation/Pain Negative 2 Management Disposition of staff Positive 17 Staff Named Negative 2 Hygiene/Cleanliness Positive 16 Clinicians/Specialists etc. Negative 1 Theme Comment Total Theme Comment Total Type Comments Type Comments
Qs Answered/Info or Positive 15 Convenience Negative 1 advice Previous experience Positive 14 Discharge Negative 1 Communication Positive 9 Equality and Diversity Negative 1 Empathy/Understanding Positive 9 FFT related comment Negative 1 Expertise/Proficiency Positive 9 Help/Support Negative 1 NHS - general comment Positive 9 Hygiene/Cleanliness Negative 1 Respect Positive 6 Infrastructure Negative 1 Facilities Positive 4 Meeting and greeting Negative 1 Meeting and greeting Positive 4 Neutral Negative 1 Comfort Positive 3 Patient Transport Negative 1 Patience Positive 3 Reassured/Put at ease Negative 1 Sedation/Pain Positive 3 Management Aftercare Positive 2 Atmosphere Positive 2 Sedation/Pain Positive 2 Management Dignity Positive 1 Discharge Positive 1 Environment Positive 1 Equality and Diversity Positive 1 Hospital closure/new Positive 1 hospital etc. Medication Positive 1 Noise Positive 1 Staffing levels Positive 1
Miscellaneous Neutral 208 Neutral Neutral 72
151 Annual Report and Accounts 2015 – 2016 Inpatient Themes comments – Positive (green), Negative (red) and Neutral (blue):
Theme Comment Total Theme Comment Total Type Comments Type Comments
Staff (general) Positive 9503 Staffing levels Negative 190 Care/Compassion Positive 5909 Staff (general) Negative 109 Friendliness Positive 3808 Food Negative 101 Help/Support Positive 2950 Communication Negative 87 Nursing/Care staff Positive 1246 Timeliness/Wait Times Negative 87 Service/Customer Service/ Positive 1162 Noise Negative 55 Management Disposition of staff Positive 970 Discharge Negative 49 Professionalism Positive 950 Environment Negative 40 Attentiveness Positive 821 Medication Negative 38 Efficiency Positive 781 Qs Answered/Info/Advice/ Negative 31 Explanations Treatment Positive 752 Attentiveness Negative 30 Qs Answered/Info/Advice/ Positive 704 Clinicians/Specialists etc. Negative 30 Explanations Hygiene/Cleanliness Positive 524 Facilities Negative 30 Reassured/Put at ease Positive 498 Hygiene/Cleanliness Negative 30 Politeness Positive 496 Miscellaneous Negative 30 Clinicians/Specialists etc. Positive 468 Care/Compassion Negative 26 Food Positive 404 Nursing/Care staff Negative 26 Staff Named Positive 395 Efficiency Negative 25 Comfort Positive 335 Service/Customer Service/ Negative 23 Management Location Specific Positive 146 Location Specific Negative 16 Comment Comment Empathy/Understanding Positive 127 Treatment Negative 16 Respect Positive 125 Disposition of staff Negative 12 Atmosphere Positive 122 Comfort Negative 10 Communication Positive 101 Equality and Diversity Negative 8 Environment Positive 97 Equipment Negative 8 Qs Answered/Info or Positive 79 Infrastructure Negative 8 advice Expertise/Proficiency Positive 68 Previous experience Negative 8 Timeliness/Wait Times Positive 65 Sedation/Pain Negative 8 Management FFT related comment Positive 62 Moving Wards Negative 6 152 Meeting and greeting Positive 60 Privacy/Confidentiality Negative 6 Dignity Positive 58 Atmosphere Negative 4
Annual Report and Accounts 2015 – 2016 Staffing levels Positive 52 Dignity Negative 4 Facilities Positive 51 Politeness Negative 4 Patience Positive 43 Qs Answered/Info or Negative 4 advice Unreadable Positive 32 Staff Named Negative 4 Aftercare Positive 30 Ancillary staff Negative 2 Ancillary staff Positive 30 Assistance with Feeding Negative 2 Previous experience Positive 30 Empathy/Understanding Negative 2 NHS - general comment Positive 27 Expertise/Proficiency Negative 2 Medication Positive 25 Friendliness Negative 2 Experience Positive 24 Location specific comment Negative 2 Discharge Positive 18 Respect Negative 2 Theme Comment Total Theme Comment Total Type Comments Type Comments Sedation/Pain Positive 18 Atmosphere/Environment Positive 2 Management Infrastructure Positive 2 Admin and reception staff Positive 14 Privacy/Confidentiality Positive 2 Noise Positive 13 Recommendation patient Positive 2 Convenience Positive 12 Transport Positive 2 Equality and Diversity Positive 10 Understanding Positive 2 Moving Wards Positive 8 Visiting Times Positive 2 Assistance with Feeding Positive 6
Hospital closure/new Positive 6 Miscellaneous Neutral 842 hospital etc. Neutral Neutral 241 Consistency Positive 5 To note: It is possible to have more than one comment on a Appointment Length Positive 2 returned questionnaire.
“The level of care was extremely good, the Nursing Staff were very professional, understanding and helpful with answers to all your questions. The Doctor was quite wonderful.” [sic]
“Everyone has been so caring, I thank you all for being so kind and helpful. Spent most of my time watching TV or reading magazine.” [sic]
“I can only say that the care that my husband received on this Ward (Ward40) was exemplary. They brought him back from the Brink. Doctors and Nurses are fantastic with their care.” [sic]
153 Annual Report and Accounts 2015 – 2016 North Tees and Hartlepool NHS Foundation Friends and Family word bubble The word bubble is displayed on each ward with the positive and negative comments for that specific ward, this allows the public to see what is being said about individual wards. The Trust also produces a Trust version incorporating the negative and positive comments, please see the following word bubble for the Trust during April 2015 to March 2016. What our patients have said about their hospital experience (taken from the Trust’s Friends and Family Test Comments April 15 – March 16)
Friends and Family – Maternity Services The Friends and Family Test (FFT) aims to provide a simple, headline metric which, when combined with follow-up questions, can be used across the maternity pathway to drive a culture change of continuous recognition of good practice and potential improvements in the quality of the care received by NHS patients and service users. The implementation of the FFT across all NHS services is an integral part of NHS England’s Business Plan, and is designed to help service users, commissioners and practitioners. Each woman will be asked up to four FFT questions: 1. How likely are you to recommend our antenatal service to friends and family if they needed similar care or treatment? 2. How likely are you to recommend our labour ward/birthing unit/homebirth service to friends 154 and family if they needed similar care or treatment? 3. How likely are you to recommend our postnatal ward to friends and family if they needed Annual Report and Accounts 2015 – 2016 similar care or treatment? 4. How likely are you to recommend our postnatal community service to friends and family if they needed similar care or treatment? The official guidance for Friends and Family – Maternity Services can be located at: http://www.england.nhs.uk/wp-content/uploads/2013/09/fft-mat-guide.pdf The following data refers to North Tees and Hartlepool NHS Foundation Trust from April 2015 to March 2016.
Question How likely.... recommend? 1 2 3 4 1 Extremely likely 446 298 217 352 2 Likely 61 64 65 42 3 Neither 3 7 7 0 4 Unlikely 5 2 3 2 5 Extremely unlikely 9 3 2 4 6 Don’t know 4 4 0 1 Blank 0 0 0 0 *Data from Trusts Friends and Family database - April 2015 to March 2016
Question Would recommend Wouldn’t recommend 1 96.02% 2.65% 2 95.77% 1.32% 3 95.92% 1.02% 4 98.25% 1.50%
It remains important for the Trust to monitor the type and number of comments made on the Friends and Family Test returns. For the 2015 – 16 financial year the Trust has had 14,830 returns (Emergency Care, In-patient & Maternity) of which there have 39,812 positive comments and 1,422 negative comments made. “Made me feel at ease. Completely looked after me from start to finish.”[sic]
“The support I got was brilliant. Couldn’t think of anything bad.” [sic]
“All the Doctors and Midwives are really co-operative and supportive. They make sure that you are comfortable with the procedure and everything that is going on. Very caring and soft spoken.” [sic]
Friends and Family – Staff 155 The Trust continues to ask Staff the Friends and Family Test, thus allowing staff feedback on NHS Services based on recent experience. Trust Staff are asked to respond to two questions. Annual Report and Accounts 2015 – 2016 Staff Friends and Family Test is conducted on a quarterly basis (*excluding Quarter 3 when the existing NHS Staff Survey takes place). The following data refers to Quarters 1 to Quarter 3 of the 2015 – 16 financial year. Breakdown of Responses – Care Care: ‘How likely staff are to recommend the NHS services they work in to friends and family who need similar treatment or care’.
How likely.... recommend? Q1 Q2 *Q3 Q4
1 Extremely likely 112 107 65 60 2 Likely 123 129 161 100 3 Neither 27 50 98 22 4 Unlikely 15 11 33 17 5 Extremely unlikely 11 7 10 4 6 Don’t know 2 3 0 1 Blank 0 0 0 0 *Data from Trusts Friends and Family database - April 2015 to March 2016
Quarter Would recommend Wouldn’t recommend Q1 81% 9% Q2 77% 6% *Q3 62% 12% Q4 78% 10%
Breakdown of Responses – Work Work: ‘How likely staff would be to recommend the NHS service they work in to friends and family as a place to work’.
How likely.... recommend? Q1 Q2 *Q3 Q4
1 Extremely likely 104 88 58 60 2 Likely 106 131 148 76 3 Neither 39 45 99 37 4 Unlikely 22 23 40 19 5 Extremely unlikely 17 18 20 11 6 Don’t know 2 2 0 1 Blank 0 0 0 0
*Data from Trusts Friends and Family database - April 2015 to March 2016
Quarter Would recommend Wouldn’t recommend Q1 72% 13% Q2 71% 13% 156 *Q3 56% 16%
Annual Report and Accounts 2015 – 2016 Q4 67% 15% Part 2b: 2016 – 17 quality priorities for improvement Introduction to 2016 – 17 Priorities
Key priorities for improvement for 2016 – 17 have been agreed through numerous consultation events with our patients, our staff, our governors, our HealthWatch colleagues, our commissioners, our local health scrutiny committees, our healthcare user group and our Board of Directors. We started the consultation period in September 2015 which allowed us to consult widely and provide stakeholders with a significant opportunity to consider and suggest the priorities that they would like to see us address. Quality Accounts Marketplace The Trust held the 2nd annual Quality Accounts Marketplace in December 2015. The aim of this event was to actively engage on a 1 to 1 level with our stakeholders, staff and patients. Leads from key areas were at the event to describe the work that has been undertaken during the 2015 – 16 reporting year. This event allowed the participants to discuss and actively engage with the leads for areas such as, dementia, adult safeguarding, complaints, compliments, Friends and Family Test and mortality. Feedback and third party declarations have been invited from formal stakeholders. Full details of stakeholder feedback can be found in Annex A. Our Trust governors have also been actively involved in assisting us in setting our priorities. The Trust continues to develop quality improvement capacity and capability to deliver our priorities as demonstrated throughout this Quality Account. We would like to thank all of those involved in setting priorities for 2016 – 17 which are linked to patient safety, effectiveness of care and patient experience. We all agree that our priorities for improvement should continue to reflect three key principles, they are as follows.
157 Annual Report and Accounts 2015 – 2016 Stakeholder priorities for 2016 – 17 The quality indicators that our external stakeholders said they would like to see included in next year’s Quality Accounts were: Patient Safety 1. Mortality 2. Dementia 3. Safeguarding 4. Infections Effectiveness of Care 5. Safety Thermometer 6. Discharge Medication 7. Nursing Dashboard Patient Experience 8. Palliative Care & Care For the Dying patient 9. Patient Surveys 10. Friends & Family Test Rationale for the selection of priorities for 2016 – 17 Through the Quality Accounts Marketplace and other engagement events we provided an opportunity for stakeholders, staff and patients to provide what they would like to see in the 2016 – 17 Quality Accounts as the priorities. We then chose three from each of the key themes of Patient Safety, Effectiveness of Care and Patient Experience. The Trust will continuously monitor and report progress on each of the above indicators throughout the year by reporting to the Board. The following details for each selected priority, how we will achieve it, measure it and report it. Patient Safety Priority 1 – Mortality
To reduce avoidable deaths within the Trust, by reviewing all available mortality indicators. Overview of how we will do it We will use Healthcare Evaluation Data (HED) benchmarking tool to monitor and interrogate the data to determine areas that require improvement. We will also review/improve existing processes involving palliative care, documentation and coding process. 158 And finally, we will continue to work closely with the North East Quality Observatory System (NEQOS) for third party assurance.
Annual Report and Accounts 2015 – 2016 Overview of how will measure it We will monitor mortality within the Trust using the two national measures of Hospital Standardised Mortality Ratio (HSMR) and Summary Hospital-level Mortality Indicator (SHMI). Overview of how we will report it • Report to Board of Directors • Report quarterly to the commissioners • Report to Keogh Delivery Group Priority 2 – Improving care for people with dementia
There are currently approximately 14,000 people with a diagnosis of dementia across County Durham & Darlington and Tees. NHS Hartlepool/Stockton-on-Tees has the highest projected increase of dementia across the North East by 2025. All stakeholders identified dementia as a key priority. All hospital patients admitted with dementia will have a named advocate and an individualised plan of care. Overview of how we will do it We will use the Stirling Environmental Tool to adapt and audit the impact on our hospital environment. We will ensure that all patients over 65 receive an Abbreviated Mental Test (AMT) and are, where appropriate referred for further assessment. Patients with Dementia will be appropriately assessed and referred on to specialist services. Overview of how will measure it The Stirling Environmental audit assessment tool will be used to monitor the difference pre and post environmental adaptation. The percentage of patients who receive the AMT and, where appropriate, further assessment will be reported monthly via UNIFY (national reporting system). We will audit the number of patients over 65 admitted as an emergency that are reported as having a known diagnosis of dementia, or have been asked the (Prime Ministers) dementia case finding question. We will continue to be involved in the National Audits and to review the outcomes. Overview of how we will report it • Dementia Strategy Group quarterly • Integrated Professional Nursing and Midwifery Board (IPNMB) • Monthly UNIFY Priority 3 – Safeguarding Adults with Learning Disabilities (LD)
The Trust and Commissioners believe that people with LD should not be in hospital unless absolutely necessary. When it is necessary to admit patients with LD, they must have an individualised plan of care and a named advocate. Overview of how we will do it All patients with LD will be referred on admission to the LD specialist nurse. The LD specialist nurse will act as the named advocate and will ensure that an individualised plan of care is in place and reasonable adjustments documented. Overview of how we will measure it 159 Audits will be carried out and results reported and areas highlighted will be acted upon.
Overview of how we will report it Annual Report and Accounts 2015 – 2016 Audit results and action plans to be reported to Adult Safeguarding Group quarterly. Priority 4 – Infection Prevention and Control
Rationale: Key stakeholders asked us to report on infections in 2016 – 17 due to the increase in infections during 2015 – 16. Overview of how we said we would do it • We will closely monitor testing regimes, antibiotic management and repeat cases and ensure we understand and manage the root cause wherever possible. Overview of how we said we would measure it • We will monitor the number of hospital and community acquired cases • We will undertake a multi-disciplinary Root Cause Analysis (RCA) within three working days • We will define avoidable and unavoidable for internal monitoring • We will benchmark our progress against previous months and years • We will benchmark our position against Trusts in the North East in relation to number of cases reported; number of samples sent for testing and age profile of patients Overview of how we said we would report it • Board of Director meetings • Council of Governor meetings (CoG) • Infection Control Committee (ICC) • Patient Safety and Quality Standards Committee (PS & QS) • To frontline staff through Chief Executive brief • Nursing Dashboard • Clinical Quality Review Group (CQRG) Effectiveness of Care Priority 5 – Safety Thermometer
NHS Safety Thermometer The NHS Safety Thermometer is a local improvement tool for measuring, monitoring and analysing patient harm and ‘harm free’ care. The Safety Thermometer has the following indicators to prevent avoidable harm, disability or death and to ensure that our care is effective: • Falls; • Pressure Ulcers; • Catheter related urinary tract infections (UTIs); 160 • Venous thromboembolism (VTE). Overview of how we will do it
Annual Report and Accounts 2015 – 2016 This indicator will continue to be audited on one day per month across the Trust and community services and the data submitted to the Health and Social Care Information Centre. The data will be monitored by the Nursing Quality and Patient Safety Directorate. Overview of how we will measure it • Monthly data collection survey of the ward areas along with community bases. Overview of how we will report it • To Improving Patient Safety and Experience (IPSE); • To Patient Safety and Quality (PS & QS) Committee. Priority 6 – Discharge processes – Medication
The latest national patient experience survey identified that the Trusts still have improvements to make with regards to medication discharge processes. Overview of how we will do it All patients will receive information about medication side-effects to watch out for at home. Overview of how we will measure it We will measure it via improvements in national and local patient surveys. Overview of how we will report it • Local audit reports reported to Drug and Therapeutic Committee; • National inpatient survey report to Patient Safety and Quality (PS & QS) Committee. Priority 7 – Nursing & Midwifery Dashboard
The Nursing & Midwifery Dashboard will support close monitoring of nurse sensitive patient indicators on a day-to-day basis. It will support sharing of best practice and speedy review of any potential areas of concern. Overview of how we will do it Training will be undertaken and each department will evidence that their results have been disseminated and acted upon. Ward matrons will present their analysis on a public area of the ward for patients and staff to see. The results will be discussed at ward meetings. Overview of how we will measure it The dashboard will be a standing agenda item on the Senior Clinical Matrons (SCMs) meeting. SCMs will monitor ward areas to ensure that data is up to date, accurate and displayed in a public areas. Overview of how we will report it • Monthly dashboard analysis to the Director of Nursing, Quality and Patient Safety; • Monthly to Senior Clinical Matron meeting and to IPNMB. Patient Experience Priority 8 – Care For the Dying Patient (formerly End of Life Pathway) and Family’s Voice
The Trust has continued the use of Care For the Dying Patient (CFDP) and Family’s Voice. Stakeholders and the Trust believe that this still needs to remain a priority in 2016 – 17 both in hospital and in the community. 161 Overview of how we will do it Annual Report and Accounts 2015 – 2016 We will continue to embed use of the Family’s Voice in hospital and continue to roll its use out in the community. Overview of how we will measure it We will evaluate feedback in relation to pain, nausea, breathlessness restlessness, care for the patient and care for the family. Overview of how we will report it • Quarterly to IPNMB; • Annually to PS & QS. Priority 9 – Patient Surveys
Trust and key stakeholders believe that it is important to ask the Friends and Family question through internal and external reviews. Overview of how we will do it We will ask the question(s) to every patient interviewed in the Staff, Patient Experience and Quality Standards (SPEQS) reviews. We will also ask the question in all Trust patient experience surveys, along with monitoring patient feedback from national surveys. Overview of how we will measure it We will analyse feedback from SPEQS and patient experience/national surveys. Overview of how we will report it • Reports to Board of Directors Priority 10 – Friends and Family recommendation
The Department of Health require Trusts to ask the Friends and Family recommendation questions from April 2013. Stakeholders agreed that this remains being reported in the 2016 – 17 Quality Account. Overview of how we will do it We have incorporated the Friends and Family test wording into SPEQS and patient surveys. We currently ask patients to complete a questionnaire on discharge from hospital for in-patients, Accident & Emergency and Maternity Overview of how we will measure it We analyse feedback from SPEQS and patient surveys and discharge questionnaires. Overview of how we will report it • Report to Improving patient safety experience (IPSE) group; • Report to Board.
162 Annual Report and Accounts 2015 – 2016 Part 2c: Statements of Assurance from the Board of Directors
Review of Services During 2015 – 16 the North Tees and Hartlepool NHS Foundation Trust provided and/or subcontracted 64 relevant health services. The majority of our services were provided on a direct basis, with a small number under sub-contracting or joint arrangements with others. The North Tees and Hartlepool NHS Foundation Trust has reviewed all the data available to them on the quality of care in 64 of these relevant health services. The income generated by the relevant health services reviewed in 2015 – 16 represents 100% of the total income generated from the provision relevant health services by North Tees and Hartlepool NHS Foundation Trust for 2015 – 16. Participation in clinical audits All NHS Trusts are audited on the standards of care that they deliver and our Trust participates in all mandatory national audits and national confidential enquiries. The Healthcare Quality Improvement Partnership (HQIP) provides a comprehensive list of national audits which collected audit data during 2015 – 16 and this can be found on the following link: http://www.hqip.org.uk/national-programmes/quality-accounts/ During 2015 – 16, 46 national clinical audits and 7 national confidential enquiries covered the relevant health services that North Tees and Hartlepool NHS Foundation Trust provides. During 2015 – 16 North Tees and Hartlepool NHS Foundation Trust participated in 100% of national clinical audits and 100% of 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 that North Tees and Hartlepool NHS Foundation Trust was eligible to participate in during 2015 – 16 are as follows:
National Clinical Audit Acute Coronary Syndrome or Acute Myocardial Infarction (MINAP) Adult Asthma (BTS) Bowel Cancer (NBOCAP) Adult Critical Care Case Mix Programme (CMP) Diabetes (Paediatric) (NPDA) Elective Surgery (National PROMs Programme) (based on return rate of the pre-operative questionnaire) Emergency Use of Oxygen (BTS) Falls and Fragility Fractures Audit programme (FFFAP) Inflammatory Bowel Disease (IBD) programme Major Trauma Audit (TARN) Maternal, Newborn and Infant Clinical Outcome Review Programme National Cardiac Arrest Audit (NCAA) 163 National Chronic Obstructive Pulmonary Disease (COPD) Audit programme
National Comparative Audit of Blood Transfusion programme Annual Report and Accounts 2015 – 2016 National Diabetes Audit – Adults National Emergency Laparotomy Audit (NELA) National Heart Failure Audit National Joint Registry (NJR) National Lung Cancer Audit (NLCA) National Prostate Cancer Audit Neonatal Intensive and Special Care (NNAP) Non-Invasive Ventilation – Adults (BTS) Oesophago-gastric Cancer (NAOGC) Paediatric Asthma (BTS) National Clinical Audit Paediatric Intensive Care (PICANet) Paediatric Pneumonia (BTS) Rheumatoid and Early Inflammatory Arthritis Sentinel Stroke National Audit programme (SSNAP) UK Parkinson’s Audit
NCEPOD study title Acute Pancreatitis Physical and mental health care of mental health patients in acute hospitals Sepsis Gastro-intestinal Haemorrhage Non-invasive ventilation Chronic Neurodisability Young People’s Mental Health
The national clinical audits and national confidential enquiries that North Tees and Hartlepool NHS Foundation Trust participated in during 2014 – 15 are as follows:
National Clinical Audit Acute Coronary Syndrome or Acute Myocardial Infarction (MINAP) Adult Asthma (BTS) Bowel Cancer (NBOCAP) Adult Critical Care Case Mix Programme (CMP) Diabetes (Paediatric) (NPDA) Elective Surgery (National PROMs Programme) (based on return rate of the pre-operative questionnaire) Emergency Use of Oxygen (BTS) Falls and Fragility Fractures Audit programme (FFFAP) Inflammatory Bowel Disease (IBD) programme Major Trauma Audit (TARN) Maternal, Newborn and Infant Clinical Outcome Review Programme National Cardiac Arrest Audit (NCAA) National Chronic Obstructive Pulmonary Disease (COPD) Audit programme National Comparative Audit of Blood Transfusion programme National Diabetes Audit – Adults National Emergency Laparotomy Audit (NELA) 164 National Heart Failure Audit National Joint Registry (NJR)
Annual Report and Accounts 2015 – 2016 National Lung Cancer Audit (NLCA) National Prostate Cancer Audit Neonatal Intensive and Special Care (NNAP) Non-Invasive Ventilation – Adults (BTS) Oesophago-gastric Cancer (NAOGC) Paediatric Asthma (BTS) Paediatric Intensive Care (PICANet) Paediatric Pneumonia (BTS) Rheumatoid and Early Inflammatory Arthritis Sentinel Stroke National Audit programme (SSNAP) UK Parkinson’s Audit NCEPOD study title Acute Pancreatitis Physical and mental health care of mental health patients in acute hospitals Sepsis Gastro-intestinal Haemorrhage Non-invasive ventilation Chronic Neurodisability Young People’s Mental Health
The national clinical audits and national confidential enquires that North Tees and Hartlepool NHS Foundation Trust participated in, and for which data collection was completed during 2015 – 16, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.
Audit title Participation % cases submitted M=Mandatory N=Non-mandatory Acute Coronary Syndrome or Acute Myocardial Yes (M) Continuous monitoring Infarction (MINAP)
Adult Asthma (BTS) Yes (M) 100% Bowel Cancer (NBOCAP) Yes (M) Continuous monitoring Adult Critical Care Case Mix Programme (CMP) Yes (N) Continuous monitoring
Diabetes (Paediatric) (NPDA) Yes (M) 100% Elective Surgery Hip replacement Yes (N) 94% (National PROMs Programme) (based Knee replacement Yes (N) 94% on return rate of the pre-operative Varicose Vein Yes (N) 52% questionnaire) Groin Hernia Yes (N) 56% Emergency Use of Oxygen (BTS) Yes (M) 100% Falls and Fragility Fracture Liaison Service Yes (M) Continuous monitoring Fractures Audit Database programme (FFFAP) Falls Yes (M) 100% National Hip Fracture Yes (M) Continuous monitoring Database Inflammatory UK IBD Registry Yes (M) 100% Bowel Disease (IBD) programme Major Trauma Audit (TARN) Yes (N) Continuous monitoring 165 Maternal, Newborn Perinatal Mortality Yes (M) Continuous monitoring
and Infant Clinical Surveillance Annual Report and Accounts 2015 – 2016 Outcome Review Perinatal mortality and Yes (M) Continuous monitoring Programme morbidity confidential enquiries (term intrapartum related neonatal deaths) Maternal morbidity and Yes (M) Continuous monitoring mortality confidential enquiries (cardiac (plus cardiac morbidity) early pregnancy deaths and pre- eclampsia, plus psychiatric morbidity) Maternal mortality Yes (M) Continuous monitoring surveillance Audit title Participation % cases submitted M=Mandatory N=Non-mandatory National Cardiac Arrest Audit (NCAA) Yes (N) Continuous monitoring
National Chronic Pulmonary rehabilitation Yes (M) Continuous monitoring Obstructive Secondary Care Yes (M) Continuous monitoring Pulmonary Disease (COPD) Audit programme National Use of blood in Yes (N) 100% Comparative Haematology Audit of Blood Audit of Patient Blood Yes (N) 100% Transfusion Management in Scheduled programme Surgery National Diabetes National Footcare Audit Yes (M) 100% Audit – Adults National Inpatient Audit Yes (M) 100% National Pregnancy in Yes (M) 100% Diabetes Audit National Emergency Laparotomy Audit (NELA) Yes (M) Year 1: 22% Year 2: 58% National Heart Failure Audit Yes (M) Continuous monitoring National Joint Knee replacement Yes (M) Continuous monitoring Registry (NJR) Hip replacement Yes (M) Continuous monitoring National Lung Lung Cancer Consultant Yes (M) 100% Cancer Audit Outcomes Publication (NLCA) National Prostate Cancer Audit Yes (M) 100% Neonatal Intensive and Special Care (NNAP) Yes (M) Continuous monitoring
Non-Invasive Ventilation – Adults (BTS) Yes (M) 100%
Oesophago-gastric Cancer (NAOGC) Yes (M) 100%
Paediatric Asthma (BTS) Yes (M) 100% Paediatric Intensive Care (PICANet) Yes (M) 100%
Paediatric Pneumonia (BTS) Yes (M) 100% Rheumatoid and Clinician/Patient Follow-up Yes (M) Continuous monitoring Early Inflammatory Clinician/Patient Baseline Yes (M) Continuous monitoring 166 Arthritis Sentinel Stroke SSNAP Clinical Audit Yes (M) Continuous monitoring Annual Report and Accounts 2015 – 2016 National Audit programme (SSNAP) UK Parkinson’s Occupational Therapy Yes (N) 100% Audit Speech and Language Yes (N) 100% Therapy Physiotherapy Yes (N) 100% Patient Management, Yes (N) 100% elderly care and neurology National Clinical Audits The reports of 7 national clinical audits were reviewed by the provider in 2015 – 16 and North Tees and Hartlepool NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided:
Audit title Actions taken/in progress Inflammatory Bowel Disease Shortfalls were identified in terms of: (IBD) programme • Insufficient toilets on the gastro ward • Maintenance of patient database • Frequency of MDT meetings • National Pouch Registry not being used • Insufficient resilience with respect to IBD Specialist Nurse role The Trust performed very well in the inpatient part of the audit, with all standards being achieved. In terms of use of biologics, a scoring system was not being used locally to check response to treatments; however this is now in place. National Audit of Asthma in Teaching update required for nursing staff about when and how Children to measure vital signs in children using RCN standards in liaison with Paediatric Department staff. Teaching to be undertaken with all staff on treatment of asthma. Asthma patient information leaflet has been updated. National Audit of Paracetamol A&E team to improve documentation in patient healthcare Overdose records. System in place to fast track patients to mental health services. Teaching sessions to review MHRA guidelines. Massive Blood Loss Audit Wastage to be more closely monitored. Drills to be performed once a year. Tranexamic Acid to be used in Major Haemorrhage associated with trauma. Initial Management of the A simple proforma for recording information about a fit to be Fitting Child developed. Patient information leaflets for febrile seizures and ‘first fit’ to be written and given out to parents or carers. Assessing for Cognitive Early Warning Score to be reviewed. Impairment in Older People Screening for Dementia/Delirium and information to be shared with GPs. Mental Health in A&E Standardised proforma to be developed for mental health assessment. Work with Estates Department in relation to assessment room layout and facilities.
167 Annual Report and Accounts 2015 – 2016 Local Clinical Audits The reports of 105 local clinical audits were reviewed by the provider in 2015 – 16 and North Tees and Hartlepool NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided:
Audit title Actions taken/in progress
Temporal Biopsy Audit Doctors to discuss and record nerve injury risk with the patients. Scaphoid Fracture Audit Clinical team to review guidelines and documentation as part of the ’10 a day’ teaching sessions in A&E. Managing Bone Health in A new guideline for maintaining bone health in all non- Children with Cerebral Palsy ambulant children will be developed. Elective Consent (Anaesthetics) Designated Consultant to support and lead recommendations which should improve results in future audits. Paracetamol Overdose in Provide training to triage nurses to recognise staggered Adults overdoses. Management of Pre-labour Ensure patient information leaflet is available in clinic and Spontaneous Rupture of maternity areas. Membrane (SRM) Elderly Care Patients More patients to be reviewed by Elderly Care Physicians to build Undergoing Surgery on current progress. Beta-Human Chorionic Guideline will be adjusted so that everyone follows the same Gonadotropin Serum (BHCG) procedure consistently. Clinical Coding – Elective Upper Surgical procedures to be coded more accurately. Limb Patients AKI Mortality Audit Learning points identified from review of cases to be cascaded to clinical teams. All Clinical Directors to cascade results within their areas. Trust-wide 'Sepsis 6' Audit Education programme required along with regular data collection to review outcomes. Hand Trauma Clinic Education programme required for referring centre. An additional Monday afternoon clinic to be implemented. Suction Audit Improvements evident since previous audit. Recommendations to be monitored by the medical device group and re-assessed in 2016.
168 Annual Report and Accounts 2015 – 2016 All national audit reports are considered by the Audit and Clinical Effectiveness (ACE) Committee which reports to the Patient Safety and Quality Standards (PS & QS) Committee, PS & QS reports directly to the Board of Directors. The Trust participated in all seven national confidential enquiries (100%) that it was eligible to participate in, namely: National Confidential Enquiries (NCEPOD):
NCEPOD study title Participation % cases submitted M=Mandatory N=Non-mandatory Acute Pancreatitis Yes (M) 100% Physical and mental health care of mental Yes (M) 100% health patients in acute hospitals Sepsis Yes (M) 80% Gastro-intestinal Haemorrhage Yes (M) 50% Non-invasive ventilation Yes (M) Data collection on-going Chronic Neurodisability Yes (M) Data collection on-going Young People’s Mental Health Yes (M) Data collection on-going
169 Annual Report and Accounts 2015 – 2016 Patients recruited into research The Government wishes to see a dramatic and sustained improvement in the performance of providers of NHS services in initiating and delivering clinical research. The aim is to increase the number of patients who have the opportunity to participate in research and to enhance the nation’s attractiveness as a host for research by faster approvals and delivering to time and target. Performance Data Total year on year recruitment into National Institute for Health Research (NIHR) portfolio research is shown below:
Total Recruitment 2008-09 159 2009-10 412 2010-11 458 2011-12 1,147 2012-13 1,666 2013-14 956 2014-15 1,144 2015-16 908
2,000 1,800 1,666 1,600 1,400 1,200 1,147 1,144 956 1,000 908 800 600 Patient Recruitment Patient 412 458 400 200 159 0 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 Total Recruitment
*Data from Research and Development Department Nationally there has been a decrease in the overall total numbers of patients being recruited as there are fewer of the large observational studies. Within NTHFT we have seen an increase in the number of more complex interventional and commercial studies at the expense of larger, simpler observational studies. So whilst our overall recruitment figures are slightly lower, the trials we are participating in are more complex and we are accruing year on year additional follow-up burden 170 for patients in existing trials. For 2015 – 16 of the patients recruited so far, 81% were recruited into interventional studies with Annual Report and Accounts 2015 – 2016 just 19% recruited into observational studies. 2015 – 16 Study participation – number of studies The National Institute of Health Research Clinical Research Network (NIHR CRN) portfolio is a database of clinical research studies that are supported by the NIHR CRN in England. Adoption on to the portfolio is dependent on a study meeting eligibility criteria. The Clinical Research Network provides infrastructure support including NHS Service Support costs (SSCs) and access to R&D support. Research studies are reviewed for inclusion in the NIHR CRN Portfolio in parallel with the NHS Ethics review and R&D governance process. A non-portfolio study is a research study without the above support that has not been adopted onto the portfolio. Study participation – number of studies open
Study Type Number of Actively recruiting In follow-up Studies patients NIHR portfolio Observational 53 100 42 Interventional 89 Non-portfolio Observational 26 30 1 Interventional 5 Total Observational 79 Interventional 94
The number of studies currently active within the Trust has increased on last year. Last year we had 165 studies open, but 173 in this year which further illustrates that despite the overall numbers decreasing we are actually running more trials than in previous years. The number of patients receiving relevant health services provided or subcontracted by North Tees and Hartlepool NHS Foundation Trust in 2015 – 16 that were recruited during that period to participate in research approved by a research ethics committee was 862 (portfolio and non- portfolio studies). National position/ranking
Year Overall national position Ranking in “medium sized acute Trusts” category 2012-13 101st out of 394 organisations* 7th out of 48 Trusts 2013-14 157th out of 454 organisations 25th out of 47 Trusts 2014-15 141st out of 445 organisations 26th out of 47 Trusts 2015-16 Not available Not available
*2015 – 16 information not available at the time of print Performance in Initiation and Delivery of research (PID data) From 2013, government funding for research to our Trust has become conditional on meeting national benchmarks. We report quarterly to the Department of Health on the following performance measures. Latest figures relate to our quarter 3 submission. • For non-commercial studies: meeting a 70-day benchmark to recruit first patients for trials;
70 day benchmark met No of Studies Reason Yes 7 No 5 1 NHS delay 2 Sponsor delay 2 Neither – no eligible patients seen/consented
• For commercial studies: Recruitment to time and target stated in clinical trial agreement;
Time and target met No of Studies Reason 171 Yes 5
No 7 4 closed early – competitive recruitment meant Annual Report and Accounts 2015 – 2016 national target was met before we reached our local target 1 change in PI* at site – delay in replacement PI* impacted on our recruitment 2 lack of suitable patients seen – v tight inclusion/ exclusion criteria Still on-going 6
*Principal Investigator (PI) Failure to provide acceptable explanation for poor performance over two consecutive quarters may result in financial penalties. We have provided extensive narrative to support why sometimes these metrics haven’t been met; the R&D team meet monthly to review the data and work with teams to highlight when benchmarks are in danger of not being met and develop an action plan. Once submitted to the DH, we have to post this information in a publically accessible area of the Trust’s website. A response to our submission is given to the Chief Executive so we ensure he receives a copy of our submission prior to upload so that any queries can be resolved prior to the receipt of the official response from DH. Achievements The research and development (R&D) continue to work with departments across the Trust to promote the importance of healthcare professionals being involved in research. Through the Trust’s provision of an R&D Incentive fund of £50,000 we have been able to help to develop staff knowledge and skills to enable them to lead and/or be involved in research studies. Four members of R&D delivery staff have been supported with course fees for research related MSc fees and two individuals (Neonatal and Gastroenterology) have received part-funding of their MD/PhDs. Two members of staff (Pathology and Respiratory Medicine) have received sessional support to enable them to complete a research grant application. We currently have 133 members of staff with valid Good Clinical Practice (GCP) training. Most specialisms and all directorates are now participating in research to a greater or lesser degree. The few exceptional areas where activity is non-existent are in active discussion with the R&D department, specifically to identify potential studies that might be relevant. We have seen exceptional increases in the involvement in research from the out of hospital (community) directorate – notably from the Podiatry team who over recruited on the 'REFORM' study (a randomised trial of a multifaceted podiatry intervention for fall prevention in patients over 65 years of age). They were set an initial target of 20 patients to recruit and actually recruited 161 patients. They have been nominated by the R&D department for a regional research award in acknowledgement of this achievement. Another area that hadn’t traditionally been research active that has engaged with research within the last year has been the Occupational Health Service who recruited very well to the SCIN trial (A cluster randomised controlled trial of a behavioural change package to prevent hand dermatitis in nurses working in the National Health Service). They recruited 49 patients against a target of 40 and are keen to be involved in further projects. There are 65 members of staff acting as principal investigators/local collaborators in research approved by a research ethics committee within the Trust, some of whom have up to ten studies in their research portfolio. We have 26 clinical research network funded research staff within the Trust (nurses, midwifes, data assistants, team leader and Pharmacy technician) and two nurses/research practitioners funded from commercial income. Our bi-monthly research nurses working group continues to be well attended and provides professional support and mentorship as well as assisting us with national research initiatives such as raising the profile of research with patients, involving patients in meaningful PPI (patient and public involvement), developing training packages for research nurses and training nurses for commercial studies. 70 day benchmark. We have appointed a part-time band 7 Research Team Leader to assist with staff oversight, revalidation, appraisal and mentoring as well being a first contact advisor and mentor for new 172 grant applications for potential Chief Investigators. Commercially Sponsored Studies Annual Report and Accounts 2015 – 2016 We continue to increase our participation in commercially sponsored studies. We now have 16 commercially sponsored studies active within the Trust in this year (12 last year) within Respiratory Medicine, Paediatrics, Neonates and Cardiology and more recently Gastroenterology and Orthopaedics. Our respiratory and cardiology research teams are developing their reputation as a “preferred site” for commercially sponsored research studies with the Cardiology research team recently visited by the global representatives from the commercial company to learn lessons from their very successful recruitment strategies for the RELAX-2 study. We have been the first UK site to trial a new contactless patient monitoring system that aims to prevent patient deteriorations, falls and pressure sores. The 'Early Sense' monitors were installed on two wards in November 2015. The project has been overseen by the R&D manager. A research project will take place during 2016 to determine their impact and obtain data on outcomes before a decision is made as to their long term patient benefit and financial viability. The R&D department are also exploring external business development opportunities to develop a clinical trials facility on the North Tees site. Professor Samir Gupta has successfully completed the pilot phase of his £3m HTA funded research study and has now received permission to commence the multi-centre study. The study aims to determine whether or not an echocardiographically confirmed large Patent Ductus Arteriosus (PDA) in extremely premature babies should be treated with ibuprofen within 72 hours of birth. The multi-centre study will recruit 730 babies over 30 recruiting centres. Awards and accolades We have submitted four nominations to the regional NIHR awards event in March and await the outcome of these. The R&D department have nominated a number of teams and individuals to recognise their continued performance and dedication to the research endeavour in the Trust. We have two research ideas that will be progressed for external grant applications imminently (Gastroenterology and Respiratory Medicine) and a further two potential Chief Investigator led studies to work up with the relevant investigators (Pathology and Surgery). Four nominations were shortlisted for members of the research team in different categories for Trust Annual Shining Stars awards; despite not winning this was an encouraging recognition of the contribution research staff make to the Trust. The Trust met four of the six Local Clinical Research Network Continuous Improvement Objectives which resulted in us securing additional funding of £20,000. We were also successful in being awarded funding for a half time trainee research nurse through a competitive funding round with the research network.
173 Commissioning for quality and innovation (CQUIN) Annual Report and Accounts 2015 – 2016 A proportion of North Tees and Hartlepool NHS Foundation Trust income in 2015 – 16 was conditional on achieving quality improvement and innovation goals agreed between North Tees and Hartlepool NHS Foundation 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. 2014 – 15 income The total income received through achievement of CQUIN goals in 2014 – 15 was £3,909,087 from the total amount available of £5,243,262. Further details of agreed goals for 2015 – 16 and the following 12 month period are available electronically at: http://www.england.nhs.uk/wp-content/uploads/2014/02/sc-cquin-guid.pdf 2015 – 16 income (Q1 to Q3) The total income received through achievement of CQUIN goals in 2015 – 16 is £1,896,055 (Q1 to Q3) from £2,548,357 available; This value was conditional upon achieving quality improvement and innovation goals. Care Quality Commission (CQC)
North Tees and Hartlepool NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is registered without conditions for all services provided. North Tees and Hartlepool NHS Foundation Trust has not participated in any special reviews or investigations by the Care Quality Commission during the reporting period. The Care Quality Commission (CQC) has not taken enforcement action against North Tees and Hartlepool NHS Foundation Trust during 2015 – 16. The CQC inspection team visited the Trust during the 7 to 10 July 2015 to undertaken the mandated inspection that all Trusts must have. The CQC inspection looks at five domains, asking are services safe, caring, responsive, effective and well-led and rates each of them from inadequate, requiring improvement, good and outstanding. The inspectors rated the University Hospital of Hartlepool good for safe, caring and responsive and requiring improvement for effectiveness and well-led care. The way the rating system works is that two or more requiring improvements out of five results, gives a rating of requiring improvement. However, it’s good for staff, patients and the public to know that three out of the five areas were rated as good. The Trust was very open with the inspectors about areas which were thought could be improved and the Trust were already taking action to address these areas. The inspectors rated the University Hospital of North Tees good for caring and responsive services but as requiring improvement for safe, effective and well-led services. Again the Trust was very open with the inspectors before, during and after the visit about areas we thought could be improved and we are already taking action to address these areas. The CQC rated the Trust as ‘requiring improvement’. There were 85 individual ratings of which the Trust was rated as good for 65. A number of areas were identified as good practice, including surgery, critical care, end-of-life care, the Trust’s simulation suite, community services and the Trust’s services at One Life Hartlepool. Overall ratings for the Trust
Overall rating for the Trust Requires improvement 174 Are services at this Trust safe? Good
Annual Report and Accounts 2015 – 2016 Are services at this Trust effective? Requires improvement Are services at this Trust caring? Good Are services at this Trust responsive? Good Are services at this Trust well-led? Requires improvement The full inspection report can be found on the CQC website: http://www.cqc.org.uk/provider/RVW The following tables demonstrate the ratings for the North Tees and Hartlepool sites, Minor injuries unit/One Life Centre and community health services. University Hospital of North Tees
Safe Effective Caring Responsive Well-led Overall Urgent and Requires Requires Good Good Requires Requires emergency improvement improvement improvement improvement services Medical care Good Requires Good Good Requires Requires improvement improvement improvement Surgery Good Good Good Good Good Good
Critical care Good Good Good Good Good Good Maternity and Requires Requires Good Good Requires Requires gynaecology improvement improvement improvement improvement Services for Good Good Good Good Requires Good children and improvement young people End-of-life care Good Good Good Good Good Good
Outpatients Good Good Good Good Requires Good and diagnostic improvement imaging Overall Requires Requires Good Good Requires Requires improvement improvement improvement improvement University Hospital Hartlepool
Safe Effective Caring Responsive Well-led Overall Medical care Requires im- Requires im- Requires im- Requires im- Inadequate Requires im- provement provement provement provement provement Surgery Good Good Good Good Good Good
Maternity Good Requires im- Not Rated Good Requires Requires im- and provement improvement provement gynaecology Services for Good Good Good Good Requires Good children improvement and young people Outpatients Good N/A Good Good Requires Good and improvement diagnostic imaging Overall Good Requires Good Good Requires Requires im- improvement improvement provement
Minor Injuries Unit, One Life Centre 175 Safe Effective Caring Responsive Well-led Overall
Urgent and Good Good Not Good Good Good Annual Report and Accounts 2015 – 2016 emergency Rated services Overall Good Good N/A Good Good Good Community health services
Safe Effective Caring Responsive Well-led Overall Community Good Good Good Good Requires Good health services improvement for adults Community Good Requires Good Good Good Good health services improvement for children End-of-life care Good Good Good Good Good Good
Community Good Good Good Good Good Good dental services Overall Good Good Good Good Good Good
Areas the Trust MUST take to improve The following 14 are actions that the CQC stated the Trust MUST take to improve, what the Trust has put in place and the current status of the action:
CQC MUST do Action Status 1 Ensure there are Monitor compliance through audit process/ WHO checklist in use within theatres at time systems and processes spot checks. of inspection Implemented August 2015. in place to minimise Surgery to work with Anaesthetic directorate Adapted tool utilised for ward/department the likelihood of risks to ensure the 5 steps to safer surgery are based procedures by April 2016. by completing the 5 maintained in line with Trust policy/procedures Steps to Safer Surgery Monitored through perioperative services checklist group. 2 Ensure staff follow Audit of Kardex to be undertaken to include: Maternity – monthly drug Kardex audit Trust policies and • Administration commenced February 2016 – 10 Kardex to be procedures for • Missed doses reviewed per month. managing medicines, • Quality of documentation. In hospital care – the directorate has devised including controlled a plan of weekly patient safety walkabouts drugs, ensure that reviewing 5 patient records per ward with medicines are stored specific measurable outcomes to allow according to storage continuous monitoring and sustainability of requirements to standards. maintain their efficacy Monitor compliance with storage requirements Integral part of (SPEQS). through Staff, Patient Experience and Quality SPEQS results reported within Quality Report to Standards visit (SPEQS). Board of Directors Monthly controlled drug (CD) check to be Within planned Trust programme of work. undertaken on each area. A&E update/In hospital care the directorates complete a daily check of all CD’s. Areas of concern are identified and actioned in real time. Pharmacy validates as part of a three monthly control drug checks as per policy. Maternity – work to be undertaken with medicine management specialist nurse. 176 Annual Report and Accounts 2015 – 2016 CQC MUST do Action Status 3 Ensure that risk All assessments will be completed within given A&E/In hospital care – directorates have devised assessments are times scale inclusive of reassessments when a plan of weekly patient safety walk rounds to documented along appropriate. monitor compliance for those patients requiring with personal care risk assessments as per policy. and support needs Assessments monitored through local Maternity – implementing adapted intrapartum and evidence that a documentation audit through: WHO maternity checklist. capacity assessment • Health Care Record Audits. has been carried out • Staff, Patient Experience and Quality Deprivation of Liberty Safeguards (DoLS) activity where required Standards visit. and teaching specific training has been carried out at the Holdforth Unit – Ward 3 and Ward 4. Safeguarding champion sessions were carried out in September and October 2015. 55 champions have been trained. Monthly meetings have been arranged with the DoLS teams of both local authorities to identify any issues and specific training needs that are required. Safeguarding team attend the mandatory training days on Emergency Care and Obstetrics and plan to attend Orthopaedics. Sessions cover DoLS/Mental Capacity Act (MCA). A grand round and junior doctors teaching have also covered DoLS. Policy and Procedures The DoLS and safeguarding policies have both been updated to reflect Cheshire West implications. A sample copy of the DoLS paperwork has also been produced to help assist staff to complete it. Sharepoint has also been changed to make access to the regularly used forms more accessible. A workbook has been completed in conjunction Tees-wide Adult Safeguarding Board to be used within the Trust, a trial on this was stated in December. The training department are currently working on a E-Learning package for Level 2 training. 4 Ensure pain in Pain score tool to be implemented within Age appropriate pain charts/Standard children and young children’s services. Operating Procedures (SOP) to be introduced people is assessed and by April 2016, when processed via Health managed effectively care records committee. Pain score also to be incorporated in the PEWS. 5 Ensure that the Develop training package. Completed. Triage training package developed competency including PowerPoint presentation. criteria for staff Implement training package: Included in local induction programme. who are triaging Training package to be delivered to all new patients are clearly staff in department. documented and include recognised Roll out to existing staff and new starters from Commenced 01 February 2016. competency–based February 2016. triage training 6 Ensure that infection Ensure that infection control procedures are Nursing dashboard results are taken to monthly 177 control procedures are followed in relation to hand hygiene and use to senior staff and directorate meetings for followed in relation to of PPE. discussion and agreed actions. hand hygiene and use Annual Report and Accounts 2015 – 2016 of personal protective equipment (PPE) 7 Ensure that Continued auditing by Ward Matrons/ Audit reports and any resulting actions to resuscitation and Department Matrons/Senior Clinical Matron. senior staff meetings. emergency equipment is checked on a daily basis in line with Trust guidelines 8 Ensure cleanliness SPEQS/SCM ward rounds/Ward Matron ward Results to senior staff meeting for discussion standards are rounds encourage staff to report immediately and agreed action – monthly. maintained non-compliance with cleanliness standards. CQC MUST do Action Status 9 Ensure effective Radiology In place and on-going. systems are in place Risk assessments undertaken Northern Medical Physics and Clinical which enable staff to RM19 offered to staff involved in incidents, Engineering input for radiation risks assess, monitor and litigation and complaints. assessments. mitigate risks relating Community Health Service for Adults Completed to the health, safety Appropriate leadership is in place on the and welfare of people Holdforth Unit (HFU) with on-going monitoring who use the service. and review. All training needs reviewed and application of Completed knowledge and understanding in relation to capacity assessment, cognitive function, DOLs, Malnutrition Universal Screening Tool (MUST). This will be subject to quality audit and part of the HFU dashboard to ensure sustainability. Weekly healthcare records audit will continue On-going weekly until the compliance standard is above 95% for 3 months and monitored on the Holdforth Unit dashboard. HCR are held in two separate files – one file for Completed nursing assessments and daily charts. SOP will be in draft format for the 29Th February 2016. Medical and therapy Healthcare Record (HCR) in second file to enable contemporaneous records and decision making documents to be held in a safe and easily accessible way. DNACPR/Advanced Care Plan (ACP)/Emergency Health Care Plan (EHCP)/DOLs/MCA1/2 documents all to be in the medical file held in the trolley and not on the person bed space. Any person who has a confirmed diagnosis On-going of dementia or has a DOL’s in place has a designated sign above the bed (white board) to notify Trust employees of status. MDT form agreed and implemented for the Completed HFU which is completed on a weekly basis as part of the MDT approach with nursing, therapy and medical input. Staffing model is 50:50 nursing. Appropriate Completed escalation is in place in terms of meeting safe staffing levels. Additional catering items of crockery and jugs Ordered 15.02.16. etc. ordered which supports the principles of Waiting delivery identifying those people who require assistance and prompting for diet and fluid support. Unannounced healthcare and clinical audit On-going including HCR and medicine management. This will remain weekly until the compliance standard is above 95% for 3 months. Pilot trial of the Omnicell drug trolley completed and outcome of review to be implemented. Review of storage and patients own prescription administration system in progress. 178 All Registered Nurses (RN) and Associate Completed Practitioner (AP) staff completed Trust medicines management training. This will be Annual Report and Accounts 2015 – 2016 subject to quality audit and part of the HFU dashboard to ensure sustainability. Ensure compliance with Trust Appraisal Policy On-going which is monitored through the directorate RAG report. Intentional rounding implemented utilising the On-going Trust procedure. Trust currently engaging in a research project with Kings Fund regarding the intentional rounding benefits/procedure. Healthcare assistants have all completed the Completed newly implemented ‘Care Certificate’. ‘Safer care’ acuity tool piloted on HFU and Trust pilot in progress on-going. Acuity monitoring of patients transferred to the HFU in line with SOP monitored through Holdforth Unit dashboard. CQC MUST do Action Status 9 Ensure effective Mentor training completed for all registered Completed systems are in place nurses undertaking the role of mentor. This will which enable staff to form part of any new staff induction. assess, monitor and Advanced falls training completed for all Completed mitigate risks relating nursing and therapy staff on the HFU in to the health, safety relation to falls management and prevention. and welfare of people Monitored through directorate RAG report. who use the service. All staff who undertake Datix investigations Completed have received appropriate training. Review of the HFU vision in line with the nurse Completed led principles and support from community services specialist underpinned by the Directorate Strategy with revised SOPs. Review of the environment in line with Completed dementia friendly approach currently in progress with additional training being delivered by the Community Dementia Liaison Service. Stirling environmental audit completed 2015. Action plan submitted to the Director of Nursing (DoN). Complex discharge planning and engagement On-going across external agencies to ensure the discharge process is right first time. ‘Decision Support Tool’ processes to be a multi- disciplinary approach and utilise the knowledge and skills of therapists, mental health provider and other specialists to provide the right information for accurate outcome based decisions. Community Dementia Liaison Service (CDLS) Completed will support home visits and assessments for those persons with cognitive functional decline utilising their expertise re safety in the residence they are to be discharged too. The HFU will be managed by a Senior Clinical Completed Matron/Professional to ensure the effective integration of therapy and nursing roles based upon competency frameworks. Clinical Director holds regular meetings with Completed service leads to drive forward the vision and strategic approach to the HFU. Continue monitoring hand hygiene compliance Completed HFU currently 100% compliance re: via monthly audit by IPCT. hand hygiene. Results displayed on dashboard. Monitoring of cleanliness and effectiveness of Domestic services cleaning audit tools domestic service via monthly audit. undertaken as per Trust programme. January 2016 98% compliance. 10 Ensure that all policies Governance Reported through audit committee. and procedures All policies, guidelines and procedures be up to in the In-Hospital date and evidence based. care directorate are Maternity Completed reviewed and brought Implementation of bi-monthly obstetrics and Bi-monthly obstetrics and gynaecology up to date. gynaecology guideline meeting. guideline meeting in place. 179 Monitoring of guidelines through bi-monthly Completed. Monthly audits/reporting in place. patient safety meetings in maternity services. 11 Midwifery policies, Implementation of bi-monthly obstetrics and Complete Annual Report and Accounts 2015 – 2016 guidelines and gynaecology guideline meeting. Bi-monthly obstetrics and gynaecology procedural documents guideline meeting in place. must be up to date Monitoring of guidelines through bi-monthly Monitoring in place and evidence based. patient safety meetings in maternity services. CQC MUST do Action Status 12 Ensure there are Appointment of senior nurse with a specific Complete always sufficient focus on nursing and midwifery workforce. numbers of suitably Review of registered and unregistered nursing All directorates have agreed current qualified, skilled and staff establishments and requirements. establishments, and vacancies. Staffing review experienced staff to April 2016. deliver safe care in a timely manner. Development of the model ward team. Other models under review. Currently working with pharmacy around medicine administration in order to complete phase 1. Plan to profile other roles and responsibilities. Refresh of recruitment strategy. Weekly meetings in place to take forward with workforce team. 13 Ensure that all annual Annual reviews will be completed in line with Complete reviews for midwives requirements. take place on a timely Appointment of a full time contact supervisor Complete- Full time contact supervisor basis. of midwives to oversee midwifery supervision appointed. requirements and compliance. Compliance will be monitored on a monthly Monthly basis by the contact Supervisor. Annual review of compliance through the LSA August 2016 audit process. 14 Ensure all staff Monthly RAG reports to ensure training is up Mandatory training compliance of nursing staff attend the relevant to date. reviewed at senior staff and ward matron 1:1 resuscitation training. Non-attendance flagged to GM’s of staff not meetings. attending training.
Duty of Candour Duty of Candour is the process of being open and transparent with people who use the Trust's services and other ‘relevant persons’ (people acting lawfully on their behalf) in general in relation to care and treatment. Trusts are set specific requirements that must be followed when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology when things go wrong. Actions taken by the Trust • From the time of the final consultation in relation to the regulations, the Trust had been preparing to review the processes already in place for Being Open (NPSA). Once the regulations were in their final draft the Trust Policy C40 was reviewed and approved for immediate use; • The Trust policy includes details of how the application of the regulations should be recorded; this is supported by the provision of a healthcare document to be completed and stored in the patients records, full completion of this records sheet will ensure all of the necessary regulatory points are recorded; • As various published guidance has been released, this has been disseminated across the organisation in order to utilise every possible way of ensuring staff are fully aware of the professional bodies advice in relation to the application of the regulations; • The various clinical teams have developed their approach towards applying the regulations in line with the Trust policy; decision making around the regulations is initiated within the clinical team; • The Datix (Trust reporting system) was updated so that a 'pop up' message appears whenever an 180 incident is logged with a harm level of moderate or above; this prompts the reporter to consider the regulations and if they are not applied, to provide a reason for this. The Datix system is also Annual Report and Accounts 2015 – 2016 the agreed storage for any documentation for Duty of Candour; • At the Trust's weekly Serious Untoward Incidents (SUI) Panel a report is presented from Datix giving details of all incidents reported as moderate harm or above, on the system for the last week. The panel members consider the approaches taken and where necessary challenge the decisions made; • Compliance audit initiated to be completed via the Datix system end of quarter 4 2015 – 16. Training/Education • Prior to the regulations being passed by Parliament the Trust had already commenced update training sessions for all grades of staff; a wide range of opportunities for information sharing were utilised in order to reach as many staff as possible; • Duty of Candour requirements have been included into training sessions previously in place i.e. Trust induction, Leadership & Management training. The Simulation team also include Duty of Candour as an area for consideration within their sessions; • Training data is being analysed to enable an understanding of the take up of training over 2015 across the staff groups and departments. At this time the training is not within the mandatory programme, however there are plans to include this on the training RAG report as one off training from April 2016. Positive findings • The Trust staff are very open to applying these regulations and the feedback obtained from them at the training session is very positive; • There have been some examples of excellent communication between patients, families and staff as a result of the use of the regulations. There has been some positive feedback and thanks received from patients who have gone through the process; • This is currently anecdotal, but the Patient Safety teams feel this work is having a positive impact on the numbers and level of formal complaints being received; • Increased incident reporting as a result of examining the criteria for application of the regulations; however this may also have a negative impact as there is a consequential rise in reporting of incidents resulting in harm. Areas for improvement • In some incidents there is evidence that there has been a discussion with the patient or their family; however the records may not provide the necessary information to cover all of the specific requirements of the regulations. This then requires further follow up with clinical teams to confirm the content of the discussion; • There are delays in getting the evidence of compliance stored in the Datix system; this then requires follow up with the relevant safety teams and can delay compliance assessments; • The timeliness of incident reporting around the occurrence of complications is improving but there are on occasion delays in reporting, which then delays the application of the regulations; • Some colleagues still find it difficult to apologise for something going wrong, particularly when there is no fault to be attributed. Future plans • The inclusion of Duty of Candour training in the mandatory training programme and the RAG report; • Development of workshops for colleagues in relation to sharing of experiences and learning from application of the regulations in order to enhance confidence in relation to the initial discussion, apology documentation; • Planning for patient feedback survey to occur Q3 2016 – 17, by which time the regulations will have been in place for two years; 181 • Continue to work with clinical teams to ensure the required Duty of Candour evidence is
uploaded onto Datix early in an investigation rather than being added at the end; Annual Report and Accounts 2015 – 2016 • Audit North review of processes planned for quarter 4 2015 – 16. Sign Up to Safety The Trust's Sign up to Safety campaign aims to reduce the incidence of avoidable harm that occurs to service users within the organisation by 50% over the next 3 years, with a specific focus on: • Reducing pressure ulcers; • Reducing falls with fracture; • Reducing Obstetric Birth Injuries; • Reducing surgical complications; • And Reducing Pressure damage. Whilst this is an overall aim, there will be focussed areas of work undertaken to examine specific areas of high risk. These have been identified through analysis of data available from current and past harm reporting from complaints, incidents and claims. In the lifetime of this strategy on-going monitoring of trends associated with harm will be used to identify areas for action as the data analysis evolves. Commissioners Assurance The Trust had two unscheduled Commissioner Assurance visits during 2015 – 16. The scheduled visit took place in May 2015 for Ward 42, Ward 37 and A&E. An action plan has been developed for all three areas and delivered on any suggestions and/or comments received during the visit; this has been shared with the commissioners. Quality of Data Good quality information underpins the effective delivery of patient care and helps staff to understand what they do well and where they might improve. The members of the Council of Governors are encouraged to test the data reports they receive through participation in SPEQS reviews. This enables governors to speak directly to patients and staff and provides assurance that standards are aligned with information reported. Training staff in critical appraisal is a vital part of ensuring that evidence is considered in an objective and balanced way. We develop clinical staff so that they have the skills and knowledge to use evidence in a way that supports them to make the best clinical decisions. Additional assurance in relation to data quality is provided independently by Audit North. This provides rigorous and objective testing of data collection and reporting standards. Results of these independent audits are reported to the audit committee and provide the Trust with independent appraisal of clinical, financial and business governance standards. This process of internal audit enables the Trust to test quality assumptions and pursue its philosophy of continual improvement. In order to test and improve quality of data the Trust will continue to commission independent audits of its key business. EPR (Electronic Patient Record) In October 2015 the Trust implemented a new EPR (Electronic Patient Record) which replaced the following systems: • patient administration system; • accident and emergency system; • maternity; • discharge summary system; • coding system; • referral to treatment system. In the next phase the theatre system will be replaced followed by the order communications and a new implementation of an e-prescribing system. The implementation of the systems has been challenging for staff and understandably has had an impact on data quality. In the long term the change of system will capture more accurate and timely data, especially patient demographics as it is linked to the personal demographic service. 182 NHS number and general medical practice validity North Tees and Hartlepool NHS Foundation Trust submitted records during 2015 – 16 to the
Annual Report and Accounts 2015 – 2016 Secondary Uses Service (SUS) for inclusion in the Hospital Episodes Statistics (HES) which are included in the latest published data. The percentage of records in the published data is shown in the following table:
Which included the patient’s valid NHS % Which included the patient’s valid % number was: general medical practice code was: Percentage for admitted patient care 98.90 Percentage for admitted patient care 100 Percentage for outpatient care 99.90 Percentage for outpatient care 100 Percentage for accident and emergency 99.20 Percentage for accident and emergency 99.90 care care *Data for April 2015 to March 2016 Information governance (IG) Information governance means keeping information safe. This relies on good systems, processes and monitoring. Every year we audit the quality of specific aspects of information governance through the national information governance toolkit. Staff training and awareness of Information Governance is a key indicator, in 2015 – 16 we again had to ensure that 95% of all of our staff had received information governance training. This target was challenging, however we have continued to make significant progress and for the fifth year running we have met the target with a total of 95% of all staff trained during the year. We continue to provide assurance to the Board of Directors that we are constantly assessing and improving our systems and processes to ensure that information is safe The Trusts Information Governance Toolkit Assessment* compliance score of 77% for 2015 – 16 was graded as 'Satisfactory' Green and gives assurance that quality standards are being maintained. North Tees and Hartlepool NHS Foundation Trust Information Governance Assessment Report overall score for 2015 – 2016 was 77% and was graded as GREEN. A 'Satisfactory' green rating is achieved where Trusts achieve level 2 or above on all requirements; a 'Not Satisfactory' red rating is achieved where Level 2 or above is not evidenced for all requirements.
Requirement 2012-13 2013-14 2014-15 2015-16 Green Green Green Green Information governance management 93% 100% 100% 93% Green Green Green Green Corporate Information Assurance 66% 77% 77% 77% Confidentiality and Data Protection Green Green Green Green assurance 79% 87% 91% 70% Green Green Green Green Clinical information assurance 93% 93% 86% 73% Green Green Green Green Secondary use assurance 83% 83% 79% 79% Green Green Green Green Information security assurance 75% 75% 84% 75% Green Green Green Green Overall Assessment 81% 84% 86% 77% *The IG toolkit is available on connecting for health website. www.igt.connectingforhealth.nhs.uk We receive a number of Freedom of Information (FOI) requests every year. In order to be transparent about information we have been asked to provide, we have developed a virtual reading room on our Trust internet site. Since 1 January 2012, we have been posting responses to Freedom of Information requests on the site and these can be viewed by the public on: www.nth.nhs.uk/foirr Clinical coding error rate Clinical coding translates medical terms written by clinicians about patient diagnosis and treatment 183 into codes that are recognised nationally.
North Tees and Hartlepool Foundation Trust was not subject to the Payment by Results clinical Annual Report and Accounts 2015 – 2016 coding audit during the reporting period by the Audit Commission. The Audit Commission no longer audits every Trust every year where they see no issues. The in- house clinical coding audit manager conducts a 200 episode audit every year as part of the IG Toolkit and also as part of continuous assessment of the auditor. • Primary diagnoses correct (91.50%) • Secondary diagnoses correct (89.94%) • Primary procedures correct (91.43%) • Secondary procedures correct (83.41%) The services reviewed within the sample were 200 finished consultant episodes (FCEs) in consultant episodes taken from a random sample of all specialties. The results should not be extrapolated further than the actual sample audited. The errors include both coder and documentation errors of which the coding errors will be fed back to the coders as a group and individually. The documentation errors will be taken to directorate meetings. Depth of coding and key metrics is monitored by the Trust in conjunction with mortality data. External monthly coding audits are undertaken to provide assurance that coding reflects clinical management. Any issues are taken back to the coder or clinician depending on the error. The clinical coders also attend the mortality review meetings to ensure the correct coding of deceased patients. Our coders organise their work so that they are closer to the clinical teams. This results in sustained improvements to clinical documentation. This supports accurate clinical coding and a reduction in the number of Healthcare Resource Group changes made. This is the methodology which establishes how much we should get paid for the care we deliver. We will continue to work hard to improve quality of information because it will ensure that NHS resources are spent effectively. Specific issues highlighted within the audit have been feedback to individual coders and appropriate training planned where required. North Tees and Hartlepool NHS Foundation Trust will be taking the following actions to improve data quality. The Trust has recruited and trained 6 additional coders to start coding all inpatient activity from notes. This started in January with the Emergency Assessment Unit and is to be rolled out over the remaining wards during 2016. This will improve the capture of additional co- morbidities that are used to calculate HSMR and SHMI.
184 Annual Report and Accounts 2015 – 2016 Part 2d: Core set of Quality Indicators
Measure Measure Description Data Source 1a The value and banding of the summary Health and Social Care hospital-level mortality indicator (SHMI) Information for the Trust Centre Portal (HSCIC)
SHMI Definition The SHMI is the ratio between the actual number of patients who die following hospitalisation at the Trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there. It includes deaths which occur in hospital and deaths which occur outside of hospital within 30 days (inclusive) of discharge. Summary Hospital-level Mortality Indicator (SHMI) – Deaths associated with hospitalisation, England, October 2014 – September 2015
Time period OD Trust National Highest – SHMI Lowest – SHMI banding Score Average Trust Value in Trust Value in the country the country Oct 2012 – Sept 2013 Band 1 1.130 1.00 1.185 0.630 Jan 2013 – Dec 2013 Band 1 1.128 1.00 1.176 0.624 Apr 2013 – Mar 2014 Band 1 1.160 1.00 1.197 0.539 Jul 2013 – Jun 2014 Band 1 1.162 1.00 1.198 0.541 Oct 2013 – Sept 2014 Band 1 1.189 1.00 1.198 0.597 Jan 2014 – Dec 2014 Band 1 1.182 1.00 1.243 0.655 Apr 2014 – Mar 2015 Band 1 1.210 1.00 1.210 0.670 Jul 2014 – Jun 2015 Band 1 1.209 1.00 1.209 0.661 Oct 2014 – Sept 2015 Band 1 1.177 1.00 1.177 0.651
OD band 1 – higher than expected, OD band 2 – as expected, OD band 3 – lower than expected
Trust SHMI scores per 12 month rolling period 1.30 1.20 1.10 1.00 0.90 0.80 0.70 Oct '12 - Jan '13 - Apr '13 - Jul '13 - Oct '13 - Jan '14 - Apr '14 - Jul '14 - Oct '14 - Sep '13 Dec '13 Mar '14 Jun '14 Sep '14 Dec '14 Mar '15 Jun '15 Sep '15
Trust Score National Average 185 Oct 2014 – Sept 2015 Annual Report and Accounts 2015 – 2016 Trust OD Trust banding Score NORTH TEES AND HARTLEPOOL NHS FOUNDATION TRUST Band 1 1.177 SOUTH TYNESIDE NHS FOUNDATION TRUST Band 1 1.139 SOUTH TEES HOSPITALS NHS FOUNDATION TRUST Band 2 1.088 NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUST Band 2 1.047 COUNTY DURHAM AND DARLINGTON NHS FOUNDATION TRUST Band 2 0.995 CITY HOSPITALS SUNDERLAND NHS FOUNDATION TRUST Band 2 0.994 THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST Band 2 0.988 GATESHEAD HEALTH NHS FOUNDATION TRUST Band 2 0.952 The North Tees and Hartlepool NHS Foundation Trust considers that this data is as described for the following reason. SHMI mortality data when reviewed against other sources of mortality data including Hospital Standardised Mortality Ratio (HSMR) and when benchmarked against other NHS organisations will provide an overview of overall mortality performance either within statistical analysis or for crude mortality. The North Tees and Hartlepool NHS Foundation Trust has taken the following actions to improve this measure. The Trust continues to undertake weekly mortality reviews. This work is linked closely with the work being undertaken regionally and has provided the opportunity for peer reviews to give assurance of the quality of the reviews but also the opportunity to benchmark regionally and also to share best practice. The clinical reviews undertaken provide the organisation with the opportunity to assess the quality of care being provided as this will continue to be the priority over and above the statistical data. The reviews have been increased from once a week to twice a week, thus enabling more clinicians to attend to review cases. The Trust continues to run the Keogh Delivery Group; the group is responsible for application of the eight ambitions identified within the Keogh Report. This group is led from Director Level and the on-going work is aimed at impacting positively on the mortality levels across the Trust. The Trust has put in place a lead clinician for mortality to drive forward changes from the Keogh Delivery Group. The work that has been delivered during 2015 – 16 has made an impact on the HSMR value and early indications look promising for the SHMI value too. The work is aimed at promoting good, safe clinical care but also considers the issues relating to the actual data collection that impacts on the statistical calculations. Over the last year the Trust continues to review the process for recording patients who are receiving Specialist Palliative Care or End of Life Care, to ensure that this activity is included in the data collection from clinical coding. To aid in this the Trust appointed an End-of-Life Co-ordinator in May 2015, thus enabling more patients to be seen. The Trust continues to take a key role in regional Community Acquired Pneumonia Project which is running in conjunction with other North East Trusts; the Trust has also joined the Serious Infections – SEPSIS Project with informatics performed by Clarity in both instances.
Measure Measure Description Data Source 1b The percentage of patient deaths with Health and Social Care Information palliative care coded at either diagnosis Centre Portal (HSCIC) or specialty level for the Trust
Percentage of deaths with palliative care coding, October 2014 – September 2015
Time Diagnosis Diagnosis Highest – Lowest – Combined Combined Highest – Lowest – period Rate Rate Diagnosis Diagnosis Rate Rate Combined Combined National Rate Rate National Rate Rate Average Average Oct 2013– 16.70 25.32 49.40 0.00 16.70 25.44 49.40 0.00 Sept 2014 Jan 2014– 18.40 25.74 48.30 0.00 18.40 25.89 48.30 0.00 Dec 2014 Apr 2014– 20.60 25.74 50.90 0.00 20.60 25.85 50.90 0.00 186 Mar 2015 Jul 2014– 25.20 26.00 52.90 0.00 25.20 26.11 52.90 0.00 Annual Report and Accounts 2015 – 2016 Jun 2015 Oct 2014– 29.60 26.50 53.50 0.20 29.60 26.60 53.50 0.20 Sept 2015 Latest Time Period benchmarking position – October 2014 – September 2015
Provider Diagnosis Combined Rate Rate NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUST 34.20 35.40 CITY HOSPITALS SUNDERLAND NHS FOUNDATION TRUST 25.10 25.10 SOUTH TYNESIDE NHS FOUNDATION TRUST 20.80 20.80 THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST 23.00 23.00 SOUTH TEES HOSPITALS NHS FOUNDATION TRUST 22.90 22.90 COUNTY DURHAM AND DARLINGTON NHS FOUNDATION TRUST 18.60 18.60 NORTH TEES AND HARTLEPOOL NHS FOUNDATION TRUST 29.60 29.60 GATESHEAD HEALTH NHS FOUNDATION TRUST 16.30 16.60 National Average 26.50 26.60
The North Tees and Hartlepool NHS Foundation Trust considers that this data is as described for the following reason. The use of palliative care codes in the Trust had remained static over previous years. Processes and procedures were reviewed in 2015 – 16 and adjusted where necessary. The North Tees and Hartlepool NHS Foundation Trust has taken the following actions to improve this number, and so the quality of its service. The review of case notes continues to demonstrate that there are a high number of patients who have been discharged home to die in accordance with their wishes and this has affected the hospital HSMR and SHMI value. Over the last year the Trust continues to review the process for recording patients who are receiving Specialist Palliative Care or End of Life Care, to ensure that this activity is included in the data collection from clinical coding. To aid in this the Trust appointed an End-of-Life Co-ordinator in May 2015, thus enabling more patients to be seen, improving the quality of care for those patients and also increasing the numbers receiving Specialist Palliative Care. The Trust has also provided a detailed training course by the Specialist Palliative Care team to increase education for clinical staff, this along with the changes made to documentation will improve the quality of documentation and in turn the quality of the Trusts clinical coding. The Trust continues to work with commissioners to review pathways of care and support patient choice of residence at end of life wherever possible. Further work is on-going with GPs to try and reduce inappropriate admissions to the Trust. Specialist palliative care processes have been reviewed, with amendments made to both practice and procedures. With an improvement in specialist palliative care being documented, this allows for the information to be coded more accurately, thus in turn help reduce the HSMR value.
Measure Measure Description Data Source Value 2 The Trust’s patient reported outcome Health and Social Adjusted average health measure scores (PROMS) for- Care gain 1. Groin hernia surgery Information EQ-5D Index 2. Varicose vein surgery Centre Portal 3. Hip replacement surgery (HSCIC) 4. Knee replacement surgery 187 The data for hips and knee replacements is now split between primary and revisions.
Hip Hip Knee Knee Annual Report and Accounts 2015 – 2016 April 13 to Groin Varicose replacement replacement replacement replacement March 14 hernia vein - Primary - Revisions - Primary - Revisions Trust Score 0.059 0.046 0.433 0.273 0.361 No data National 0.085 0.093 0.436 0.255 0.323 0.245 Average Highest 0.139 0.150 0.342 0.365 0.416 0.290 National Lowest 0.008 0.023 0.545 0.154 0.215 0.100 National Hip Hip Knee Knee April 14 to Groin Varicose replacement replacement replacement replacement March 15 hernia vein - Primary - Revisions - Primary - Revisions Trust Score 0.044 0.121 0.446 No data 0.343 No data National 0.084 0.095 0.436 0.277 0.315 0.258 Average Highest 0.154 0.154 0.523 0.343 0.420 0.330 National Lowest 0.026 0.003 0.322 0.195 0.202 0.176 National
Hip Hip Knee Knee April 15 to Groin Varicose replacement replacement replacement replacement Dec 15 hernia vein - Primary - Revisions - Primary - Revisions Trust Score 0.036 No data 0.455 No data 0.380 No data National 0.087 0.100 0.449 0.286 0.331 0.268 Average Highest 0.132 0.147 0.528 0.353 0.400 No data National Lowest 0.024 0.042 0.270 0.353 0.215 No data National
The North Tees and Hartlepool NHS Foundation Trust considers that this data is as described for the following reasons. The Trust has been identified as having a lower than the national average ‘adjusted average health gain’ score in relation to groin hernia surgery. The North Tees and Hartlepool NHS Foundation Trust has taken the following actions to improve this score. The Trust continues to carry out 3 reviews, the reviews will occur at six weeks, followed by 6 months with the final review being at 12 months. The reviews will be carried out by the joint replacement practitioners unless otherwise identified. The Trust continues to use the telephone review clinics, thus ensuring that communication remains open with the patient listening and acting upon any issues/concerns that they may have.
Measure Measure Description Data Source 3 The percentage of patients readmitted to a hospital Health and Social Care which forms part of the Trust within 28 days of being Information discharged from a hospital which forms part of the Trust Centre Portal during the reporting period; aged: (HSCIC) (i) 0 to 15; and (ii) 16 or over.
188 Annual Report and Accounts 2015 – 2016 Age Value Data for Data for Data for Data for Data for Group 2012-13 2011-12 2010-11 2009-10 2008-09 standardised standardised standardised standardised standardised to persons to persons to persons to persons to persons 20xx-xx 2007-08 2006-07 2006-07 2006-07 Trust Not Available 8.79 11.45 12.23 11.87 Score National Not Available 10.01 10.15 10.18 10.09 Average 0 to Band Not Available B5 A1 A1 A1 15 Highest Not Available 14.94 25.80 22.53 22.73 National Lowest Not Available 0.00 0.00 0.00 0.00 National Trust Not Available 11.80 11.48 11.23 11.32 Score National Not Available 11.45 11.42 11.16 10.90 Average 16 or Band Not Available W W W A5 over Highest Not Available 17.72 23.99 16.82 24.43 National Lowest Not Available 0.00 0.00 0.00 0.00 National
5 Band Comparison against national average Note 1: National Comparison, based on 95% and 99.8% confidence intervals of the rate B1 = Significantly better than the national average at the 99.8% level; B5 = Significantly better than the national average at the 95% level but not at the 99.8% level; W = National average lies within expected variation (95% confidence interval); A5 = Significantly poorer than the national average at the 95% level but not at the 99.8% level; A1 = Significantly poorer than the national average at the 99.8% level. To Note: the publication of the 2012 – 13 data has been delayed, therefore is not available at the time of print. The North Tees and Hartlepool NHS Foundation Trust considers that this data is as described for the following reasons. The Trust monitors and reports readmission rates to the Board of Directors and directorates on a monthly basis. The January 2016 position indicates the Trust has an overall readmission rate of 7.18% against the internal stretch target of 7.70%, a 0.81% improvement from the 2015 position. Directorates perform regular audits with the aim to identify themes to inform service improvements. An annual audit of readmissions is carried out in conjunction with commissioners and clinical stakeholders to identify the level of avoidable and unavoidable readmissions to feed 189 into the annual contract agreements.
The North Tees and Hartlepool NHS Foundation Trust has taken the following actions to improve Annual Report and Accounts 2015 – 2016 performance in preventing avoidable readmissions within 30 days of discharge. This continues to present a considerable challenge for the Trust and is being addressed by several means including the reinvestment of readmission penalty money and other non-recurrent funding sources. With the required focused clinical leadership and strategic approach there has been a continued improvement to the elective and emergency readmission position. Patient pathways continue to be redesigned to incorporate an integrated approach to collaboration with primary and social care services, providing care closer to home and reducing hospital admissions and readmissions. There have been a number of initiatives introduced within 2015 – 16 including: review of the discharge liaison team of therapy staff to actively support timely discharge; inclusion of social workers within the hospital teams to facilitate discharge with appropriate packages of care to prevent readmission; the redesign of integrated care pathways for long term conditions by direction and delivery through an executive director led programme; utilisation of ambulatory care facilities. Measure Measure Description Data Source 4 The Trusts responsiveness to the personal Health and Social Care needs of its patients Information Centre Portal (HSCIC)
Period of Coverage National Average NORTH TEES AND HARTLEPOOL NHS FOUNDATION TRUST (out of 100) 2015-16 Not Available Not Available 2014-15 68.90 68.10 2013-14 68.70 69.00 2012-13 68.10 68.70 2011-12 67.40 71.00 *2014 – 15 data not available at the time of print Benchmarked against over North East Trusts for 2014 – 15;
Trust Overall Score (out of 100) The Newcastle Upon Tyne Hospitals NHS Foundation Trust 76.80 Gateshead Health NHS Foundation Trust 74.10 South Tees Hospitals NHS Trust 73.00 Northumbria Healthcare NHS Foundation Trust 72.80 South Tyneside NHS Foundation Trust 71.60 City Hospitals Sunderland NHS Foundation Trust 68.80 North Tees & Hartlepool NHS Foundation Trust 68.10 County Durham and Darlington NHS Foundation Trust 65.30 NB: Average weighted score of 5 questions relating to responsiveness to inpatients’ personal needs (Score out of 100). The scores are out of 100. A higher score indicates better performance: if patients reported all aspects of their care as 'very good' we would expect a score of about 80, a score around 60 indicates 'good' patient experience. The domain score is the average of the question scores within that domain; the overall score is the average of the domain scores. The Trust has worked hard in order to further enhance its culture of responsiveness to the personal needs of patients. The North Tees and Hartlepool NHS Foundation Trust considers that this data is as described for the following reasons. The Trust has developed its Patients First strategy and understanding patient views in relation to responsiveness, personal needs helps us to understand how well we are performing. 190 The North Tees and Hartlepool NHS Foundation Trust has taken the following actions to improve this score, and so the quality of its services, by delivering accredited programmes that focus on responsiveness of patient and carers for both registered and unregistered nurses on. We use human Annual Report and Accounts 2015 – 2016 factors training to raise awareness of the impact of individual accountability on patient outcomes and experience. When compared against the national average score the Trust continues to be rated well by patients. “I have had first class treatment from Doctors. Nurses were brilliant, loving and caring. Brilliant at their job. Well done North Tees Hospital.” [sic] Measure Measure Description Data Source 5 The percentage of staff employed by, or Health and Social Care under contract to, the Trust during the Information reporting period who would recommend Centre Portal the Trust as a provider of care to their (HSCIC) family or friends. All NHS organisations providing acute, community, ambulance and mental health services are now required to conduct the Staff, Friends and Family Test each quarter. The aim of the test is to: Encouraging improvements in service delivery – by 'driving hospitals to raise their game' The Trust believes that the attitude of its staff is the most important factor in the experience of patients. We will continue to work with staff to develop the leadership and role modelling required to further enhance the experience of patients, carers and staff. National NHS Staff Survey Question: If a friend or relative needed treatment, I would be happy with the standard of care provided by this Trust.
Survey Year Trust Name 2011 2012 2013 2014 2015 Trust 1 59 63 59 65 70 Trust 2 49 50 57 53 61 Trust 3 73 69 70 75 76 North Tees & Hartlepool 63 60 58 54 62 Trust 4 70 69 77 70 85 Trust 5 69 74 76 80 72 Trust 6 63 68 64 53 62 Trust 7 79 86 87 84 89 North East 66 67 68 67 72 England 62 65 67 67 70 National High - 94 93 93 National Low - 38 36 37
Friends and Family Test – Staff Care: ‘How likely staff are to recommend the NHS services they work in to friends and family who need similar treatment or care’. *Q1 *Q2 **Q3 *Q4 Percentage Recommended – Care 81% 77% 62% 78% Percentage Not Recommended – Care 9% 6% 12% 10% 191 *Q1, Q2 and Q4 data obtain from the Friends and Family Test for Staff **Q3 information taken from the NHS National Staff Survey Annual Report and Accounts 2015 – 2016 Work: ‘How likely staff would be to recommend the NHS service they work in to friends and family as a place to work’. *Q1 *Q2 **Q3 *Q4 Percentage Recommended – Work 72% 71% 56% 67% Percentage Not Recommended – Work 13% 13% 16% 15% *Q1, Q2 and Q4 data obtain from the Friends and Family Test for Staff **Q3 information taken from the NHS National Staff Survey More detail can be found for the Friends and Family Test in Part 3: Review of Quality Performance 2014 – 15, under Priority 3: Patient Experience – Friends and Family recommendation, point 3. The North Tees and Hartlepool NHS Foundation Trust considers that this data is as described for the following reasons. The Trust continue to actively engage with and encourage staff to complete and return the Staff Survey along with the quarterly Staff Friends and Family Test, so that areas of improvement(s) can be identified and acted upon in future. The North Tees and Hartlepool Foundation Trust has taken the following actions to further improve this percentage, and so the quality of its services, by involving the views of the staff in developing a strategy for care. Understanding the views of staff is an important indicator of the culture of care within the organisation, and as such all departments are monitored in relation to the Staff Friends and Family test, ensuring that all anonymous negative comments made on the returns are reviewed and plans put in place to improve the level of care provided by the Trust. National Staff Survey Percentage of staff experiencing harassment, Percentage believing that Trust provides bullying or abuse from staff in the last 12 equal opportunities for career progression or months promotion
2014 2015 National Average 2014 2015 National Average 21% 26% 24% 90% 90% 87%
Measure Measure Description Data Source 6 Friends and Family Test – Patient Health and Social Care All Acute providers of adult NHS funded care, covering Information services for inpatients and patients discharged from Centre Portal Accident and Emergency. (HSCIC)
Please refer to Part 3, Priority 3 – Patient Experience point 5 – Friends and Family Recommendations The North Tees and Hartlepool Foundation Trust considers that this data is as described for the following reasons. The Trust collects, analyses the data and produces reports for all areas using internal staffing without the need to employ an external company to conduct these tasks. By keeping the service in-house, the Trust can implement changes and/or recommendations made from staff and patients swiftly. The Trusts in-patients who would recommend the service to friends or family has increased from 95.30% in 2014 – 15 to 96.03% in 2015 – 16. The North Tees and Hartlepool Foundation Trust has taken the following actions to continue to improve this percentage, and so the quality of its services, whilst it remains a challenge to increase response rates for a survey that is truly voluntary, the Trust is managing to collect good numbers and actively listens to all staff recommendations to improve the method of distributing the survey without delaying patient discharges. The Trust uses the Friends and Family data along with other patient surveys to build up a more comprehensive position for patient care within the organisation.
192 Annual Report and Accounts 2015 – 2016 Measure Measure Description Data Source 7 The percentage of patients who were admitted to Health and Social Care hospital and who were risk assessed for venous Information thromboembolism (VTE) Centre Portal (HSCIC)
VTE Risk Assessment 95.42%96.30% 95.40%96.20% 95.83%95.39% 95.02%95.69% 100% 80% 60% 40% 20% 0% Q1 Q2 Q3 Q4
2013-2014 2014-2015
Two year reporting trend
Measure Report- 2014-2015 2015-2016 ing Year Quarter Q1 Q2 Q3 Q4 Q1 Q2 Q3 *Q4 Value 96.30% 96.20% 95.39% 95.94% 96.63% 95.20% 96.87% N/A National 96% 96% 95.95% 95.97% 96.05% 95.86% 95.48% N/A Average Highest 100% 100% 100% 100% 100% 100% 100% N/A National Lowest 87.20% 86.40% 81.19% 79.23% 86.08% 75.04% 61.50% N/A
Venous Thrombo- Venous embolism National *Q4 data no available at time of print North East Trust benchmarking 2015 – 16
2015-16 Trust Q1 Q2 Q3 Q4* North Tees and Hartlepool NHS Foundation Trust 96.63% 95.20% 96.87% N/A City Hospitals Sunderland NHS Foundation Trust 98.18% 98.21% 98.25% N/A South Tees Hospitals NHS Trust 95.76% 96.31% 96.11% N/A South Tyneside NHS Foundation Trust 97.15% 96.42% 95.65% N/A County Durham and Darlington NHS Foundation Trust 95.76% 95.30% 96.26% N/A 193 Gateshead Health NHS Foundation Trust 95.59% 95.12% 95.01% N/A Annual Report and Accounts 2015 – 2016 The Newcastle Upon Tyne Hospitals NHS Foundation Trust 95.93% 96.37% 96.20% N/A Northumbria Healthcare NHS Foundation Trust 94.77% 95.36% 94.35% N/A *Q4 data no available at time of print The Trust has promoted the importance of doctors undertaking assessment of risk of VTE for all appropriate patients in line with best practice. The North Tees and Hartlepool Foundation Trust considers that this data is as described for the following reasons. By understanding the percentage of patients who were admitted to hospital who were risk assessed for VTE helps the Trust to reduce cases of avoidable harm. The Trust has ensured that a robust reporting system is in place and adopts a systematic approach to data quality improvement. The North Tees and Hartlepool Foundation Trust has taken the following actions to continue to improve this percentage, and so the quality of its services, by updating the training booklets to keep them relevant, ensuring that it is part of the mandatory training and providing guidance on the importance of VTE risk assessment at induction of clinical staff. Consultants continue to monitor performance in relation to VTE risk assessment on a daily basis. The Trust ensures that each Directorate clinical leads are responsible for monitoring and audit of compliance of NICE VTE guidelines and this will be presented yearly to the Audit and Clinical Effectiveness (ACE) Committee. The following table demonstrates the venous thromboembolism (VTE) mandatory training for the whole Trust as recorded at the end of March 2016.
Requiring Training Trained % Compliance 1,287 1,224 95% *data as of 31 March 2016
Measure Measure Description Data Source 8 The rate per 100,000 bed days of cases of C.difficile Health and Social Care infection that have occurred within the Trust amongst Information patients aged 2 or over during the reporting period. Centre Portal (HSCIC)
Rate per 100,000 bed-days for specimens taken from patients aged 2 years and over Reporting Trust C Trust Rate National Highest Lowest Period difficile cases Average National rate National rate April 2015 – 36 Not Available Not Available Not Available Not Available March 2016 April 2014 – 20 10.40 15.10 62.20 0.00 March 2015 April 2013 – 30 15.70 13.60 37.10 0.00 March 2014 April 2012 – 61 30.80 17.40 31.20 0.00 March 2013 April 2011 – 68 35.80 22.20 58.20 0.00 March 2012 April 2010 – 53 27.10 29.70 71.20 0.00 March 2011 April 2009 – 136 63.90 35.30 128.90 0.00 March 2010 * 2015 – 16 data not available at the time of print
194 Trust C difficile cases
150 Annual Report and Accounts 2015 – 2016
100
50
0 April 2009 - April 2010 - April 2011 - April 2012 - April 2013 - April 2014 - April 2015 - March 2010 March 2011 March 2012 March 2013 March 2014 March 2015 March 2016
Trust C difficile cases The North Tees and Hartlepool Foundation Trust considers that this data is as described for the following reasons. The Trust has a robust reporting system in place and adopts a systematic approach to data quality checks and improvement. The North Tees and Hartlepool Foundation Trust has taken the following actions to improve this, and so the quality of its services; enhanced ward cleaning and decontamination of patient equipment, including the use of steam, hydrogen peroxide and Ultraviolet (UV) light, and the introduction of a mattress decontamination service to reduce the risk of infection and improve quality of service to patients, raised awareness and audit of antimicrobial prescribing and stewardship including the identification of antibiotic champions for each directorate and the introduction of competency assessments for prescribers, an emphasis on high standards of hand hygiene for staff and patients and daily monitoring of affected patients to ensure good clinical management and the reduction in risk of cross infection. The Trust intends to continue with these measures and will explore every opportunity for further improvement in 2016 – 17.
Measure Measure Description Data Source 9 The number and, where available, rate of patient safety Health and Social Care incidents that occurred within the Trust during the Information reporting period, and the percentage of such patient Centre Portal safety incidents that resulted in severe harm or death. (HSCIC)
Reporting and understanding patient safety incidents is an important indicator of a safety culture within an organisation. Provider: Acute (Non Specialist) – Organisational incident data by organisation in 6-month period, October 2014 – March 2015
Based on occurring National Our Trust dataset Degree of harm Degree of harm (Degree of Harm – All) Severe or Death Severe or Death Report period Number of Rate per Average Highest Lowest Number of % incidents 1,000 Bed % % % incidents occurring Days Oct 14 – Mar 15 3,074 30.40 0.19 1.50 0.02 7 0.07 Apr 14 – Sep 14 3,068 32.40 0.19 1.09 0.00 8 0.08
Regional Benchmarking
October 2014 – March 2015 Trust Degree of Harm Degree of Harm (All) – Rate per (Severe or Death) 1,000 bed days Gateshead Health NHS Foundation Trust 27.90 0.16 The Newcastle Upon Tyne Hospitals NHS Foundation Trust 29.70 0.12 North Tees & Hartlepool NHS Foundation Trust 30.40 0.07 South Tees Hospitals NHS Trust 34.00 0.04 195 Northumbria Healthcare NHS Foundation Trust 35.20 0.07 County Durham and Darlington NHS Foundation Trust 35.30 0.07 Annual Report and Accounts 2015 – 2016 South Tyneside NHS Foundation Trust 39.20 0.17 City Hospitals Sunderland NHS Foundation Trust 72.80 0.04
The North Tees and Hartlepool Foundation Trust considers that this data is as described for the following reasons. The safety culture of the Trust can be assessed by considering the understanding of staff, within the organisation, in relation to reporting of all incidents but in particular those where the outcome in relation to the level of harm caused by an incident was serious or death. The need to ensure that the Duty of Candour regulations are considered against all incidents where moderate or more serious actual harm occurs, further supports and promotes the need to report and investigate such incidents in a timely manner. The North Tees and Hartlepool Foundation Trust has taken the following actions to improve the proportion of this rate and so the quality of its services. The Trust ensures that all reported incidents are reviewed internally within the local departments for accuracy of harm assessment; but also externally from the reporting team, to provide assurance that the appropriate level of harm has been allocated in higher level harm incidents. Where discrepancies are noted the reporting team are asked to provide further details in order to allow for a decision to be made regarding the level of investigation. Where there are uncertainties around the level of harm the Medical Director and/or the Director of Nursing, Quality and Patient Safety are asked to arbitrate and agree upon the level of investigation. Weekly meetings, held to review all serious incidents within the Trust, provide a forum for any cases to be discussed within a multidisciplinary team and agree a way forward. The incidents are then managed within the national framework for serious incidents and the current requirements for the Clinical Commissioning Groups (CCGs). The weekly safety panel not only considers newly reported incidents where there has been serious harm or death reported as an outcome; the panel also considers the final Comprehensive Investigation reports developed from the internal investigations into these incidents. Once an investigation into any serious incident, which has been reported to the CCG, has been agreed as complete by this panel; and there are assurances that actions have been initiated to reduce the risks of recurrence; the reports and action plans are forwarded to the CCG for external review and approval prior to closure. The Trust also uses a similar process for incidents where any actual harm is identified as being at a lower level, but when the incident is reviewed the Trust feels that lessons can be learnt from further analysis outside of the reporting team. It is felt that this proactive approach to safety and quality allows the Trust to internally consider areas of service provision before they escalate in more serious concerns. The Safety panel also reviews a summary of all incidents where moderate or more serious harm is reported on the incident reporting system. This allows validation of those where Duty of Candour regulations have been applied; but also allows challenge to those cases where the decisions around the regulations have not been identified by the relevant clinical team. On-going education and updating of relevant staff groups, supports the application of the regulations and the need to ensure there is proactive reporting of safety incidents for investigation and trend analysis, not only for application of these regulations but to enhance learning across the organisation.
196 Annual Report and Accounts 2015 – 2016 Part 3a: Additional Quality Performance measures during 2015 – 16
This section is an overview of the quality of care based on performance in 2015 – 16 against indicators In addition to the three local priorities outlined in Section 2, the indicators below further demonstrate that the quality of the services provided by the Trust over 2015 – 16 has been positive overall. The following data is a representation of the data presented to the Board of Directors on a monthly basis in consultation with relevant stakeholders for the year 2015 – 16. The indicators were selected because of the adverse implications for patient safety and quality of care should there be any reduction in compliance with the individual elements. Patient Safety Infection Control
4. Infection Prevention and Control Rationale: Key stakeholders asked us to continue to report on C. difficile in 2015 – 16 as this remains high on the patient safety agenda. Overview of how we said we would do it • We will closely monitor testing regimes, antibiotic management and repeat cases and ensure we understand and manage the root cause wherever possible. Overview of how we said we would measure it • We will monitor the number of Trust and non-Trust attributed cases • We will undertake a multi-disciplinary Root Cause Analysis (RCA) within 3 working days for all Trust attributed cases. • We will benchmark our progress against previous months and years. • We will benchmark our position against Trusts in the North East and peers across England in relation to number of cases reported and number of samples tested. Overview of how we said we would report it • Board of Directors meetings • Council of Governor meetings (CoG) • Infection Control Committee (ICC) • Patient Safety and Quality Standards Committee (PS & QS) • To frontline staff through Chief Executive brief. • Nursing Dashboard 197 • Clinical Quality Review Group (CQRG)
Completed and reported? Annual Report and Accounts 2015 – 2016 Reported at every Board of Directors meeting Reported at every Council of Governors meeting Discussed at each Infection Control Committee Discussed in detail at Audit Committee and Directorate meetings Reported in detail to Monitor Nursing and Midwifery Dashboard contains infection data Clostridium difficile infection (CDI) Clostridium difficile is a bacterium that is found in the gut of around 3% of healthy adults. It seldom causes a problem as it is kept under control by the normal bacteria of the intestine. However certain antibiotics can disturb the bacteria of the gut and Clostridium difficile can then multiply and produce toxins which cause symptoms such as diarrhoea. During 2015 – 16 the Trust did not achieve the Clostridium difficile target having reported36 Trust attributed cases against a trajectory of 13 cases. This is disappointing given the reduction achieved in the previous two years. The Trust continues to work hard to control and reduce opportunity for infections to spread when we treat people in our clinical premises or in their own homes. The Trust has maintained a consistent approach to cleanliness across all important areas of our environment including enhanced decontamination with hydrogen peroxide vapour and the development of a mattress decontamination facility. A greater focus has been placed on antimicrobial stewardship with the identification of ‘champions’ across all directorates. The importance of adherence to high standards of hand hygiene has remained unchanged and is the basis of much of our infection prevention and control activity. The Trust action plan has been developed and reviewed following external expert reviews. This action plan is under continual review by the CDI task and finish group and progress reported to the Healthcare Associated Infection Operational Group and Infection Control Committee. The action plan is regularly shared with commissioners. How did we do? In 2015 – 16, a challenging Clostridium difficile target was set by our commissioners of no more than 13 cases, which the Trust did not achieve, reporting 36 cases; this was 23 cases over trajectory. The following table identifies the numbers of hospital acquired cases of Clostridium difficile cases reported by the Trust against the target for that period. The table also identifies the number of community acquired cases of Clostridium difficile reported by our laboratory.
Target for Trust attributed Number of Trust attributed Number of non-Trust cases cases attributed cases (acquired in people’s own homes) Q1 4 8 14 Q2 3 10 21 Q3 3 7 13 Q4 3 11 20 Total 13 36 68 *Data obtained from Healthcare Associated Infections (HCAI) data capture system The following tables identify the performance against trajectory for the eight North East Trusts in 2014 – 15 and 2015 – 16.
2014-15 Trust Monitor Target Total Trust 1 51 42 198 Trust 2 37 18 Trust 3 24 26
Annual Report and Accounts 2015 – 2016 North Tees & Hartlepool NHS Foundation Trust 40 20 Trust 5 30 30 Trust 6 49 76 Trust 7 10 13 Trust 8 80 89 *Data obtained from HCAI data capture system 2015-16 Trust Monitor Target Total Trust 1 34 61 Trust 2 19 21 Trust 3 19 47 North Tees & Hartlepool NHS Foundation Trust 13 36 Trust 5 30 21 Trust 6 50 61 Trust 7 8 24 Trust 8 77 94 *Data obtained from HCAI data capture system April 2015 to March 2016 HCAI – Clostridium difficile rate per 100,000 Bed Days – 2015 – 16
C.diff rate per 100,000 Bed Days Trust 1 29.00 Trust 7 25.50 Trust 3 25.30 Trust 6 18.00 North Tees & Hartlepool NHS Foundation Trust 17.50 Trust 8 15.20 Trust 5 8.00 Trust 2 6.20 *Data obtained from the Healthcare Evaluation Data (HED) – data from April 2015 to January 2016 Clostridium difficile trend year on year for the Trust
Trust attributed Non-Trust attributed 2011-12 68 109 2012-13 61 95 2013-14 30 95 2014-15 20 71 2015-16 36 68 *Data obtained from HCAI data capture system Escherichia coli (E coli) Rationale: Key stakeholders asked us to report on all infections in 2015 – 16 Escherichia coli is a very common bacterium found in the human gut which can cause serious infections such as blood poisoning 199 How did we do?
The numbers of E coli bacteraemia (blood stream infection) reported across by the Trust for the year Annual Report and Accounts 2015 – 2016 are shown in the table below. As the majority of these cases are those that are identified within the first 48 hours of hospital admission work is required across all healthcare settings to achieve improvements. Root cause analysis is completed for all cases deemed to have been Trust attributable and action plans are developed where actions are identified. In many cases these infections are related to urine infections and are thought to be not preventable with only a very small percentage of cases being in patients with a urinary catheter where they may be potential for improved practices.
Trust attributed Non-Trust attributed 2011-12 41 149 2012-13 31 194 2013-14 22 169 2014-15 28 176 2015-16 44 224 *Data obtained from HCAI data capture system HCAI – E coli rate per 100,000 Bed Days – 2015 – 16
E coli rate per 100,000 Bed Days Trust 5 148.54 Trust 1 128.65 Trust 6 126.61 North Tees & Hartlepool NHS Foundation Trust 115.89 Trust 2 104.68 Trust 3 97.88 Trust 7 85.15 Trust 8 70.49 *Data obtained from the Healthcare Evaluation Data (HED) – data from April 2015 to January 2016 Methicillin-Resistant Staphylococcus Aureus (MRSA) bacteraemia Staphylococcus aureus is a bacterium commonly found on human skin which can cause infection if there is an opportunity for the bacteria to enter the body. In serious cases it can cause blood stream infection. MRSA is a strain of these bacteria that is resistant to many antibiotics, making it more difficult to treat Many patients carry MRSA on their skin and this is called colonization. It is important that we screen patients when they come into hospital so that we know if they are carrying MRSA. Screening involves a simple skin swab. If positive, we can provide special skin wash that helps to get rid of MRSA. This measure reduces the risk of them going on to develop an infection. How did we do? In 2015 – 16 our organisation reported two Trust attributed MRSA, an increase on the previous year when one case was reported. This exceeds the national zero tolerance trajectory and was particularly disappointing given previous good performance. A significant amount of work has been undertaken in the Trust to improve infection prevention practices such as intravenous line care and wound care and as a result we do not see these things as sources of infection. Samples which are contaminated and not a true bacteraemia are now counted automatically against 200 the organisation which submitted the sample and one of our cases this year has fallen into that category. Work continues to improve training and competency assessment of staff who take blood
Annual Report and Accounts 2015 – 2016 culture samples in order to reduce the risk of further cases. The other case this year was thought to be unpreventable with all appropriate measures having been taken. MRSA bacteraemia cases 2011 – 16
Trust attributed Non-Trust attributed 2011-12 0 1 2012-13 2 6 2013-14 0 4 2014-15 1 2 2015-16 2 3 *Data obtained from HCAI data capture system MRSA bacteraemia rate in North east Trusts per 100,000 Bed Days 2015 – 16
MRSA bacteraemia rate per 100,000 Bed Days Trust 8 1.90 Trust 5 0.70 Trust 2 0.60 Trust 6 0.60 Trust 1 0.00 Trust 3 0.00 North Tees & Hartlepool NHS Foundation Trust 0.00 Trust 7 0.00 *Data obtained from the Healthcare Evaluation Data (HED) – data from April 2015 to January 2016 Methicillin-sensitive Staphylococcus Aureus (MSSA) MSSA is a strain Staphylococcus Aureus that can be effectively treated with many antibiotics. It can cause infection if there is an opportunity for the bacteria to enter the body and in serious cases it can cause blood stream infection. How did we do? In 2015 – 16 we reported 24 cases of Trust attributed MSSA bacteraemia. Each case is subject to a root cause analysis and the analysis of these investigations has shown that there are no apparent trends in terms of linked cases or frequently seen sources of infection. In many cases the source has been a chest or skin infection which would have been difficult to prevent. However, the Trust recognises that improvement is needed in this infection and increased emphasis on clinical practices will be a focus of for the future in an attempt to reduce the number of MSSA bacteraemia. An increase in non-Trust attributed cases was also seen this year. MSSA bacteraemia rate in North East Trusts per 100,000 Bed Days - 2015 – 16
MSSA bacteraemia rate per 100,000 Bed Days Trust 8 14.80 North Tees & Hartlepool NHS Foundation Trust 13.60 Trust 5 12.70 Trust 2 9.30 Trust 6 7.90 Trust 3 6.90 Trust 1 6.80 Trust 7 3.40 *Data obtained from the Healthcare Evaluation Data (HED) – data from April 2015 to January 2016
Trust attributed Non-Trust attributed 2013-14 13 30 201 2014-15 18 41 2015-16 24 64 Annual Report and Accounts 2015 – 2016 *Data obtained from HCAI data capture system Falls Why/How we chose this measure. Following consultation with key stakeholders it was evident that falls continue to be one of the Trusts key harm measures to monitor and improve on. Patients aged 65 years and over are at highest risk of falling and patients aged 85 and over are at highest risk of injury from a fall. Falls with Fracture During 2015 – 16 the Trust has experienced 33 falls resulting in fracture, this has decreased from 39 in the 2014 – 15 reporting period.
2013-14 2014-15 2015-16 Apr 1 1 4 May 2 4 3 Jun 1 2 11 Jul 1 9 1 Aug 4 1 4 Sep 4 4 1 Oct 4 3 1 Nov 1 5 2 Dec 1 3 0 Jan 0 3 0 Feb 1 3 3 Mar 1 4 3 Total 21 39 33 *Data obtained via the Trusts Incident Reporting database (Datix).
Falls with Fracture by Age Group 20 18 18 16 14 12 10 8 7 6 4 4 2 1 1 1 1 0 202 30-39 40-49 50-59 60-69 70-79 80-89 90-99
The Trust works on the basis that Out of Hours working is 8pm to 8am and In Hours working is Annual Report and Accounts 2015 – 2016 8am to 8pm. The following table demonstrates the number of ‘Falls with Fracture’ suffered both In and Out of Hours:
Number of Falls with Fracture Out of Hours (8pm to 8am) 13 In Hours (8am to 8pm) 20 Falls Injury, No Fracture During 2015 – 16 the Trust has experienced 212 falls resulting in an injury and no fracture, this has decreased significantly from 355 in the 2014 – 15 reporting period.
2013-14 2014-15 2015-16 Apr 28 25 16 May 21 27 23 Jun 27 19 11 Jul 35 29 19 Aug 22 33 22 Sep 37 29 21 Oct 23 27 16 Nov 26 31 15 Dec 31 33 20 Jan 30 37 19 Feb 24 40 13 Mar 26 25 17 Total 330 355 212 *Data obtained via the Trusts Incident Reporting database (Datix).
Falls Injury, No Fracture by Age Group
140
120
100 86 80
60 53
40 24 21 20 6 9 8 1 4 0 0
<30 30-39 40-49 50-59 60-69 70-79 80-89 90-99 100+ No DOB
The following table demonstrates the number of ‘Falls with Injury, No Fracture’ suffered both In and 203 Out of Hours:
Number of Falls with Injury, No Fracture Annual Report and Accounts 2015 – 2016 Out of Hours (8pm to 8am) 116 In Hours (8am to 8pm) 96 Falls with No Injury During 2015 – 16 the Trust has experienced 947 falls resulting in no injury, this has decreased from 1,094 in the 2014 – 15 reporting period.
2013-14 2014-15 2015-16 Apr 100 120 65 May 110 87 69 Jun 67 66 91 Jul 98 84 56 Aug 71 108 93 Sep 80 93 72 Oct 84 97 76 Nov 96 84 95 Dec 88 88 71 Jan 101 85 88 Feb 78 100 85 Mar 70 82 86 Total 1043 1094 947 *Data obtained via the Trusts Incident Reporting database (Datix).
Falls No Injury by Age Group
350 319 300
250 222 200
150 117 107 100 68 43 50 31 21 18 1 0
<30 30-39 40-49 50-59 60-69 70-79 80-89 90-99 100+ No DOB
The following table demonstrates the number of ‘Falls with No Injury’ suffered both In and Out of 204 Hours:
Number of Falls with No Injury Annual Report and Accounts 2015 – 2016 Out of Hours (8pm to 8am) 445 In Hours (8am to 8pm) 502 National Falls Audit – 2015
National audit of inpatient falls 2015 – RCP audit results The Royal College of Physicians’ (RCP) National Audit for Inpatient Falls (NAIF) has launched its first report on how well hospital Trusts and health boards in England and Wales are working to prevent patients falling whilst in hospital. This audit measures performance against the NICE evidence based standards (CG161) on falls assessment and prevention. The Full report can be found at: https://www.rcplondon.ac.uk/projects/outputs/naif-audit-report-2015
Falls resulting in Falls per 1,000 moderate/severe harm Occupied Bed Days or death per 1,000 (OBD) Occupied Bed Days (OBD) City Hospitals Sunderland NHS Foundation Trust 0.22 8.34 County Durham and Darlington NHS 0.17 6.88 Foundation Trust Gateshead Health NHS Foundation Trust 0.21 8.22 North Tees and Hartlepool NHS Foundation 0.38 7.69 Trust Northumbria Healthcare NHS Foundation Trust 0.29 9.60 South Tees Hospitals NHS Foundation Trust 0.13 6.25 South Tyneside NHS Foundation Trust 0.39 10.66 The Newcastle Upon Tyne Hospitals NHS 0.15 7.07 Foundation Trust
Actions taken by the Trust To ensure that the risk of suffering a fall within the Trust resulting in injury is mitigated, where possible, the Trust has drawn together a Falls Management action plan. Key elements with the plan are as follows: Review the template for the development of Root Cause Analysis (RCA) to ensure directorates cover all areas of possible causes of the fall All Strategic Executive Information System (STEIS) reportable SUIs (falls) have a set information requirement as laid out by the Trust falls group. The information pertains to policy, best practice and NICE guidance. This process enables a standardised approach to the report leads who do not have the clinical background to question and interpret findings from statements and investigation. Falls policy to be reviewed The Trusts falls policy was reviewed and implemented following the release of NICE guidance 161 and 86. Changes were made and rolled out across all adult in patient areas according to need. New 205 documentation was authorised via the Healthcare Records Committee and is due for audit via Audit
North during Q4. All relevant audit forms pertaining to falls have been updated accordingly to Annual Report and Accounts 2015 – 2016 reflect the changes. Further develop the DATIX reporting of falls categories to allow more comprehensive analysis of the falls incidents that do not result in Fracture Additional fields have been added to the investigation process within the Datix system. Quarterly reports are formatted to reflect on the additional fields e.g., known dementia, prescribed antipsychotics, bed number etc. This provides additional information supporting the current beliefs of an increasingly vulnerable and complex population across Hartlepool and Stockton Identification of the Impact on patient medications of the risk of falls The revised policy C29 has had a red, amber, green (RAG) rated medication chart attached to enable ward areas and clinical rooms for medical staff to understand and appreciate the risk aligned to a number of common medications in use today. This is promoted within the ‘fallsafe’ approach led by the Royal College of Physicians. Environmental impact For the last year some low level work has been completed by the estates/decorating team within the Trust. The main work has been painting the door frames on wards for all bathroom/toilet facilities. The true benefits from environmental design has not been recognised in its true sense and requires a more detailed approach as the Trust moves forward with refurbishment work. Stirling University and the Kings Fund have robust evidence to support change for the environment to meet the needs of the majority attending the Trust for a service of some kind. Falls Training Two forms of falls training is delivered within the Trust, the mandated version which is for everyone employed within the Trust. The advanced version is for the four clinical areas with the highest rate of falls in the previous year. Monitoring occurs of the areas throughout the year and from April 2016 on a quarterly basis clinical settings will be asked to report back to the Trust falls group with the detailed action plan they are working to, to reduce specific areas of concern. Sensor Training Sensors are provided to the majority of clinical areas within the Trust who have a falls concern. Training and rollout occurred within these areas. Progress to date is to change this process due to demand and flexibility across clinical areas. All sensors on the NT site will be pulled back and realigned to facilitate an increase and repair of some items. Following this the individual based kits will be placed and maintained in the medical equipment library. Sensors are highlighted within the action plans as a first line measure before moving to requiring a 1:1 nursing need. Never Events The Trust continues to work hard to improve patient safety therefore stakeholders and the Board wanted to reflect the low numbers of Never Events in the organisation. Never Events are serious incidents that are wholly preventable as guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers. Each Never Event type has the potential to cause serious patient harm or death. However, serious harm or death is not required to have happened as a result of a specific incident occurrence for that incident to be categorised as a Never Event Since 2008 the Trust has had nine Never Events and they are broken down as follows:
Reporting Year Number of Never Events 2008-09 1 2009-10 0 2010-11 2 2011-12 1 2012-13 1 2013-14 1 2014-15 1 2015-16 2 206 Totals: 9
There has been two Never Events reported in the period of 2015 – 16; Annual Report and Accounts 2015 – 2016 One in September 2015 relating to a retained foreign object following surgery, the second in February 2016 related to a wrong side pain relief injection. In both incidents the patients suffered low levels of harm and are fully aware of the incidents and investigations. Both incidents were reported to NHS England and Commissioners on the Strategic Executive Information System (STEIS), the CQC and Monitor as required. The NHS England report can be accessed via: http://www.england.nhs.uk/ourwork/patientsafety/never-events/ne-data/ Effectiveness of Care Staff, Patient Experience and Quality Standards (SPEQS)
Patient experience is what drives the Trust in ensuring that the standard of care being provided is of a high standard. The following data for Staff, Patient Experience and Quality Standards (SPEQS) is an internal reporting tool used when visits have taken place. The SPEQS led by the Director of Nursing, Quality and Patient Safety and Quality or by the Associate Director of Nursing, Quality and Patient Experience is undertaken by Senior Clinical Matrons, members of the Board, Assistant Directors and our Governors. SPEQS is an additional avenue to provide valuable feedback on patient’s standard of care. Each visit of the ward/area is documented on a standard SPEQS template and is input into the SPEQS database when reporting back the results. The database records all reviews allowing for detailed analysis, the trends are available for each area and ward allowing them to monitor and share good practice as well as providing support where needed. The SPEQS data is automatically linked to the Trusts Nursing and Midwifery Dashboard, so the wards can see their results instantly. To reward good practice, each area that achieves 100% across all areas is rewarded with a certificate to display on the ward. Over the reporting year, during our scheduled SPEQS visits, our senior nurses, governors and directors have visited 333 wards/areas which are achieving an average SPEQS score of 96.86%. The following table provides data relating to the 2015 – 16 visits: SPEQS Visit First Nursing Patient Staff Month Impressions % Evidence % Experience % Involvement % 2015-2016 2015-2016 2015-2016 2015-2016 Q1 April 94.81 96.30 98.85 94.81 May 99.35 (G) 93.03 (R) 97.97 (R) 93.46 (R) June 94.70 (R) 93.18 (G) 98.57 (G) 97.73 (G) Q2 July No Visit due to CQC August 99.17 (G) 92.78 (R) 99.54 (G) 97.08 (R) September 98.33 (R) 90.83 (R) 98.43 (R) 89.58 (R) Q3 October No Visit due to NEEP Level November No Visit due to NEEP Level December 96.97 (R) 93.18 (G) 98.06 (R) 95.83 (G) Q4 January 97.04 (G) 91.85 (R) 99.01 (G) 94.07 (R) February No Visit due to NEEP Level March 97.22 (G) 92.59 (G) 98.15 (R) 95.83 (G) *Data obtained from the Trusts internal SPEQS visits database and is up to March 2016 Reports from the SPEQS reviews are provided to the Board of Directors and to the Council of 207 Governors periodically.
The following table is a combined In Hospital and Out of Hospital results, the table provides an Annual Report and Accounts 2015 – 2016 opportunity to see year-on-year scores for the reported four areas; to note, from 2014 – 15 year the data includes the Staff Involvement element.
2011-12 2012-13 2013-14 2014-15 2015-16 First Impressions 91% 85% 92% 97% 97% Nursing Evidence 90% 87% 90% 91% 93% Patient Experience 98% 96% 97% 98% 99% Staff Involvement N/A N/A N/A 95% 95% The following two tables provide a breakdown between Hospital and Integrated Services scores for 2015 – 16.
Hospital 2015-2016 Integrated Services 2015-2016 First Impressions 97.20% First Impressions 100% Nursing Evidence 93.03% Nursing Evidence 97.98% Patient Experience 98.58% Patient Experience 100% Staff Involvement 94.74% Staff Involvement 96.97% *Data obtained from the Trusts internal PEQS visits database and is up to March 2016 In total, the Trust has inspected 865 toilets of which 850 (98.27%) were clean, also 408 commodes of which 372 (91.18%) were clean and taped. The majority of the commodes that were deemed not clean were due to them not being taped and signed post cleaning. Clinical Effectiveness Indicators Why/How we chose this as a priority. The Trust has decided to include more detail around some of the Clinical Effectiveness indicators; this will be built on year on year, including more detailed data around the Monitor Compliance Framework. For this report the Trust has chosen, High Risk TIAs and Stroke indicators. The following table demonstrates the quarter on quarter performance with a benchmark position against 2014 – 15 data and against the 2015 – 16 performance target.
2014-15 2015-16 2015-16 Q1 Q2 Q3 *Q4 Performance Target Performance Stroke – 80% of people with stroke to spend at least 90% of their time 92% 80% 83% 87% 85% 91% 87% on a stroke unit
Percentage high risk TIA cases treated within 24 88% 75% 90% 73% 89% 76% 82% hours
Patient Experience Why/How we chose this as a priority. The Trust continues to work hard to improve customer satisfaction through patient experience. We do recognise that we don’t always get things right and this is why we have a dedicated patient experience team to listen to and investigate any concerns or complaints. We continue to work hard to provide high standards of clinical care delivered with dignity and compassion for everyone. Feedback from patients is important because it helps us to understand what we do well and what we can improve further. 208 Complaints Complaints process Annual Report and Accounts 2015 – 2016 The Trust continues to use three complaints streams: • Stage 1 – concern; to be dealt with by the Patient Experience Team (PET) or at the time of complaint at ward level; • Stage 2 – for a meeting to be arranged with the complainant to discuss the complaint with the Senior Clinical Matron, consultant and relevant personnel involved in the complaint with hopefully a resolution at this stage; • Stage 3 – Formal; if Stage 1 or stage 2 did not resolve the issue or the complainant did not want to go through those routes, a formal stage 3 is then raised. The Trust is ensuring that all possible complainants have an opportunity to air their grievances/ concerns with an immediate Trust response, rather than waiting the statutory 25/40 days if the complaint goes the formal route. The Trust continues to use the complaints dashboard. The dashboard displays how many complaints the Trust has received along with how many are still open and in which category.
Stage Number of Complaints Stage 1 945 Stage 2 74 Stage 3 (Formal) 295
There are additional sections within the dashboard that show monthly trends on the complaints for Directorates, method of complaint, method of receipt, average time taken to close complaint types and the complaints subject. Since the 1 April 2015, the Trust has received 1,314 complaints of which 295 have gone onto the formal complaint process, this only equates to 22.47% of the complaints. Stage 3 – Formal Complaints The number of formal complaints received over the last seven years is shown in the following table:
Formal Complaints 2009-10 358 2010-11 341 2011-12 371 2012-13 396 2013-14 315 2014-15 331 2015-16 295 *Data obtained via the Trusts Incident Reporting (Datix)
Formal Complaints 450 371 396 400 358 350 341 315 331 295 300 250 200 150 100 50 0 2009-2010 2010-2011 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016 Formal Complaints
The following table trends the 2015 – 16 formal complaints by quarter. 209 2015-16 Q1 2015-16 Q2 2015-16 Q3 2015-16 Q4 Total
Totals 81 61 63 90 295 Annual Report and Accounts 2015 – 2016 *Data obtained via the Trusts Incident Reporting (Datix) Formal Complaints per Qtr 100 90 81 80 61 63 60
40
20
0 15/16 Q1 15/16 Q2 15/16 Q3 15/16 Q4
2015 – 16 Formal Complaints by complaint type: From the 295 formal complaints received in 2015 – 16 there are 658 complaint types. Please see the following breakdown of the top 20 complaint types.
Category of Complaint Number of Complaint types Communication - Insufficient 155 Attitude - unprofessional 62 Treatment and procedure delays 59 Failure to monitor 43 Competence of staff member 41 Delay to diagnosis 38 Care and compassion 24 Pain Management 22 Discharge arrangements 21 Incorrect diagnosis 18 Prescription issues, incl delays/unavailable 16 End of life concerns incl DNAR 16 Dignity & respect 15 Record Keeping 15 Nutrition 13 Outpatient delay 11 Infection Control issues 9 Failure to follow guidelines/policy 7 Timeliness of discharge 7 Communication 7 210 *Data for 2015 – 16 obtained via the Trust's Nursing and Midwifery Dashboard – via Datix All lessons learned from complaints are taken back into the clinical teams and managed proactively. Annual Report and Accounts 2015 – 2016 The themes are collated and aggregated analysis is considered in the Trust’s quarterly Complaints, Litigation, Incidents and Performance (CLIP) report. The Directorates identify the top themes within their area and provide actions for improvement which is then followed up in the subsequent quarterly CLIP report. Formal Complaints Compliance with 25 day target We continually monitor the percentage of formal complaints that the Trust responds to in the required 25 day turn-around period.
Month Compliance Rate Apr-15 100% May-15 86% Jun-15 97% Jul-15 95% Aug-15 92% Sep-15 97% Oct-15 86% Nov-15 91% Dec-15 95% Jan-16 86% Feb-16 100% Mar-16 96% *Data obtained from Trust complaints dept. The Trust Complaints dashboard produces a weekly report; this data details the number of open complaints and which stage they fall under, the report also details the number of days open. The report is circulated to the Patient Safety Co-ordinators in each directorate to review the cases to see if they can be closed. Compliments In 2009 – 10 we started to record the number of compliments received. The number of thank you and complimentary comments has increased year on year. Trends in compliments can be seen in the following table and chart.
Year Compliments 2009-10 2,212 2010-11 3,786 2011-12 5,097 2012-13 5,414 2013-14 9,296 2014-15 11,357 2015-16 11,367
Compliments 15,000 211 11,357 11,367 9,296
10,000 Annual Report and Accounts 2015 – 2016
5,097 5,414 5,000 3,786 2,212
0 2009-2010 2010-2011 2011-2012 2012-2013 2013-2014 2014-2015 2015-2016
*Data from 2014 – 15 obtained via the Trusts Nursing and Midwifery Dashboard, all previous years are from each individual department Pressure ulcers (also known as decubitus ulcer or pressure sores) Why/How we chose this as a priority. Following consultation with key stakeholders it was evident that pressure ulcers continue to be one of the Trusts key measures for improvement, therefore it was agreed to retain this indicator as rolling priority for our patients. Reducing the risk of pressure ulcers has been a high priority for all healthcare staff across the Trust. Year on Year Comparison – In-Hospital Acquired
Reporting Period Grade 1 Grade 2 Grade 3 Grade 4 2012-13 0 317 25 0 2013-14 0 343 25 0 2014-15 114 326 18 2 2015-16 78 258 12 1 *Data obtained via the Trusts Incident Reporting database (Datix) Year on Year Comparison – Out of Hospital Acquired
Reporting Period Grade 1 Grade 2 Grade 3 Grade 4 2012-13 0 458 124 0 2013-14 3 759 187 0 2014-15 118 667 74 25 2015-16 81 336 21 8 *Data obtained via the Trusts Incident Reporting database (Datix) To note: prior to 2014 – 15 reporting year, Pressure ulcers were classified as Grade 2 and below and Grade 3 and above, this explains the zero values in the above table for 2012 to 2014. Actions taken by the Trust: An additional tissue viability nurse has been in post since May 2015 and this has enhanced the ability of the service to review patients in a timely manner, offer advice and management plans and to provide training in the prevention and recognition of pressure ulcers. Part of this work has been the provision of training and information to care home and social care staff, who are responsible for day to day care of people in care homes or their own home who may be on a district nurse caseload. Improving the ability of these carers to recognise the early signs of pressure damage will assist with the prompt provision of advice and equipment and reduce the risk of damage deteriorating further. The Trust has also participated in a regional collaborative improvement project, with two wards participating and the aim being to rollout successful action to all areas. Part of the project involves using the hand symbol from the SSKIN (surface inspection, skin inspection, keep moving, incontinence and nutrition) bundle as a visual reminder of patients who are at risk and require appropriate position change and assessment. Communication between services continues to be promoted in order that seamless holistic care 212 can be achieved when patients move between hospital and community. A key element of this is ensuring wound care information is passed onto the next care provider.
Annual Report and Accounts 2015 – 2016 A weekly review panel discusses all incidents of pressure damage and agrees which of them require reporting through the Serious Incident Framework. Reports on these cases are presented to the Serious Untoward Incident panel prior to submission to commissioners. Learning from incidents is shared via directorate meetings and newsletters. The Integrated Professional Nursing and Midwifery Board continue to oversee the Pressure Ulcer Operational Group which has the remit of reviewing the Trust action plan and Trust policies and guidelines to pursue continuous improvement in performance. Monthly pressure ulcer prevalence reports are compiled via the NHS Safety Thermometer, along with larger scale pressure ulcer prevalence audits which are conducted across all areas, as a minimum, on an annual basis. Section 3b: Performance from key national priorities from the Department of Health Operating Framework, Appendix B of the Compliance Framework
The Trust continued to deliver on key cancer standards throughout the year; two week outpatient appointments, 31 days diagnosis to treatment and 62 day urgent referral to treatment access targets. The Trust demonstrated a positive position with evidence of continuous improvement against the cancer standards introduced in the Going Further with Cancer Waits guidance (2008). www.connectingforhealth.nhs.uk/nhais/cancerwaiting/cwtguide7.pdf The compliance framework forms the basis on which the Trusts’ Annual Plan and in year reports are presented. Regulation and proportionate management remain paramount in the Trust to ensure patient safety is considered in all aspects of operational performance and efficiency delivery. The current performance against national priority, existing targets and cancer standards are demonstrated in the table with comparisons to the previous year.
Monitor Compliance Framework Indicators 2015/16 2015/16 2014/15 Achieved Target Performance Performance (cumulative) Clostridium Difficile - meeting the C.Diff objective 13 36 20 MRSA - meeting the MRSA objective 0 2 0 Cancer 31 day wait for second or subsequent 94% 100.00% 97.47% treatment - surgery * (Qtr 4 provisional) Cancer 31 day wait for second or subsequent treatment - anti cancer drug treatments * (Qtr 4 98% 100% 99.84% provisional) Cancer 31 day wait for second or subsequent 94% N/A N/A N/A treatment – radiotherapy Cancer 62 Day Waits for first treatment (urgent GP 85% 82.19% 84.23% referral for suspected cancer) * (Qtr 4 provisional) Cancer 62 Day Waits for first treatment (from NHS 90% 96.43% 96.70% cancer screening service referral) * (Qtr 4 provisional) Cancer 31 day wait from diagnosis to first treatment 96% 99.04% 98.85% * (Qtr 4 provisional) Cancer 2 week wait from referral to date first seen, all urgent referrals (cancer suspected) * (Qtr 4 93% 93.03% 93.75% provisional) Cancer 2 week wait from referral to date first seen, symptomatic breast patients (cancer not initially 93% 93.61% 93.89% suspected) (Qtr4 provisional) Maximum time of 18 weeks from point of referral to 79.25% 91.83% treatment in aggregate, admitted patients (Feb 16) Maximum time of 18 weeks from point of referral to 97.19% 98.21% treatment in aggregate, non-admitted patients (Feb 16) 213 Maximum time of 18 weeks from point of referral
to treatment in aggregate, patients on incomplete 92% 92.21% 96.77% Annual Report and Accounts 2015 – 2016 pathways Mar 16) A&E: maximum waiting time of 4 hours from arrival 95% 94.60% 95.16% to admission/transfer/discharge (Apr 15 – Mar 16) Community care data completeness - referral to 50% 95.38% 93.55% treatment information completeness (Feb 16) Community care data completeness - referral 50% 93.40% 92.61% information completeness (Feb 16) Community care data completeness - activity 50% 93.66% 72.51% information completeness (Feb 16) Community care data completeness - patient identifier information completeness (Shadow 50% 93.66% Monitoring) (Feb 16) Monitor Compliance Framework Indicators 2015/16 2015/16 2014/15 Achieved Target Performance Performance (cumulative) Community care data completeness - End of life patients deaths at home information completeness 50% 88.64% (Shadow Monitoring) (Feb 16) Compliance with access to healthcare for patients Full Full Full with learning disabilities compliance compliance compliance Other National and Contract Indicators 2015/16 2015/16 2014/15 Achieved Target Performance Performance Cancelled Procedures for non medical reasons on the 0.80% 0.44% 0.41% day of op (Apr 15 – Mar 16) Cancelled Procedures reappointed within 28 days 100% 96.91% 100% (Apr 15 – Mar 16) Eliminating Mixed Sex Accommodation (Apr 15 – Mar Zero cases 0 0 16) A&E Trolley waits > 12 hours Zero cases 0 Choose and Book slot issues < 4% No data 3.53% Stroke - 90% of time on dedicated Stroke unit 80% 87% 91.91% Stroke - TIA assessment within 24 hours 75% 82% 88.24% Delayed transfers of care (Apr 15 – Mar 16) < 3.5% 1.63% 2.65% Breast Feeding at Delivery (Apr – Sep 15) > = 50% 49.36% 51.22% Number of Diagnostic waiters over 6 weeks (Apr 15 – 99% 99.65% 99.30% Mar 16) Retinal Screening - offered an appointment within 48 95% 92.91% 92.86% hours (Mar 16) VTE Risk Assessment (Apr – Dec 15) 95% 95.57% 95.94% Health Visitor Numbers (Mar 16) 73.49 68.49 61.39 * Retinal Screening can have more than 1 offer per patient; therefore can be greater than 100% Additional Assurance: A The following indicators for 2015 - 16 have been subject to limited assurance review by the independent auditors PricewaterhouseCoopers:
Further assurance Definition indicators Percentage of incomplete The Trust uses the following criteria for measuring the indicator for inclusion in pathways within 18 the Quality Report: weeks for patients on • The indicator is expressed as a percentage of incomplete pathways within 18 incomplete pathways at weeks for patients on incomplete pathways at the end of the period; the end of the reporting • The indicator is calculated as the arithmetic average for the monthly reported 214 period “incomplete performance indicators for April 2015 to March 2016; pathways indicator” • The clock start date is defined as the date that the referral is received by the Annual Report and Accounts 2015 – 2016 Foundation Trust, meeting the criteria set out by the Department of Health guidance; and The indicator includes only referrals for consultant-led service, and meeting the definition of the service whereby a consultant retains overall clinical responsibility for the service, team or treatment. Percentage of patients The Trust uses the following criteria for measuring the indicator for inclusion in with a total time in A&E the Quality Report: of four hours or less from • The indicator is defined within the technical definitions that accompany arrival to admission, Everyone counts: planning for patients 2014/15 - 2018/19 and can be found at transfer or discharge "4 www.england.nhs.uk/wp-content/uploads/2014/01/ec-tech-def-1415-1819.pdf hour A&E waiting times • Detailed rules and guidance for measuring A&E attendances and emergency indicator" admissions can be found at https://www.england.nhs.uk/statistics/wp- content/uploads/sites/2/2013/03/AE-Attendances-Emergency-Definitions-v2.0- Final.pdf Annex A: Third party declarations
We have invited comments from our key stakeholders. Third party declarations from key groups are outlined below: Statement from NHS Hartlepool and Stockton-on-Tees Clinical Commissioning Group (HAST) and Durham, Dales, Easington and Sedgefield (DDES) Clinical Commissioning Group, for North Tees and Hartlepool Hospital NHS Foundation Trust (NTHFT) Quality Account 2015 – 16 – 29 April 2016 NHS Hartlepool and Stockton-On-Tees Clinical Commissioning Group (HAST CCG) commission healthcare services for the population of Hartlepool and Stockton-On-Tees. NHS Durham, Dales, Easington and Sedgefield Clinical Commissioning Group (DDES CCG) commission services for its respective populations. Both CCGs welcome the opportunity to submit a statement on the Annual Quality Account for North Tees and Hartlepool NHS Foundation Trust (NTHFT). HAST and DDES CCGs can confirm that to the best of their ability, the information provided within the Annual Quality Account is an accurate and fair reflection of the Trust’s performance for 2015 – 16. The CCGs would like to provide the following statement. The quality of services delivered and associated performance measures are the subject of discussion and challenge at the Clinical Quality Review Group (CQRG) meetings. These provide an opportunity for CCGs and Trust to gain assurance that the systems and processes in place to promote the delivery of safe, effective and high quality care are effective. We are happy to see that Quality remains the Trust’s number one priority for 2016 – 17 and it is reassuring to see that the priorities identified for 2016 – 17 are also reflective of the CCG’s priorities. We are pleased that the Chief Executive’s overview to the Quality Account emphasises the important contribution of the Trust’s staff and other stakeholders, in working together to achieve high performance and good outcomes for patients across the Trust. The CCGs note that following the CQC visit to the Trust in July 2015 there are actions underway to address the key areas of concern highlighted during the inspection. The CCG’s will continue to support and collaborate with the Trust to ensure that changes are made to support delivery of the important objectives identified. The CCGs recognise that mortality performance indicators remain a challenge and also the hard work the Trust has undertaken to improve these metrics. They look forward to seeing the results from the additional external support the Trust has obtained through working with Advancing Quality Alliance (AQuA) and their review of processes for Sepsis and Acute Kidney Injury (AKI). The CCGs will continue to provide robust scrutiny and challenge in relation to this during 2016 – 17 and will work with the Trust to identify opportunities for shared learning across the health economy. The CCGs are very pleased to see continual good compliance rates for Safeguarding Children training across all levels and the bespoke practice clinics addressing local safeguarding concerns. The CCGs are very pleased to see the continued focus on improving care for people with dementia, particularly as the localities of Hartlepool and Stockton on Tees have the highest projected increase of dementia across the North East by 2025. The Trust has achieved important improvements in dementia care, working with partners; supporting carers of people with dementia and improving the diagnosis rate. 215 There is a positive focus on Health Care Associated Infection (HCAI) in the report and the
reintroduction of HCAI as a priority patient safety focus is welcomed. We acknowledge the Annual Report and Accounts 2015 – 2016 challenging target for Clostridium Difficile infection last year and for the forthcoming year. Improving discharge processes continue to be a priority for 2016 – 17. It is noted that measurement data is presented for 2015 – 16 and comparisons are made with audits undertaken in 2013 – 14. It would have been helpful to understand more about the actions taken in light of the discharge audit results, particularly around the lower scores for procedures and operations recorded and medication changes. We look forward to seeing further developments with the Nursing & Midwifery Dashboard at the Clinical Quality Review Group meetings. It is encouraging to see that there is to be a continued commitment to Care for the Dying Patient and embedding use of the Family’s Voice both in hospital and community settings, and that End of Life Care was identified as good practice by the CQC in July 2015. We also note the Trust’s involvement in national surveys and the continued focus on Patient Surveys and Friends and Family recommendation for 2016 – 17. The CCGs would have liked to have seen some specific actions identified to improve the Accident & Emergency returns which are below the England average. The CCG is pleased to note that the Trust has committed to the national ‘Sign up to Safety’ campaign. This aims to halve avoidable harm in the NHS, and we are reassured that along with the overall aim, there will be focussed areas of work undertaken to examine specific areas of high risk, for example in relation to pressure ulcers and falls with fractures. Never Events are Serious Incidents (SIs) which are wholly preventable with appropriate procedures in place. We are pleased to see that this is identified as an additional priority area following the Trust’s two Never Events reported in 2015 – 16. Inclusion of some of the identified learning from the associated investigations would have been a welcome addition to this report. The CCGs look forward to seeing the outputs of this learning demonstrated in improved systems to promote the quality and safety of care. We look forward to continuing to work in partnership with the Trust in delivering high quality effective care for patients. Yours sincerely Ali Wilson Chief Officer (HAST CCG) Gillian Findley Director of Nursing, Patient Safety and Quality (DDES CCG)
216 Annual Report and Accounts 2015 – 2016 Hartlepool HealthWatch – 04 May 2016 Following receipt of the draft quality account, HealthWatch Hartlepool wish to make a formal response to the approach taken by the Trust with regards to quality. This response encompasses the views of HealthWatch members. Please note this opinion is based on factual data presented to HealthWatch Hartlepool, referrals received into HealthWatch Hartlepool and actual patient experience of HealthWatch Hartlepool members. Our view of future priorities would be the addressing of concerns raised in the most recent, published, CQC report to improve Patient Safety, Effectiveness of Care and Patient Experience. We firmly believe the key findings of the CQC inspection need to be addressed as a matter of urgency, in particular the strategic management of the Trust. At the moment we would welcome greater focus on reducing mortality rates as this has been of great concern to HealthWatch Hartlepool over recent years and yet, whilst there has been some improvement, the figures are excessively above the national average. In addition, year on year we raise concerns about accessibility and the current transport provision is not adhering fully to the Equality Act 2010 and the patient cannot be priority if a preferential booking system is operated for staff. One area HealthWatch Hartlepool is very keen for the Trust to undertake is ensuring consultation on any service changes is both meaningful and timely. The recent proposed changes to the Assisted Reproduction Unit had no regard for HealthWatch as a statutory consultee and we would not like to see a repeat should any further changes to service delivery be forthcoming. Overall, HealthWatch Hartlepool welcomes the opportunity to respond to the Draft Quality Account and would hope it will continue to reflect the views we present as the sole statutory consultation body for the people of Hartlepool. Yours Faithfully, Margaret Wrenn – Chair HealthWatch Hartlepool Stockton HealthWatch – 03 May 2016 HealthWatch (HW) Stockton on Tees acknowledges the progress made by the Trust across a wide area of Quality Improvement Priorities, the outcome of the CQC inspection and the information published about infection control, complaints and compliments etc. Some of the areas identified for further improvement and investigation reflect similar results found by HW in its own investigations. There remain a number of areas for further improvement such as mortality rates, discharge arrangement and dementia identification and treatment where we would be happy to support the Trust in its future work. Jane Hore HealthWatch Stockton-on-Tees Statement from Adult Services and Health Select Committee, Stockton-on-Tees – 29 April 2016 The Committee welcomes the opportunity to consider and comment on the quality of services at the Trust. The Committee has met twice with Trust representatives to consider the Quality priorities and overall performance in line with previous years. This year there has also been discussion on service changes and the CQC report, and there have been comprehensive responses to requests for information. The Committee has previously reviewed the mortality indicators from the Trust and discussed 217 the issue in some detail during 2014 – 15. The Committee was briefed on the actions taken, recognising the complexity of the issues involved. During 2015 – 16, the most recent figures for both HSMR and SHMI (the key indicators) were still above expected levels, and the SMHI data was Annual Report and Accounts 2015 – 2016 the highest value in the country for three reporting periods. However, during the period since the previous Quality Account, the overall trend has been positive with a reduction in the HSMR figures from the period April 2014 to March 2015 onwards. HSMR data for February 15 to January 16 showed a much improved figure compared to the data for December 14 to November 15. The latest SHMI figures were not available at the time of the Committee’s review of the draft Quality Account, but it was noted that the Trust fully expected the same positive trend as with HSMR. This is a key issue and the Committee supports its retention as a priority for 2016 – 17. This will enable stakeholders to continue to track the actions taken and the expected improvements in the data. The Committee supports the other quality priorities for 2016 – 17, in particular the re-introduction of Infection Control as a priority for 2016 – 17. The ‘target’ number of cases of C.diff as originally set by Monitor is recognised as challenging; however there has been an increase in Trust-acquired cases. Two issues were likely to have contributed to a rise in infections: lack of availability of the decant ward to undertake cleaning and fogging of a full ward, due to pressure on beds, and the difficulty in recruitment leading to increased use of temporary staff. Members see the availability of a decant ward as being important, and were pleased to see that this should be available in 2016 – 17, with a contingency plan was in place to undertaken cleaning and fogging in occupied wards should the decant option not be available. Members continue to see the process involved in an effective discharge from hospital as being crucial to patient experience and wellbeing. The continued focus on this as a priority is supported. The audit of discharge documentation did note a drop in recording of procedures and medication changes between 13 – 14 and 15 – 16. The Trust provided information outlining actions that would be taken, recognising the importance of the issues. It is pleasing to see the on-going work to reduce medication errors, and the improved national maternity survey results are welcome. The Committee asked for further information relating to the staff survey results regarding experience of bullying or harassment (the results were slightly above but close to the national average), and continue to monitor the results relating to staff recommendation of the Trust as a place to receive treatment (an improvement on previous years). In relation to Bullying and Harassment, the Trust outlined the work on the new Freedom to Speak policy. During 2015 – 16, the Committee has undertaken a review of access to universal, community services for people with learning disabilities and/or autism. As part of this, Members considered how services were provided in healthcare settings, and the Committee was pleased to see the work undertaken by the Learning Disability Liaison Nurse. The priority of Safeguarding Adults with a Learning Disability therefore continues to be supported, and should see a continuing focus on this work. A recommendation has been made in the Committee’s report to undertake further work to ensure that learning disability status is effectively communicated between Primary and Secondary care, and the Council’s Adult Services will contribute to this work. The Trust may also find it useful to consider the report as a whole. The Quality Account summarises a range of safeguarding information, including the number of adult safeguarding referrals. It would be beneficial to include an explanation outlining that safeguarding responsibilities are aligned with local authority areas; any alerts that originate from a hospital would be recorded by the local authority where the hospital is based, and so may not relate to where the patient usually lives. It would also be useful to see figures reported ‘per 100,000 people’, where appropriate, to reflect the difference in the populations served by the Trust. A key event this year was the publication of the CQC Inspection Report. The Committee recognised that the majority of individual services were rated as Good, however due to the overall rating of Requires Improvement the Committee explored the reasons for this with senior staff from the Trust. Following the inspection the Committee has been informed of the action plan and the monitoring process, and welcomes the transparent way in which the Trust has provided information on the report and actions taken, including on the website. The Committee noted that many of the issues 218 highlighted in the inspection had been quickly resolved. An important, longer term issue was the continued pressure on staffing, particularly nurses, and Annual Report and Accounts 2015 – 2016 the number of temporary and agency staff being used. As noted this can impact on a range of issues including knowledge of procedures, and infection control. The recent recruitment of nurses from overseas should assist in this regard but such recruitment would not be a sustainable solution. It is clear that this is an issue across the health service in the region and a concerted effort will be necessary. Whilst recognising that sections of the Quality Account are compulsory, we would again encourage the Trust to ensure the published version is as accessible as possible, including consideration of best practice, and that summary and easy-read versions are also produced. The Trusts Council of Governors – 28 April 2016 On behalf of the Council of Governors, members of the Quality Account Working Group confirm that Governors have been involved in the preparation of the Trust’s Annual Quality Account and have been briefed throughout 2015 – 16 in respect of specific aspects of its content regarding performance. A successful market place event was held on 9 December 2015 to obtain the views from Governors and key stakeholders, in relation to the Quality Account and to help define the key priority areas to be included for the forthcoming year. The role of the Governor Quality Accounts Working Group is to act on behalf of the Council of Governors in reviewing the draft Annual Quality Account providing challenge and seeking assurance regarding its content, in addition to making constructive comments in respect of design, layout and language. In July 2015 the Trust underwent an inspection by the Care Quality Commission (CQC), as part of the requirement for all provider organisations to be inspected by December 2015. The inspection followed a well governed process, and incorporated engagement with a wide range of staff groups and stakeholders including Governors, through facilitated focus groups. The inspection was largely positive with many areas commended for good practice; however, the overall rating was ‘requires improvement’. The Council of Governors were fully briefed regarding the inspection process in advance of it commencing during one of the development sessions following a Council of Governors meetings, and have subsequently received regular updates from the Acting Director of Nursing, Patient Safety and Quality regarding progress being made. Other topics in the development sessions included: An update on national recommendations and reviews: Francis Review, Kirkup Report and Savile Review; Overseas Visitor Requirements; Trust Corporate Strategy; Clinical Service Strategy implementation including estates reconfiguration and infrastructure; Integrated Care Pathway Respiratory Team; and the Electronic Patient Record Project. The sessions allow a detailed review of important issues and provide assurance to Governors regarding work being undertaken in these areas. Regular reports presented to the Council of Governors highlight the performance, compliance and quality of the services provided by the Trust against the range of indicators and targets it is measured by. The reports ensure that the Governors are appraised of the valuable improvements being made to patient care and pathways, including the work surrounding the Clinical Services Strategy, as well as being aware of the challenges being faced by the Trust. It has been a difficult year for the health service as a whole in respect of the current financial situation and unprecedented demands on services, particularly emergency care. The meetings are an opportunity for the Governors to openly provide challenge to the Board of Directors and raise any concerns. The programme of Governor Sub-committees continued throughout 2015 – 16, which includes: Nominations Committee; Travel and Transport Committee; Membership Strategy Committee, and Strategy and Service Development Committee, and provide the opportunity for detailed debate and discussion regarding key topics, allowing the Governors to take an active part in shaping Trust strategies. The Strategy and Service Development Committee’s remit is to keep Governors updated regarding service developments and future vision. Presentations included: Community Services; Operational Standards; Surge Resilience Initiatives; Trust’s Corporate Strategy; CQUIN & Clinical Audit; Cancer Services; Clinical Services Strategy; Bowel Screening; Breast Services and the Trust’s Annual Plan. Governors have also been assisting with the recruitment and engagement of new members and the development of a membership plan going forward to increase membership numbers overall and a wider representation from the community we serve. Governors are involved in a number of other 219 groups; the Menu Review Group, Patient Information Evaluation Group and the Healthcare User
Group, and ad-hoc working groups covering a range of topics and service issues. Annual Report and Accounts 2015 – 2016 Governors are invited to take part in the monthly Staff, Patient Experience, Quality and Standards (SPEQS) panels, which include senior nursing staff and are led by the Acting Director of Nursing, Patient Safety & Quality. They provide the opportunity for panel members to visit clinical areas and speak directly with patients, visitors and staff about their experiences at the Trust. The panel reviews the standards of care given to our patients both in hospital and community services and allows Governors to witness this first hand. The process is being updated in 2016 to allow for more in-depth scrutiny. Reports and feedback are shared at every Council of Governors meeting. Hartlepool Borough Council - Audit and Governance Committee – 28 April 2016 Hartlepool Borough Council’s Audit and Governance Committee on the 11 February 2016 considered the North Tees and Hartlepool NHS Foundation Trust’s Quality Account for 2015 – 16, with the following comments made for inclusion in the Committee’s Third Party Declaration:- An update on the new indicator for mortality was provided to the Committee, which included the care coding culture and the national measures of SHMI (Summary Hospital-level Mortality Indicator) and HSMR (Hospital Standardised Mortality Ratio). Members were informed that the HSMR and SHMI values for the Trust were above the national average but more investigative work was being undertaken to identify why, with a view to reduce these. Members expressed concern at the higher than national average mortality rates. The Committee noted that the Trust indicated that the number of deaths in North Tees and Hartlepool hospitals was reducing and becoming closer to the national mean number. The Committee requested comparison information for NHS Trusts of a similar catchment size for the HSMR and SHMI rates. This information could not be considered by the Committee before the Quality Account deadline due to Purdah restrictions. Members were informed that there had been a number of issues around the documentation and recording of data used in the calculations of HSMR and SHMI rates. Members noted that there had been a lot of work undertaken to look at good practice and improvements made, which included the recording of information more appropriately. Regarding maternity services, Members expressed concern that women were being influenced to have their babies at North Tees Hospital, which was consultant led rather than Hartlepool Hospital which was midwifery-led. The Committee noted that the choice of where to give birth was with the prospective parents, subject to clinical advice. Members were informed that the Trust representatives would look into this matter to ensure women were given all the information necessary to make an informed choice. The Committee commented on the excellent work being undertaken to support patients with dementia. Members were informed that there were Dementia Support Teams working out of the Hospital, within communities, to ensure patients were discharged safely. The local pharmacists were fully supportive of the work and contributed to it by managing medication requirements. The implementation of the Friends and Family questionnaires was questioned. The Committee noted that all friends and family of patients discharged from hospital should be given a questionnaire as part of their individual discharge package. It was suggested by the Committee that the distribution and retrieving of the questionnaires should be monitored more rigorously to ensure that feedback was received from the majority of people. In addition to this, it was suggested that if feedback was not received then this should be explored further. The Committee requested a breakdown of the Friends and Family questionnaires on a ward by ward basis to determine if there were any ward specific issues. This information could not be considered by the Committee before the Quality Account deadline, due to Purdah restrictions. The Committee sought clarification on the staff surveys undertaken and questioned staff morale. Members were informed that staff were surveyed regularly and staff focus groups had been implemented for specific issues. As the surveys were anonymous it was not always easy to identify specific issues, but the Trust were very open to listen to staff and undertook significant engagement with all employees. Healthcare User Group (HUG) – 25 April 2016 The main role of the Healthcare User Group (HUG) is to assist the Trust with the Patient and Public 220 Involvement (PPI) agenda. This is achieved through independent visits to inpatient wards and outpatient clinics, talking to staff and patients. HUG is also represented on a number of Trust
Annual Report and Accounts 2015 – 2016 Committees including the Audit & Clinical Effectiveness Group (ACE), Quality Standards Steering Group (QSSG), Discharge Steering Group, Infection Control Committee (ICC) and Patient Quality & Safety Standards Group (PS & QS). A HUG representative also attends the Trust Board. We have been very aware of the emphasis on Patient Safety during our visits to the Trust especially relating to dementia and safeguarding adults and children with learning difficulties. The focus on staff training and screening of dementia patients is evident, and the Dementia Champion programme will ensure there are staff with a greater knowledge of dementia. These will improve the care provided to such patients. HUG also acknowledges the work carried out by the Trust in raising awareness in the areas of adult and children safeguarding, enhancing and developing standards. Especially pleasing is the significant improvement in mortality rates which reflects the work carried out by the Trust in improving the processes to aid mortality in the area. We acknowledge that the Trust has continued to focus on end of life care for the dying patient and support the work done by staff with respect to palliative and dying patients. The aim to increase the knowledge and skills of staff and for them to feel more confident in providing care to palliative and dying patients and their families is to be commended. Our findings from our inpatient and outpatient visits confirm that this care is appreciated. The Trust has provided the right level of support to allow HUG to perform its independent visits to various wards and clinics. Our reports have been acknowledged and concerns or recommendations have been acted upon in a prompt manner. We view the Quality Accounts as a true and fair reflection of what we have seen on our visits to the Trust’s inpatient wards and outpatient clinics. HUG supports the priorities selected for 2016 – 17 and as a stakeholder, has had the opportunity to influence these priorities. Whilst the Care Quality Commission (CQC) report rated the Trust as ‘requiring improvement’, HUG can only report from visits carried out this year, that we found no areas that gave any cause for concern. In the main, there were many good practice points we identified. HUG will continue to be an impartial and encouraging party, assisting in monitoring and helping to develop patient services within the Trust. Bill Johnson Healthcare User Group
221 Annual Report and Accounts 2015 – 2016 Annex B – QUALITY REPORT STATEMENT
Statement of Directors’ Responsibilities in Respect of the Quality Account The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS Foundation Trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS Foundation Trust boards should put in place to support 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 2015/16 and supporting guidance • the content of the Quality Report is not inconsistent with internal and external sources of information including: --board minutes and papers for the period April 2015 to April 2016 --papers relating to Quality reported to the Board over the period April 2015 to April 2016 --feedback from commissioners dated 27/04/2016 --feedback from governors dated 28/04/2016 --feedback from Stockton HealthWatch dated 3 May 2016 and Hartlepool HealthWatch dated 4 May 2016 --feedback from Overview and Scrutiny Committee dated 29/04/2016 --the Trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated Q3 2015/2016 --the latest national patient survey 2015 --the latest national staff survey 2015 --the Head of Internal Audit’s annual opinion over the Trust’s control environment dated April 2016 --CQC Quality Report – Inspection Report 03/02/2016 --the Quality Report presents a balanced picture of the NHS Foundation Trust’s performance over the period covered; --the performance information 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 in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to 222 appropriate scrutiny and review; and --the Quality Report has been prepared in accordance with Monitor’s annual reporting guidance Annual Report and Accounts 2015 – 2016 (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). 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 NB: sign and date in any colour ink except black
Chief Executive...... Chairman......
Date: 27 May 2016 Date: 27 May 2016 Annex C
Independent Auditors’ Limited Assurance Report to the Council of Governors of North Tees and Hartlepool NHS Foundation Trust on the Annual Quality Report We have been engaged by the Council of Governors of North Tees and Hartlepool NHS Foundation Trust to perform an independent assurance engagement in respect of North Tees and Hartlepool NHS Foundation Trust’s Quality Report for the year ended 31 March 2016 (the ‘Quality Report’) and specified performance indicators contained therein.
Scope and subject matter The indicators for the year ended 31 March 2016 subject to limited assurance (the “specified indicators”) marked with the symbol A in the Quality Report, consist of the following national priority indicators as mandated by Monitor:
Specified indicators Specified indicators criteria Percentage of incomplete pathways within 18 weeks for patients Page 214 on incomplete pathways at the end of the reporting period (“incomplete pathways indicator”) Percentage of patients with a total time in A&E of four hours or Page 214 less from arrival to admission, transfer or discharge (“4 hour A&E waiting times indicator”)
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 specified indicators criteria referred to on pages of the Quality Report as listed above (the "Criteria"). The Directors are also responsible for the conformity of their Criteria with the assessment criteria set out in the NHS Foundation Trust Annual Reporting Manual (“FT ARM”) and the “Detailed requirements for quality reports 2015-16” issued by the Independent Regulator of NHS Foundation Trusts (“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 does not incorporate the matters required to be reported on as specified in Annex 2 to Chapter 7 of the FT ARM and the “Detailed requirements for quality reports 2015-16”; • The Quality Report is not consistent in all material respects with the sources specified below; and • The specified indicators have not been prepared in all material respects in accordance with the Criteria set out in the NHS Foundation Trust Annual Reporting Manual (“FT ARM”) and the “2015-16 Detailed guidance for external assurance on quality reports”. We read the Quality Report and consider whether it addresses the content requirements of the FT ARM and the “Detailed requirements for quality reports 2015-16; 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 the following documents: • Board minutes for the financial year, April 2015 to April 2016; 223 • Papers relating to Quality report reported to the Board over the period April 2015 to April 2016; Annual Report and Accounts 2015 – 2016 • Feedback from the commissioners dated 27 April 2016; • Feedback from governors dated 28 April 2016; • Feedback from Stockton HealthWatch dated 3 May 2016 and Hartlepool HealthWatch dated 4 May 2016; • Feedback from Overview and Scrutiny Committee dated 29 April 2016; • The Trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated Q3 2015/16; • The latest national patient survey 2015; • The latest national staff survey 2015; • The Head of Internal Audit’s annual opinion over the Trust’s control environment dated April 2016; and • CQC Quality Report - Inspection report 3 February 2016. 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. Our Independence and Quality Control We applied the Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics, which includes independence and other requirements founded on fundamental principles of integrity, objectivity, professional competence and due care, confidentiality and professional behaviour. We apply International Standard on Quality Control (UK & Ireland) 1 and accordingly maintain a comprehensive system of quality control including documented policies and procedures regarding compliance with ethical requirements, professional standards and applicable legal and regulatory requirements. Use and distribution of the report This report, including the conclusion, has been prepared solely for the Council of Governors of North Tees and Hartlepool NHS Foundation Trust as a body, to assist the Council of Governors in reporting North Tees and Hartlepool 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 indicators. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Council of Governors as a body and North Tees and Hartlepool NHS Foundation Trust for our work or this report save 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 (Revised)’). Our limited assurance procedures included: • Reviewing the content of the Quality Report against the requirements of the FT ARM and 'Detailed requirements for quality reports 2015/16'; • Reviewing the Quality Report for consistency against the documents specified above; • Obtaining an understanding of the design and operation of the controls in place in relation to the collation and reporting of the specified indicators, including controls over third party information (if applicable) and performing walkthroughs to confirm our understanding; • Based on our understanding, assessing the risks that the performance against the specified indicators may be materially misstated and determining the nature, timing and extent of further procedures; • Making enquiries of relevant management, personnel and, where relevant, third parties; • Considering significant judgements made by the NHS Foundation Trust in preparation of the specified indicators; • Performing limited testing, on a selective basis of evidence supporting the reported performance 224 indicators, and assessing the related disclosures; and • Reading the documents.
Annual Report and Accounts 2015 – 2016 A limited assurance engagement is less in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement. Limitations Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information. The absence of a significant body of established practice on which to draw allows for the selection of different but acceptable measurement techniques which can result in materially different measurements and can impact 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 thereof, may change over time. It is important to read the Quality Report in the context of the assessment criteria set out in the FT ARM the 'Detailed requirements for quality reports 2015/16' and the Criteria referred to above. The nature, form and content required of Quality Reports are determined by Monitor. This may result in the omission of information relevant to other users, for example for the purpose of comparing the results of different NHS Foundation Trusts. In addition, the scope of our assurance work has not included governance over quality or non- mandated indicators in the Quality Report, which have been determined locally by North Tees and Hartlepool NHS Foundation Trust. Basis for Disclaimer of Conclusion – Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the reporting period. The Trust reports monthly to Monitor on the Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways indicator, based on the waiting time of each patient who has been referred to a consultant but whose treatment is yet to start. The 18 week indicator is calculated each month based on a snapshot of incomplete pathways and reported through the Unify2 portal. The data reported is subsequently updated for any identified errors through a monthly validation process. However, the data is reviewed and corrected only on a sample basis. The Trust was not able to provide final accurate and complete data to check the waiting period from referral to treatment reported across the year. Conclusion (including disclaimer of conclusion on the Incomplete Pathways indicator) Because the data required to support the indicator has been retrospectively altered, as described in the Basis for Disclaimer of Conclusion paragraph, we have not been able to form a conclusion on the incomplete pathways indicator. Based on the results of our procedures, nothing has come to our attention that causes us to believe that for the year ended 31 March 2016: • The Quality Report does not incorporate the matters required to be reported on as specified in Annex 2 to Chapter 7 of the FT ARM and the 'Detailed requirements for quality reports 2015 – 16'; • The Quality Report is not consistent in all material respects with the documents specified above; and • The 4 hour A&E waiting times indicator has not been prepared in all material respects in accordance with the Criteria set out in the NHS Foundation Trust Annual Reporting Manual ('FT ARM') and the 'Detailed guidance for external assurance on quality reports 2015 – 16'.
PricewaterhouseCoopers LLP Newcastle upon Tyne 27 May 2016 The maintenance and integrity of the North Tees’s and Hartlepool NHS Foundation Trust’s website is the responsibility of the directors; the work carried out by the assurance providers does not involve consideration of these matters and, accordingly, the assurance providers accept no responsibility for any changes that may have occurred to the reported performance indicators or criteria since they were initially presented on the website.
225 Annual Report and Accounts 2015 – 2016 Annex D We would like to hear your views on our Quality Accounts.
North Tees & Hartlepool NHS Foundation Trust value your feedback on the content of this year’s Quality Account. Please fill in the feedback form below, tear it off and return to us at the following address: Patient Experience Team North Tees & Hartlepool NHS Foundation Trust Hardwick Road Stockton-on-Tees Cleveland TS19 8PE ...... Thank you for your time.
Feedback Form (please circle all answers that are applicable to you) What best describes you: Patient Carer Member of public Staff Other Did you find the Quality Account easy to read? Yes No Did you find the content easy to understand? Yes all of it Most of it None of it Did the content make sense to you? Yes all of it Most of it None of it Did you feel the content was relevant to you? Yes all of it Most of it None of it Would the content encourage you to use our hospital? Yes all of it Most of it None of it Did the content increase your confidence Yes all of it Most of it None of it in the services we provide? Are there any subjects/topics that you would like to see included in next year’s Quality Account? ...... In your Opinion, how could we improve Our Quality Account? ...... 226 ...... Annual Report and Accounts 2015 – 2016 ...... Alternatively you can email us at: [email protected] With the Subject Quality Accounts Glossary
A&E Accident and Emergency ACE Committee Audit and Clinical Effectiveness Committee – the committee that oversees both clinical audit (i.e. monitoring compliance with agreed standards of care) and clinical effectiveness (i.e. ensuring clinical services implement the most up-to-date clinical guidelines) ACL Anterior Cruciate Ligament – one of the four major ligaments of the knee AMT Abbreviated Mental Test AquA Advancing Quality Alliance CABG Coronary Artery Bypass Graft (or “heart bypass”) CFDP Care For the Dying Patient CCG Clinical Commissioning Group CHKS Comparative Health Knowledge System Clostridium Difficile An infection sometimes caused as a result of taking certain antibiotics (infection) for other health conditions. It is easily spread and can be acquired in the community and in hospital CLRN Comprehensive Local Research Network COPD Chronic Obstructive Pulmonary Disease CSP Co-ordinated System for gaining NHS Permission CQC The Care Quality Commission – the independent safety and quality regulator of all health and social care services in England CQRG Clinical Quality Review Group CQUIN Commissioning for Quality and Innovation – a payment framework introduced in 2009 to make a proportion of providers’ income conditional on demonstrating improvements in quality and innovation in specified areas of care DAHNO Data for Head and Neck Oncology (Head and Neck Cancer) DARs Data Analysis Reports DoLS Deprivation of Liberty Safeguards DVLA Driver and Vehicle Licensing Agency EAU Emergency Assessment Unit E coli (infection) Escherichia coli – An infection sometimes caused as a result of poor hygiene or hand-washing EMSA Eliminating mixed sex accommodation EOL End of Life EWS Early Warning Score – a tool used to assess a patient’s health and warn of any deterioration FCE Finished Consultant Episode – the complete period of time a patient has spent under the continuous care of one consultant 227 FICM Faculty of Intensive Care Medicine FOI (act) The Freedom of Information Act – gives you the right to ask any public Annual Report and Accounts 2015 – 2016 body for information they have on a particular subject FFT Friends and Family Test Global trigger tool Used to assess rate and level of potential harm. Use of the GTT is led by a (GTT) medical consultant and involves members of the multi-professional team. The tool enables clinical teams to identify events through triggers which may have caused, or have potential to cause varying levels of harm and take action to reduce the risk GCP Good Clinical Practice GM General Manager HCAI Health Care Acquired Infection HED Healthcare Evaluation Data (A major provider of healthcare information and benchmarking) HEE Health Education England HES Hospital Episode Statistics HMB Heavy Menstrual Bleeding HQIP Healthcare Quality Improvement Partnership HRG Healthcare Resource Group – a group of clinically similar treatments and care that require similar levels of healthcare resource HSMR Hospital Standardised Mortality Ratio – an indicator of healthcare quality that measures whether the death rate in a hospital is higher or lower than you would expect HUG Healthcare User Group IBD Inflammatory Bowel Disease ICNARC Intensive Care National Audit and Research Centre ICS Intensive Care Society IMR Intelligent Monitoring Report tool for monitoring compliance with essential standards of quality and safety that helps to identify where risks lie within an organisation LD Learning Difficulties IG Information Governance Intentional A formal review of patient satisfaction used in wards at regular points rounding throughout the day IPNMB Integrated Professional Nursing Midwifery Board IPC Infection Prevention and Control Kardex (prescribing A standard document used by healthcare professionals for recording details kardex) of what has been prescribed for a patient during their stay KEOGH Sir Bruce Keogh LD Learning disabilities Liverpool End of Used at the bedside to drive up sustained quality of care of the dying Life Care Pathway patient in the last hours and days of life MBRRACE-UK Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries in the UK MCA Mental Capacity Act MHA Mental Health Act MHRA Medicines and Healthcare products Regulatory Agency MIU Minor Injuries Unit MINAP The Myocardial Ischaemia National Audit Project Monitor The independent regulator of NHS Foundation Trusts MRSA Methicillin-Resistant Staphylococcus Aureus - a type of bacterial infection that is resistant to a number of widely used antibiotics MUST Malnutrition Universal Screening Tool NCEPOD The National Confidential Enquiry into Patient Outcome and Death 228 NCRN National Cancer Research Network NEEP North East Escalation Plan Annual Report and Accounts 2015 – 2016 NEPHO North East Public Health Observatory NEQOS North East Quality Observatory System NEWS National Early Warning Score NICE The National Institute of Health and Clinical Excellence NICOR The National Institute for Cardiovascular Outcomes Research NIHR National Institute for Health Research NNAP National Neonatal Audit Programme OFSTED The Office for Standards in Education PALS Patient Advice and Liaison Service PAS Patient Administration System Patient Safety and The Committee responsible for ensuring provision of high quality care and Quality Standards identifying areas of risk requiring corrective action (Ps&Qs) Committee PICANet Paediatric Intensive Care Audit Network PREVENT The government’s counter-terrorism strategy PROMs Patient Reported Outcome Measures Pseudonymisation A process where patient identifiable information is removed from data held by the Trust R&D Research and Development RAG Red, Amber, Green chart denoting level of severity RCA Root Cause Analysis RCOG The Royal College of Obstetricians and Gynaecologists RCPCH The Royal College of Paediatric and Child Health REPORT-HF International Registry to assess Medical Practice with longitudinal observation for Treatment of Heart Failure RESPECT 'Responsive, Equipped, Safe and secure, Person centered, Evidence based, Care and compassion and Timely' - a nursing and midwifery strategy developed with patients and governors aimed at promoting the importance of involving patients and carers in all aspects of healthcare RMSO Regional Maternity Survey Office SBAR Situation, Background, Assessment and Recommendation - a tool for promoting consistent and effective communication in relation to patient care SCM Senior Clinical Matron SCMOoH Senior Clinical Matron Out-of-Hours SHA Strategic Health Authority SHMI Summary Hospital Mortality-level Indicator - a hospital-level indicator which reports inpatient deaths and deaths within 30-days of discharge at Trust level across the NHS sic The Latin adverb sic (“thus”; in full: sic erat scriptum, “thus was it written”), inserted immediately after a quoted word or passage, indicates that the quoted matter has been transcribed exactly as found in the source text, complete with any erroneous or archaic spelling, surprising assertion, faulty reasoning, or other matter that might otherwise be taken as an error of transcription. SINAP Stroke Improvement National Audit Programme SPEQS Staff & Patient Experience and Quality Standards SPOC Single point of contact SSKIN Surface inspection, skin inspection, keep moving, incontinence and nutrition SSU Short Stay Unit STAMP Screening Tool for the Assessment of Malnutrition in Paediatrics STEIS Strategic Executive Information System 229 STERLING Environmental Audit Assessment Tool
Tough-books Piloted in 2010, these mobile computers aim to ensure that community Annual Report and Accounts 2015 – 2016 staff has access to up-to-date clinical information, enabling them to make speedy and appropriate clinical decisions UHH University Hospital of Hartlepool UNIFY Unify2 is an online collection system used for collating, sharing and reporting NHS and social care data. UHNT University Hospital of North Tees VSGBI The Vascular Society of Great Britain and Ireland VTE Venous Thromboembolism WRAP Workshop to Raise Awareness of PREVENT WTE Whole Time Equivalent - is a unit that indicates the workload of an employed person in a way that makes workloads or class loads comparable 6 External Audit Opinion
Independent Auditors’ Report to the Council of Governors of North Tees and Hartlepool NHS Foundation Trust
230 Annual Report and Accounts 2015 – 2016 Annual Report and Accounts 2015 – 2016 231 Annual Report and Accounts 2015 – 2016 232 Annual Report and Accounts 2015 – 2016 233 Annual Report and Accounts 2015 – 2016 234 Annual Report and Accounts 2015 – 2016 235 Annual Report and Accounts 2015 – 2016 236 Annual Report and Accounts 2015 – 2016 237 7 Financial Performance 2015 – 16
7.1 Foreword to the accounts
These Accounts, for the year ended 31 March 2016, have been prepared by North Tees and Hartlepool NHS Foundation Trust in accordance with paragraphs 24 & 25 of Schedule 7 within the National Health Service Act 2006 and have been audited by PricewaterhouseCoopers (PWC) the Trust's external auditors. The Accounts have received an unqualified opinion that they give a true and fair view of the state of affairs of the Trust as at 31 March 2016 including its income and expenditure for the period. This report contains the four primary financial statements: • The Consolidated Statement of Comprehensive Income (for the Group and the Trust only) • The Statements of Financial Position (for the Group and the Trust only) • Statement of Changes in Taxpayers' Equity (for the Group and the Trust only) • Statement of Cash Flows (for the Group and the Trust only). Also included for information are the supporting notes to the Accounts. 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.
Alan Foster MBE Chief Executive 27 May 2016
238 Annual Report and Accounts 2015 – 2016 7.2 Financial Performance against plan 2015 – 16
The challenging economic climate has continued to impact on the Trust and whilst the focus has been on delivering high quality patient care, which has been achieved throughout the year, this has been at a cost to the financial position. The overall financial position has been behind plan however it has exceeded the revised target as agreed with Monitor. This is the first year that the Trust has reported an overall deficit since becoming a Foundation Trust. The Trust has secured access to the Sustainable Transformation Programme funding for 2016 – 17 and together with funding secured from the Department for Health the Trust begins an investment programme across the sites to implementing the Clinical Services Strategy to further improve the services offered to patients in this area and will develop the Electrical Infrastructure and construct a new Energy Centre at the University Hospital of North Tees. For 2015 – 16 the consolidated Trust position reported a £3.036m deficit for the year, after an exceptional item of £4.656m which has benefitted the financial position (from a valuation gain on land and buildings). The operational deficit was £7.396m (excluding Charitable Funds and its subsidiary). This exceptional item arose because the Trust needs to report its capital assets at fair value. This is a non-cash technical adjustment and it is appropriate to show this benefit in the statement of comprehensive income for the year. During the year the Trust has actively managed its financial position. Operational pay budgets for the Directorates have remained under pressure with recourse to locum and agency staff to meet the unprecedented demand for services. In addition the Service Improvement and Efficiency Programme (SIEP) remained behind plan as a result of the increased demand placed on services throughout the whole year. The efficiency challenge in 2015 – 16 was £10.9m. At the year end the programmes delivered £6.163m and where directorate plans have not been delivered these have been carried forward into 2016 – 17. The Trust complies with IAS 27 which requires the preparation of consolidated accounts for a group of entities under the 'control' of a parent. Control is defined as 'the power to govern the financial and operating policies of an entity so as to obtain benefit from its activities'. The Trust has therefore consolidated the Charitable Funds and its wholly owned subsidiary company into the Group position for 2015 – 16. This is the first year that the Trust has consolidated the accounts of its wholly owned subsidiary, Optimus Health Limited, which has been operating for 17 months. This company is trading as Panacea Pharmacy and offers a dispensing service for outpatients on the North Tees site, as well as retail goods to all visitors and staff. In its first period of operation the company made a loss of £193k which has been included in the Group position. The Charitable Funds also reported a loss of £103k for the year made up of a decrease in value of £64k in the market value of its portfolio of investments with the difference being the expenditure in the Trust exceeding the fund raising income. During the year Charitable Funds have continued to support a wide range of chartable and health related activities benefiting both patients and staff. In general they are used to provide goods and services to improve patient care and staff welfare that the NHS is unable to provide within available resources. The table overleaf summarises the actual financial performance against plan for the Group. 239 Annual Report and Accounts 2015 – 2016 Income & Expenditure Summary as at March 2016
Annual Accounts Variance budget 2015-16 £000 £000 £000 Income Commissioning Agreements (240,122) (240,440) (318) Other Income from Patient Care (6,687) (8,594) (1,907) Other Income from Non Patient Care (24,421) (27,119) (2,698) Charitable Funds Consolidation Income - (215) (215) Exceptional Item - (4,254) (4,254) Total Income (271,230) (280,622) (9,392) Total Operational Income (271,230) (276,368) (5,138) Total Non-Operational Income - (4,254) (4,254)
Expenditure Pay 186,277 191,548 5,271 Non Pay 84,397 83,163 (1,234) Charitable Funds Consolidation Expenditure - 106 106 SIEP (4,738) - 4,738 Depreciation 6,324 5,452 (872) Impairment of Trust Asset Base - - - Total Expenditure 272,260 280,269 8,009 Total Operational Expenditure 265,936 274,817 8,881 Total Non-Operational Expenditure 6,324 5,452 (872)
Financing Costs Interest Payable Loans & Leases 172 142 (30) PDC 3,780 3,780 - Interest Receivables (150) (103) 47 Charitable Funds & Dividends Income - (55) (55) Movement in Fair Value of Investments Charitable Funds - 64 64 Unwinding of Discount 20 20 - Total Financing Costs 3,822 3,848 26
Deficit from Operations (4,852) (3,495) (1,357) 240 Revaluation of Trust Asset Base - 459 (459) Total Comprehensive Income for the Year (4,852) (3,036) (1,816) Annual Report and Accounts 2015 – 2016 Table 1 – Financial Performance against Plan 2015 – 16
Plan Actual Variance Closing Cash Balance £37.476m £23.336m (£14.140m) (Excluding Charitable Funds and subsidiary) Delivery of Cost Efficiencies - £10.901m £6.164m (£4.737m) Recurring & Non Recurring 7.3 Income and contract performance
Income in 2015 – 16 totalled £280.6m (which includes the £4.254m exceptional gain as a result of the increased valuation of the Trust’s estate by the Independent District Valuer). The majority of the Trust’s income (£240.4m, 87%) was derived from Clinical Commissioning Groups (CCGs) and NHS England in relation to healthcare services provided to patients during the year. Other operating income relates to services provided to other Trusts, including training and education and miscellaneous fees and charges. A summary of total income is provided in table 2 and the chart below: Table 2 – Analysis of Sources of Operating Income 1 April 2015 to 31 March 2016
Operating Income £m % CCGs and NHS England 240.44 87 Other Patient Care Income 8.59 3 Education, Training and R&D 10.03 4 Non-patient Care Services to 10.72 4 Other Bodies Other 6.59 2 Total Operating Income 276.37 100%
Services provided to the patients of Hartlepool and Stockton CCG accounted for 71% of total income received from Clinical Commissioning Groups. A summary of income from Clinical Commissioning Groups and NHS England is provided in table 3 and the chart below: Table 3 – Analysis of Income from Clinical Commissioning Groups and NHS England 1 April 2015 to 31 March 2016
CCGs and NHS England £m % NHS Hartlepool & Stockton-on-Tees CCG 173 71 NHS Durham, Dales, Easington & 36 15 Sedgefield CCG Cumbria, Northumberland, Tyne and Wear 9 4 Area Team Durham, Darlington & Tees Area Team 17 7 NHS South Tees CCG 3 1 NHS Darlington CCG 1 1 Other CCGs and NHS England 1 1 Total CCGs and NHS England Income 240 100% Expenditure 241 An analysis of the Trust’s operating expenditure is presented in table 4 and the chart below:
Table 4 – Analysis of Operating Expenses 1 April 2015 to 31 March 2016 Annual Report and Accounts 2015 – 2016
Operating Expenses £m % Employee Expenses 191 68 Drugs Costs 21 7 Supplies and services - clinical (excluding 26 9 drug costs) Supplies and services - general 4 1 Services from NHS Organisations 1 0 Other Costs 37 15 Total Operating Expenses 280 100% Tables 5 and 6 below show the Trust’s activity profile over current and previous years. The key highlights to note are as follows: • Ambulatory is now counted as part of non-elective activity; • Elective performance shows a decrease of 188 spells compared to 2014 – 15. Procedures within a day case setting have seen an increase of 1,572 spells; • Non-elective performance (excluding well babies) shows a decrease of 118 spells. The substantial decrease between the previous 2 years has slowed down; • First outpatient attendances have increased by 913. There has been a general increase in referrals in some specialties; • Follow-up attendances has decreased by 3,198. There has been improvement in the new to review ratio across the Trust; • Outpatient procedures have increased by 2,616. There are more referrals for procedures, but there has also been better coding of procedures so this partially offsets the decrease in follow- ups. Table 5 – Analysis of the financial components of the 2015 – 16, 2014 – 15, 2013 – 14 and 2012 – 13 Contracts
60,000
45,000
30,000
15,000
0 2015-16 2014-15 2013-14 2012-13
Non-elective (emergency Day case spells Elective inpatient spells spells) and Ambulatory
Analysis of Activity 2015-16 2014-15 2013-14 2012-13 Day Case Spells 33,839 32,267 30,839 28,859 Elective Inpatient Spells 5,318 5,506 5,983 6,068 Non Elective (Emergency Spells) and Ambulatory 47,069 36,737 38,008 40,046
242 Annual Report and Accounts 2015 – 2016 Table 6 – Analysis of the 2015 – 16, 2014 – 15, 2013 – 14 and 2012 – 13 Contract Activity
200,000
150,000
100,000
50,000
0 2015-16 2014-15 2013-14 2012-13
First Follow Up Outpatient Outpatient Outpatient Procedures Attendances Attendances
Analysis of Activity 2015-16 2014-15 2013-14 2012-13 First Outpatient Attendances 61,004 60,091 59,485 61,905 Follow Up Outpatient Attendances 161,277 164,475 179,465 183,887 Outpatient Procedures 18,098 15,482 13,243 14,504
7.4 Capital investment
In terms of capital investment the Trust spent £8.1m in the following areas during 2015 – 16: • Medical Equipment - £1.449m • ICT schemes - £0.875m • Service developments and transformation - £3.228m • Estates and backlog maintenance schemes - £2.489m • Donated Assets from Charitable Funds - £0.094m 7.5 Financial Outlook for 2016 – 17
Financial Overview The Trust has a history of strong financial performance and has implemented a financial recovery plan which will bring the Trust back to a surplus financial position in 2016 – 17, without negatively impacting on patient safety or the quality of care that patients receive. The financial plan supports the longer term strategic direction of the Trust as it focuses on the Clinical Services Strategy over 243 the next five years and delivers a surplus of £2.1m in 2016 – 17. The plan reflects the Trust Board’s commitment to delivering the target set by NHS Improvement. Annual Report and Accounts 2015 – 2016 The planned surplus is predicated on receiving the £7.9m support from the Sustainability and Transformation Fund and delivering a £7.9m cost improvement target. A significant focus for 2016 – 17 is the implementation of robust governance arrangements with a performance framework based on the “model hospital” outlined in the Lord Carter recommendations published in February 2016. The Trust is confident with the revised governance arrangements focusing on cost efficiencies and the agreed support from the Sustainability Transformation Programme that the Trust will be in recurrent financial balance. The Board of Directors recognises the need to balance the requirement for maintaining high quality and safe care against delivering efficiency savings. The ability to continually deliver efficiencies over the next year, and into the future, will be extremely challenging. Financial Outlook The continued delivery of financial efficiencies will be extremely challenging and to assist with this agenda the Trust has recently undertaken a self-assessment against Monitor's Grip and Control checklist to provide confidence in the robustness of financial, activity, performance and governance controls. The recommendations from the review have been reported to the Trust Executive Team and aim to build on existing financial controls, performance management and governance arrangements to ensure that the Trust is well placed to deliver incremental improvements in the quality of services provided to patients and deliver the financial and performance targets set and agreed. It is recognised that in the long term the financial systems which the Trust operates within needs to change by developing a more holistic approach, aligned to ensuring that the total resources across the whole health and social care system are used to the advantage of patients and their carers. The Trust is continuing to work with NHS Improvement as one of the change agent sites to gain clinical ownership of costs incurred in treating patients, with a view to advancing the accuracy and relevance of financial information; this will help in ensuring any future financial models are based on realistic activity and financial drivers going forward. The Trust will strive to deliver the challenging financial agenda and will maintain or improve upon the quality, patient experience and service performance in the difficult years ahead. Work continues across the health and social care settings to develop systems to ensure resources are used to the advantage of patients and their carers including the continued roll out of the Electronic Patient Record, the implementation of the Scan4Safety (GS1) initiative outlined in the procurement section below and the development of partnership working across the wider health and social care locality. Cost improvement and service efficiencies are integral to the Trust’s financial planning and require good, sustained performance in order to be achieved. The Trust confronts a national tariff with built-in efficiency savings (2% in 2016 – 17), rising inflation and increasing contract volumes with commissioners with aging demographics and limited financial resources. Generating cost improvements has been challenging for the Trust over the last two years, however, to continue to deliver at the levels required in the tariff, change will need to be transformational. For 2016 – 17, the efficiency target and consequent plans equates to 3.1% of expenditure. This reflects the ambition of the Trust to continue to develop services and maintain quality and safety as a key priority but recognises that efficiencies through incremental service change is increasingly challenging. The Trust has adopted a strategic approach that incorporates enabling strategies, corporate reviews and directorate specific initiatives. Greater focus is also placed on procurement savings, appropriate use of drugs and support services redesign, with a view to looking further at shared services and collaboration across the patch. Clinical directorates will be assigned a savings target which will need to be delivered through driving out inefficiencies, appropriate use of products and test requests and through continuous improvement. The efficiency strategy has been developed alongside service planning to ensure safe services can be sustained and will drive quality improvement, in recognition that high quality and value for money are not competing alternatives. The Lord Carter report received from the Department of Health Team in the autumn of 2015 highlighted a number of areas as being opportunities for financial efficiency. These include: • Obstetrics and Gynaecology; • Surgery and Urology; 244 • Trauma and Orthopaedics;
Annual Report and Accounts 2015 – 2016 • Paediatrics. The Trust is preparing action plans for the areas highlighted by Lord Carter to understand further the reasons for the difference when comparing the cost of the services with those comparable Trusts that appear to be more cost effective. Lord Carter made 15 recommendations covering the following areas: • Optimisation of Clinical Resources; • Optimisations of Non Clinical Resources; • Quality and efficiency across the Patient Pathway; • Creating the model hospital and an integrated performance framework; • Implementation and further engagement with Trusts. An Executive Director has been assigned to lead each of the 15 recommendations and they will feed back monthly to the Executive Team meetings and the various governance Committees across the Trust, depending on the topic. One of the key recommendations of the interim report was to create a 'model dashboard', to set out a clear, consistent approach to address improved clinical and financial efficiencies. The outcome of the Keogh review has required organisations to monitor and publish staffing information; however the shortage of healthcare professionals has and will continue to place significant pressure on the Trust by increasing the requirement for locum and agency staff to ensure safe staffing numbers are maintained. The Trust has historically had recourse to off framework agencies and at pay rates that have exceeded the Monitor breach caps to maintain safe staffing levels for both nursing and medical staffing. This is the main focus for delivering the workforce financial savings in 2016 – 17. To facilitate this agenda the Trust is in the process of strengthening the management of temporary staffing which will include the co-ordination and standardisation of roster production and the enforcement of Trust policy with regard to the booking of temporary staffing. During 2015 – 16 the Trust implemented STAFFflow, the direct engagement model for employing agency medical staff with the primary aim of reducing spend on temporary medical staff. The system provides the necessary framework to migrate to an internal bank solution for medical staffing in 2016 – 17. The system will facilitate bank collaboration with neighbouring Trusts, allowing the Trust to utilise another Trust’s bank worker before going out to agency. In addition, the Trust continues to actively recruit to substantive posts to avoid recourse to external temporary staffing which is neither clinically ideal nor financially sustainable. As part of the Trust’s seasonal and resilience planning last financial year an overseas recruitment exercise was performed in July 2015 with the aim of recruiting circa 60 additional nurses to commence duties over the winter period. Once fully trained, the additional capacity will provide an additional 6,000 hours per month of nursing resource from June 2016. This additional nursing resource will mitigate demand for temporary staffing during 2016 – 17. The Trust plans further recruitment and additional bank staff appointments during the year. Other initiatives planned in 2016 – 17 to reduce external temporary staffing costs include: • Procurement initiatives – Where the Trust sources agency staff the application of contractual target fill rates for recruitment agencies to meet vacant shifts. In addition, reduce and rationalise the number of agencies the Trust utilises; • Creation of Internal bank for Administrative and Clerical staff group, thereby avoiding cost implications of recourse to agency; • Standardisation and early planning of Nursing/Medic rosters six weeks prior to known vacancies to provide maximum opportunity for shifts to be filled by bank or substantive staff rather than the use of agency staff. In May 2014, the Department of Health published its eProcurement Strategy which drives the adoption of Global Standards 1 (GS1) identification and Pan European Public Procurement On Line (PEPPOL) transaction messaging standards throughout the NHS. The Trust has been successful in this bid and has recently been appointed as one of the six demonstrator sites. The Trust will implement this initiative under the Scan4Safety project. The cost of the implementing the programme is £1.76m over an 18 month period and will be fully funded by the Department of Health. It is estimated that GS1 and PEPPOL adoption at the Trust will 245 deliver benefits to the organisation of £2.8m, derived from pay and non-pay efficiencies, as well as
a considerable release of clinical time to patient care. Annual Report and Accounts 2015 – 2016 Capital Planning As a result of the pause in the new hospital development, significant capital investment will be required on the North Tees site in the next five years and the capital programme reflects this position. The capital plan for 2016 – 17 includes a £25m loan secured from the Independent Trust Financing Facility (ITFF). This initial tranche of funding is to support the Estates Strategy and the development of the Trust’s electrical, heating, water and steam infrastructure and also includes the building of an energy centre for the North Tees Hospital site. The Trust is developing its clinical services strategy and as the infrastructure programme progresses further funds will be required to reconfigure and refurbish the hospital sites to meet the needs of this strategy. It is envisaged that an additional loan of c£30m will be required to reconfigure the service provision in line with the Clinical Services Strategy and potentially a further £10m to reconfigure emergency pathways across the Tees Valley. From 2017/18 the capital programme reflects the anticipated additional £10m required for emergency pathway reconfiguration. In 2014 – 15 the Trust was successful in its bid from the Safer Hospitals Safer Wards fund and has invested, over a two year period, c£8m in new technology. The phased implementation of an Electronic Patient Record, coupled with the move towards an Electronic Document Management System and Electronic Prescribing system will move the organisation towards a paperless environment and deliver efficiencies that will start to materialise in 2017/18. In total the capital programme is funded to the value of £11.219m in 2016 – 17 with the Trust continuing to invest in Directorate equipment replacement plans to ensure patients receive high quality care. The capital allocations are categorised into the following areas of work:
2016-17 £m Estates Backlog 0.50 Medical Equipment (including Donated) 3.58 ICT & Electronic Patient Record 2.49 Investment in New Build (Energy Centre) 4.65 Total 11.22
7.6 Summary
In setting the financial plan for 2016 – 17 the Trust Board recognise the need to maintain high quality and safe care and deliver financial balance. The efficiency target of £7.9m set within the plan is still challenging however the Trust has firm plans and governance arrangements in place to deliver these savings. The Trust will embark on a challenging capital programme that will result in a significant upgrade to the site infrastructure and an ambitious technology programme which will ultimately drive future efficiencies and improve both patient safety and the delivery of patient care. This will complement the development of the Sustainability and Transformation Plan that is being developed across the wider health and social care economy.
246 7.7 Key Performance Targets
Annual Report and Accounts 2015 – 2016 The Trust will meet a number of targets, as set out by NHS Improvement and detailed in the Risk Assessment framework.
Regulatory Ratings A number of key financial measures are translated into the Financial Sustainability Risk rating, which are reviewed on a monthly basis, based on the Trust’s actual performance. The risk rating represents NHS Improvement’s assessment of how likely the organisation is in relation to breaching its operating licence. There are four elements: liquidity, capital servicing capacity, income and expenditure margin and variance from plan in relation to the income and expenditure margin. Whilst the Trust is starting the year at a rating of 2 it is expecting to achieve a risk rating of 4 by the end of 2016 – 17 and continue at that level in the future. 7.8 Annual Accounts 2015 – 16 including Financial Statements and Notes
Consolidated Statement Of Comprehensive Income Group Note Operating result & Exceptional Item Exceptional Item * Operating result excluding Exceptional Item Operating result & Exceptional Item Exceptional Item* Operating result excluding Exceptional Item 2015-16 2015-16 2015-16 2014-15 2014-15 2014-15 £000 £000 £000 £000 £000 £000 Operating income 3,4 280,622 4,254 276,368 285,548 11,325 274,223 Operating expenses 5,7 (280,269) (57) (280,212) (276,001) (756) (275,245) Operating Surplus/ 353 4,197 (3,844) 9,547 10,569 (1,022) (Deficit)
Finance costs: Finance income 9 158 - 158 212 - 212 Finance cost - 10 (142) - (142) (134) - (134) financial liabilities Finance cost - 23 (20) - (20) (20) - (20) unwinding of discount on provisions PDC Dividends payable (3,780) - (3,780) (3,208) - (3,208) (3,784) - (3,784) (3,150) - (3,150)
(Deficit)/Surplus For (3,431) 4,197 (7,628) 6,397 10,569 (4,172) The Year**
Other comprehensive income Will not be reclassified to income and expenditure: Revaluations gains on 459 459 - 690 690 - property, plant and equipment Other reserve - - - 69 69 - movements May be reclassified to income and expenditure when certain conditions 247 are met: Fair Value (losses)/ (64) - (64) 152 - 152 Annual Report and Accounts 2015 – 2016 gains on available- for-sale financial investments Total Comprehensive (3,036) 4,656 (7,692) 7,308 11,328 (4,020) (Expense)/Income For The Year
The notes numbered 1 - 33 form part of these accounts. Fair value (losses)/gains on available-for-sale financial investments of £(64)k (2014/15: £152k) relate to charitable funds investment. * Exceptional item within the operating (deficit)/surplus relates to a reversal of a prior year impairment £4,254,000 for property plant and equipment (2014-15: £11,325,000) and an impairment of £57,000 on dwellings (2014-15: £21,000 on dwellings and £735,000 on land). ** Operational Group Deficit (£7,628,000) includes Charitable Funds operational deficit of (£39,000) and Optimus Health Ltd a wholly owned subsidiary deficit of (£193,000). The Trust operational deficit is (£7,396,000). *** The revaluation gain of £459,000 is in relation to the Peterlee Community Hospital. Statement Of Comprehensive Income Trust Note Operating result & Exceptional Item Exceptional Item * Operating result excluding Exceptional Item Operating result & Exceptional Item Exceptional Item* Operating result excluding Exceptional Item 2015-16 2015-16 2015-16 2014-15 2014-15 2014-15 £000 £000 £000 £000 £000 £000 Operating income 3,4 280,354 4,254 276,100 285,243 11,325 273,918 Operating expenses 5,7 (279,734) (57) (279,677) (275,458) (756) (274,702) Operating Surplus/ 620 4,197 (3,577) 9,785 10,569 (784) (Deficit)
Finance costs: Finance income 9 103 - 103 151 - 151 Finance cost - 10 (122) - (122) (134) - (134) financial liabilities Finance cost - 23 (20) - (20) (20) - (20) unwinding of discount on provisions PDC Dividends payable (3,780) - (3,780) (3,208) - (3,208) (3,819) - (3,819) (3,211) - (3,211)
(Deficit)/Surplus For (3,199) 4,197 (7,396) 6,574 10,569 (3,995) The Year**
Other comprehensive income Will not be reclassified to income and expenditure: Revaluations gains on 459 459 - 690 690 - property, plant and equipment Other reserve - - - 69 69 - movements May be reclassified to income and expenditure when certain conditions are met: Fair Value gains on ------248 available-for-sale financial investments Annual Report and Accounts 2015 – 2016 Total Comprehensive (2,740) 4,656 (7,396) 7,333 11,328 (3,995) (Expense)/Income For The Year
The notes numbered 1 - 33 form part of these accounts. * Exceptional item within the operating (deficit)/surplus relates to a reversal of a prior year impairment £4,254,000 for property plant and equipment (2014-15: £11,325,000) and an impairment of £57,000 on dwellings (2014-15: £21,000 on dwellings and £735,000 on land). ** The revaluation gain of £459,000 is in relation to the Peterlee Community Hospital. Statements Of Financial Position Group Trust 31 March 31 March 31 March 31 March
Note 2016 2015 2016 2015 £000 £000 £000 £000 Non-current assets Intangible assets 11 124 177 117 177 Property, plant and equipment 12 121,550 118,357 121,550 118,357 Other investments 14 1,366 1,530 - - Trade and other receivables 18 1,128 - 1,128 - Total non-current assets 124,168 120,064 122,795 118,534
Current assets Inventories 17 8,340 7,935 8,219 7,935 Trade and other receivables 18 16,326 11,000 17,431 11,011 Cash and cash equivalents 19 23,516 37,549 23,336 37,476 Total current assets 48,182 56,484 48,986 56,422
Current liabilities Trade and other payables 20 (23,670) (21,361) (24,398) (21,361) Other liabilities 21 (1,849) (1,861) (1,849) (1,861) Borrowings 22 (162) (184) (162) (184) Provisions 23 (498) (612) (498) (612) Total current liabilities (26,179) (24,018) (26,907) (24,018) Total assets less current liabilities 146,171 152,530 144,874 150,938
Non-current liabilities Other liabilities 21 (2,771) (5,771) (2,771) (5,771) Borrowings 22 (327) (479) (327) (479) Provisions 23 (1,206) (1,378) (1,206) (1,378) Total non-current liabilities (4,304) (7,628) (4,304) (7,628) Total assets employed 141,867 144,902 140,570 143,310
Financed by Public Dividend Capital 130,906 130,906 130,906 130,906 Revaluation reserve 1,294 835 1,294 835 Income and expenditure reserve 8,212 11,569 8,370 11,569 Charitable fund reserve 16 1,455 1,592 - - 249 Total Taxpayers’ Equity 141,867 144,902 140,570 143,310
The notes on pages 253 to 288 form part of these accounts. Annual Report and Accounts 2015 – 2016 The accounts on pages 247 to 252 and the notes on pages 253 to 288 were approved by the Board on 26th May 2016 and signed on its behalf by:
Alan Foster, MBE Chief Executive Statement Of Changes In Taxpayers' Equity For The Year Ended 31 March 2016 Group 2015-2016 equity reserve reserve Income and Revaluation expenditure capital (PDC) funds reserves NHS charitable Public dividend Total taxpayers' Total £000 £000 £000 £000 £000 Taxpayers’ Equity at 1 April 2015 - brought 130,906 835 11,569 1,592 144,902 forward (Deficit)/surplus for the year - - (3,493) 63 (3,431) Revaluations - 459 - - 459 Recycling losses on available-for-sale financial - - - (64) (64) investments Other reserve movements - - 136 (136) - Taxpayers’ Equity at 31 March 2016 130,906 1,294 8,212 1,455 141,867 Statement Of Changes In Taxpayers' Equity For The Year Ended 31 March 2015 Group 2014-2015 equity reserve reserve Income and Revaluation expenditure capital (PDC) funds reserves NHS charitable Public dividend Total taxpayers' Total £000 £000 £000 £000 £000 Taxpayers’ Equity at 1 April 2014 - brought 123,841 145 4,926 1,617 130,529 forward Surplus for the year - - 6,282 115 6,397 Revaluations - 690 - - 690 Recycling gains on available-for-sale financial - - - 152 152 investments Public dividend capital received 7,134 - - - 7,134 Other reserve movements (69) - 361 (292) - Taxpayers' Equity at 31 March 2015 130,906 835 11,569 1,592 144,902
250 Annual Report and Accounts 2015 – 2016 Statement Of Changes In Taxpayers' Equity For The Year Ended 31 March 2016 Trust 2015-2016 equity reserve reserve Income and Revaluation expenditure capital (PDC) Public dividend Total taxpayers' Total £000 £000 £000 £000 Taxpayers’ Equity at 1 April 2015 - brought 130,906 835 11,569 143,310 forward Deficit for the year - - (3,199) (3,199) Revaluations - 459 - 459 Taxpayers’ Equity at 31 March 2015 130,906 1,294 8,370 140,570 Statement Of Changes In Taxpayers' Equity For The Year Ended 31 March 2015 Trust 2014-2015 equity reserve reserve Income and Revaluation expenditure capital (PDC) Public dividend Total taxpayers' Total £000 £000 £000 £000 Taxpayers’ Equity at 1 April 2014 - brought 123,841 145 4,926 128,912 forward Surplus for the year - - 6,574 6,574 Revaluations - 690 - 690 Public dividend capital received 7,134 - - 7,134 Other reserve movements (69) - 69 - Taxpayers’ Equity at 31 March 2015 130,906 835 11,569 143,310
251 Annual Report and Accounts 2015 – 2016 Statement Of Cash Flows For The Year Ended 31 March 2016 Group Trust 2015-16 2014-15 2015-16 2014-15 NOTE £000 £000 £000 £000 Cash flows from operating activities Operating surplus 353 9,547 620 9,785
Non-cash income and expense Depreciation and amortisation 5.1 5,452 5,303 5,452 5,303 Impairments and reversals of impairments 6 (4,197) (10,569) (4,197) (10,569) Loss on disposal of non-current assets 5.1 202 - 202 - Income recognised in respect of capital (95) - (95) - donations Increase in receivables and other assets (6,477) (1,114) (7,538) (1,114) Increase in inventories (405) (906) (284) (906) (Decrease)/increase in payables and other (604) 980 91 980 liabilities Decrease in provisions (306) (49) (306) (49) Net cash (used in)/generated from operating (6,077) 3,192 (6,055) 3,430 activities
Cash flows from investing activities Interest received 158 212 103 151 Purchase of intangible assets - (31) - (31) Purchase of Property, Plant, Equipment and (8,062) (11,051) (8,062) (11,051) Investment property Sales of Property, Plant, Equipment and 3,998 - 3,998 - Investment property Net cash generated used in investing (3,906) (10,870) (3,961) (10,931) activities
Cash flows from financing activities Public dividend capital received - 7,134 - 7,134 Movement on other loans (22) (74) (22) (74) Capital element of PFI, LIFT and other service (152) (142) (152) (142) concession payments Interest paid on PFI, LIFT and other service (127) (130) (108) (130) concession obligations 252 Other interest paid (15) - (15) - PDC dividend paid (3,827) (2,915) (3,827) (2,915) Annual Report and Accounts 2015 – 2016 Financing cash flows of NHS charitable funds 93 218 - - Cash flows used in other financing activities - (5) - (5) Net cash generated (used in)/from financing (4,050) 4,086 (4,124) 3,868 activities Decrease in cash and cash equivalents (14,033) (3,592) (14,140) (3,633) Cash and cash equivalents at 1 April 37,549 41,141 37,476 41,109 Cash and Cash equivalents at 31 March 19.1 23,516 37,549 23,336 37,476 Notes to the Accounts
Note 1 Accounting policies and other information 1.1 Basis of preparation 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 NHS Foundation Trust Annual Reporting Manual (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. 1.2 Accounting convention 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. 1.3 Going concern The day to day operations of the Trust are funded from agreed contracts with Clinical Commissioning Groups and Specialist Commissioners. The uncertainty in the current economic climate has been mitigated by agreeing contracts with the Clinical Commissioning Groups and Specialist Commissioners for a further year. These payments provide a reliable stream of funding minimising the Trust exposure to liquidity and financing problems. The Trust's budgets and expenditure plans are based on this level of commissioned service and indicate that the Trust has sufficient resource to meet on-going commitments. The Board of Directors have assessed the criteria of a going concern in accordance with IAS 1 and in their opinion, given the facts at their disposal, it is correct to prepare the accounts on a going concern basis. The Cash flow forecast over the next 12 months indicate that the Trust has a monthly cash surplus available for investment. The Trust treasury policy governs the risk exposures of monetary financial assets and limits the value that can be placed with each approved counterparty to minimise the risk of loss. The counterparties are limited to the approved financial institutions with high credit ratings. Given the economic uncertainty, particular in the banking sector, the Trust has solely invested in the Governments National Loan Fund and has not been exposed to bank insolvency risks. 1.4 Consolidation NHS General Charitable Fund The NHS Foundation Trust is the corporate Trustee to North Tees and Hartlepool NHS Foundation Trust General Charitable Fund. The Foundation Trust has assessed its relationship to the charitable fund and determined it to be a subsidiary because the Foundation Trust is exposed to, or has rights to, variable returns and other benefits for itself, patients and staff from its involvement with the General Charitable Fund and has the ability to affect those returns and other benefits through its power over the fund. The Charitable Fund’s statutory accounts are prepared to 31 March in accordance with the UK 253 Charities Statement of Recommended Practice (SORP) which is based on UK Financial Reporting Standard (FRS) 102. On consolidation, necessary adjustments are made to the charity’s assets, Annual Report and Accounts 2015 – 2016 liabilities and transactions to: • recognise and measure them in accordance with the Foundation Trust’s accounting policies and • eliminate intra-group transactions, balances, gains and losses. Other subsidiaries - Optimus Health Limited Subsidiary entities are those over which the Trust is exposed to, or has rights to, variable returns from its involvement with the entity and has the ability to affect those returns through its power over the entity. The income, expenses, assets, liabilities, equity and reserves of subsidiaries are consolidated in full into the appropriate financial statement lines. This is the first year that the accounts of Optimus Health Limited have been incorporated into the Trust Accounts. The amounts consolidated are drawn from the published financial statements of the subsidiary for the 17 month period to 31 March 2016. Where subsidiaries’ accounting policies are not aligned with those of the Trust (including where they report under UK FRS 102) then amounts are adjusted during consolidation where the differences are material. Inter-entity balances, transactions and gains/losses are eliminated in full on consolidation. 1.5 Income Income 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 Trust is contracts with commissioners in respect of health care services. Where income is received for a specific activity which is conditional on delivery in a subsequent financial year, that income is deferred. Income 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. 1.6 Expenditure on employee benefits Short-term 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. 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 accounts 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 the scheme liability is carried out annually by the scheme actuary 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, 254 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. Annual Report and Accounts 2015 – 2016 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 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. The last published actuarial valuation undertaken for the NHS Pension Scheme was completed for the year ending 31 March 2012. The Trust estimates that its employer contributions into the scheme in 2015/16 will be approximately £16.9m. c) Scheme provisions The NHS Pension Scheme provides defined benefits, which are summarised below. This list is an illustrative guide only, and is not intended to detail all the benefits provided by the Scheme or the specific conditions that must be met before these benefits can be obtained. The Scheme is a 'final salary' scheme. Annual pensions are normally based on 1/80th for the 1995 section and of the best of the last three year pensionable pay for each year of service, and 1/60th for the 2008 section of reckonable pay per year of membership. Members who are practitioners as defined by the Scheme Regulations have their annual pensions based upon total pensionable earnings over the relevant pensionable service. 1.7 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. 1.8 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 Trust; • it is expected to be used for more than one financial year and; • the cost of the item can be measured reliably; • the item has a cost of at least £5,000; or • collectively, a number of items 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; • 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; or • items, such as salary costs are directly attributable to the asset. 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 255 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 Annual Report and Accounts 2015 – 2016 condition necessary for it to be capable of operating in the manner intended by management. All assets are measured subsequently at fair value. On the 31 March 2016 Land and Buildings were revalued using the Modern Equivalent Valuation methodology by the District Valuer, who is an appropriately qualified member of the Royal Institution of Chartered Surveyors (RICS). Properties in the course of construction for service or administration purposes are carried at cost, less than impairment loss. Cost includes professional fees but not borrowing costs, which are recognised as expenses immediately, as allowed by IAS 23 for assets held at fair value. Assets are revalued and depreciation commences when they are brought into use. The revaluation undertaken at that date was accounted for on 31 March 2016. The next revaluation will be prior to and no later than the 1 April 2017. Additional alternative open market value figures have only been supplied for operational assets scheduled for imminent closure and subsequent disposal. An increase arising on revaluation is taken to the revaluation reserve except when it reverses an impairment for the same asset previously recognised in expenditure, in which case it is credited to expenditure to the extent of the decrease previously charged there. An item of property, plant and equipment 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. Subsequent expenditure Subsequent expenditure relating to an item of property, plant and equipment is recognised as an increase in the carrying amount of the asset when it is probable that additional future economic benefits or service potential deriving from the cost incurred to replace a component of such item will flow to the enterprise and the cost of the item can be determined reliably. Where a component of an asset is replaced, the cost of the replacement is capitalised if it meets the criteria for recognition above. The carrying amount of the part replaced is de-recognised. Other expenditure that does not generate additional future economic benefits or service potential, such as repairs and maintenance, is charged to the Statement of Comprehensive Income in the period in which it is incurred. Depreciation 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 which is normally on a straight line basis. Freehold land is considered to have an infinite life and is not depreciated. Equipment is depreciated on fair value evenly over the estimated life of the asset. Asset Lives fall into the following periods. • Buildings excluding dwellings - forty to ninety years • Dwellings - eighty years • Assets Under Construction - Not depreciated • Plant and Machinery - seven to twenty five years • Transport Equipment - seven years • Information Technology - seven to eight years • Furniture and Fittings - seven to twelve years 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 Trust, respectively. Revaluation gains and losses Revaluation gains are recognised in the revaluation reserve, except where, and to the extent that, they reverse a revaluation decrease that has previously been recognised in operating expenses, in which case they are recognised in operating income. Revaluation losses are charged to the revaluation reserve to the extent that there is an available balance for the asset concerned, and thereafter are charged to operating expenses. 256 Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income as an item of ‘other comprehensive income’.
Annual Report and Accounts 2015 – 2016 Impairments In accordance with the FT ARM, impairments that arise from a clear consumption of economic benefits or of 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 that arises from a clear consumption of economic benefit or of 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. 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. 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. Donated, government grant and other grant funded assets Donated and grant funded property, plant and equipment 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. The donated and grant funded assets are subsequently accounted for in the same manner as other items of property, plant and equipment. Private Finance Initiative (PFI) transactions PFI transactions which meet the IFRIC 12 definition of a service concession, as interpreted in HM Treasury’s FReM, are accounted for as ‘on-Statement of Financial Position’ by the Trust. In accordance with IAS 17, the underlying assets are recognised as property, plant and equipment, together with an equivalent finance lease liability. Subsequently, the assets are accounted for as property, plant and equipment and/or intangible assets as appropriate. The annual contract payments are apportioned between the repayment of the liability, a finance cost and the charges for services. The service charge is recognised in operating expenses and the finance cost is charged to finance costs in the Statement of Comprehensive Income. 257 A-Payment for fair value of services received; Annual Report and Accounts 2015 – 2016 B-Payment for the PFI asset, including finance costs; and C-Payment for the replacement of components of the asset during the contract 'Lifecycle replacement'. Useful Economic lives of property, plant and equipment Useful economic lives reflect the total life of an asset and not the remaining life of an asset. The range of useful economic lives are shown in the table below:
Min Life Max Life Years Years Land 999 999 Buildings, excluding dwellings 5 115 Dwellings 105 105 Plant & machinery 5 25 Transport equipment 7 15 Information technology 1 12 Furniture & fittings 7 12
1.9 Intangible assets Recognition Intangible assets are non-monetary assets without physical substance which are capable of being sold separately from the rest of the 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 Trust and where the cost of the asset can be measured reliably; and where the cost is at least £5,000. 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: • the project is technically feasible to the point of completion and will result in an intangible asset for sale or use • the Trust intends to complete the asset and sell or use it • the Trust has the ability to sell or use the asset • how the intangible asset will generate probable future economic or service delivery benefits, eg, 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 Trust to complete the development and sell or use the asset; and • the Trust can measure reliably the expenses attributable to the asset during development. Software Software which is integral to the operation of hardware, eg an operating system, is capitalised as 258 part of the relevant item of property, plant and equipment. Software which is not integral to the operation of hardware, eg application software, is capitalised as an intangible asset.
Annual Report and Accounts 2015 – 2016 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. Useful economic life of intangible assets Useful economic lives reflect the total life of an asset and not the remaining life of an asset. The range of useful economic lives are shown in the table below:
Min Life Max Life Years Years Intangible assets - internally generated Information technology 7 8 Intangible assets - purchased Software 7 8 Licences & trademarks 1 40
1.10 Revenue government and other grants Government grants are grants from government bodies other than income from commissioners or NHS Trusts for the provision of services. Where a grant is used to fund revenue expenditure it is taken to the Statement of Comprehensive Income to match that expenditure. 1.11 Inventories Inventories are valued at current market price by reference to supplier information, on a first out basis. This is considered to be a reasonable approximation to fair value due to the high turnover of inventory. Pharmacy stocks are valued at current cost which is not materially different from the lower of cost or net realisable value. Provision is made for obsolete and defective stock whenever evidence exists that a provision is required. 1.12 Financial instruments and financial liabilities Recognition Financial assets and financial liabilities which arise from contracts for the purchase or sale of non- financial items (such as goods or services), which are entered into in accordance with the Trust’s normal purchase, sale or usage requirements, are recognised when, and to the extent which, performance occurs, i.e., when receipt or delivery of the goods or services is made. Financial assets and financial liabilities are recognised when the Trust becomes a party to the contractual provisions of the instrument. De-recognition All financial assets are de-recognised when the rights to receive cash flows from the assets have expired or the Trust has transferred substantially all of the risks and rewards of ownership. Financial liabilities are de-recognised when the obligation is discharged, cancelled or expires. Classification and measurement 259 Financial assets are categorised as loans and receivables. Financial liabilities are classified as other financial liabilities. Annual Report and Accounts 2015 – 2016 Financial assets and financial liabilities at 'fair value through income and expenditure' Financial assets and financial liabilities at 'fair value through income and expenditure' are financial assets or financial liabilities held for trading. A financial asset or financial liability is classified in this category if acquired principally for the purpose of selling in the short-term. Derivatives are also categorised as held for trading unless they are designated as hedges. Derivatives which are embedded in other contracts but which are not 'closely-related' to those contracts are separated- out from those contracts and measured in this category. Assets and liabilities in this category are classified as current assets and current liabilities. These financial assets and financial liabilities are recognised initially at fair value, with transaction costs expensed through the Statement of Comprehensive Income. Loans and receivables Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. They are included in current assets. The Trust’s loans and receivables comprise: Cash at bank and in hand, NHS receivables, accrued income and 'other receivables'. Loans and receivables are recognised initially at fair value, net of transactions costs, and are measured subsequently at amortised cost, using the effective interest method. The effective interest rate is the rate that discounts exactly estimated future cash receipts through the expected life of the financial asset or, when appropriate, a shorter period, to the net carrying amount of the financial asset. Interest on loans and receivables is calculated using the effective interest method and credited to the Statement of Comprehensive Income. Other financial liabilities All 'other' financial liabilities are recognised initially at fair value, net of transaction costs incurred, and measured subsequently at amortised cost using the effective interest method. The effective interest rate is the rate that discounts exactly estimated future cash payments through the expected life of the financial liability or, when appropriate, a shorter period, to the net carrying amount of the financial liability. They are included in current liabilities except for amounts payable more than 12 months after the Statement of Financial Position date, which are classified as long-term liabilities. Interest on financial liabilities carried at amortised cost is calculated using the effective interest method and charged to the statement of financial position. Impairment of financial assets At the Statement of Financial Position date, the Trust assesses whether any financial assets, other than those held at 'fair value through income and expenditure' are impaired. Financial assets are impaired and impairment losses are recognised if, and only 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. 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 through the use of an allowance account/bad debt provision. 1.13 Leases 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. 1.14 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 260 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 Annual Report and Accounts 2015 – 2016 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. 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 24 but is not recognised in the NHS Foundation Trust’s accounts. 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 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. 1.15 Contingencies Contingent assets (that is, assets arising from past events whose existence will only be confirmed by one or more future events not wholly within the entity’s control) are not recognised as assets, but are disclosed in note 25 where an inflow of economic benefits is probable. Contingent liabilities are not recognised, but are disclosed in note 25, unless the probability of a transfer of economic benefits is remote. 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. 1.16 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. HM Treasury has determined that PDC is not a financial instrument within the meaning of IAS 32. 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. The dividend thus calculated is not revised should any adjustment to net assets occur as a result the audit of the annual accounts. 1.17 Value added tax Most of the activities of the NHS 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. 1.18 Corporation tax Foundation Trusts are exempt from corporation tax on their principal healthcare income streams 261 under section 519A Income and Corporation Taxes Act 1988. In determining whether other income may be taxable, a three-stage test must be employed which asks whether the activity is an authorised activity related to the provision of core healthcare, whether the activity is actually or Annual Report and Accounts 2015 – 2016 potentially in competition with the private sector, and whether the annual profits of the activity are in excess of £50,000 per trading activity. The Trust has assessed its car parking and catering income against this criteria and does not have any corporation tax liability in the current or prior year. Optimus Health Limited has carried out its own tax computation and no corporation tax is payable on its first trading period. 1.19 Foreign exchange The functional and presentational currencies of the 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 Trust has assets or liabilities denominated in a foreign currency at the Statement of Financial Position 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 Statement of Financial Position 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. 1.20 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. However, they are disclosed in a separate note to the accounts in accordance with the requirements of HM Treasury’s FReM. 1.21 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 that individual cases are handled. Losses and special payments are charged to the relevant functional headings in expenditure 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). However the losses and special payments note is compiled directly from the losses and compensations register which reports on an accrual basis with the exception of provisions for future losses. 1.22 Early adoption of standards amendments and interpretations No new accounting standards or revisions to existing standards have been early adopted in 2015 – 16. 1.23 Estimation techniques These are methods adopted by the Trust to arrive at monetary amounts, corresponding to the measurement basis selected for assets, liabilities, gains, losses and charges to the Reserves. Where the basis of measurement for the amount to be recognised under Accounting Policies is uncertain, an estimation technique is applied. In the application of the Trust’s 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 262 experience and other factors that are considered to be relevant. Actual results may differ from those estimates and the estimates and underlying assumptions are continually reviewed. Revisions
Annual Report and Accounts 2015 – 2016 to accounting estimates are recognised in the period in which the estimate is known. The estimates and assumptions that have a significant risk of causing a material adjustment to the Accounts are highlighted below: Work in progress The Trust prepares an estimate of income generated for incomplete in-patient spells at the year end. This estimate is based on the previous months equivalent information and partially coded data as at the 31 March 2016. Legal claims Legal claims are based upon professional assessments, which are uncertain to the extent that they are an estimate of the likely outcome of individual cases. In the majority of cases the estimate is based on advice from the NHS Litigation Authority. Asset valuation and indices The valuation of land and buildings is based on building cost indices provided by and used by the District Valuer in his valuation work. These indices are based on an indication of trend of accepted tender prices within the construction industry as applied to the Public Sector. Asset Impairments An assessment is made each year as to whether an asset has suffered an impairment loss. 1.23.1 Critical judgements in applying accounting policies In accordance with IAS 1, Foundation Trusts should disclose details of critical accounting judgements and key sources of estimation and uncertainty in these accounts. The following are the critical judgements, apart from those involving estimations (see above), that management has made in the process of applying the Trust's accounting policies. 1.23.2 Going concern The day to day operations of the Trust are funded from agreed contracts with Clinical Commissioning Groups and Specialist Commissioners. The uncertainty in the current economic climate has been mitigated by agreeing contracts with the Clinical Commissioning Groups and Specialist Commissioners (formerly Primary Care Trusts) for a further year. These payments provide a reliable stream of funding minimising the Trust exposure to liquidity and financing problems. The Trust's budgets and expenditure plans are based on this level of commissioned service and indicate that the Trust has sufficient resource to meet ongoing commitments. The Board of Directors have assessed the criteria of a going concern in accordance with IAS 1 and in their opinion, given the facts at their disposal, it is correct to prepare the accounts on a going concern basis. The cash flow forecast over the next 12 months indicate that the Trust has a monthly cash surplus available for investment. The Trust treasury policy governs the risk exposures of monetary financial assets and limits the value that can be placed with each approved counterparty to minimise the risk of loss. The counterparties are limited to the approved financial institutions with high credit ratings. Given the economic uncertainty, particularly in the banking sector, the Trust has predominantly invested in the Government's National Loan Fund and has not been exposed to bank insolvency risks. 1.23.3 Key sources of estimation uncertainty Trade receivables mainly consist of transactions with commissioners under contractual terms that require settlement of obligation within a time frame established generally by the Department of Health. The following are the key assumptions concerning the future, and other key sources of estimation uncertainty at the end of the reporting period, that have a significant risk of causing a material adjustment to the carrying amounts of assets and liabilities within the next financial year. The amounts included within Provisions for liabilities and charges, note 23, are based upon advice from relevant external bodies, including the NHS Litigation Authority, NHS Pensions Agency and the Trust's external legal advisors. On the 31 March 2016 Land and Buildings were revalued using the Modern Equivalent Valuation methodology by the District Valuer (who is an appropriately qualified member of the Royal Institute of Chartered Surveyors). Note 2 Operating Segments 263 The Trust has determined that the chief operating decision maker for the Trust is the Board of
Directors, on that basis all strategic decisions are made by the Board. No segmental information is Annual Report and Accounts 2015 – 2016 presented to the Board of Directors so on that basis it has been determined that there is only one business segment, that of healthcare. Differences between the amounts presented to the Board in May 2016 and those included within these accounts are purely presentational. The Trust conducts the majority of its business with Health Bodies in England. Transactions with entities in Scotland , Ireland and Wales are conducted in the same manner as those within England. Organisations which contribute 5% or more of the Trust's income in either period are set out in the table below. Further information can be found in note 30, Related Party transactions. 2015-16 2014-15 Hartlepool and Stockton-on-Tees Clinical Commissioning Group 68% 69% Durham Dales, Easington and Sedgefield Clinical Commissioning Group 15% 15% Cumbria, Northumberland, Tyne and Wear Area Team 3% 7% North East Commissioning Hub 7% -
Note 3 Operating income from patient care activities
2015-16 2014-15 £000 £000 3.1 Income from patient care activities (by nature) Acute services Elective income 35,264 35,686 Non elective income 69,599 63,912 Outpatient income 26,210 28,728 A & E income 8,764 7,954 Other NHS clinical income 60,405 68,477 Community services Community services income from CCGs and NHS England 37,082 36,066 Community services income from other commissioners 6,494 3,346 All services Private patient income 136 157 Other clinical income * 5,080 5,211 Total Income from activities 249,034 249,537
* The other clinical income is the money received in relation to CQUIN (Commissioning for Quality and Innovation).
2015-16 2014-15 £000 £000 3.2 Income from patient care activities (by source) Income from patient care activities received from CCGs and NHS England 240,440 243,475 Local authorities 5,338 3,346 Department of Health 181 - Other NHS Foundation Trusts 1,179 877 NHS other - 788 Non-NHS: private patients 136 157 Non-NHS: overseas patients (chargeable to patient) 116 43 264 NHS injury scheme (was RTA) 979 814 Non NHS: other 665 37 Annual Report and Accounts 2015 – 2016 Total income from activities 249,034 249,537 Of which: Related to continuing operations 249,034 249,537 2015-16 2014-15 £000 £000 3.3 Overseas visitors (relating to patients charged directly by the NHS Foundation Trust) Income recognised this year 116 43 Cash payments received in-year 18 20 Amounts added to provision for impairment of receivables - 22
Note 4 Other operating income
2015-16 2014-15 £000 £000 Research and development 1,087 830 Education and training 8,944 8,846 Non-patient care services to other bodies 10,715 9,757 Reversal of impairments 4,254 11,325 Rental revenue from operating leases 324 265 Incoming resources received by NHS charitable funds 215 305 Other income * 6,049 4,683 Total other operating income 31,588 36,011 Of which: Related to continuing operations 31,588 36,011
* This is made up of income from car parking, staff accommodation rentals, catering and property rentals.
4.1 Income from activities arising from commissioner requested services Under the terms of its provider license, the Foundation 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:
2015-16 2014-15 £000 £000 Income from services designated (or grandfathered) as commissioner 247,138 247,698 requested services Income from services not designated as commissioner requested 33,484 37,850 services ** Total 280,622 285,548
** This comprises of the other operating income in note 4 and additional winter pressures funding from Hartlepool and Stockton- on-Tees Clinical Commissioning Group. 265
4.2 Profits and losses on disposal of property, plant and equipment Annual Report and Accounts 2015 – 2016 During the year the Trust disposed of land purchased for the site of a new build hospital. The long term ambition is to move to a single site hospital. In the interim a new strategy is being developed reflecting additional investment in the North Tees site in a new Energy Centre and also the implementation of the Clinical Services Strategy. • Net Book Value of the land was £4.200m • Sales proceeds were £3.998m • Loss on disposal of the land was £0.202m Note 5 Operating Expenses
5.1 Operating Expenses 2015-16 2014-15 £000 £000 Services from NHS Foundation Trusts 898 893 Services from NHS Trusts 1 1 Services from CCGs and NHS England - 130 Services from other NHS bodies 68 - Purchase of healthcare from non NHS bodies 956 193 Employee expenses - executive directors 1,138 1,054 Remuneration of Non-Executive directors 130 128 Employee expenses - staff 190,280 186,756 NHS Charitable Funds - employee expenses 31 - Supplies and services - clinical 26,464 26,992 Supplies and services - general 4,101 4,651 Establishment 2,401 2,429 Research and development 108 62 Transport 1,519 2,903 Premises 10,685 10,235 Increase/(decrease) in provision for impairment of receivables 217 (14) Increase in other provisions 290 - Change in provisions discount rate(s) 5 49 Drug costs 14,535 14,584 Inventories consumed 6,273 6,270 Rentals under operating leases 1,235 1,348 Depreciation on property, plant and equipment 5,399 5,195 Amortisation on intangible assets 53 108 Impairments 57 756 Audit fees payable to the external auditors audit services- statutory audit 71 68 other auditor remuneration (external auditors only) 54 12 audit services - charitable funds 4 4 Clinical negligence 9,099 5,971 Loss on disposal of land 202 - Legal fees 171 181 Consultancy costs 324 577 266 Internal audit costs 254 254 Training, courses and conferences 789 818
Annual Report and Accounts 2015 – 2016 Car parking & security 1,203 1,248 Redundancy 768 891 Hospitality 1 1 Insurance 167 158 Other services, e.g. external payroll 12 - Losses, ex gratia & special payments 31 15 Other resources expended by NHS charitable funds 173 247 Other 102 833 Total 280,269 276,001 Of which: Related to continuing operations 280,269 276,001 5.2 Other auditors' remuneration
2015-16 2014-15 £000 £000 Other auditors' remuneration paid to the external auditors: 1. Audit of accounts of any associate of the Trust 9 4 2. Audit-related assurance services - - 3. Taxation compliance services 45 12 4. All taxation advisory services not falling within item 3 - - above 5. Internal audit services - - Total 54 16
5.3 Limitation on auditors' liability
The limitation on auditors' liability for external audit work is £1m (2014 – 15: £1m).
Note 6 Impairment of assets (Group and Trust)
2015-16 2014-15 £000 £000 Net impairments charged to operating (deficit)/surplus resulting from: Changes in market price (4,197) (10,569) Total net impairments charged to operating (deficit)/surplus (4,197) (10,569)
Note 7 Employee benefits
Group 2015-16 2014-15 Permanent Other Total Total £000 £000 £000 £000 Salaries and wages 155,556 777 156,333 150,381 Social security costs 9,614 1,014 10,628 10,600 Employer's contributions to NHS pensions 15,256 1,614 16,870 16,448 Pension cost - other - 32 32 20 Agency/contract staff - 7,564 7,564 10,361 NHS charitable funds staff 31 - 31 - Total gross staff costs 180,457 11,001 191,458 187,810 Recoveries in respect of seconded staff - - - - 267 Total staff costs 180,457 11,001 191,458 187,810 Annual Report and Accounts 2015 – 2016 Details of staff numbers and exit packages can be found in the staff report.
7.1 Retirements due to ill-health During 2015 – 16 there were 5 early retirements from the Trust agreed on the grounds of ill-health (5 in the year ended 31 March 2015). The estimated additional pension liabilities of these ill-health retirements is £96k (£254k in 2014 – 15). The cost of these ill-health retirements will be borne by the NHS Business Services Authority - Pensions Division. 7.2 Directors' remuneration The aggregate amounts payable to directors were:
2015-16 2014-15 £000 £000 Salary 1,209 1,015 Taxable benefits 19 16 Other remuneration 80 177 Employer's pension contributions 104 - Total 1,412 1,208
Further details of directors' remuneration can be found in the remuneration report. Note 8 Operating leases 8.1 North Tees and Hartlepool NHS Foundation Trust as a lessor This note discloses income generated in operating lease agreements where North Tees and Hartlepool NHS Foundation Trust is the lessor. The Trust receives rental income from a number of agreements in relation to the leasing of land and accommodation space. No contingent rent is payable.
Group
Operating lease revenue 2015-16 2014-15 £000 £000 Minimum lease receipts 324 265 Total 324 265 31 March 2016 31 March 2015 £000 £000 Future minimum payments due: - Not later than one year 369 265 - Later than one year and not later than five years - 1,011 Total 369 1,276
8.2 North Tees and Hartlepool NHS Foundation Trust as a lessee This note discloses costs and commitments incurred in operating lease arrangements where North Tees and Hartlepool NHS Foundation Trust is the lessee. The Foundation Trust leases certain items of equipment where financial assessment has determined that leasing represents better value than the outright purchase of the equipment. The majority of agreements are in relation to lease vehicles over a three year period. Other agreements include the provision of medical equipment.
268 Group
Arrangements containing an operating lease 2015-16 2014-15 Annual Report and Accounts 2015 – 2016 £000 £000 Minimum lease payments 1,235 1,348 Total 1,235 1,348 31 March 31 March 2016 2015 £000 £000 Future minimum lease payments due: - Not later than one year 1,120 1,299 - Later than one year and not later than five years 1,926 2,392 - Later than five years 205 247 Total 3,251 3,938 Note 9 Finance income Finance income represents interest received on assets and investments in the period.
Group
2015-16 2014-15 £000 £000 Interest on bank accounts 103 151 Dividend income on NHS charitable funds financial assets 55 61 Total 158 212
Note 10 Finance expenditure Finance expenditure represents interest and other charges involved in the borrowing of money.
Group
2015-16 2014-15 £000 £000 Interest expense: Interest on late payment of commercial debt 15 - Main Finance costs on PFI and LIFT scheme obligations 41 54 Contingent finance costs on PFI and LIFT scheme obligations 86 80 Total interest expense 142 134
10.1 The late payment of commercial debts (interest) Act 1998
2015-16 2014-15 £000 £000 Amounts included within interest payable arising from claims 15 - made under this legislation
Note 11 Intangible assets - 2015 – 16 Group
Software Intangible assets Total licences under construction £000 £000 £000 Valuation/gross cost at 1 April 2015 1,321 10 1,331 Reclassifications - - - Gross cost at 31 March 2016 1,321 10 1,331 269 Accumulated Amortisation at 1 April 2015 - 1,154 - 1,154
brought forward Annual Report and Accounts 2015 – 2016 Provided during the year 53 - 53 Accumulated Amortisation at 31 March 2016 1,207 - 1,207
Net book value at 31 March 2016 114 10 124 Net book value at 1 April 2015 167 10 177 11.1 Intangible assets - 2014 – 15 Group
Software Intangible assets Total licences under construction £000 £000 £000 Valuation/gross cost at 1 April 2014 1,309 - 1,309 Additions 21 10 31 Reclassifications (9) - (9) Valuation/gross cost at 31 March 2015 1,321 10 1,331
Accumulated Amortisation at 1 April 2014 - 1,046 - 1,046 as previously stated Provided during the year 108 - 108 Accumulated Amortisation at 31 March 2015 1,154 - 1,154
Net book value at 31 March 2015 167 10 177 Net book value at 1 April 2014 263 - 263
11.2 Intangible assets 2015 – 16 Trust
Software Intangible assets Total licences under construction £000 £000 £000 Valuation/gross cost at 1 April 2015 1,321 10 1,331 Disposals/derecognition (7) - (7) Gross cost at 31 March 2016 1,314 10 1,324
Amortisation at 1 April 2015 1,154 - 1,154 Provided during the year 53 - 53 Amortisation at 31 March 2016 1,207 - 1,207
Net book value at 31 March 2016 107 10 117 Net book value at 1 April 2015 167 10 177
11.3 Intangible assets 2014 – 15 Trust
Software Intangible assets Total licences under construction 270 £000 £000 £000 Valuation/gross cost at 1 April 2014 1,309 - 1,309 Annual Report and Accounts 2015 – 2016 Additions 21 10 31 Reclassifications (9) - (9) Valuation/gross cost at 31 March 2015 1,321 10 1,331
Amortisation at 1 April 2014 1,046 - 1,046 Provided during the year 108 - 108 Amortisation at 31 March 2015 1,154 - 1,154
Net book value at 31 March 2015 167 10 177 Net book value at 1 April 2014 263 - 263 Note 12 Property, plant and equipment
2015-16 Group and Trust Land Buildings excluding dwellings Dwellings Assets Under Construction Plant and machinery Transport equipment Information technology & Furniture fittings Total £000 £000 £000 £000 £000 £000 £000 £000 £000 Valuation/Gross cost at 1 April 14,777 254,644 997 4,413 43,115 1,117 19,755 5,139 343,957 2015 - brought forward Additions - 2,215 64 3,228 1,449 38 875 267 8,136 Impairments - - (57) - - - - - (57) Reversal of - 4,254 ------4,254 impairments Reclassifications 98 (122) 24 ------Revaluations - 459 ------459 Disposals/ (4,200) ------(4,200) derecognition Valuation/Gross cost at 31 March 10,675 261,450 1,028 7,641 44,564 1,155 20,630 5,406 352,549 2016
Accumulated depreciation at 5,147 168,971 563 - 30,241 1,031 16,294 3,353 225,600 1 April 2015 - brought forward Provided during - 1,738 8 - 2,387 26 958 282 5,399 the year Accumulated depreciation at 5,147 170,709 571 - 32,628 1,057 17,252 3,635 230,999 1 April 2016
NBV at 31 March 5,528 90,741 457 7,641 11,936 98 3,378 1,771 121,550 2016 NBV at 1 April 9,630 85,673 434 4,413 12,874 86 3,461 1,786 118,357 2015
271 Annual Report and Accounts 2015 – 2016 12.1 Property, plant and equipment (prior year)
Group and Trust Land Buildings excluding dwellings Dwellings Assets Under Construction Plant and machinery Transport equipment Information technology & Furniture fittings Total £000 £000 £000 £000 £000 £000 £000 £000 £000 Valuation/Gross cost at 1 April 14,777 239,001 945 518 41,262 1,086 18,534 4,685 320,808 2014 - as previously stated Additions - purchased/leased/ - 3,716 27 3,895 1,927 24 1,158 378 11,125 grants/donations Reversals of - 11,325 ------11,325 impairments Reclassifications - (88) 25 - (74) 7 63 76 9 Revaluations - 690 ------690 Valuation/Gross cost at 31 March 14,777 254,644 997 4,413 43,115 1,117 19,755 5,139 343,957 2015
Accumulated depreciation at 4,412 167,558 556 - 27,630 1,009 15,405 3,079 219,649 1 April 2014 - as peviously stated Provided during - 1,392 7 - 2,611 22 889 274 5,195 the year Impairments 735 21 ------756 Reversals of ------impairments Accumulated depreciation at 5,147 168,971 563 - 30,241 1,031 16,294 3,353 225,600 31 March 2015
NBV at 31 March 9,630 85,673 434 4,413 12,874 86 3,461 1,786 118,357 2015 NBV at 1 April 10,365 71,443 389 518 13,632 77 3,129 1,606 101,159 2014
12.2 Property, plant and equipment financing
Group and Trust 272 Annual Report and Accounts 2015 – 2016 Land Buildings excluding dwellings Dwellings Assets Under Construction Plant and machinery Transport equipment Information technology & Furniture fittings Total £000 £000 £000 £000 £000 £000 £000 £000 £000 Net book value at 31 March 2016 Owned 5,528 90,361 457 7,641 10,642 98 3,359 1,601 119,687 On-SoFP PFI contracts and other service - - - - 272 - - - 272 concession arrangements Donated - 380 - - 1,022 - 19 170 1,591 NBV total at 31 5,528 90,741 457 7,641 11,936 98 3,378 1,771 121,550 March 2016 12.3 Property, plant and equipment financing
Group and Trust Land Buildings excluding dwellings Dwellings Assets Under Construction Plant and machinery Transport equipment Information technology & Furniture fittings Total £000 £000 £000 £000 £000 £000 £000 £000 £000 Net book value at 31 March 2015 Owned 9,630 85,303 434 4,413 11,545 86 3,457 1,616 116,484 On-SoFP PFI contracts and other service - - - - 376 - - - 376 concession arrangements Donated - 370 - - 953 - 4 170 1,497 NBV total at 31 9,630 85,673 434 4,413 12,874 86 3,461 1,786 118,357 March 2015
Note 13 Revaluations of property, plant and equipment During the year the assets were revalued by the District Valuer and the following adjustments have been made as an exceptional item:
2015-16 £000 Reversal of previous impairment (to the Statement of Comprehensive Income) Buildings excluding dwellings 4,254 Increase in Revaluation Reserve Peterlee Community Hospital 459
An impairment of £57k on dwellings has been taken to the Statement of Comprehensvie Income.
Note 14 Investments
14.1 Investments - Group
2015-16 Other investments £000 Carrying value at 1 April 2015 1,530 Disposals (164) 273 Carrying value at 31 March 2016 1,366 Annual Report and Accounts 2015 – 2016
14.2 Investments - Prior year
2015-16 £000 Carrying value at 1 April 2014 1,530 Acquisitions in year - Disposals (164) Carrying value at 31 March 2015 1,366
These investments are held within the NHS General Charitable Fund and are used for the benefit of healthcare services. North Tees and Hartlepool NHS Foundation Trust also has an investment in a wholly owned subsidiary company Optimus Health Limited trading as Panacea Pharmacy. The Trust owns 100% of the share capital of £1 ordinary shares in this organisation and two of the Trust directors make up the Board of this company. The company provides an outpatient dispensary service as well as healthcare products for general sale.
Note 15 Information on Reserves
NHS charitable funds reserves This balance represents the ring-fenced funds held by the NHS charitable funds consolidated within these accounts. These reserves are classified as restricted or unrestricted. 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. 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. Income and expenditure reserve The balance of this reserve is the accumulated surpluses and deficits of the NHS Foundation Trust.
Note 16 Analysis of charitable fund reserves
31 March 31 March 2016 2015 £000 £000 Unrestricted funds: Unrestricted income funds 127 135 Restricted funds: Restricted income funds 1,328 1,457 1,455 1,592
Unrestricted income funds are accumulated income funds that are expendable at the discretion of the Trustees in furtherance of the charity's objects. Unrestricted funds may be earmarked or designated for specific future purposes which reduces the amount that is readily available to the 274 charity. Restricted funds are accumulated income funds which are expendable at the Trustee's discretion only in furtherance of the specified conditions of the donor and the objects of the charity. They Annual Report and Accounts 2015 – 2016 may also be capital funds (e.g. endowments) where the assets are required to be invested, or retained for use rather than expended. 16.1 Expenditure (Grants Made) During the year direct charitable expenditure was £310,000 (2014 – 15 : £527,000). Major individual purchases of medical equipment made during the year are set out below:
Expenditure £000 Microscope 14 Air Conditioning Unit 8 ECG Arrhythmia detection system monitors 10 Philips ultra sound system 46 Other smaller medical equipment 12 90
The Charity has contributed £77,000 (2014 – 15 : £83,000) to refurbishments in North Tees and Hartlepool NHS Foundation Trust. The major refurbishments during the year are shown below:
Expenditure £000 Refurbishment of the new Cancer Information Centre at the University Hospital of 10 North Tees Installation of an Intercom kit with audio input in Cardiology 5 Chemotherapy computer system software upgrade 10 CCTV/Video equipment to provide cross site links between the North Tees site and 15 the Hartlepool Tees site during Endoscopy procedures & seminars Other smaller refurbishment costs, office equipment, computer hardware, books, 37 printing & stationery 77
The Charity has spent £58,000 (2014 – 15 : £84,000) on staff training, welfare and development which represents a significant contribution to staff development and provision of high quality health care within the Trust.
Note 17 Inventories
Group Trust 31 March 31 March 31 March 31 March 2016 2015 2016 2015 £000 £000 £000 £000 Drugs 1,495 1,669 1,374 1,669 Consumables 6,845 6,266 6,845 6,266 275 Total 8,340 7,935 8,219 7,935 Annual Report and Accounts 2015 – 2016 There is no material difference between the Statement of Financial Position value of stocks and their replacement cost. Inventories recognised as an expense £51.4m in 2015/16 (£52.5m in 2014/15). Note 18 Trade and other receivables
18.1 Analysis of trade and other receivables
Group Trust 31 March 31 March 31 March 31 March 2016 2015 2016 2015 £000 £000 £000 £000 Current Trade receivables due from NHS bodies 6,983 5,194 8,355 5,194 Other receivables due from related parties - 2,097 - 2,097 Capital receivables 0 0 0 0 Provision for impaired receivables (1,389) (1,172) (1,389) (1,172) Deposits and advances 0 0 0 0 Prepayments (non-PFI) 2,377 2,198 2,377 2,198 Accrued income 6,478 1,160 6,478 1,160 VAT receivable 729 318 465 318 Other receivables 1,127 1,158 1,124 1,169 Trade and other receivables held by NHS 21 47 21 47 charitable funds Total current trade and other receivables 16,326 11,000 17,431 11,011 Non-current Trade receivables due from NHS bodies - - - - Other receivables due from related parties 1,128 - 1,128 - Total non-current trade and other 1,128 - 1,128 - receivables
18.2 Provision for impairment of receivables
Group Trust 2015-16 2014-15 2015-16 2014-15 £000 £000 £000 £000 At 1 April 1,172 1,186 1,172 1,186 Increase/(decrease) in provision 217 (14) 217 (14) At 31 March 1,389 1,172 1,389 1,172
276 Annual Report and Accounts 2015 – 2016 18.3 Analysis of impaired receivables
Group 31 March 2016 31 March 2015 Trade Other Trade Other receivables receivables receivables receivables £000 £000 £000 £000 Ageing of impaired receivables 0 - 30 days 105 21 388 17 30 - 60 Days 152 21 69 17 60 - 90 days 54 21 17 17 90 - 180 days 108 66 69 50 Over 180 days 478 363 233 297 Total 897 492 776 398
Ageing of non-impaired receivables past their due date 0 - 30 days 4,984 113 3,775 87 30 - 60 Days 481 3 525 87 60 - 90 days 525 3 49 87 90 - 180 days 37 9 643 262 Over 180 days 92 1,148 201 523 Total 6,119 1,276 5,193 1,046
Trust 31 March 2016 31 March 2015 Trade Other Trade Other receivables receivables receivables receivables £000 £000 £000 £000 Ageing of impaired receivables 0 - 30 days 105 21 388 17 30 - 60 Days 152 21 69 17 60 - 90 days 54 21 17 17 90 - 180 days 108 66 69 50 Over 180 days 478 363 233 297 Total 897 492 776 398
Ageing of non-impaired receivables past their due date 0 - 30 days 6,092 113 3,775 87 30 - 60 Days 481 3 525 87 60 - 90 days 525 3 49 87 277 90 - 180 days 37 9 643 262 Annual Report and Accounts 2015 – 2016 Over 180 days 92 1,148 201 523 Total 7,227 1,276 5,193 1,046 Note 19 Cash and cash equivalents
19.1 Cash and cash equivalents movements 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.
Group Trust 2015-16 2014-15 2015-16 2014-15 £000 £000 £000 £000 At 1 April 37,549 41,141 37,476 41,109 Net chnage in year (14,033) (3,592) (14,140) (3,633) At 31 March 23,516 37,549 23,336 37,476 Broken down into: Cash at commercial banks and in hand 287 252 107 179 Cash with the Government Banking Service 23,229 37,297 23,229 37,297 Total cash and cash equivalents as in SoFP 23,516 37,549 23,336 37,476 Bank overdrafts (GBS and commercial banks) - - - - Total cash and cash equivalents as in SoCF 23,516 37,549 23,336 37,476
19.2 Third party assets held by the NHS Foundation Trust
North Tees and Hartlepool 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.
Group and Trust 31 March 31 March 2016 2015 £000 £000 Bank balances 12 16 Total third party assets 12 16
Note 20 Trade and other payables
Group Trust 31 March 31 March 31 March 31 March 2016 2015 2016 2015 £000 £000 £000 £000 Current 278 Receipts in advance 221 - 221 - NHS trade payables 2,122 325 2,122 325 Annual Report and Accounts 2015 – 2016 Amounts due to other related parties - 2,305 - 2,305 Other trade payables 8,215 6,123 8,943 6,123 Capital payables 265 287 265 287 Social security costs 3,351 3,394 3,351 3,394 Other taxes payable 2,304 - 2,304 - Other payables 41 100 41 100 Accruals 7,151 8,783 7,151 8,783 PDC dividend payable - 44 - 44 Total current trade and other payables 23,670 21,361 24,398 21,361 Non-current There are no non current trade and other payables in 2015 – 16.
Note 21 Other liabilities
Group Trust 31 March 31 March 31 March 31 March 2016 2015 2016 2015 £000 £000 £000 £000 Current Deferred grants income 1,640 1,400 1,640 1,400 Other deferred income 209 461 209 461 Total other current liabilities 1,849 1,861 1,849 1,861
Non-current Deferred grants income 2,552 5,591 2,552 5,591 Deferred goods and services income 219 180 219 180 Total other non-current liabilities 2,771 5,771 2,771 5,771
Note 22 Borrowings
Group Trust 31 March 31 March 31 March 31 March 2016 2015 2016 2015 £000 £000 £000 £000 Current Other loans - 22 - 22 Obligations under PFI, LIFT or other 162 162 162 162 service concession contracts (excl. lifecycle) Total current borrowings 162 184 162 184
Non-current Obligations under PFI, LIFT or other 327 479 327 479 service concession contracts Total non-current borrowings 327 479 327 479
279 Annual Report and Accounts 2015 – 2016 Note 23 Provisions for liabilities and charges analysis
Group and Trust Pensions - Other legal Redundancy Other Total other staff claims £000 £000 £000 £000 £000 At 1 April 2015 810 176 339 665 1,990 Change in the discount rate 3 - - 2 5 Arising during the year (32) 122 172 28 290 Utilised during the year (85) (128) (339) (49) (601) Unwinding of discount 12 - - 8 20 At 31 March 2016 708 170 172 654 1,704 Expected timing of cash flows: - not later than one year (32) 170 172 188 498 - later than one year and (130) - - 148 18 not later than five years - later than five years 870 - - 318 1,188 Total 708 170 172 654 1,704
The amounts and timings of cash flows are based upon advice from the NHS Litigation Authority and the NHS Pensions Agency. Included in the 'other' category and arising during the year are provisions for injury benefits of £654,000 of which £188,000 are current and £466,000 are non current; redundancy costs of £172,000 are all included within current. Legal claims - based upon professional assessments, which are uncertain to the extent that they are an estimate of the likely outcome of individual cases. Due dates of settlement of claims are based upon estimates supplied by the NHS Litigation Authority and/or Legal Advisers. The Trust has an insurance arrangement through the NHS Litigation Authority in respect of clinical negligence, with liabilities covered by an annual premium payment. Excluded from this note therefore is a sum of £143.4m (2014 – 15 £70.4m) which is included within the provisions of the NHS Litigation Authority in respect of clinical negligence liabilities of the Trust.
Note 24 Clinical negligence liabilities At 31 March 2016, £143,425k was included in provisions of the NHSLA in respect of clinical negligence liabilities of North Tees and Hartlepool NHS Foundation Trust (31 March 2015: £70,400k).
Note 25 Contingent assets and liabilities
Group Trust 31 March 31 March 31 March 31 March 2016 2015 2016 2015 280 £000 £000 £000 £000 Value of contingent liabilities Annual Report and Accounts 2015 – 2016 Legal claims (19) (101) (19) (101) Gross value of contingent liabilities (19) (101) (19) (101) Amounts recoverable against liabilities - - - - Net value of contingent liabilities (19) (101) (19) (101) Net value of contingent assets - - - -
Contingent liabilities are not recognised in the accounts as the probability of a transfer of economic benefits is remote. Note 26 Contractual capital commitments
Group Trust 31 March 31 March 31 March 31 March 2016 2015 2016 2015 £000 £000 £000 £000 Property, plant and equipment 2,977 2,251 2,977 2,251 Intangible assets - - - - Total 2,977 2,251 2,977 2,251
Note 27 On-SoFP PFI, LIFT or other service concession arrangements The scheme is for the redevelopment of the Energy Plant at the University Hospital of Hartlepool. The plant was commissioned in November 2002 and expires in November 2017. the agreement is with Dalkia Utilities and the service they provide is that of electricity to the hospital. The contract price is uplifted in line with the RPI annually. At the end of the 15 year agreement, the asset reverts to the Trust. The financial penalty for terminating the contract in 2015 – 16 is £187,000. Under IFRIC 12, the plant is treated as an asset of the Trust.
27.1 Imputed finance lease obligations The Trust has the following obligations in respect of the finance lease element of on-Statement of Financial Position PFI and LIFT schemes:
Group and Trust 31 March 2016 31 March 2015 £000 £000 Gross PFI liabilities 705 1,017 Of which liabilities are due - not later than one year 288 283 - later than one year and not later than five years 417 734 Finance charges allocated to future periods (216) (376) Net PFI liabilities 489 641 - not later than one year 162 162 - later than one year and not later than five years 327 479
27.2 Total on-SoFP PFI, LIFT and other service concession arrangement commitments The Trust's total future obligations under these on-SoFP schemes are as follows:
Group and Trust 281 31 March 2016 31 March 2015
£000 £000 Annual Report and Accounts 2015 – 2016 Total future payments committed in respect of the 707 1,329 PFI, LIFT or other service concession arrangements Of which liabilities are due - not later than one year; 289 594 - later than one year and not later than five years; 418 735 27.3 Analysis of amounts payable to service concession operator This note provides an analysis of the Trust's expenditure in 2015 – 16:
31 March 2016 31 March 2015 £000 £000 Unitary payment payable to service concession operator 594 587 Consisting of: - Interest charge 41 54 - Repayment of finance lease liability 162 148 - Service element 305 305 - Contingent rent 86 80 Total amount paid to service concession operator 594 587
Note 28 Financial instruments
28.1 Financial risk management Financial reporting standard IFRS 7 requires disclosure of the role that financial instruments have had during the year in creating or changing the risks a body faces in undertaking its activities. Because of the continuing service provider relationship that the NHS Foundation Trust has with commissioners and the way those commissioners 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. 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 primary care Trusts, 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 282 significant liquidity risks. Annual Report and Accounts 2015 – 2016 28.2 Financial assets
Group Loans and Total receivables £000 £000 Assets as per SoFP as at 31 March 2016 Trade and other receivables excluding non financial assets 16,326 16,326 Cash and cash equivalents at bank and in hand 23,516 23,516 Total at 31 March 2016 39,842 39,842
Group (prior year) Loans and Total receivables Assets as per SoFP as at 31 March 2015 Trade and other receivables excluding non financial assets 11,000 11,000 Cash and cash equivalents at bank and in hand 37,549 37,549 Total at 31 March 2015 48,549 48,549
Trust Loans and Total receivables £000 £000 Assets as per SoFP as at 31 March 2016 Trade and other receivables excluding non financial assets 17,431 17,431 Cash and cash equivalents at bank and in hand 23,336 23,336 Total at 31 March 2016 40,767 40,767
Trust (prior year) Loans and Total receivables Assets as per SoFP as at 31 March 2015 Trade and other receivables excluding non financial assets 11,011 11,011 Cash and cash equivalents at bank and in hand 37,476 37,476 Total at 31 March 2015 48,487 48,487
283 Annual Report and Accounts 2015 – 2016 28.3 Financial liabilities
Group Other Total financial liabilities £000 £000 Liabilities as per SoFP as at 31 March 2016 Obligations under PFI, LIFT and other service concession contracts 489 489 Trade and other payables excluding non financial liabilities 23,670 23,670 Provisions under contract 1,704 1,704 Total at 31 March 2016 25,863 25,863
Group (prior year) Other Total financial liabilities £000 £000 Liabilities as per SoFP as at 31 March 2015 Borrowings excluding finance lease and PFI liabilities 22 22 Obligations under PFI, LIFT and other service concession contracts 641 641 Trade and other payables excluding non financial liabilities 28,993 28,993 Provisions under contract 1,990 1,990 Total at 31 March 2015 31,646 31,646
Trust Other Total financial liabilities £000 £000 Liabilities as per SoFP as at 31 March 2016 Obligations under PFI, LIFT and other service concession contracts 489 489 Trade and other payables excluding non financial liabilities 24,398 24,398 Provisions under contract 1,704 1,704 Total at 31 March 2016 26,591 26,591
Trust (prior year) Other Total financial liabilities £000 £000 Liabilities as per SoFP as at 31 March 2015 Borrowings excluding finance lease and PFI liabilities 22 22 284 Obligations under PFI, LIFT and other service concession contracts 641 641 Trade and other payables excluding non financial liabilities 28,993 28,993
Annual Report and Accounts 2015 – 2016 Provisions under contract 1,990 1,990 Total at 31 March 2015 31,646 31,646 28.4 Maturity of financial liabilities
Group Trust 31 March 31 March 31 March 31 March 2016 2015 2016 2015 £000 £000 £000 £000 In one year or less 26,179 24,018 26,445 24,018 In more than one year but not more than 4,304 7,628 4,304 7,628 two years Total 30,483 31,646 30,749 31,646
Fair value is not considered to be significantly different from the book value.
Note 29 Losses and special payments
2015/16 2014/15 Total Total Value Total Total Value Number of of cases Number of of cases cases cases Number £000 Number £000 Losses Bad debts and claims abandoned 51 299 32 8 Stores losses and damage to property 64 8 75 13 Total losses 115 307 107 21 Special Payments Ex-gratia payments 25 23 27 6 Total special payments 25 23 27 6 Total losses and special payments 140 330 134 26 Compensation payments received 2 3
NHS Foundation Trusts are required to report to the Department of Health any losses or special payments, as the Department still retains responsibility for reporting these to Parliament. By their very nature such payments should not arise, and they are therefore subject to special control procedures compared to payments made in the normal course of business. There were no payments which exceeded £300,000. The Trust has not made any losses or special payments other than those disclosed in the table above. Of the £31,000 of losses and special payments, £9,000 is included in employee expenses.
Note 30 Related parties
30.1 Ultimate parent 285
North Tees and Hartlepool NHS Foundation Trust is a public benefit corporation established under Annual Report and Accounts 2015 – 2016 the National Health Service Act 2006. Monitor, the Independent Regulator for NHS Foundation Trust, has the power to control the Trust within the meaning of IAS27 'Consolidated and Separate Financial Statements.' Monitor does not prepare group accounts but does prepare separate NHS Foundation Trust Consolidated Accounts. The NHS FT Consolidated Accounts are included within the Whole of Government Accounts. Monitor is accountable to the Secretary of State for Health and therefore the Trust's ultimate parent is HM Government. 30.2 Wider Government Accounting All government bodies which fall within the Whole of Government accounts boundary are regarded as related parties because they are all under the common control of HM Government and Parliament. This includes for example all NHS bodies, all local authorities and central government bodies. Significant transactions and balances with other NHS bodies are detailed below:
31 March 2016 Payables Receivables Income Expenditure £000 £000 £000 £000 Hartlepool and Stockton-on-Tees Clinical - 278 172,830 - Commissioning Group Durham Dales, Easington and Sedgefield - 908 36,484 - Clinical Commissioning Group NHS North Durham CCG - - 1,540 - Durham, Darlington & Tees Area Team* - - - - Cumbria, Northumberland, - - - - Tyne & Wear Area Team* NHS England - Cumbria and North East - - 8,813 - NHS England - North East Commissioning - 516 16,647 77 Hub NHS South Tees CCG - 8 2,748 - NHS Darlington CCG - - 1,360 - NHS Hambleton, Richmondshire and - 155 380 - Whitby CCG South Tees Hospitals NHS Foundation Trust 918 2,454 3,359 1,130 Tees Esk Wear Valley NHS Foundation Trust - 59 948 69 The NHS Litigation Authority - - - 9,099 Health Education England 63 84 8,955 63 Public Health England (PHE) - 395 1,238 91
31 March 2015 Payables Receivables Income Expenditure £000 £000 £000 £000 Hartlepool and Stockton-on-Tees Clinical - 1,551 170,306 - Commissioning Group Durham Dales, Easington and Sedgefield - 152 36,935 88 Clinical Commissioning Group NHS North Durham CCG - 4 807 - Durham, Darlington & Tees Area Team* 6,991 282 11,774 - Cumbria, Northumberland, - 491 18,566 - 286 Tyne & Wear Area Team* NHS England - Cumbria and North East - - - - Annual Report and Accounts 2015 – 2016 NHS England - North East Commissioning - - - - Hub NHS South Tees CCG - 31 2,758 - NHS Darlington CCG - 8 1,339 - NHS Hambleton, Richmondshire and - 106 504 - Whitby CCG South Tees Hospitals NHS Foundation Trust 887 693 3,211 796 Tees Esk Wear Valley NHS Foundation Trust - 30 923 63 The NHS Litigation Authority - - - 5,971 Health Education England - 746 8,718 - Public Health England (PHE) - 268 634 - * Demised organisation 30.3 Directors and key management staff During the year none of the Trust board members or members of the key management staff, or parties related to any of them, has undertaken any material transactions with North Tees and Hartlepool NHS Foundation Trust. Details of related party transactions with individuals are as follows:
31 March 2016 Payments Receipts Amounts Amounts to Related from owed to due from Party Related Related Related Party Party Party £ £ £ £ Mr Kenneth Lupton Councillor Leader for Stockton-on-Tees Borough Council - - - - Mr Paul Garvin Family member employed by Ward Hadaway (Trust’s legal advisors) 15,896 - - - Mr Alan Foster Non Executive Director of the Academic Health Science Network 12,000 60,284 - - Family member employed by Ward Hadaway (Trust's legal advisors) 15,896 - - - Mr Jonathon Erskine Research Fellow at Durham University 4,292 - - - Mrs Lynne Hodgson Family member of Homefair Blinds 340 - - -
31 March 2015 Payments Receipts Amounts Amounts to Related from owed to due from Party Related Related Related Party Party Party £ £ £ £ Mr Kenneth Lupton Councillor Leader for Stockton-on-Tees Borough Council 823,000 2,087,000 - - Mr Paul Garvin Family member employed by Ward Hadaway (Trust’s legal advisors) 24,103 - - - Mr Alan Foster Non Executive Director of the Academic 287 Health Science Network 24,103 - - -
Family member employed by Ward Annual Report and Accounts 2015 – 2016 Hadaway (Trust's legal advisors) - - - - Mr Jonathon Erskine Research Fellow at Durham University - - - - Mrs Lynne Hodgson Family member of Homefair Blinds - - - -
The Trust has also received revenue and capital payments from a number of charitable funds, certain of the Trustees for which are also members of the NHS Foundation Trust Board. The audited accounts/the summary financial statements of the Funds Held on Trust are available from the Charity Commission website www.charity-commission.gov.uk Note 31 Events after the reporting year There are no events reported following the close of the reporting year.
Note 32 Accounting standards that have been issued but have not yet been adopted The following IAS standards are applicable from future dates: FRS11 (amendment): Acquisition of a joint operation - Applicable from 2016 – 17 IAS16 (amendment): Depreciation and amortisation - Applicable from 2016 – 17 IAS 18 (amendment): Depreciation and amortisation - Applicable from 2016 – 17 IAS16 (amendment): Bearer plants - Applicable from 2016 – 17 IAS 27 (amendment): Equity method in separate financial statements - Applicable from 2016 – 17 FRS 10 (amendment): Sale or contribution of assets - Applicable from 2016 – 17 FRS 10 (amendment): Investment entities applying consolidation exception - Applicable from 2016 – 17 IAS 1 (amendment): Disclosure initiative - Applicable from 2016 – 17 FRS 15: Revenue from contracts with customers - Applicable from 2017 – 18 Annual improvements to FRS 2012-2015 cycle - Applicable from 2017 – 18 FRS 9: Financial instruments - Applicable from 2018 – 19
Note 33 Trust address The Trust's domicile and registered address and principal activities are disclosed within the Trust's Annual Report.
288 Annual Report and Accounts 2015 – 2016 8 Contact Information
Alan Foster MBE, Chief Executive Tel: 01642 617617 Email: [email protected]
Patient Experience Team If you would like information, support or advice about the Trust’s services, contact: Tel: 01642 624719 or 07795 061883 Email: [email protected]
Membership If you would like to become a member of our NHS Foundation Trust, contact: Tel: 01642 383765 Email: [email protected]
Recruitment If you are interested in becoming a member of staff at North Tees and Hartlepool NHS Foundation Trust, contact: Tel: 01642 383273 Email: [email protected]
Further Information If you have a media enquiry or require further information, contact: Tel: 01642 624339 Email: [email protected] Web: www.nth.nhs.uk
Trust address If you wish to write the Trust the postal address is: North Tees and Hartlepool NHS Foundation Trust University Hospital of North Tees Hardwick 289 Stockton Annual Report and Accounts 2015 – 2016 TS19 8PE Annual Report and Accounts 2015 – 2016 290
Annual Report and Accounts 2015 – 2016