One Big Team... Ipswich Hospital Annual Report 2013 / 14

Our Passion, Your Care. Annual Report 2013 / 14 Annual Report 2013 / 14 Contents

COMMUNICATIONSCOMMUNICATIONSCOMMUNICATIONSCOMMUNICATIONSCOMMUNICATIONSCOMMUNICATIONS AND AND AND AND AND AND AND COMMUNITY AND COMMUNITY COMMUNITY COMMUNITY COMMUNITY COMMUNITY ENGAGEMENTENGAGEMENTENGAGEMENTENGAGEMENTENGAGEMENTENGAGEMENT STRATEGYSTRATEGYSTRATEGYSTRATEGYSTRATEGYSTRATEGY For our design this year, we have chosen If you would like a short summary This Annual Report has been Welcome ...... 3 of this document, or the whole prepared in accordance with to feature photographs of colleagues IfIf you you Ifwould If wouldyouIf you youIf would youwouldlike likewould awould a likeshort shortlike like a a like summaryshort a summaryshort short a shortsummary summary summary of ofsummary of of of ofContents ContentsContentsContentsContents Chair’s Foreword ...... 4 nominated in the Staff Awards of documentthisthis document, document,thisthisthis document, document,this document, translated document,or or the the or wholeor whole orthe the theintoor whole documentwhole the documentwhole another whole document document document document Contents the requirements set out in the translatedtranslatedtranslatedtranslatedtranslated into translatedinto another anotherinto into into another intoanother anotherlanguage, language, another language, language, language, please language,please please please please please Chief Executive’s Overview ...... 5 The Ipswich Hospital NHS Trust 2014. language, please ask an English- 2013 / 2014 NHS Trust Manual for speakingaskask an anask askEnglish-speaking askEnglish-speaking an an ask friendan English-speaking English-speaking English-speakingan English-speaking to contact friend friend friend to friend tofriend us friend toon to to to 33 AboutAbout3 3 3NHSAbout NHSAboutAbout3 Suffolk Suffolk AboutNHS NHS NHS Suffolk SuffolkNHS Suffolk Accounts.Suffolk contactcontactcontactcontact contactus us oncontact on us01473 us01473 us on on onus 01473 01473 770014 on01473770014 01473 770014 770014 770014 770014 • • Our strategic vision and values Our strategic vision and values • • • Our strategic vision and values Our strategic vision and values Our strategic vision and values • Our strategic vision and values 01473 704770. Strategic Report ...... 6 Front cover photos: 55 StrategicStrategic5 5 5Strategic Strategic Strategicobjectives5 objectives Strategic objectives objectives objectives objectivesThe Quality Account 2013 / 14 is • • Our top ten priorities Our top ten priorities • • • Our top ten priorities Our top ten priorities Our top ten priorities • Our top ten prioritiesa companion document to this Statutory Basis – background and context ...... 6 Row 1 Polish język polski 8 Communications8 8 8Communications CommunicationsCommunications8 Communications and engagement: andreport and and engagement: engagement: andengagement: andengagement: is available online at Dermatology 8 Communications and engagement: Business Information including structure and management ...... 7 Jeśli chcieliby Państwo otrzymać krotkie background background background background background backgroundwww.ipswichhospital.nhs.uk Nominee: Team of the Year Award podsumowanie niniejszego dokumentu lub • • The national context The national context • • • The national context The national context The national context • The national context Amgad Ragheb, Pain Relief Consultant cały dokument w innym języku, prosimy o • • The local context The local context • • • The local context The local context The local context • The local context Performance Against Key Indicators ...... 17 Nominee: Living the Values Award skontaktowanie się z Nami przy pomocy • • The NHS Constitution The NHS Constitution • • • The NHS Constitution The NHS Constitution The NHS Constitution • The NHS Constitution osoby anglojęzycznej pod numerem • • The engagement cycle The engagement cycle • • • The engagement cycle The engagement cycle The engagement cycle • The engagement cycle Operating Financial Review ...... 20 Radiotherapy Service Team • Engagement timeline • • • Engagement timeline Engagement timeline Engagement timeline • Engagement timeline telefonu 01473 704770. • Engagement timeline Nominee: Team of the Year Award • • Continual learning Continual learning • • • Continual learning Continual learning Continual learning • Continual learning Employees ...... 22 Row 2 Portuguese Português • • Our engagement initiatives Our engagement initiatives • • • Our engagement initiatives Our engagement initiatives Our engagement initiatives• Our engagement initiatives • • Key principles of effective community Key principles of effective community • • • Key principles of effective community Key principles of effective community Key principles of effective community • Key principles of effective community Key Relationships Daniel Read, Estate Coordinator Se pretende obter un pequeno resumo engagement engagement engagementengagementengagement engagement Nominee: Support Colleague of the Year Award deste documento, ou caso pretenda que including social, community and human rights issues ...... 23 Val Dyer, Volunteer todo o documento seja treduzido para 1010 Communications Communications1010 10 Communications Communications Communications10 Communications and and engagement: engagement: and and and engagement: engagement: andengagement: engagement: outro idioma, por favor peça a um colega current current work current current currentin work progresswork work in workin progressin progress progress in progress Nominee: Volunteer of the Year Award current work in progress Sustainability Report...... 26 que fale Inglês para nos contactar através • • Media relations and horizon scanning Media relations and horizon scanning • • • Media relations and horizon scanning Media relations and horizon scanning Media relations and horizon scanning • Media relations and horizon scanning Ian Olding, Ward Receptionist – Martlesham Ward do número 01473 704770. • • Internal communications Internal communications • • • Internal communications Internal communications Internal communications • Internal communications Winner: Living the Values Award • • Public information and campaigns Public information and campaigns • • • Public information and campaigns Public information and campaigns Public information and campaigns • Public information and campaigns • External communications • • • External communications External communications External communications • External communications Directors’ Report ...... 28 Row 3 • External communications • • Electronic media Electronic media • • • Electronic media Electronic media Electronic media • Electronic media Aris Saoulidis, Pharmacist • • Reputation management Reputation management • • • Reputation management Reputation management Reputation management • Reputation management Composition of the Board...... 28 Nominee: Support Colleague of the Year Award • • Branding/social marketing Branding/social marketing • • • Branding/social marketing Branding/social marketing Branding/social marketing • Branding/social marketing • Emergency preparedness • • • Emergency preparedness Emergency preparedness Emergency preparedness • Emergency preparedness Emergency Department 01473 704770 • Emergency preparedness • • Community engagement Community engagement • • • Community engagement Community engagement Community engagement • Community engagement Nominee: Team of the Year Award Remuneration Report ...... 36 • • Equality and Diversity Equality and Diversity • • • Equality and Diversity Equality and Diversity Equality and Diversity • Equality and Diversity Celia Steward, Nuclear Medicine Remuneration Report ...... 36 Highly Recommended: Clinician of the Year Award 1414 Our Our14 top14 top 14 Our ten Our ten Our14 top priorities top prioritiesOurtop ten ten topten priorities priorities tenprioritiesfor for 2009-12priorities 2009-12 for for for 2009-12 2009-12 2009-12for 2009-12 Action Action Actionplan ActionplanAction Action plan plan plan plan Row 4 Money Money Moneymatters MoneymattersMoney Money matters matters matters matters 2013 / 14 Governance Statement ...... 42 Lauren Filbey, Specialist Registrar – Child Health Short term communications crises plan Short term communications crises plan Short term communications crises plan Short term communications crises plan Short term communications crises plan Short term communications crises plan Nominee: Trainee Doctor of the Year Award and Clinician of the Year Award Risks Risks assessment assessment RisksRisksRisks assessment Risksassessment assessment assessment Declaration of Interests 2013 / 14 ...... 57 SWOT analysis SWOT analysis SWOT analysis SWOT analysis SWOT analysis SWOT analysis Hospital School Teachers Nominee: Team of the Year Award 1616 Appendix Appendix1616 16 Appendix Appendix Appendix16one one Appendix – – stakeholder onestakeholder one one – – stakeholder one –stakeholder stakeholder – map stakeholdermap and and map map map and andmap and and Glossary of Terms ...... 58 Ryan Wood, Specialty Trainee in Trauma and Orthopaedics communications communications communications communications communications communications methods methods methods methods methods methods Winner: Trainee Doctor of the Year Award 01473 704770 IfIf you youIfIf would Ifyou wouldyou youIf wouldyou would wouldlike like would this likethis like like report thisreport likethis this reportthis report report report Thank You To ...... 59 inin another anotherininin another another anotherin format anotherformat format format format – – formatsuch such – – –such as such assuch – such as as as as EasyRead,EasyRead,EasyRead,EasyRead,EasyRead,EasyRead, large large large largeprint, print,large large print, print, Braille print,Braille print, Braille Braille Brailleor or Braille or or or or audioaudioaudioaudio – audio– please pleaseaudio – – –please please please telephone –telephone please telephone telephone telephone telephone 01473 0147301473014730147301473 770014 77001401473 770014 770014 770014 770014 704770

Nicola Hemmingway, Doctor in Training Generic Research Team Winner: Living the Values Award Nominee: Team of the Year Award

2 3 Annual Report 2013 / 14 Annual Report 2013 / 14 Welcome Chair’s Foreword Chief Executive’s Overview

This year The Ipswich been nationally recognised for I am immensely proud to of the emergency department Hospital NHS Trust laid a their outstanding contributions be the chief executive of making consistent, sustained and solid foundation towards in their field. Sarah Higson, our this hospital. This is my highly recognised improvements, becoming a hospital for the Patient Experience lead, was first year in the role and and becoming one of the top awarded the NHS East of England three hospitals in the country future. We have engaged in I am overwhelmed by Leadership Award for Community for performance, against this a widespread transformation Champion. the number of positive background of rising demand. process designed to create responses and comments Another notable highlight of a sustainable, high quality, Sally Ryan, one of our specialist I get from members of the nurses who has devoted her our year was HRH The Countess high performing provider career to working with people public, often stopping me of Wessex formally opening of healthcare to a growing with learning disabilities, has won in the street. It is clear to The Ipswich Heart Centre, in population with complex a top national award – Patient me that this hospital has March. We successfully planned, care needs. Experience Professional of the a huge place in people’s built and delivered this major Year. hearts. Everyone who works new heart centre on time and Our significant progress and solid on budget. The Sterile Services The Radiotherapy VERT (virtual here knows that affection operational achievements are Ann Tate CBE, Nick Hulme, Centre is another new service. environment radiotherapy is earned by delivering safe, Chief Executive. testimony to the success of the Chair. Both these developments which training) team has also won a high quality, compassionate transformation programme to cost £10.8 million in total prestigious award for their use care to patients. date. will make a real difference to The Medical Director of NHS of 3D scans to inform and help patients and allow us to deliver However the year was not England, Sir Bruce Keogh, radiotherapy cancer patients. I recognise that we don’t get it A listening programme called services closer to home for the without challenges, most notable opened our cutting edge right for everyone and that the The Future of Care involved In the pages which follow, you community we serve. I am going of these being the constrained simulation centre. The £250,000 great care we hear about most of hundreds of patients and staff in will find our strategic report and to be meeting the people we financial environment of the NHS East Anglian Simulation and the time, should be great care all a series of In Your Shoes sessions. directors’ report, outlining what serve on a regular basis at a series as a whole, together with the Training Centre includes high of the time. We should be getting We asked patients about their we need to tell you about the of open forum. If you would need to provide seven-day clinical fidelity medical simulation it right for every patient, every experiences in this hospital so way the hospital is managed and like me to come to your area, services to the highest possible equipment and facilities. It has carer, every day. The journey we that we could build on and governed. let me know. You can also send standard. been developed to increase are taking to get to this point improve our services. A shared patient safety through improved My thanks to all of the staff, set of values and behaviours me a message via my blog on The ongoing partnership we is outlined in the pages which clinically led education and volunteers and supporters of the have developed from this work. our hospital website or use our have developed with our follow. training. The hospital matched hospital who every day work as These include patient promises, Twitter account. commissioners, together A new management structure, a generous donation from the part of a team of 3,700 people colleague promises and an explicit My best regards, with internal restructuring to Dinwoodie Settlement Charity. who make lives better for the to develop a clinically led framework highlighting what emphasise clinical leadership, has community we serve. organisation was introduced just anyone in our hospital will see. created the best conditions locally We are extremely proud of at the start of our year in April My thanks to everyone who took for meeting these challenges. the high standard of medical 2013. We have been working part in this vibrant and thoughtful learning and teaching provided Our notable achievements with it for 12 months, and programme. by our consultants and the whole include investing almost £8 have just carried out detailed health care team. The standards Like many NHS hospitals, we Nick Hulme million in new services. National Ann Tate CBE assessment interviews to evaluate have been validated by Health have seen a marked increase in Chief Executive funding of almost £1 million Chair its impact. It is fair to say that it Education East of England which the need for health care with 31 March 2014 enabled us to develop a complex 31 March 2014 is a work in progress, it is evident oversees the quality of education growing numbers of people care suite and to transform two that it has made decision making and training. needing urgent and immediate further wards into safer, warmer a lot more objective, with more care. We are all extremely proud and caring environments for In addition, we have all been very decisions taken closer to patients. people with dementia. proud of colleagues who have

4 5 Annual Report 2013 / 14 Annual Report 2013 / 14 Strategic Report Statutory Basis – background and content Business Information including structure and management

The Ipswich Hospital NHS Trust is a National Health Service Business Information care services shared between to speak up when they feel it is NHS and local authorities – it appropriate, the responsibilities Trust providing hospital-based healthcare to more than 443,000 The Health and Social Care Act was created with the intention that managers have in being ‘fit people who live in and around Ipswich and east Suffolk. The has led to major changes in the to deliver better outcomes and and proper’ people to lead vital Trust is established under the NHS and Community Care Act of structure of how services are greater efficiencies through services as well as ensuring that commissioned and will continue 1990. The Secretary of State for Health approved Trust status for more integrated services) will a comprehensive set of measures to be commissioned in the Ipswich Hospital in April 1993. potentially release more funding is in place to identify where coming years. There have also to innovate for services outside services may be running at risk. been significant enquiries and the hospital but also create new Ensuring that organisations are: The hospital is geographically The hospital has 552 beds (as Suffolk’s Local Health Economy reports published into the failings pressures on finding flows into located in the Suffolk of 31 March 2014) in general currently consists of two local in some healthcare organisations. • safe acute provider organisations. county town of Ipswich, and acute, maternity, paediatric and clinical commissioning groups The Media continues with its • effective In addition to these national administratively within the neonatal services and had an (West Suffolk CCG, Ipswich & unending interest in the NHS. • caring boundaries of Ipswich & East annual turnover of £249 million East Suffolk CCG), Norfolk & There are increased calls for influences, there are local • responsive to People’s need Suffolk Clinical Commissioning in 2013 / 14. Across its 46-acre Suffolk NHS Foundation Trust changes in how and where priorities that the Trust will seek Group, Suffolk County Council site, we employ just over 3,700 (mental health services) and services are delivered and political to support over the coming years. • well led and NHS Trust Development whole-time equivalent NHS staff. West Suffolk NHS Foundation complexities of how service are at the core of the revised Authority Midlands and East. Trust (acute services) and us. We are proud of the services changes can be achieved cannot inspection regime. The All partners work to serve the The Francis and Keogh It is a vibrant single-site, medium- we provide and of our staff be underestimated. Managing organisation has reflected upon Suffolk population and have built reports size acute hospital, renowned who go ‘above and beyond’ demand, safety quality and the findings of these key reports, strong and cohesive working for providing a high standard of to do the very best they can in patient experience in addition The recommendations from and in addition to delivering the arrangements. The Local Health specialist healthcare services to what can sometimes be difficult to financial sustainability will be the Francis and Keogh reports action plans we have developed Economy partners work together the residents of Ipswich and east circumstances. challenging to all NHS Trusts. continue to impact upon all in response to them, we will with Suffolk County Council at Suffolk, and some specialties such According to Chris Hopson, chief healthcare providers and both continue to build this learning We have a longstanding focus the System Leaders Partnership as spinal surgery, radiotherapy executive of the Foundation Trust will continue to influence public into our Quality, Productivity on improving the quality of Board and Health and Wellbeing and percutaneous coronary Network: policy for the duration of this and People, Development and our services, and we set high Board. intervention (PCI) from September strategy. Their recommendations Education Strategies. By ensuring standards for ourselves. The Trust ‘The next five years will be among 2013 to a wider population, as have led to significant changes that we have the plans in place offers a comprehensive range of the most challenging in the NHS’s well as outreach services in a and broadening of the inspection and deliver these strategies, acute and secondary care patient history. The service faces an number of clinical specialties. regime for hospitals. They have then we believe that our services services. unprecedented financial squeeze highlighted the vital role that will be rated as ‘Good’ or whilst needing to reconfigure culture plays in allowing people ‘Outstanding’ by the CQC. to ensure long-term clinical and financial sustainability; move to new integrated models of care; improve quality of care and patient outcomes; and tackle long-standing health inequalities’. The establishment of the Better Care Fund (which is a pooled budget for health and social

Woodbridge Ward Jonathan Douse, Respiratory Consultant Joint Winner: Team of the Year Award Highly Recommended: Leadership Award

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Care Quality Commission Our services to be characterised by Our Values Phase I (2013 / 14 and beyond): areas where our performance and carers who are hugely proud The Care Quality Commission A cheerful, friendly welcome RESPECT Embed a model of clinical can improve although internal and passionate about the success is the independent regulator Kind people who care for you KINDNESS leadership in the organisation productivity alone cannot meet of the organisation. The new which ensures all aspects of the financial challenge facing the commissioning environment of health and adult social care To be fully involved LISTEN & INVOLVE services in England. Every hospital care are delivered – safety, organisation. means that we have new partners To feel reassured and safe PROFESSIONAL quality people and financial. who need to feel as confident is monitored to make sure they When considering our An organised and efficient services EFFICIENT Central to our leadership model in the capability and potential of continue to meet essential commissioners’ intentions A skilled team, always improving IMPROVING TOGETHER is the embedding of our values the organisation. We will work in standards of quality and safety. it is clear that their demand and during Phase 1 we will partnership with commissioners Ipswich Hospital was visited management initiatives will aim start the process of setting and providers across the local by the CQC in February 2014 to redirect patients to other our values into our people health economy to ensure and was found to be meeting To deliver this we need all those How will we approach the services and reduce the number processes. Our Accountability that Ipswich Hospital takes a essential standards of quality who are part of the organisation, next five years? of patients requiring admission to Framework includes all these leadership position the centre and safety inspected with one our staff, volunteers, suppliers Our plan for the next five years hospital. Our commissioners will elements of performance. An of the local healthcare provider minor concern noted about and those who work with us to is set against a period of an also seek increased competition important component of our network. documentation for Do Not deliver care to share our vision. unprecedented combination of for less complex services from quality drive will be to build Attempt Resuscitation. organisational change for the private and community and third Our commissioners are clear in At the core of the organisation our reputation for the quality NHS coupled with an increasingly sector providers. In the light of their desire to deliver integrated are a set of values we expect of the research, education and challenging financial climate. these intentions we must release care and the importance of an everyone to commit to. learning environment within the Our Vision and Values direct and indirect costs to deliver Integrated Care Model. The vision Developed with our patients and We will: organisation. This will have both The Trust’s strategy is based on staff over the past 18 months our cost improvement challenge, of integrated care is one wholly • build on the opportunity that direct patient and employee delivering quality, compassionate, they represent us at our best increase market share particularly supported by the Board of IHT. changes in commissioning experience benefits. sustainable patient care for the and our ambition is that these at the boundaries of our It requires organisations to work arrangements represents; patients we serve. represent us every day for all our Phase II (2013 / 14 to 2015 / 16): traditional patient geographies. effectively across boundaries and • ensure the continued delivery Ensure that the services we our commitment to a continuing Our vision is: patients and colleagues. Phase III (2015 / 16 to 2016 / 18): of efficient and effective provide are as efficient as they programme of clinical leadership Take the opportunities that To be trusted by patients, their services delivered to every practically can be and work development reflects our belief the changing environment carers and our staff to provide patient every day; and constructively with our health in the value of working across for delivering healthcare the high quality healthcare and community to provide care in clinical boundaries. • deliver this within the Trust’s offers, across care settings expertise our patients need – for the right settings and moving financial esources.r and organisations. We have Phase IV (2016 / 18): Consolidate themselves and those they care care effectively between settings. By doing this we place ourselves demonstrated good quality and opportunities and build the about. This will require the continuing in the position to take all operational performance and organisation reputation and reach improvement in quality whilst opportunities in the future to have the benefit of many patients across our community. reducing costs. Like all other make a sustainable future. district general hospitals we In looking at the our strategic are challenged to deliver cost position, our short- to medium- improvements, streamline systems term organisation objectives can and deliver quality improvements. be described in four key but not We have identified a number of separate phases of development:

Renée Ward, Woodbridge Ward Human Resources Support Services Winner: Clinician of the Year Award Nominee: Team of the Year Award Nominee: Emerging Leader Award and Innovator of the Year Award

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As part of our strategy it is our “The vision of the CCG is ‘long In support of achieving these Our Quality Strategy Our Quality Strategy sets out our Patient safety improvements intention to achieve Foundation and healthy lives for everyone in outcomes there are three system- priorities and how we intend to The decisions regarding which To identify areas for improvement Trust status as a standalone Ipswich and east Suffolk.” wide workstreams that Ipswich achieve them and they fall into services are provided, where in patient safety in line with organisation. The Board of Hospital contributes to. These are three broad objectives. There are four strategic outcomes and how they are provided and emerging evidence base. Ipswich Hospital NHS Trust focussed on: that have been agreed by the ensuring that these are safe, Objective One – Building a believes that it is in the best IESCCG, West Suffolk CCG, • Health and Independence effective, caring and responsive Patient Safety Culture To be a high reporter of interests of the patients we serve clinical incidents Suffolk County Council and to people’s need are core to and the people we employ that • Urgent Care Vital in any healthcare Suffolk Providers. These are: Organisations with a high level of • Efficient Elective Care the business of a healthcare environment is both a focus we achieve this. adverse incident reporting have • Every child in Suffolk has the organisation. Ensuring that these on patient safety and a culture an open and responsive culture to best start in life. Local Area Teams services are well led starts at the where we willingly share The Suffolk Health Economy patient safety. We will continue Strategic Outcomes Whilst our local CCG Board and an overarching priority experiences, learn from things • Suffolk residents have access to benchmark the Trust against commissions many local of the Trust Board is to provide going wrong and proactively Ipswich and East Suffolk Clinical to a health environment and other comparable Trusts, and services from IHT, NHS England leadership in the areas of quality use risk assessment and monitor Commissioning Group (IESCCG) take responsibility for their make improvements to systems commissions a number of services and patient safety. improvement. Our values is our major commissioner. own health and wellbeing. to improve the safety of our 1 directly via its 27 local area In addition to the established underpin all that we do and The IESCCG is committed • Older people in Suffolk have a patients. teams. The local area team for “to ensuring a clinically and good quality of life. Board assurance committees these very intentionally include East Anglia works with Clinical there is a comprehensive the need to continually improve, financially sustainable future for • People in Suffolk have the Implementation of effective Commissioning Groups and oversight programme that the speak up and keep our patients the local acute hospital, Ipswich opportunity to improve their falls reduction programme Hospital, and to ensuring that providers of NHS services for the whole board is engaged in – from safe. and elimination of avoidable mental health and wellbeing. populations of Cambridgeshire, primary, community and social informal Board visits to structured The Trust will operate within a pressure ulcers Peterborough, Suffolk and care services ensure that patients quality audits involving executive, well-developed governance and To improve on the Norfolk. They commission primary are only treated in a hospital non-executive and patient incident reporting procedure implementation of the Seven care and public health services for setting when this is the best place representatives. The combination and promote an open, learning Simple Steps to achieve a our area, along with specialised to deliver the assessment and of formal feedback from visits, culture. reduction in the number of treatment the patient needs. services and health and justice comprehensive reporting to board The Trust will aim to eliminate all patients who fall, and reduce 1 services from providers in the as well as ‘soft intelligence’ are NHS Ipswich and East Suffolk CCG the number of patients who East of England (including Essex, avoidable harm to patients by the Integrated plan 2012 / 13 – 2014 / 15 all essential components of the are injured as the result of a Hertfordshire and Bedfordshire). prevention of errors and adverse board’s assurance processes. fall. To implement assessment They are also host to the East effects to patients associated with The Trust has been registered and care to eliminate avoidable of England Clinical Senate and health care. with the Care Quality pressure ulcers, for example, care Strategic Clinical Networks. Commission since 2010. From We will create a patient safety rounding. As specialised services are both a patient experience and culture by: commissioned from the local compliance perspective it is area team they are a key partner essential that the five standards organisation for IHT. set by the CQC are maintained on an ongoing basis.

Sheila Garwood, Pharmacy Andy White, Volunteer – Fracture Clinic Winner: Volunteer of the Year Award Highly Recommended: Volunteer of the Year Award

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Reduction and prevention of Objective Two – Building a through the use of Patient Objective Three – Building a We will improve patient and acted upon. Publication of medication errors Clinical Effectiveness Culture Reported Outcome Measures Patient Experience Culture experience by: ‘You said, We did’ within the (PROMs) and post 30 days follow- hospital and on the website, and Clearly, reducing medication The Trust will build on our well- Our work on the Future of up interventions. Patient experience regular updates to show how errors reduces the risk of patient established culture of monitoring Care to develop our values has improvements improvements to quality of care harm, and we will reduce errors clinical outcomes and learning great patient experience at its Venous thromboembolism have been achieved in response by standardising and simplifying from best practice examples to core. In addition to building our To identify areas for improvement (VTE) to patient / carer concerns and systems. improve the quality of health clinical effectiveness as above in patient experience in line with recommendations. outcomes for our patients, as To meet the national 90% we will work with our patients emerging evidence base. Minimise the rate of set out in the NHS Outcomes and local 98% target for to improve this experience. Our Optimise patient experience Healthcare Associated Framework and NICE Quality assessing patients for venous revised operating structures build Develop our range of patient Infections experience feedback routes pathways for key groups Standards. thromboembolism. in the importance of the patient Patients rightly expect the ‘voice’ at more levels than ever Feedback from patients and Through the work of the Older We will improve clinical healthcare environment in which Ensure audits are in line before and we will look to build carers via in-house surveys and People Pathway Group, Children effectiveness by: with organisational risks and they are treated to take all on this valuable experience. Our the National Patient Survey and Young People Pathway priorities necessary steps to prevent them exceptional relationship with Programme. We will increase Group, through the work of Clinical effectiveness acquiring an infection. Excellent Ensure mandatory reflection on real-time monitoring of patient the End of Life Group, as well improvements our community is reflected in hand hygiene, MRSA screening key outcomes for consultant staff the quality of our active hospital experience. We will continue to as the various user groups We will identify areas for on admission, thorough cleaning, and wider clinical teams. user groups (such as IHUG), work in partnership with patients, whose membership includes improvement in clinical adherence to High Impact and the number of volunteers the public and stakeholders to patients, carers and community effectiveness in line with Interventions requirements, Further develop care for and fundraisers we have. These improve the patient experience. representatives. emerging evidence base. and infection control training specified patient groups individuals and groups keep us for staff are monitored at least Develop care for specific groups closer to our patients and we will Complaints, concerns and Volunteers Guideline development, monthly with results reported such as patients with dementia in continue to use them in addition compliments will be addressed We will further develop and learning from audits and to the Hospital Infection line with national best practice. to patient feedback, thanks, There will be a programme of support the services provided by enquiries Control Committee. Improved compliments and complaints to ward / clinical area visits by Board volunteers through the hospital Increase the profile for learning communication to the public on Redesign of care pathways shape our plans. members. Information about the to enhance the quality of the the importance of good hand from the results of audits, Redesign of care pathways with a Patient Advice and Liaison Service patient experience and in support Whilst we have an obligation to hygiene and why this is important enquiries and reports. Monitor focus on quality and safety eg the (PALS) and the Hospital Advice of staff. include patients, stakeholders will assist infection control clinical outcomes, for example emergency care pathway to be and Complaints Service and how and the public at the earliest measures within the hospital. redesigned so that each individual these services can be accessed; opportunity in the review, patient is managed in the correct how complaints and concerns reorganisation and planning of setting. are dealt with, lessons learned services, we will go further than our legal obligations to welcome Monitor and act on feedback from all of those who benchmarked mortality and experience the care we provide. morbidity data Continue to progress improvement in hospital standardised mortality rate and Dr Foster comparative data.

Diabetic Foot Clinic Carly Ravenhill, Vascular Team Secretary Nominee: Team of the Year Award Nominee: Living the Values Award

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Monitor the leadership of Increased staff awareness at to peaks and troughs in Given these likely changes we increase in shared rotas across Stage 1: ‘Right size’ our patient experience and quality all levels emergency demand and will also have identified the principles we a number of specialities. In the capacity – to support current of care Through improved bring benefits to staff in terms of will consider in deciding which current financial envelope it will demand and greater flexibility to Through regular review of the communication of the purpose the smooth transition between services it is appropriate for us to not be feasible to significantly respond to short-term change. care settings. Work to support build, maintain, divest, or deliver increase consultant staff costs Care Quality Commission (CQC) and value of IHUG and Stage 2: Sustain and improve a single urgent care system, differently through, for example within every speciality to meet Essential Standards, using self and patient experience feedback performance – move our integrated care and reduced collaboration. this demand and therefore peer review and development of in promoting the partnership productivity to the levels we have emergency admissions will be changes in working arrangements actions for improvement. between care providers and We will look to retain services identified through benchmarking. vital to the sustainability of the will likely be combined with patients/carers. in the Trust where we can organisation. collaborative working across Stage 3: Respond to local The Future of Care evidence the quality of care organisations. environment – use available We will recruit to our values and and sustainability (clinically, Specialist Services capacity to respond to change in have explicit standards we expect Our Clinical Services financially and from a workforce The sustainability of services demand. of all staff in terms of how they Strategy Within the NHS there is an ever perspective) of the service, and within any organisation needs to treat patients, carers and their emerging picture of increasingly where clinical outcomes for consider the workforce challenges As part of the annual business colleagues. We will support Integrated Care centralised specialist care. The patients compares well. facing the service and a number planning cycle all clinical divisions every member of staff to meet Our Commissioners have clearly NHS England 10-year strategy of specialties have experienced identify growth opportunities as We will support centralisation of these standards and expect these identified though the publication reinforces this broad message. recruitment difficulties and others well as the services within their services where there is a clinically standards to be consistently met. of their commissioning intentions The definition of specialised anticipate significant retirements portfolio which are likely to be identified patient benefit and and five-year strategy, both care and what can and should over the coming years. In subject to an AQP (any qualified where services move we will Develop relationships between the specific services they wish be delivered in different settings response to these challenges, provider) tendering process or work with our patients to ensure patients and professionals to tender and their more will continue to emerge over changes in how and who delivers potentially at risk in terms of their the smooth transition between and increase community general intent to move to a the lifetime of this strategy elements of clinical pathways sustainability from a quality or providers. participation more integrated model of document. It is likely that an need to be considered and financial contribution perspective. Through pathway redesign work delivery. To support this, we increased number of pathways Collaboration again this may lead to increased This process includes considering involving Ipswich Hospital User will have elements which are will work in partnership with collaboration across organisation the quality risks associated with Group (IHUG) members, Shadow delivered in specialist units. IHT A number of significant factors our commissioners to develop boundaries. changing accreditation standards, Governors and HealthWatch integrated models of care that will need to respond by adapting will lead to more clinical services Our clinical strategy can be capital requirements or workforce involvement in future planning will help manage preadmission our governance structures and being provided collaboratively described in three key stages: shortages. The ongoing review of and reconfiguration of services. working practices to ensure safe across organisation boundaries and discharge pathways from the which services or parts of services and seamless integrated patient over the coming five years. hospital. Better integration will are provided will continue to be care. bring advantages for patients, for The national drive for an overseen by the Board. example in terms of responding increased level senior medical presence / support seven days of the week is likely to lead to an

Tracy Murphy, Specialty Trainee in Haematology Sterile Service Centre Highly Recommended: Trainee Doctor of the Year Award Nominee: Team of the Year Award

14 15 Annual Report 2013 / 14 Annual Report 2013 / 14

Business Information Performance Against Key Indicators including structure and management

The Trust’s approach to Probity and Corporate provided support and advice The Trust maintained a Key facts and figures ensuring Ipswich Hospital is Governance to the Trust managers and strong performance across well led The Trust subscribes to the workforce. a range of targets, national Births: Following the Board’s decision NHS Standards of Business Non-clinical risk is monitored standards and other key 3,623 to introduce a revised, clinically Conduct and the NHS Code of and reviewed by the Trust Safety performance indicators led operating structure in April Accountability, as laid out in the Group and the Risk Management including achieving Emergency Department 2013, the model will continue to Hospital’s Standards of Business Committee. establish itself. Support for clinical Conduct Policy. This lays out 18-weeks maximum wait for attendances: leaders to develop in their roles the standards to which staff are Progress has been made on the patients during the year. The 78,804 will be an important focus for the expected to adhere in carrying objectives for 2013 / 14 where Trust reduced its number of Trust. out their duties. the focus was been on training, hospital-acquired infections Planned admissions: assessment, incident reporting particularly C.difficile very 45,787 After a period of significant The Trust operates a robust and action follow-up. change the Board of the Trust counter fraud strategy, and significantly. has appointed an experienced engages the services of a Local Work on strengthening the Unplanned emergency executive team and non-executive Counter Fraud Specialist (LCFS) management of non-clinical admissions: members bring a breadth of whose role is to investigate any risk was a focus for 2013 / 14 29,680 experience from other sectors suspected cases of fraud, as well particularly following the to the Board table. The ongoing as to raise awareness of fraud restructure across the Trust. The Outpatient attendances: programme of development of amongst staff. Contact details advisors will continue to provide 458,661 this team is in place in addition to for the service are published advice and assistance to all and guidance on how the Trust can activities that include the next tiers throughout the hospital. Number of appointments continue to comply with its legal of leadership within the Trust. people did not attend: responsibilities and obligations. Our Accountability Framework Health and Safety Performance 31,150 sets out our expectations in The Chief Executive has overall terms of quality, safety, finance, responsibility for all matters Diagnostic Imaging patient and staff experience of health and safety and for examinations: for all teams within the Trust. ensuring mechanisms are in place 250,004 Explicitly converting these into for the overall implementation, Referrals from the expectations of individuals via monitoring and revision of non- GPs and dentists: the personal development plans clinical risk policies. 113,584 (PDP) process is the next stage of The Associate Director for Estates development of the accountability is responsible for providing clear framework. information about Health and The rollout of service line reporting Safety, Security and Fire issues to and patient level income and the Chief Executive and the Trust costing (PLICs) will help us to Board. make more informed decisions The Ipswich Hospital NHS Trust about service profitability and has advisors for Health and productivity. In addition it will Safety, Security and Fire who help in decisions about the future report through to the Associate sustainability of services and Director of Estates. Throughout responding to commissioning Emma Hardwick, Head of Midwifery the year the advisors have Winner: Leadership Award intentions.

16 17 Annual Report 2013 / 14 Annual Report 2013 / 14

Performance Against Key Indicators

Governance Risk Ratings Historic Data

Qtr to Qtr to Qtr to Qtr to Area Ref Indicator Subsections Threshold Weighting Jun 13 Sept 13 Dec 13 Mar 14

2a From point of referral to treatment in aggregate (RTT) – admitted Maximum time of 18 weeks 90% 1.0 NO YES YES NO

2b From point of referral to treatment in aggregate (RTT) – non-admitted Maximum time of 18 weeks 95% 1.0 YES YES YES YES

2c From point of referral to treatment in aggregate (RTT) – patients on an incomplete pathway Maximum time of 18 weeks 92% 1.0 YES YES YES YES Patient

Experience 2d Certification against compliance with requirements regarding access to healthcare for people with a learning disability N / A 0.5 YES YES YES YES

Surgery 94%

3a All cancers: 31-day wait for second or subsequent treatment, comprising: Anti-cancer drug treatments 98% 1.0 YES YES YES YES

Radiotherapy 94%

From urgent GP referral for suspected cancer 85% 3b All cancers: 62-day wait for first treatment: 1.0 YES YES YES NO From NHS Cancer Screening Service referral 90%

3c All cancers: 31-day wait from diagnosis to first treatment 96% 0.5 YES YES YES YES Quality All urgent referrals 93%

3d Cancer: 2-week wait from referral to date first seen, comprising: For symptomatic breast patients 0.5 NO YES YES YES 93% (cancer not initially suspected)

3e A&E: From arrival to admission / transfer / discharge Maximum waiting time of four hours 95% 1.0 YES NO YES YES

Is the Trust below the de minimus 12 NO NO NO NO 4a Clostridium difficile 1.0 Is the Trust below the YTD ceiling 21 YES NO YES NO

Is the Trust below the de minimus 6 YES YES YES YES 4b MRSA 1.0 Is the Trust below the YTD ceiling 1 NO YES YES YES

CQC Registration

Safety A Non-Compliance with CQC Essential Standards resulting in a major impact on patients 0 2.0 NO NO NO NO

B Non-Compliance with CQC Essential Standards resulting in enforcement action 0 4.0 NO NO NO NO

NHS Litigation Authority – Failure to maintain, or certify a minimum published CNST level of 1.0 C 0 2.0 NO NO NO NO or have in place appropriate alternative arrangements

TOTAL 2.5 2.0 0.5 3.0 RAG RATING AMBER / AMBER / AMBER / GREEN RED RED RED GREEN = Score less than 1

AMBER / GREEN = Score greater than or equal to 1, but less than 2

AMBER / RED = Score greater than or equal to 2, but less than 4

RED = Score greater than or equal to 4

18 19 Annual Report 2013 / 14 Annual Report 2013 / 14

Operating Financial Review Operating Financial Review

to carefully manage cash flow strong financial strategy in order to find ways to ensure the 2013/14 was a year of Key target Requirement Result Achieved? transition for Ipswich during the year led to a reduction to succeed and the medium-term hospital remains financially and Income and expenditure £749k surplus in the number of invoices paid financial plans show that with clinically sustainable. Hospital, but also the year Break-even Yes surplus (£50k adjusted*) within 30 days of receipt to 66%, which saw the start of gradually increasing surpluses, Demand for care is growing, Capital cost absorption down from over 90% in the the Trust aims to move out of a its transformation into a 3.5% 3.5% Yes but the money to pay for it is rate previous year. cumulative deficit position before reducing across the system, and hospital for the future. the end of the five-year planning External financing limit Less than £2.4m (£5.5m) Yes During 2013 / 14, the Trust also that is a challenge we must all period. Capital resource limit Up to £8.9m £7.8m Yes made the final repayment on its work on together if we want working capital loan with the The Trust has shown that the Ipswich Hospital to thrive. The Trust reported a surplus * Technical accounting reporting requirements mean that the reported income and expenditure surplus has to be shown with and without the external income received from government grants and charitable funds. Department of Health. high quality care provided in of £749,000 after meeting 2013 / 14 can be delivered within The Trust spent nearly £8m on all accounting and technical tight income streams supported reporting requirements. (This improving its assets, with the key As a result the hospital met all The Trust had received £7.5m by strong budget management year the Income and Expenditure areas of investment being: the key financial targets again. additional funding (non- and cost control based on the (I&E) account included net recurrently) in-year reflecting the • delivery of the new Patient achievement of CIPs. We must non-recurrent costs associated The Trust achieved this stronger costs of maintaining emergency Administration System; also recognise the financial with impairments of property financial position through performance and increased • PGME Simulation Training challenge facing all hospitals – of £333,000 and non-recurrent focussing on managing activity costs of delivering high-quality Suite; how to deliver sustainable seven- grants and charitable fund against plan on a weekly basis healthcare. This included • dementia ward improvements; day clinical services within an income net of depreciation of and by reassessing the position delivering recurrent savings of ever tightening financial envelope £1,032,000). The underlying against the year-end forecast with • Maternity refurbishment; and £14m. – a problem that is particularly regular forward monthly financial surplus before recognising • backlog and general pressing for hospitals of our size forecasts at both Trust and Our total income rose by £14m; the above in year issues was maintenance. and geography. Divisional level. This work was non-pay costs rose by £4.3m, £50,000. 2013 / 14 was the first full year for accompanied by regular Clinical primarily through the increased It is only by continually working The delivery of both a reported the hospital operating under the Division financial meetings with cost of drugs, and total pay with our new partners in clinical surplus of £749,000 and clinical management structure, a strong focus by the Project costs increasing by £8.9m; the commissioning groups (CCGs) an underlying surplus is an and a significant development on Management Office (PMO) on increased staffing costs are that we can deliver this challenge. important milestone for the our journey to deliver our vision the Trust delivery of the full Cost almost exclusively in medical and While the core service of our Trust and evidences the positive of high quality care in a safe and Improvement Programme (CIPs). nursing support costs. hospital remains the delivery of outcome of the actions taken in compassionate environment. 24 / 7 emergency and maternity We ended the year with £8.5m 2013 / 14 to improve the Trust’s This vision has to be based on a care, we need to work together financial resilience. in our bank account. The need

Diane Tricker, Hostess – Capel Ward Fracture Liaison Service Nominee: Support Colleague of the Year Award Nominee: Team of the Year Award

20 21 Annual Report 2013 / 14 Annual Report 2013 / 14

Employees Key Relationships including social, community and human rights issues

We have over 3,700 Equality and fairness, and guidance to staff on their health Patients are at the centre • Patients receive excellent We have a well-established members of staff (3,174 recognising diversity within our and wellbeing. We continue with of all we do. We have a fundamental care including framework of patient WTE) and around 500 community and staff are always our successful programme of strong heritage of working good food and adequate help representative or user groups volunteers all working at the heart of the services we health and wellbeing activities together with patients to with basic personal care. within the hospital. The Ipswich provide. Our Equal Opportunities and promotional events for staff, Hospital User Group (IHUG) is together to provide safe make sure their voices are • Patients and the public are and Diversity Policy sets out in which have been warmly received the over-arching group with and caring services to our heard; their views shape included in the planning detail how we provide equal with requests for more. Below is and evaluation of service representation from each patients. There is a new opportunities. Our staff are an analysis of gender distribution decisions and they are provision and feedback individual group, being full structure within the hospital, actively involved in promoting for directors, senior managers active partners in planning that they provide (via members with Suffolk Family enabling more clinicians to health and wellbeing within and employees: services. user groups, surveys) and Carers and Healthwatch as ex- be involved in the decisions the workplace, with some keen PALS & Complaints is used officio members. promoters of fitness volunteering Staff Head- A Patient and Carer Experience being taken and providing Level Gender count appropriately. IHUG meets with the Directors to be trained as running coaches the direction and steer Group which includes user • Information is available for and Non-Executive Directors to establish for the first time ‘The Director Female 4 to enable the continued representatives who voice the patients and carers throughout of the hospital on a six-weekly Ipswich Hospital Running Club’, Male 4 views of patients, their families their journey, and support to basis allowing issues to be taken success of the organisation. primarily aimed at newcomers NED Female 1 and visitors, is now well- understand that information is ‘straight to the top’ as well as to running, encouraging staff established and monitors the There are always ways in which Male 5 made available. enabling senior management to be active, fit and look after Trust’s strategy and performance we can improve services for • There is adequate access to to engage with patient and themselves. With a sickness Senior Female 86 around patient experience. The patients and quality of life for spiritual, pastoral and religious carer representatives around absence rate of 4.13% for Level Staff Male 37 key principles of our Patient our staff and we are proud to support. operational issues as well as key 2013 / 14 we are keen to do all Standard Female 2788 Experience work are: policy and strategy developments. have launched the ‘In Your Shoes’ • Family members’ and carers’ we can to provide support and Male 689 and ‘In Our Shoes’ programmes • All staff have a responsibility needs are considered and There are 14 user groups covering to listen to both staff and Grand Total 3614 for creating an environment access to support is available. both specific conditions, for patients, enabling us to set aside where patients receive a good • Bereaved family and carers example, cancer and diabetes, dedicated time to hear stories patient experience. We continue to invest in the have access to support. and addressing wider issues such from everyone of what their • All patients and visitors should as disability and older people. training and education of all • Patients and family / carers experiences have been when feel welcomed, informed Members are patients, carers and our staff, and have a dedicated receive high quality ‘end of they have either used or provided and treated with dignity and representatives from community Education Centre on site, working life’ care. services here. respect throughout their partners such as Age UK. More closely with the local universities • Equality and diversity are patient journey. than 150 people are actively in East Anglia, with some of our respected at all times. staff teaching on programmes of • The environment is clean, involved in these groups and higher education. Our Education welcoming and well Centre is used by all staff, not just furnished. clinical professionals. • Patients feel safe and informed about infection control measures.

Jo Wood, Human Resources Bereavement Team Winner: Emerging Leader Award Nominee: Living the Values Award High Recommended: Team of the Year Award

22 23 Annual Report 2013 / 14 Annual Report 2013 / 14

Key Relationships Key Relationships including social, community and human rights issues including social, community and human rights issues provide insight to enable the programme for communities who Initially established in April 2012, Serco The Trust works with our Local • The Trust carries out patient and carer perspective have traditionally not had the as part of the NHS reforms, the The Trust has been working with Strategic Partnerships and uses benchmark comparisons and experience to influence the same level of access to health CCG became responsible for Serco from September 2013 the Good Corporate Citizen against similar trusts. development and provision of services (often referred to as ‘hard commissioning (buying-in) and on an enhanced procurement Model to inform our decision • The Trust will continue to work services. to reach’ groups). managing healthcare services programme making and support our with the Carbon Trust and following the disestablishment The hospital already collates development in Corporate Social other sustainability / ecological Key strategic alliances of the primary care trust, NHS patient feedback in a number of Sustainability Responsibility (CSR). organisations. Suffolk, on 1 April 2013. ways including asking if patients NHSLA The Trust is committed to The sustainable key actions are as The Trust continues to seek to would recommend the service The NHSLA is the litigation The CCG serves a population sustainability of finite resources follows: reduce its estate and carbon to their friends and family, in- of approximately 385,000 and has developed a proactive authority which works to improve • The Trust has developed a footprint where possible. house and national patient patients and is expected to have sustainability agenda. The risk management practices in Carbon Reduction Plan to surveys, monitoring of complaints funding of £425m to commission Trust has developed a Carbon the NHS. Every NHS hospital is achieve carbon emissions and compliments and using healthcare services each year. Reduction Plan which has been visited by independent assessors reduction in line with technology to help capture the discussed and adopted by the once every two to three years, The Governing Body of the CCG government national targets feedback such as iPads (hand- Trust Board. The plan has also and this includes visits to wards, comprises 13 voting members: for the NHS. held digital devices). been approved by the Carbon looks at how we manage clinical seven GPs elected by their Trust as part of the Trust’s sign-up • The Trust has calculated its risk and informs the premium peers, lay members governance, Community to the NHS Carbon Challenge. carbon footprint. we pay for clinical negligence patient and public involvement, The Carbon Reduction Plan seeks • An action plan of projects has We work closely with our claims. In February 2011 we were accountable officer, a secondary to reduce the carbon emissions been developed to deliver the commissioners and partners accredited at NHSLA level 2. We care doctor (who has to be from of the Trust to enable the required carbon reduction both within the NHS and local had previously attained level 1 out of the area) and a chief Government carbon reduction targets. authorities (Suffolk County accreditation so we are very finance officer. The governing targets to be met and addresses Council, Ipswich Borough pleased to have reached this body also includes four non- • A Sustainable Development direct energy consumption, Council, Mid Suffolk, Babergh, higher status. voting chief officers. Management Plan has been and Suffolk Coastal District procurement, transport and introduced. As well as working closely with Councils) to understand and Local context waste. The Trust’s Transport • The Trust has signed up Clinical Commissioning Groups, respond to social and community Travel Plan has been developed to the Good Corporate NHS Ipswich and East Suffolk the National Trust Development issues. These include health in conjunction with Ipswich Citizen Assessment Test Clinical Commissioning Group Agency, Local Area Team, inequalities, social inclusion, Borough Council and this has and is developing an action (the CCG) is a group of 41 GP colleague NHS trusts and local and equality of access to health been adopted by the Board. programme based upon the practices in Ipswich and the authorities, we have strategic services. We have a specific The Trust will be using the results. eastern part of Suffolk. alliances with universities and engagement and communications Premises Assurance Model as a colleges, particularly University rigorous self-assessment tool to Campus Suffolk, and medical enable the Trust to certify that schools. its premises achieve the required statutory and NHS nationally agreed standards.

Medical Records Linda Hill, Pharmacy Nominee: Team of the Year Award Nominee: Support Colleague of the Year Award

24 25 Annual Report 2013 / 14 Annual Report 2013 / 14

Sustainability Report Sustainability Report

Sustainable Management tonnes of waste recovery 0% 1305 Our organisation is continuing to develop its risk, is an important part of managing complex The NHS aims to reduce its carbon footprint by 10% We recover or recycle 1305 tonnes of waste, which Sustainable Development Management Plan (SDMP). organisations. between 2009 and 2015. Reducing the amount of is 99% of the total waste we produce. Having an up-to-date SDMP is a good way to ensure In addition to our focus on carbon, we are also energy used in our organisation contributes to this that an NHS organisation fulfils its commitment Our expenditure on waste in the last two years was committed to reducing wider environmental and goal. There is also a financial benefit which comes to conducting all aspects of its activities with due incurred as follows: social impacts associated with the procurement of from reducing our energy bill. While our electricity consideration to sustainability, whilst providing high goods and services. This is set out within our policies consumption has risen due to site development and 2012 / 13 Clinical Waste incineration £106,303 quality patient care. The NHS Carbon Reduction on sustainable procurement. We plan to start work the installation of new equipment, the consumption Domestic Waste £62,694 Strategy asks for the boards of all NHS organisations on calculating the carbon emissions associated of fossil fuel (gas) has fallen by 13%. Overall our 2013 / 14 Clinical Waste incineration £101,860 to approve such a plan. carbon emissions have changed by less than 1% goods and services we procure. Domestic Waste £66,408 We consider the potential need to adapt the from last year. The Associate Director of Estate is the Board Level organisation’s buildings and estates as a result of Lead for Sustainability. A Board Level lead for climate change, but not the potential need to adapt Energy consumption Sustainability ensures that sustainability issues have the organisation’s activities. Adaptation to climate £1,158,507 visibility and ownership at the highest level of the Our total energy consumption has risen during the change will pose a challenge to both service delivery organisation. Potential savings year, from 24,868 to 25,501 MWh. and infrastructure in the future. It is therefore Our organisation has a sustainable Transport We have put plans in place to reduce carbon We supply 60% of our space heating from appropriate that we consider it when planning how Plan. The NHS places a substantial burden on the emissions and improve our environmental renewable sources; 100% of our supplied electricity we will best serve patients in the future. sustainability. Over the next 15 years we expect to transport infrastructure, whether through patient, is from renewable sources. Sustainability issues are included in our analysis of save £1,158,507 as a result of these measures. clinician or other business activity. This generates an risks facing our organisation. Our water consumption has increased by 4,483 impact on air quality and greenhouse gas emissions. cubic meters in the recent financial year. In 2013 / 14 NHS organisations have a statutory duty to assess It is therefore important that we consider what steps we spent £297,871 on water. the risks posed by climate change. Risk assessment, are appropriate to reduce or change travel patterns. including the quantification and prioritisation of CRC payment The CRC Energy Efficiency Scheme is a mandatory scheme aimed at improving energy efficiency and cutting emissions in large public and private sector organisations. During 2013 / 14 our gross expenditure on the CRC Energy Efficiency Scheme was £134,292.

Design Services Specialist Oncology Breast Care Team Nominee: Team of the Year Award Joint Winner: Team of the Year Award

26 27 Annual Report 2013 / 14 Annual Report 2013 / 14 Directors’ Report Composition of the Board Composition of the Board

The overall management Chair and Non-Executives Trust Executive Directors of the hospital is the responsibility of the Trust Ann Tate CBE Chair Nick Hulme Chief Executive Board which comprises a Chair, five non-executive Julia Holloway* Non-Executive Director (until 31 / 05 / 2013) Rob Mallinson Trust Medical Director Ceased role on 02 / 02 / 2014 and executive directors. Alan Bateman Non-Executive Director Barbara Buckley Trust Medical Director Commenced on 03 / 02 / 2014 All non-executive director Director of Nursing and Quality, appointments up to 30 Tony Thompson Non-Executive Director Lynne Wigens September 2012 were made Infection Prevention and Control Andrew George Non-Executive Director through the Appointments Mary Leadbeater Interim Director of Finance and Performance Until 05/06/2013 Commission. Responsibility Laurence Collins Non-Executive Director (from 01 / 04 / 2013) for non-executive director Paul Scott Director of Finance and Performance Commenced on 03 / 06 / 2013 appointments transferred to the Rajan Jethwa* Non-Executive Director (from 02 / 09 / 2013) Became Foundation Trust Director NHS Trust Development Authority Julie Fryatt* Director of Human Resources from 01 October 2012. on 27 / 09 / 2012 * From 31/05/2013 until 02/09/2013, the Trust had four non-executive directors not five. The Chair and all non-executive Clare Edmondson* Director of Human Resources Commenced on 27 / 09 / 2013 directors are members of the Trust Board, and Remuneration Margaret Blackett* Interim Director of Transformation and Operations Until 31/08/13 Committee. The Remuneration Committee is attended by the systems and financial reporting appointed on an interim basis Neill Moloney Chief Operating Officer Commenced on 15 / 07 / 2013 Chief Executive and the HR processes. In particular, the whilst Julie Fryatt is seconded * Non-voting Board member Director as expert advisors to the committee’s work focuses on the to the role of Foundation Trust committee. framework of risk control and Director. All are subject to annual related assurances that underpin performance reviews and all usual On 01 April 2013, a new Director supported by a Head of The executive directors work Membership of the Audit the delivery of Trust’s objectives. Trust policies and procedures. structure for leading and Nursing and a Head of Operations closely with the divisional Committee comprises three non- During the year 2013 / 14, Paul managing the organisation was and an HR and Finance Business leadership in developing strategic executives. The Chief Executive The Audit Committee receives Scott was appointed as Director implemented. At the core of Partner. Clinical delivery groups and operational plans. A and Director of Finance and and considers reports from both of Finance and Performance and these changes is the intent to support the Board of each Trustwide leadership group (the Performance are attendees at internal and external auditors and joined the Trust on 3 June 2013. place clinicians in at the centre division and represent all areas Combined Board) contributes to each meeting as well as external reviews the annual accounts and A substantive Chief Operating of the organisation’s leadership. within the division. Corporate and implements Board, executive and internal auditors. financial statements. Through Officer Neill Moloney was Within the revised structure there services provide support to all of and clinical team decisions. this Committee, actions are The Committee meets five times appointed and joined the Trust are three operation divisions the operational areas. put in place to ensure that all a year. The role of the Audit in July 2013. Barbara Buckley, each led by a Divisional Clinical recommendations of internal and Committee is to ensure effective the Trust’s first full-time medical external audit reports are picked control programmes are in place director took up her post in up, as well as other assurance and provide an independent February 2014. Clare Edmondson functions. check upon the executive arm of took up her role on 27 September the Board. The Chief Executive and Executive 2013. Directors were appointed using The Audit Committee Details of directors’ remuneration open competition and a selection independently reviews, monitors are given on page 37 of this process. They were appointed on and reports to the Board on the report. Wendy Webb, Senior Project Manager a permanent basis with exception Nominee: Innovator of the Year Award attainment of effective control of Clare Edmondson who was

28 29 Annual Report 2013 / 14 Annual Report 2013 / 14

Composition of the Board Composition of the Board

Research and issues throughout the Trust. The The complaints service continues Low level now very well established and If a complainant wishes to take Development Strategy Trust complies with the clinical to manage the complaints Simple, non-complex issues continues to see an increase in their complaint further we governance reporting framework process much more closely than including, for example, delayed or demand. 1,739 matters were advise them they can contact The Trust’s Research and issued in November 2002. in previous years, ensuring the cancelled appointments, lack of handled by PALS in 2013 / 14. This the Parliamentary and Health Development Strategy (which also process is fair, consistent and cleanliness, transport problems. represents a further 11% increase Service Ombudsman (PHSO). In contains a policy and operational timely. Much support is being and follows the 28% increase 2013 / 14 nine complaints were Dealt with by the Complaints procedure for the management Emergency preparedness / offered to Trust staff responsible in matters raised with PALS in taken to the PHSO. Of these, Team. of intellectual property), is well major incident planning for handling complaints which 2012 / 13. four were closed by the PHSO established throughout the Trust. is welcomed. Feedback from The complaints manager leads without investigation, two cases The Trust has in place a major The PALS team attends wards Staff working in the Research staff, patients and relatives has or reviews every medium or high were investigated by the PHSO incident plan which is fully and departments regularly to and Development office provide generally been very good. level complaint investigation, but not upheld, one was upheld compliant with ‘Handling Major support staff in handling negative support and guidance to all checking responses and with a recommendation for Incidents: An Operational Complaints are recorded in feedback from patients and hospital colleagues. conclusions for accuracy and compensation Doctrine’ and accompanying three ways, depending on their relatives to encourage local bias. The final response is drafted NHS guidance on major incident / severity: resolution. As mentioned above, The PALS and complaints service or checked by the complaints emergency preparedness and our PALS service allows us to aims to not only explain and Governance manager (often with further planning. High level monitor issues that may escalate apologise when things go wrong, Clinical Governance is about questioning and investigation at Multiple issues relating to a into complaints and any issues are but work with departments to continual improvement in the this point) and then passed on longer period of care including an escalated at the time to relevant make constant improvements and quality of care provided by NHS to the Chief Executive for final Listening and learning event resulting in serious harm. senior managers. adjustments following feedback. organisations, and ensuring approval. that improvements, where We strongly encourage people Dealt with by the Complaints The teams welcome feedback Our work in this field is guided by The number of complaints needed, are made in a climate who use the Trust – patients, Team. and complaints verbally, in the Principles for Remedy set out increased by around 14% to 709 which is supportive, open and their relatives and friends – to tell person or in writing and just by the Ombudsman. These are: in 2013 / 14 compared to the learning. The hospital has a us what they think about their Medium level recently we have overcome previous year (646 in 2011 / 12 1 Getting it right Risk and Governance Group. treatment and care. This helps us the issues surrounding email Several issues relating to a short and 619 in 2012 / 13). The 2 Being customer focused Each division has a monthly to continually improve services correspondence and are therefore period of care including, for increase is Trust-wide with no Risk and Governance meeting and to address problems quickly. now able to accept and respond 3 Being open and accountable example, failure to meet care specific trends. where the groups have a vital Information leaflets and posters in needs, medical errors, incorrect to issues raised by email. Every 4 Acting fairly and role in bringing change, and wards, clinics and reception areas treatment or attitude of staff or The PALS service continues to complaint is acknowledged proportionately considering clinical developments, set out how people can make communication. handle queries and concerns in within 72 hours and a meeting 5 Putting things right a practical way, resolving and is offered on request within each service improvements, risk their views known. 6 Seeking continuous Dealt with by the Complaints addressing issues at source to acknowledgment letter. management and internal control improvement. Team. prevent issues escalating. This is a really positive step towards taking more responsibility for issues as they arise. The PALS service is

Donna Barter, Fracture Clinic Karen Aylott, Haughley Ward Winner: Innovator of the Year Award Joint Highly Recommended: Living the Values Award

30 31 Annual Report 2013 / 14 Annual Report 2013 / 14

Composition of the Board Composition of the Board

Serious Incidents In some cases, the involvement What are we doing to make Examples of key changes to Our performance Requiring Investigation of an external investigator is improvements? practice and lessons learnt preferential. This ensures those  We continue to strive to Table 1 – Incidents reported following the investigation of The hospital has a Serious Clinical with appropriate experience ensure a high reporting. SIRIs in 2013 / 14 Incident Group which meets to For the year 2013 / 14, there have been the following incidents and investigate these cases and • Surgical pathway more discuss any untoward incident  Held a number of training near misses (when an incident almost happens) reported on the demonstrates openness and streamlined now Surgical and to determine whether what sessions to help staff with root Datix risk management computer system: transparency. Assessment Unit in place. has happened is a serious clinical cause analysis of incidents. Near Type of incident Incident Total incident, or a serious incident The percentage of patient safety  Investigator training is miss • Resuscitation officers have requiring investigation (SIRI). incidents resulting in severe harm available on a 1:1 basis Access, appointment, admission, transfer, discharge 443 73 516 introduced the Universal Abusive, violent, disruptive or self-harming behaviour 165 37 202 Both incidents are rigorously or death is subject to external with the Risk Management Form of Treatment Options Accident that may result in personal injury 1743 354 2097 investigated. A Serious Incident assurance. coordinator. across the Trust to improve Anaesthesia 5 2 7 resuscitation decision making Requiring Investigation is  We have improved the way Clinical assessment (investigations, images and lab tests) 146 67 213 Duty of candour and communication with reported to both Ipswich and East in which lessons learnt are Consent, confidentiality or communication 124 56 180 patients and their families. Suffolk Clinical Commissioning Following the recommendations shared across the organisation. Diagnosis, failed or delayed 28 21 49 from the Francis Inquiry into Mid Financial loss 1 0 1 • Deteriorating Patient Group and the National Trust  A summarised version of Staffordshire NHS Foundation Patient information (records, documents, test results, scans) 329 95 424 Working Group commenced, Development Agency. serious incident investigations, Trust, all incidents deemed to Infrastructure or resources (staffing, facilities, environment) 230 96 326 looking at three other than pressure ulcers and Labour or delivery 270 72 342 Learning from incidents be medium or high severity workstreams – recognition falls, are shared with staff via Medical device / equipment 172 82 254 or resulting in the death of of the deteriorating patient, All reported incidents are the risk management pages of Medication 491 232 723 the patient are reportable to escalation processes and investigated and any lessons that the intranet. Implementation of care or ongoing monitoring / review 1342 211 1553 our commissioners. As part of Other – please specify in description 57 29 86 response processes by medical can be learnt are shared within  Learning from falls and the incident reporting process, Security 58 8 66 staff and Critical Care. the clinical area at Divisional pressure ulcers are available patients or their relatives are Treatment, procedure 169 34 203 • Introduced new Trustwide Board meetings, and via the in Trustwide action plans and informed of any such incidents. Totals 5,773 1,469 7,242 audit to review compliance intranet for hospital areas outside disseminated to each Division Of these, the following were reported as against MEWS escalation the scope of the Division involved Failure to meet this contracted via the Falls Prevention Group Serious Incidents Requiring Investigation (SIRIs): policy, reported at ward level in the incident. standard results in a financial and Pressure Ulcer Prevention monthly. It is important that when serious penalty. To date, the Trust and Action Group. Table 2 has not been subject to any • Reviewing every cardiac incidents occur, they are reported  A system to provide individual Type of incident No of SIRIs and investigated, not only to penalties relating to Duty of arrest and reporting cardiac feedback to incident reporters Developed pressure ulcers Grade 3 or 4 43 ensure that the correct action can Candour. arrests outside of Critical Care on request with the aim to Unexpected neonatal death 2 be taken, but also to ensure the Unit monthly at ward level, increase reporting is available. Retained needle tip 1 Trust learns from the incident to reportable to Board. Baby born in poor condition 5 help prevent recurrence. • Critical Care Outreach Team Information governance breach 4 now available 24 / 7. The more serious incidents Unexpected death 7 are categorised as Serious Operative management 3 Never Events Incidents Requiring Investigation Management of the deteriorating patient 4 Never Events are serious, (SIRIs) and are reported to the Incorrect documentation 1 largely preventable patient Ipswich and East Suffolk Clinical Misdiagnosis (possible mismanagement of care) 1 safety incidents that should Commissioning Group. These Fracture neck of femur 12 not occur if the available incidents are investigated, a Infection control – measles 1 preventative measures have report written and actions Patient fall 1 been implemented. implemented. Total 85

32 33 Annual Report 2013 / 14 Annual Report 2013 / 14

Composition of the Board Composition of the Board

The list of Never Events from Never Events at The Ipswich Safety Thermometer A WHO SSC review group The observational audit tool Prompt Payments Code the Department of Health was Hospital NHS Trust comprising medical, surgical, feedback concluded that the SSC The NHS Safety Thermometer is a The Prompt Payment Code is a updated and slightly amended for anaesthetic and allied health is well embedded in the culture 2011 / 12 2012 / 13 2013 / 14 tool for measuring patient safety, payment initiative developed by 2013 / 14: professional colleagues was at Ipswich. Each Division has which was introduced in April Government with the Institute 1 Wrong site surgery 0 1 2 developed in with the main aim assessed the use of the checklist. 2 Wrong implant / prosthesis 2012. The tool is used to collect of Credit Management (ICM) to review the Trust’s existing 3 Retained foreign object Regrettably, two Never information relating to some key In an audit of Datix to review to “tackle the crucial issue of systems and processes in the use post‑operation Events occurred in 2013 / 14. harm factors for each patient whether the SSC has had an late payment and help small 4 Wrongly prepared high-risk injectable and audit of the surgical safety Both concerned operative and includes VTE, pressure impact on patient safety incidents, businesses.” Details of the code medication checklist. The group meets twice 5 Maladministration of a management; the first was a ulcers, falls and urinary catheter two cases were found which can be found at a year. potassium‑containing solution peri-operative case involving infections. On a set day each identified the WHO SSC as a key www.promptpaymentcode.org.uk 6 Wrong route administration of testicular surgery and the second month, every current inpatient is Compliance at Ipswich Hospital is factor in identifying potential chemotherapy The code does not include any 7 Wrong route administration of involved a retained needle assessed for the presence of any measured in two separate ways: major errors prior to surgery. targets but is a series of principles oral / enteral treatment tip. Investigations by senior of these harms and the results are 1 electronically: Theatre staff that all NHS organisations are 8 Intravenous administration of epidural clinicians took place following recorded on a central database. medication are required to complete a expected to follow during the each incident, and areas where This allows us to monitor the 9 Maladministration of insulin ‘SSC checklist used’ (yes or normal course of business. The 10 Overdose of midazolam during improvements could be made prevalence of these harms and no) button on iOrmis (theatre hospital has signed up to and conscious sedation were identified and implemented. to assess our performance in 11 Opioid overdose of an opioid-naïve computer system). This endorsed the code. The changes implemented are providing harm-free care. patient button has to be completed 12 Inappropriate administration of daily regularly audited to ensure before the next screen can oral methotrexate they are sustained and become Surgical Safety Checklist 13 Suicide using non-collapsible rails be accessed. This measures Charging for Information embedded. Neither patient The World Health Organisation 14 Escape of a transferred prisoner whether a checklist has experienced any harm and both (WHO) Surgical Safety Checklist The Ipswich Hospital NHS Trust 15 Falls from unrestricted windows been used for a particular 16 Entrapment in bed rails have recovered well. (SSC) was developed by the complies with the Treasury’s patient (but it doesn’t check 17 Transfusion of ABO-incompatible World Health Organisation guidance on setting charges for blood components whether all three sections Serious case review and incorporated into the information. 18 Transplantation of ABO‑incompatible of the checklist have been organs as a result of error National Patient Safety The healthcare of two patients completed). 19 Misplaced naso- or oro-gastric tubes is being reviewed as part of a Agency alert, January 2009 20 Wrong gas administered The compliance rate for the system-wide serious case review. for action by the NHS. The 21 Failure to monitor and respond to year is 100%. oxygen saturation Ipswich Hospital is contributing actions included ensuring the 22 Air embolism to this review. These cases will checklist is completed for every 2 paper: Recording compliance 23 Misidentification of patients patient undergoing a surgical that all three sections (‘Sign- 24 Severe scalding of patients be ultimately peer reviewed in 25 Maternal death due to post‑partum relation to recommendations and procedure (including under local in’, ‘Time-out’ and ‘Sign-out’) haemorrhage after elective Caesarean learning. anaesthesia). of the SSC are completed, section for all patients going through The SSC is a paper document There are exclusions to each Never Recovery on one day per week comprising three distinct sections Event. within East, South, Blyth, ‘Sign-in’, ‘Time-out’ and ‘Sign- Raedwald and Ophthalmic Day out’. WHO encourages local Care Unit theatres. adaptation of the checklist to ensure it is fit for purpose. The The compliance rate for the SSC aim is to reduce patient year is 99.8%. harm, improve teamwork and flatten hierarchy. Needham Ward Nominee: Team of the Year Award

34 35 Annual Report 2013 / 14 Annual Report 2013 / 14 Remuneration Report Remuneration Report Remuneration Report

The Remuneration • ensure the terms of reference periods apply based on the early Expense All of the Remuneration termination of their contract. The Benefits payments pension- Committee acts with the Salary Other Bonus in Kind (taxable) related TOTAL delegated authority from Committee are available, notice periods on resignation are (Bands remuneration Payments (Rounded total to benefits (Bands which should set out the as follows: Salary and Pension Entitlements of of (Bands of (Bands of to nearest nearest (bands of of the Trust Board. £5,000) £5,000) £5,000) £100) £100 £2,500) £5,000) Committee’s delegated Board Members 2013 /14 (Audited) £000 £000 £000 £00 £00 £000 £000 Chief Executive – six months responsibilities and be Name and title The purpose of the Remuneration reviewed and updated Executive directors – three Nick Hulme Committee is: 165 – 170 0 0 120 23 65 – 67.5 245 – 250 annually; months. Chief Executive • to make appropriate Paul Scott The Remuneration Committee The Trust did not have a bonus 110 – 115 0 0 1 4 127.5 – 130 240 – 245 Director of Finance and Performance (06/06/2013 onwards) recommendations to comprises the Chair of the Trust scheme in operation during Julie Fryatt the Board on the Trust’s 95 – 100 0 0 1 3 32.5 – 35 130 – 135 Board, who acts as Chair, and the 2013 / 14. Director of Human Resources / Foundation Trust Director remuneration policy and the Non-executive Directors of the Clare Edmondson specific remuneration and The Trust made contributions 45 – 50 0 0 0 0 5 – 7.5 50– 55 Board. At the discretion of the Director of Human Resources (27/09/2013 onwards) totalling £13.6million, as per note terms of service of: Chair, the Chief Executive and Rob Mallinson 10.6, needed to the Pensions 25 – 30 205 – 210 10 – 15* 3 10 100 – 102.5 345 – 350 • the Chief Executive; Director of Human Resources may Trust Medical Director (01/04/2013 to 02/02/2014) Agency in the year. Note 10.6 in Barbara Buckley • the Executive Directors; and be present to advise, but not for 20 – 25 0 5 – 10* 0 0 32.5 – 35 60 – 65 the Trust’s full accounts provides Trust Medical Director (03/02/2014 onwards) any discussions concerning their • other staff as determined by further details as to the nature Lynne Wigens personal remuneration. 100 – 105 0 0 1 5 40 – 42.5 140 – 145 the Board; of the pension scheme and Director of Nursing and Quality Neill Moloney • determine targets for any A quorum will consist of the accounting proactive in relation 85 – 90 0 0 0 0 50 – 52.5 135 – 140 Chief Operating Officer (15/07/2013 onwards) performance-related pay Chair (or his / her nominated to associated liabilities. Details of Ann Tate 20 – 25 0 0 2 9 0 20 – 25 scheme contained within the representative) and at least two the pension benefits of the Trust’s Trust Chair policy; Non-executive Directors (or their senior managers are also given Julia Holloway 0 – 5 0 0 0 0 0 0 – 5 • review performance and nominated representatives). in the Remuneration Report. Exit Non-Executive Director (01/04/2013 to 31/05/2013) Alan Bateman objectives of the Chief packages are referred to within 5 – 10 0 0 1 0 0 5 – 10 The Committee will meet as a Non-Executive Director Executive and other Executive notes 10.4 and 10.5. minimum twice a year. Minutes Tony Thompson 5 – 10 0 0 0 3 0 5 – 10 RetainedDirectors; earnings relate to the cumulative deficitare takenmade by andthe Trusta report since itssubmitted inception. Non-Executive Director •The ensurerevaluation that reserve contractual reflects termsmovements in tothe thevalue Board of property, showing plant theand basisequipment and intangible assets as set out in the Andrew George 5 – 10 0 0 4 0 0 5 – 10 accountingof termination policy. The arrevaluatione fair and reserve balancefor relatingany recommendations. to each asset is released to retained earnings on disposal of that asset and Non-Executive Director as depreciation is charged on the revalued element. Laurence Collins adhered to; 5 – 10 0 0 0 0 0 5 – 10 Executive’s pay is annually Non-Executive Director • make recommendations to reviewed by the Remuneration Rajan Jethwa 0 – 5 0 0 1 4 0 0 – 5 the Board on the level of Committee. They are presented Non-Executive Director (02/09/2013 onwards) any additional payments Mary Leadbeater with benchmarking information 50 – 55 0 0 0 30 0 55 – 60 contained within the policy; to demonstrate where each Interim Director of Finance and Performance (until 05/06/2013) executive director’s salary sits Margaret Blackett • ensure that remuneration Interim Director of Transformation and Operations 80 – 85 0 0 0 0 0 80 – 85 packages enable high quality alongside similar posts in the (01/04/2013 to 31/08/2014) staff to be recruited, trained NHS. Decisions to uplift salaries *Clinical Excellence Award. and motivated and are within are based on this information, levels of affordability and internal equity, affordability, are publicly defensible and whether there has been a amenable to audit; significant change in a director’s portfolio and thus responsibility. No executive director received a pay rise this year. Notice

36 37 Annual Report 2013 / 14 Annual Report 2013 / 14

Remuneration Report Remuneration Report

Pension Benefits – Board Members 2013 /14 (Audited) Benefits in Expense All Salary Other Bonus Kind payments pension- Real Lump sum at Real (Bands remuneration Payments (Rounded (taxable) related increase Real increase Total accrued age 60 related to Cash increase Salary and Pension Entitlements of of (Bands of (Bands of to nearest total to benefits TOTAL in pension in pension pension at age accrued pension equivalent in cash £5,000) £5,000) £5,000) £100) nearest (bands of (Bands of at age 60 lump sum at 60 at at age 60 at Cash equivalent transfer equivalent Employers Board Members 2012 /13 (Audited) (Bands of age 60 (Bands 31 March 2014 31 March 2014 transfer value at value at 31 transfer contribution £000 £000 £000 £00 £100 £2,500) £5,000) £2,500) of £2,500) (Bands of £5,000) (Bands of £5,000) 31 March 2014 March 2013 value to stakeholder Name and title Name £000 £000 £000 £000 £000 £000 £000 pension £000 Andrew Reed 140 – 145 0 0 0 0 -22.5 – -25 115 – 120 Nick Hulme 2.5 – 5 7.5 – 10 40 – 55 125 – 130 807 692 99 0 Chief Executive (01/04/2012 to 18/05/2012) Julie Fryatt Julie Fryatt 0 – 2.5 N / A 5 – 10 N / A 111 87 23 0 95 – 100 0 0 0 0 25 – 27.5 120 – 125 Director of Human Resources Rob Mallinson 2.5 – 5 10 – 12.5 35 – 40 105 – 110 586 488 73 0 Peter Donaldson 20 – 25 140 – 145 0 – 5* 0 0 -27.5 – -30 140 – 145 Trust Medical Director (Tenure ended 31/03/2013) Mary Leadbeater* Stephanie (Sally) Watson 125 – 130 60 – 65** 0 2 7 -2.5 – -5 185 – 190 Paul Scott 2.5 – 5 12.5 – 15 25 – 30 80 – 85 379 285 71 0 Director of Finance and Performance Siobhan (Maureen) Jordan Clare Edmondson 0 – 2.5 0 – 2.5 5 – 10 15 – 20 114 110 1 0 20 – 25 0 0 0 0 -42.5 – -45 -25 – -20 Director of Nursing and Quality (01/04/2012 to 17/06/2012) Margaret Blackett* Lynne Wigens 60 – 65 0 0 0 0 65 – 67.5 130 – 135 Neill Moloney 0 – 2.5 2.5 – 5 30 – 35 95 – 100 494 447 26 0 Director of Nursing and Quality (13/08/2012 onwards) Barbara Buckley 0 – 2.5 0 – 2.5 50 – 55 155 – 160 1026 947 9 0 Andy Burroughs 0 – 5 10 – 15** 0 0 0 -2.5 – -5 10 – 15 Director of Business Development (01/04/2012 to 10/04/2012) Lynne Wigens 0 – 2.5 5 – 7.5 35 – 40 110 – 115 686 622 50 0 John Watson 80 – 85 0 0 0 0 105 – 107.5 185 – 190 *Were not in the NHS pension scheme. Director of Operations (01/04/2012 to 03/02/2013) As non-executive members do not receive pensionable remuneration there will be no entries in respect of pensions for non-executive members. Ann Tate 20 – 25 0 0 2 6 0 20 – 25 Chair (02/04/2012 onwards) Dave Norval 0 – 5 0 0 0 0 0 5 – 10 Non-Executive Director (01/04/2012 to 31/12/2012) Julia Holloway 5 – 10 0 0 1 0 0 5 – 10 Non-Executive Director Alan Bateman 5 – 10 0 0 0 0 0 5 – 10 Non-Executive Director Tony Thompson 5 – 10 0 0 0 0 0 5 – 10 Non-Executive Director Andrew George 5 – 10 0 0 2 0 0 5 – 10 Non-Executive Director Nigel Beverley Interim Chief Executive (21/05/2012 to 31/03/2013) 195 – 200 0 0 0 30 0 200 – 205 (Paid via Ltd company and includes VAT) Margaret Blackett Interim Director of Transformation and Operations 170 – 175 0 0 0 113 0 180 – 185 (02/07/2012 onwards) (Paid via Ltd company and includes VAT) Mary Leadbeater Director of Finance and Performance 150 – 155 0 0 0 98 0 160 – 165 (24/09/2012 onwards) (Paid through an agency and includes agency fees and VAT)

*Clinical Excellence Award **Redundancy payment Andrew Reed was seconded to NHS Midlands and East Strategic Health Authority and his salary was recharged to NHS Midlands and East SHA. Stephanie Watson was seconded to NHS Midlands and East Strategic Health Authority from 17 September 2012 until 31 March 2013.

MARS: In brief, the national scheme has been commissioned by the Department of Health and developed in partnership with the Social Partnership Forum. It does not constitute a collective agreement. It is anticipated that those non-Foundation Trust employers in England that wish to run a MARS will work in partnership with their local staff-side representatives to implement this scheme.

Revised guidance was issued by HM Treasury on 26 October 2011 regarding the calculation of CETVs in public service pension schemes. Based on this guidance the NHS Pensions Agency, with effect from 8 December 2011, has used revised and updated actuarial factors produced by GAD when calculating CETVs within the NHS Pensions Scheme.

Maggie Ruddock, Information Technology Nominee: Support Colleague of the Year Award

38 39 Annual Report 2013 / 14 Annual Report 2013 / 14

Remuneration Report Remuneration Report

Pension Benefits – Board Members 2012 /13 (Audited) Cash Equivalent Transfer the scheme at their own cost. performance-related pay, Values CETVs are calculated within benefits-in-kind as well as Real Lump sum at the guidelines and framework severance payments. It does Real increase Total accrued age 60 related to Cash Real A Cash Equivalent Transfer Value increase in pension pension at age accrued pension Cash equivalent increase Employers prescribed by the Institute and not include employer pension in pension lump sum 60 at at age 60 at equivalent transfer in cash contribution (CETV) is the actuarially assessed Faculty of Actuaries. contributions and the cash at age 60 at age 60 31 March 2012 31 March 2012 transfer value value at equivalent to capital value of the pension equivalent transfer value of (Bands of (Bands of (Bands of (Bands of at 31 March 31 March transfer stakeholder scheme benefits accrued by a £2,500) £2,500) £5,000) £5,000) 2012 2011 value pension pensions. Name £000 £000 £000 £000 £000 £000 £000 £000 member at a particular point Real Increase in CETV The banded remuneration of Andrew Reed -2.5 – 0 -5 – -2.5 55 – 60 165 – 170 1,150 1,082 12 0 in time. The benefits are the This reflects the increase in the highest paid director in Julie Fryatt 0 – 2.5 N / A 5 – 10 N / A 87 66 17 0 member’s accrued benefits and contingent spouse’s pension CETV effectively funded by the The Ipswich Hospital NHS Trust Peter Donaldson -2.5 – 0 -5 – -2.5 55 – 60 170 – 175 1,325 1,248 11 0 payable from the accrued employer. It takes account of the in the financial year 2013 / 14 Stephanie Watson -2.5 – 0 -2.5 – 0 35 – 40 105 – 110 674 626 15 0 benefits and any contingent increase in accrued pension due was £246,477.47 (2012 / 13, Andy Burroughs -2.5 – 0 N / A 0 – 5 N / A 46 44 -1 0 spouse’s pension payable from to inflation, contributions paid by £126,414.19 plus £63,000.00 John Watson 2.5 – 5 12.5 – 15 30 – 35 95 – 100 521 414 86 0 the scheme. A CETV is a payment the employee (including the value MARS payment = £189,414.19). Siobhan Jordan -2.5 – 0 -7.5 – -5 15 – 20 50 – 55 252 256 -18 0 made by a pension scheme or of any benefits transferred from This was 9.17 times (2012 / 13, Lynne Wigens 2.5 – 5 7.5 – 10 30 – 35 100 – 105 622 525 70 0 arrangement to secure pension another scheme or arrangement) 6.81 or 4.55 exc MARS payment) and uses common market As non-executive members do not receive pensionable remuneration there will be no entries in respect of pensions for non-executive members. benefits in another pension the median remuneration of the scheme or arrangement when valuation factors for the start and workforce, which was £26,822 the member leaves a scheme and end of the period. (2012 / 13, £27,798). chooses to transfer the benefits In 2013 / 14, 0 (2012 / 13, 4) accrued in their former scheme. Off-Payroll Engagements 2013 / 14 Median staff pay employees received remuneration The pension figures shown relate in excess of the highest-paid Most off-payroll engagements Number to the benefits that the individual disclosure director. In the previous year are made through established Number of existing engagements as of 31 March 2014 17 has accrued as a consequence Reporting bodies are required to their remuneration ranged from employment agencies and the Of which, the number that have existed: of their total membership of the disclose the relationship between £188,884.67 – £214,103.00. Trust does not consider that these for less than 1 year at the time of reporting 10 pension scheme, not just their the remuneration of the highest- carry a significant risk of taxes not for between 1 and 2 years at the time of reporting 3 service in a senior capacity to paid director in their organisation being properly accounted for. for between 2 and 3 years at the time of reporting 0 which disclosure applies. The and the median remuneration of for between 3 and 4 years at the time of reporting 4 Where payment is not made via CETV figures and the other the organisation’s workforce. for 4 or more years at the time of reporting 0 such an agency, the Trust insists pension details include the Total remuneration includes on a tax reference number being value of any pension benefits in salary, non-consolidated quoted on the invoice from the another scheme or arrangement Number individual or service company. which the individual has Number of new engagements, or those that reached six months in 9 transferred to the NHS pension duration, between 1 April 2013 and 31 March 2014 The Trust will review the controls scheme. They also include any Number of new engagements which include contractual clauses around off-payroll engagements additional pension benefit giving The Ipswich Hospital NHS Trust the right to request assurance to ensure controls are in place. in relation to income tax and National Insurance obligations accrued to the member as a result Number for whom assurance has been requested 1 of their purchasing additional Of which: years of pension service in assurance has been received 1 assurance has not been received --- engagements terminated as a result of assurance not being received --- Chevelle Platt, Saxmundham Ward Nominee: Living the Values Award

40 41 Annual Report 2013 / 14 Annual Report 2013 / 14

2013 /14 Governance Statement 2013 /14 Governance Statement

Scope of Responsibility The Governance Framework under a four-year tenure. The Deputy work required for strategic or Chief Executive is planning to hold and unconfirmed minutes from of the Organisation Chair was appointed as Senior other matters. During the year the regular open forums in venues across the Audit Committee, Healthcare The Trust Board is Independent Director in July 2013. Board has covered quality and risk the east of the county. Governance Committee and Finance The Trust has an integrated accountable for governance The executive team has stabilised topics including mapping board There is an established and robust and Performance Committee governance approach to ensure assurance processes to the Care at its next meeting following and internal control in The decision making is informed by a full during the year with substantive governance framework, supported appointments to the three executive Quality Commission monitoring and and maintained by a framework the committee meetings. Any Ipswich Hospital NHS Trust. range of corporate, financial, clinical Keogh Reports, patient- and family- amendments subsequently made to As Accountable Officer, and information governance. director posts that had been covered of committees. The Board has by interim appointments in the centred care, the Trust’s quality overall responsibility for the the minutes at their confirmation are and Chief Executive of this The Trust Board comprises a Chair, previous year. The Chief Executive governance framework, mortality effectiveness of the governance reported to the next Board Meeting. Board, I have responsibility five non-executive director members commenced employment on 1 data and board assurance framework framework and as such requires The Board may request further work and five executive director members: April 2013, the Director of Finance reporting. Strategic and planning that each of its sub-committees has on various issues which are raised. for maintaining a sound the Chief Executive, Medical Director, items have included sessions on the system of internal and Performance on 3 June 2013 agreed terms of reference which During the year responsibility for Director of Nursing and Quality, and the Chief Operating Officer on development of strategy, market describe duties, responsibilities and chairing the Healthcare Governance control that supports Director of Finance and Performance 15 July 2013. The executive team share, clinical strategy and actuarial accountabilities, and describes the Committee and Charitable Funds and the achievement of the and Chief Operating Officer. Two was strengthened during the year approaches and population mapping, process for assessing and monitoring Sponsorship Committee changed other executive director members by the appointment of a full-time the annual planning cycle and annual effectiveness. There are six formally following the appointment of new organisation’s policies, without voting rights attend each plan presentations from clinical aims and objectives. I also Medical Director in support of the designated committees of the Board: non-executive directors. Trust Board meeting: the Director Trust’s plans to become a clinically divisions. Performance-related issues have responsibility for of Human Resources and the covered have included the Trust’s • Audit Committee The Audit Committee meets on led organisation. The appointment a bi-monthly basis and supports safeguarding the public Foundation Trust Director. The Chair of a Foundation Trust Director accountability framework, service line • Healthcare Governance reporting, patient level information Committee the Board by providing an funds and the organisation’s has a second and casting vote. The in November 2013 to lead the Trust Secretary also attends all Board costing, information governance and independent and objective review assets for which I am development of the Trust’s strategy • Finance and Performance of the governance and assurance meetings. A non-executive vacancy further strengthened the Trust’s Procure 21+. In addition the Board Committee personally responsible as in the last quarter of 2012 / 2013 was has actively led on the development processes upon which the Board strategic focus and planning. • Remuneration and Terms of places reliance. In this capacity set out in the Accountable filled on 1 April 2013 with a new of a set of Trust Values. All Board The Board has met on a monthly members are actively encouraged Service Committee as independent reviewer of the Officer Memorandum. non-executive director appointed through the Appointments basis throughout the year with the to suggest topics for the seminar • Charitable Funds and internal control environment the Commission process under a four- first part of each meeting open to sessions. Sponsorship Committee Audit Committee is the scrutiniser the public and closing as necessary of all committees including the year tenure. A non-executive director Following discussion at a Board • Foundation Trust Steering Board vacancy arose at the end of May for a part two confidential session. Healthcare Governance and Finance Both sections of the meeting follow Development session the Board (time limited). and Performance Committees and 2013 following one of the non- agreed to change the sequencing executive directors stepping down. a structured format with each public The Audit, Healthcare Governance in this capacity receives the highlight meeting starting with a patient or of its meetings held in public from and Finance and Performance report and minutes from those The vacancy was filled in September monthly to bi-monthly, starting in 2013 with a new non-executive carer story to set the tone and focus Committees are the main assurance committees. The Audit Committee of the meeting. The patient / carer April 2014. The new arrangements committees reporting to the Board. membership comprises three non- director appointed through the new will include the opportunity to cover Trust Development Authority process story is followed by matters of quality The Board receives a highlight report executive directors, one of which is and risk, strategy, performance and any urgent items on a monthly corporate governance. basis as required. The decision was based on agreement that the In addition to the formal board Board required regular bi-monthly meetings the Board holds seminar opportunity to hold seminar sessions sessions which provide an to enable more in-depth review opportunity for the Board to be of topics and to develop strategy. briefed on a number of issues of To enable greater openness and interest or to focus on in-depth engagement with stakeholders the

Annie Oliver, Deben Ward Diabetes Centre and Information Technology Nominee: Support Colleague of the Year Award Nominee: Innovator of the Year Award

42 43 Annual Report 2013 / 14 Annual Report 2013 / 14

2013 /14 Governance Statement 2013 /14 Governance Statement

Chair of the committee. The Chief The Committee has requested contribution from clinicians and the The Audit, Healthcare Governance senior management and employees strategy, policy and the provision Executive, Director of Finance and improvement to the way the Trust leads on quality. This has resulted in and Finance and Performance employed under Ipswich Hospital’s of appropriate resources. The Trust Performance, Trust Secretary, Head triangulates quality data in the form the three divisional Clinical Directors, Committees submit an annual report terms and conditions of service, Board met as corporate trustee of Internal Audit and a representative of a visual representation as a ‘Heat the Heads of Nursing / Clinical to the Board to review the work together with other employees to approve the Ipswich Hospital from the external auditors attend Map’ to clearly identify potential Services, Head of Midwifery, Chief undertaken during the year and to as determined by the Board of charitable funds annual report and the Audit Committee meetings. areas of concern. The Committee Pharmacist, Clinical Tutor, Patient set out how they have performed Directors. The committee’s terms accounts for the year ended 31 Other officers of the Trust are invited also focuses on overseeing the Safety Lead and Patient and Carer against their responsibilities as of reference have been reviewed March 2013, to approve the Letter to attend the Audit Committee to development of risk management Experience Lead being invited to defined in their terms of reference. during the last quarter of the year of Representation and to receive the report on standing items such as the activities through the Risk attend the committee. Plans are In addition the Audit Committee and and a number of changes are being ISA260 Report from the external review of risk and also as requested Management Committee. also being developed for a clinical Healthcare Governance committees proposed for approval in the first auditors. on exceptional items. The Audit The Healthcare Governance trainee to attend the committee undertake an annual self-assessment quarter of 2014 / 15. The Board has Standing Orders, a Committee receives assurance on Committee receives assurance on as a learner voice representative. which informs the annual report. The Ipswich Hospital NHS Trust is Schedule of Matters Reserved to the fraud deterrent from regular reports the quality agenda and clinical The committee has commenced a The Audit Committee’s self- the corporate trustee for charitable Board, Standing Financial Instructions from the Trust’s Local Counter Fraud governance activities through comprehensive review of the quality assessment results are discussed at funds held on trust. The Trust Board and a Scheme of Delegation Group and from the Local Counter the Patient Safety and Clinical architecture in the Trust in the last the June Audit Committee meeting serves as its agent and has delegated which were reviewed at the end Fraud Specialist who attends the Effectiveness and Patient Experience quarter of 2013 / 14. The Healthcare and the Healthcare Governance authority to the Charitable Funds of 2012 / 13 in advance of the Committee at least once a year and Groups which report into it. The Governance Committee receives the Committee self-assessment results and Sponsorship Committee to introduction of the new organisation on request. Healthcare Governance Committee is minutes of the Audit committee to are discussed at the May committee make and monitor arrangements structure. These are currently under The Healthcare Governance chaired by a non-executive director, ensure that there is no overlap or meeting. The committee annual for the control and management review and changes will be made at Committee meets on a bi‑monthly and two other non-executive inadvertent omission on governance. reports are reviewed by the Audit of the Trust’s Charitable Funds in the end of the first quarter 2014 / 15 basis on alternate months to the directors are members of the The purpose of the Finance and Committee to inform the Annual accordance with any statutory or to reflect learning and new financial Audit Committee. It enables the committee together with a number Performance Committee is to provide Governance Statement. The Finance other legal requirements, or best systems arrangements. and Performance Committee has Board to obtain assurance that of the executive directors including the Board with an independent practice required by the Charities The Trust implemented a new high standards of care are provided the Director of Nursing and Quality, and objective overview of finance completed a full year as a non- Commission. The Committee is executive-led assurance committee divisional structure at the beginning by the Trust and, in particular, the Medical Director, Chief Executive, and performance issues to assure, chaired by a non-executive director of 2013 / 14. The overarching that adequate and appropriate Chief Operating Officer and Director suggest and make recommendations during the year and will undertake and membership comprises a further a self-assessment in line with those intention was to create a clinically governance structures, processes of Human Resources. The Trust to support the Board in ensuring the two non-executive directors, the led organisation with a single line and controls are in place to do this. Secretary attends the Healthcare Trust maintains cash liquidity and undertaken by the Audit and Director of Finance and Performance, Healthcare Governance Committees. of accountability for all aspects of The Committee has a number of Governance Committee meetings. remains as a going concern whilst Director of Nursing and Quality, performance including patient safety, reporting committees and provides The Head of Internal Audit also achieving the key performance The Remuneration and Terms of Foundation Trust Director, Patient patient experience, operational assurance to the Trust Board on all attends to mirror their attendance indicators assigned to it. It is held Service Committee is chaired by Group Representative and Head of standards, financial performance matters relating to quality including at the Audit Committee. During the week of the Board each month the Chair of the Trust Board and Communications. The committee has and staff engagement. Importantly patient safety, clinical effectiveness the course of the year a review was and its draft minutes are reviewed at the five non-executive directors of undertaken a scheme of work during the introduction of the new and outcomes and patient and undertaken of committee attendees the Board Meeting with the non- the Trust are members. The Chief the course of the year to strengthen structure sought to secure the carer experience and engagement. to enable greater participation and executive Chair of the Committee Executive and Director of Human its governance arrangements which engagement of clinicians including commencing the Board discussion Resources regularly attend meetings. has included the development of on integrated performance with The committee makes appropriate an overview of the Committee’s recommendations to the Board of discussions. This is followed by Directors on the Trust’s remuneration input from the executive director policy and the specific remuneration leads for quality, finance, national and terms of service of the Chief and contractual standards and Executive, executive directors, organisation efficiency.

Elaine Brownlee-Pinkerton, Shotley Ward Sarah Higson, Patient Experience Lead Nominee: Support Colleague of the Year Award Highly Recommended: Emerging Leader Award

44 45 Annual Report 2013 / 14 Annual Report 2013 / 14

2013 /14 Governance Statement 2013 /14 Governance Statement

doctors, nurses, midwives and Each Divisional Board is chaired Combined Board receives highlight The Care Quality Commission The Trust was found to be compliant The Risk And Control allied healthcare professionals in by a Divisional Clinical Director reports from the Divisional Boards on conducted two visits during in Outcome 4 and Outcome 9; the Framework the leadership of the hospital. The who carries responsibility for the key issues covered at their meetings 2013/ 14. The first was a outine,r areas of non-compliance identified in new structure comprised three leadership of the Division. Each and covers items which require unannounced visit on 4 June 2013 the June 2013 visit. Risk assessment clinical divisions to better reflect Division has nursing and operational escalation or further consideration when five out of 21 outcomes were The January 2014 visit found one As Chief Executive, I have overall how patients come into hospital: leads. The Nursing Lead provides by the combined group. In addition, reviewed and the Trust was found to area of minor non-compliance responsibility and accountability for Medicine and Therapies; Surgery; senior nursing and quality of care the Combined Board reviews the have two minor impact compliance relating to documentation of “Do risk management and this is shared Cancer, Women and Children’s expertise and guidance to the accountability framework reports areas. Namely Outcome 4: Care and Not Attempt Resuscitation” (DNAR) with executive directors, who along Services, supported by an executive Divisional Board. The Operations from each of the divisions. welfare of people who use services forms. The documentation was with the whole of the Trust Board function. Each Division comprises a Leads provide expert operational An evaluation of the effectiveness (pressure area care and pressure noted to be inconsistent with some are informed on risk management number of clinical sub-groups called advice to the Divisional Board. of the new structure has been ulcer management) and Outcome 9: omissions in the recording of dates and governance issues through the Clinical Delivery Groups. Whilst the The Divisional Boards oversee and undertaken in the last quarter of Management of medicines (storage and discussions with patients and Healthcare Governance Committee, restructure did not significantly affect monitor the performance of their 2013 / 14 and the NHS Leadership and recording of medicines). An family. In response a Trust-wide audit Audit Committee and Finance the composition or remit of the Clinical Delivery Groups. Whilst Academy was a major contributor. action plan to address the issues of all DNAR forms was undertaken and Performance Committee. The Board’s assurance committees, it did weeks 1 to 3 comprise separate Feedback from the review will be was developed together with the and any discrepancies discussed Director of Nursing and Quality is result in changes to the operational divisional board meetings, the used to further develop and improve establishment of weekly task-force with the medical staff and changes the executive director with delegated management of the hospital with the Combined Board meets monthly the governance of the divisional meetings. made at that point. In addition a responsibility for the coordination, creation of three Divisional Boards and comprises the executive team structure. The second visit was on 7 January multidisciplinary Trust-wide audit implementation and evaluation of and a Combined Board which follow and the senior teams from the three and 8 January 2014 which was a of clinical documentation to review a four-weekly meeting structure as divisional boards. The Combined Formal evaluation of the Board risk management systems Trust-wide. during its public and confidential follow-up visit to review the previous compliance was carried out. An follows: Board is the senior management The Trust uses the National Patient board meeting was undertaken in non-compliance issues identified in action plan and working group was decision-making group of the Safety Agency 5X5 risk matrix • Week 1: Divisional Board Clinical July 2013 by the Trust Development June 2013 and included a review of established to lead on the changes hospital with responsibility for the to assess the likelihood and Governance and Authority. The Board reviewed the following Essential Standards: required. implementation and delivery of the consequence of all risks on the Trust Risk Management Meeting. the feedback provided from the • Outcome 2: Consent to care and The action plans from Care Quality Hospital’s strategic direction, business Risk Register: • Week 2: Divisional Board plan and associated objectives, observation and there were no treatment. Commission visits are monitored Risks scoring 15 and above (strategic) Operations and Performance standards and policies to ensure the significant issues arising as the • Outcome 4: Care and welfare of by the Healthcare Governance migrate to the Board Assurance Meeting. delivery of safe, high quality, patient- Board works to continuously evolve people who use services. Committee which provides assurance Framework (BAF) and thereby • Week 3: Divisional Board centred care. Terms of reference for its practices. The Board continued on progress to the Trust Board • Outcome 9: Management of inform the Trust Board agenda. The Development session for the divisional and combined boards to assess itself and make progress through its highlight reports. medicines. following risks were reported in members (including patient were approved by the Trust Board. against the Board Governance the Board Assurance Framework in feedback). The Combined Board reports to Assurance Framework during the • Outcome 14: Supporting 2013 / 14 and were reviewed by the the Trust Board on a monthly basis year. A board development provider workers. • Week 4: Combined Board was selected during the course of Trust Board: Meeting. through a highlight report and minutes and through its members the year and a development session raising key issues as required. The was held in December 2013. In addition to the Board Governance Framework, the Trust has continued to assess itself during the year against the Quality Governance Framework.

Diabetes Inpatient Team Ellen Farrance, Bergholt Ward Nominee: Team of the Year Award Nominee: Living the Values Award

46 47 Annual Report 2013 / 14 Annual Report 2013 / 14

2013 /14 Governance Statement 2013 /14 Governance Statement

The Trust’s approach to risk and procedures, controls and has continued in 2013 / 14. Further Likelihood score management has been made reporting mechanisms, deterrent work to improve risk processes Table 1: available to all staff and risk and disciplinary actions) will differ commenced in the fourth quarter 5X5 Risk Matrix 1: 2: 3: 4: 5: management information is included and be prioritised according to of the year with a review of the risk Rare Unlikely Possible Likely Almost Certain in Trust induction training and the severity of the risk involved; management processes within the 5: Catastrophic 5 10 15 20 25 subsequent updates. Staff also • Assessment of the level of Trust. This has included a review of undertake mandatory training such residual risk – This is the the Board Assurance Framework risk 4: Major 4 8 12 16 20 as manual handling, resuscitation, assessment of the effectiveness identification process and reporting infection control, and fire safety mechanisms together with a review 3: Moderate 3 6 9 12 15 of the controls that are already in and, depending on their role, of the risk register carried out at score place and revised ones that are 2: Minor 2 4 6 8 10 additional competency training in being implemented following the Board Seminar Meetings in March

Consequence risk management as required by the and April 2014. Changes to risk 1: Negligible 1 2 3 4 5 identification of a perceived risk; NHS Litigation Authority. and reporting at Board level in the year The way in which risk is identified, have included the introduction of • Review and challenge – The information on the operational risks evaluated and controlled within the Trust monitors and reviews all • Lack of suitable environment to • Risk to financial sustainability of services or the future of the Trust scoring 15 and above. Trust is based on the following cycle: reported risks, using the same provide day unit cancer services. the Trust. Risk included on BAF in as a standalone organisation. Risk • Identification and reporting methodology as outlined above The Trust formally investigates all Risk remains on the BAF. July 2013 and remains. included on BAF in May 2014. of risk – Identification of the to ensure that controls remain serious clinical incidents (Serious • Pharmacy chemotherapy service • Impact on patient care due to • If there is no effective plan for risks facing the Trust, working in effective and robust. Incidents Requiring Investigation – at risk due to poor condition patient flow and capacity issues the known reduction of junior SIRIs), reports their findings via the a way that spreads the workload A register of identified risks facing of unit exceeding capacity. Risk within the Trust. Risk removed doctor placements there is a risk Risk Management Committee and and ensures that the initial the Trust is in place. This details risk remains on the BAF. from BAF in September 2013. to the delivery of healthcare. Risk identification of risk is not too follows up on all actions agreed as issues, severity of risk, controls in part of the outcome of the report. • Upgrade ageing lift with • Financial and reputational impact included on BAF in May 2014. onerous; place and agreed action plans. It has The Board receives a report at each associated risk of failure in of inability to meet operational The Risk Management Committee • Calculation of the importance been developed by the identification meeting on Serious Incidents, high Maternity block. Risk removed standards / key performance reviews, validates and monitors of each identified risk – and assessment of risks at a local level complaints and claims. from BAF in June 2013. indicators in Emergency all aspects of risk reporting and Achieved by undertaking an level within the Trust. All principal The Directors of the Trust are • Financial risk of Strategic Health Department. Risk included on assurance, and reports to the assessment of the ‘likelihood’ risks are subject to a continuous required to satisfy themselves that Authority delay in awarding BAF in September 2013 and Healthcare Governance Committee. of the risk occurring and process of review and validation the Trust’s annual Quality Account contract to Transforming removed in January 2014. The Trust’s Risk Management determining the ‘consequences’ by Divisions, and the Trust’s Risk presents a balanced picture of the Pathology Partnership. Risk • If there are changes to clinical Strategy states that risk management should the event occur, using Management Committee. Trust’s performance over the period removed from BAF in June 2013. commissioning which reduce is the responsibility of all managers a matrix based on the National Work started in 2012 / 13 to covered and the performance activity or increase cost of and staff, whatever their position Patient Safety Agency risk matrix; • Successful Foundation Trust align risks to the three assurance information reported in the Quality provision of services this could within the Trust and that staff will be application. Risk included on BAF • Confirmation or introduction committees via the NPSA domains Account is reliable and accurate. In impact on clinical / financial provided with adequate education, in May 2013 and removed in of controls and mitigating and to the Trust’s strategic objectives doing so, we are required to put in June 2013. sustainability of a number of training and support to enable them actions – This stage of the cycle to meet this responsibility. Managers aims to confirm or introduce are expected to incorporate risk specific controls to deter and management into all aspects of their prevent the materialisation work, from business planning to of identified risks. These local induction and training of staff, controls (for example, policies and to identify the risk management training needs of all their staff, especially as new staff join and are inducted.

Lynne Liffen, Emergency Department Theresa Hazelton, Haughley Ward Nominee: Living the Values Award Nominee: Living the Values Award

48 49 Annual Report 2013 / 14 Annual Report 2013 / 14

2013 /14 Governance Statement 2013 /14 Governance Statement

place a system of internal controls a Serious Incident Requiring members of staff with no legitimate The Trust maintains a robust During 2013 / 14 the Trust has Review of the Effectiveness over the collection and reporting of Investigation and reported to the relationship. Information has then response to incidents that occur demonstrated good performance of Risk Management and information included in the Quality Information Commissioner’s Office been divulged to third parties. The which includes the appropriate use against the key performance Internal Control Account. The Board has been actively on 10 July 2013 (ICO Reference patient affected was informed by the of human resources policies. indicators. Key achievements this involved in the preparation of the Number PCB0503894). Details of Trust. year include: As Accountable Officer, I have Actions taken to mitigate future Trust’s annual Quality Account medical conditions of five patients responsibility for reviewing the In February 2014 the Trust identified incidents include a broadcast sent • Full year compliance at 95.83% and the proposed improvement had been accessed by a member of effectiveness of the system of a level 2 information governance to all staff reminding them that the across 2013 / 14 with the priorities for the coming year. The staff with no legitimate relationship. internal control. My review is breach which was reported as only records they can legitimately 95% threshold for Accident & Trust has consulted widely on its Information has then been divulged informed in a number of ways. The a Serious Incident Requiring Emergency 4-hour waits. quality priorities with internal and to third parties. The patients affected access are in relation to their Head of Internal Audit provides Investigation and reported to the external stakeholders, who have were all informed by the Trust. work, all Central Bank staff are to • Compliance across the 18-Week me with an opinion on the overall Information Commissioner’s Office receive information governance admitted 90.5% and non- arrangements for gaining assurance an opportunity to comment on the In November 2013 the Trust on 18 February 2014 (ICO Reference training at Corporate Induction. All admitted 97.9% and incomplete through the Assurance Framework programme. identified a level 8 information Number PCB0532006). Details of information security incidents are thresholds 97.3% across the and on the controls reviewed as part governance breach which was medical conditions of one patient graded and reported according to 2013 / 14 reporting year at a Trust of Internal Audit’s work. His opinion Data security reported as a Serious Incident had been accessed by members of the Trust’s Serious Incidents Requiring level. is that the overall arrangements Requiring Investigation and reported In 2013 / 14 the Trust achieved a staff with no legitimate relationship. Investigation Policy. This enables provide satisfactory assurance that to the Information Commissioner’s • Compliance across the 2-Week, satisfactory assessment at 83% for Information has then been divulged learning to result from any incidents. there is a generally sound system Office on 25 November 2013 (ICO 31-Day and 62-Day Cancer its information governance assurance to third parties. The patient affected The Trust’s Information Management of internal control in place in the Reference Number ENF0521850). A Treatment targets across under the Information Governance was informed by the Trust. and Technology strategy is focussed areas reviewed, and the controls are redundant printer was sent to a third 2013 / 14 as a reporting year. Toolkit. In February 2014 the Trust identified generally being applied consistently party for recycling. The printer tray on a paper-light organisation and • The Trust also exceeded its and effectively. However some areas The Trust had four data security hadn’t been emptied and contained an information governance breach includes the use of Lorenzo Regional C.difficile trajectory for no more for improvement were identified. breaches that were reported to the clinical paperwork of 154 patients. (level yet to be determined) which Care, Evolve Mobile, scan-on- than 21 cases in 2013 / 14 with Information Commissioner’s Office The patients affected were informed was reported as a Serious Incident demand medical records service and 23 cases although three of these Only limited assurance could be during 2013 / 14. In 2014 / 15 to date by the Trust. Requiring Investigation and reported managed print services. The Chief cases were upheld following provided on the controls in three two breaches have been reported to the Information Commissioner’s Information Officer has attended areas: pharmacy stock control In December 2013 the Trust appeal. to the Information Commissioner’s Office on 2 May 2014 (ICO the Audit Committee to provide account reconciliation, outpatient identified a level 2 information • The Trust did not achieve its Office. Reference Number COM0539980). an overview of information and outcomes forms and complaints. governance breach which was MRSA trajectory of no more A Child Health handover sheet information technology assurance. Management have taken action to Three breaches related to paper- reported as a Serious Incident than zero cases in year, recording relating to 21 patients was found in resolve the pharmacy stock control based data loss and the other three Requiring Investigation and reported Performance against national one case across 2013 / 14. The a hospital corridor and handed in by account reconciliation and the related to staff inappropriately to the Information Commissioner’s priorities set out in the NHS Trust also failed to achieve the a member of the public. outpatient outcomes forms during accessing personal data. They were: Office on 4 February 2014 (ICO Constitution 2013 / 14 99% compliance required on the year and the actions have now Reference Number ENF0529590). In April 2014 the Trust identified diagnostic tests undertaken In July 2013 the Trust identified been completed. The audit on Details of medical conditions of an information governance breach within six weeks due to problems a level 3 information governance complaints was conducted in the last breach which was reported as one patient had been accessed by (level yet to be determined) which across the Quarter 2 and 3 of was reported as a Serious Incident 2013 / 14 achieving 97.9%. Requiring Investigation and reported to the Information Commissioner’s Office on 15 April 2014 (ICO Reference Number COM0538295). A Neonatal Unit handover sheet relating to 20 patients was found in the street in Ipswich town centre.

Sally Talbot, Acute Medical Unit John Decroo, Bergholt Ward Highly Recommended: Support Colleague of the Year Award Nominee: Support Colleague of the Year Award

50 51 Annual Report 2013 / 14 Annual Report 2013 / 14

2013 /14 Governance Statement 2013 /14 Governance Statement

quarter of the year and action plans for Foundation trainees at night in of internal control by the Board, As a result of my review I disability), and usually preventable Workforce Steering Group (MWSG) to resolve the issues raised will be Medicines and Surgery. A Health Combined Board, Audit Committee, consider the following items if the available measures have been continues to meet on a monthly addressed in 2014 / 15. In addition to Education East of England action Healthcare Governance Committee, to be significant issues and implemented by healthcare. One basis. At the meeting on 21 March the Head of Internal Audit opinion, plan was put in place in April 2013 Finance and Performance Committee therefore warrant further case involved peri-operative care for 2014, the Divisional Clinical Directors the Audit Committee Chair provides and progress was monitored by the and Risk Management Committee as disclosure: surgery (February 2014). A second and Heads of Operations were the minutes together with a brief Medical Education Forum, Strategic part of our approach to integrated The external auditors have issued an case involving a retained needle confident that job planning within summary highlighting areas for the Education Board and the Healthcare governance. In summary, the unqualified opinion on the annual tip (March 2014) has been initially their areas would be concluded by Board’s attention following each Governance Committee and Board reviews the Board Assurance financial statements and a qualified classified as a Never Event and is mid-April 2014. Progress updates committee meeting to the next Board reported to the Trust Board regularly Framework and receives minutes value for money conclusion. The subject to ongoing investigation. received since this meeting have Meeting in public. throughout the year. By the end of and highlight reports from the qualified conclusion is by exception Neither case resulted in serious harm identified that further work is still During the year the Trust November 2013 the majority of the Audit Committee, Healthcare and relates to securing financial to a patient. The Trust will ensure required in some specialties. Whilst continued its work to ensure audit action points had been achieved with Governance Committee and Finance resilience and economy, efficiency that it implements all learning points it is recognised that job planning recommendations were closed down the remaining ones subjected to close and Performance Committee. and effectiveness. There were two from the investigations. Changes discussions are ongoing, this has in a timely manner with the Audit scrutiny and monitoring to ensure The Audit Committee reviews the reasons for this conclusion. In respect implemented will be regularly not yet resulted in the submission Committee giving specific focus to sustainability before being rated underlying assurance processes and of 2014 / 15 cost improvement audited to ensure they are sustained of 2013 / 14 job plans. A review by this. Improvements in process have green. the effectiveness of the management plans (CIPs), at the time of the and become embedded. speciality and by consultant will be been made during the year with Executive directors and managers of strategic risks. A key role of the audit schemes had been identified Last year’s statement highlighted undertaken at the MWSG meeting responsibility for the management within the organisation who have Healthcare Governance Committee to the level of £13.2m of a target as a significant issue an internal on 23 May 2014 and an action plan of internal and external audit responsibility for the development is to review action plans to mitigate of £14.3m, representing 92% of audit report on the quality of developed and agreed. This will recommendations moving to the and maintenance of the system of risks identified. It is assisted in the anticipated savings needed for consultant job plan (weekly diary be monitored on a weekly basis by Finance Department and further internal control provide me with this role by the Risk Management 2014 / 15. £1.1m of savings are yet plans) records that had resulted in members of the MWSG. actions have been agreed to improve assurance. The Board Assurance Committee which identifies to be identified, costed and quality limited assurance and a number the process. Every month a report is Framework itself provides me with operational risks and ensures that assured. In addition the Trust has of recommendations including Accountable Officer: prepared by the Finance Department evidence that the effectiveness of local controls are in place to manage not met its statutory target to break one high priority recommendation Nick Hulme these. The executive directors and for the Audit Committee. The report controls that manage the risks to the even over a five-year period, with that the job planning process for Organisation: clinical divisions have a key role in highlights any recommendations organisation achieving its principal a cumulative deficit remaining of 2012 / 13 should have been fully The Ipswich Hospital NHS Trust which have passed their due date, objectives have been reviewed. My managing risks, monitoring the £3.4m. completed by December 2012. In control environment and ensuring Signature: listed by division. The report indicates review is also informed by comments An underlying £8m deficit was reviewing the job planning processes new recommendations which have in reports and other feedback from that risks are escalated to produce it had become clear that the a Board Assurance Framework identified in Quarter 3 2013 / 14. been closed during the reporting Internal Audit, External Audit, NHS As a result the Trust has declared proposed dates were not consistent period. This remains an ongoing Litigation Authority for NHS Trusts, for Board review. The internal with the scale of review, capacity auditors provide independent a financial strategy to return to improvement priority to ensure that NHS Litigation Authority for Maternity breakeven in 2015 / 16, with a planned approach and team job internal audit is embedded as a Services and internal Trust updates on assurance on the application of plan approach. Progress has been Date: governance, internal control and risk planned £4.9m deficit in 2014 / 2015. management tool. progress against the action plans from The Trust has received £7.5m of monitored throughout 2013 / 14 by 05 June 2014 various internal and external reviews management. The external auditors the Audit Committee. The Medical A significant issue raised within provide independent assurance in non-recurrent commissioner support last year’s statement relating to of internal control and from the from NHS England to support the Care Quality Commission. I also take respect of statutory accounts and the outcome of a Midlands and value for money. continuity of services in 2013 / 14. East Multiprofessional Deanery into consideration reviews by other external bodies including the Ipswich Two Never Events have been notified performance and quality assurance and investigated during the year. visit in March 2013 as part of a Hospital Users Group, the Ipswich and East Suffolk Clinical Commissioning Never Events are classified as adverse scheduled two-yearly cycle has been events that are unambiguous (clearly addressed during the course of Group, Suffolk County Council Health Scrutiny Committee, Healthwatch identifiable and measurable), serious 2013 / 14. The decision of the Deanery (resulting in death or significant in relation to medical education Suffolk, the Trust Development and training had been met with Authority and the Department of conditions. The conditions related to Health patient safety issues in the Emergency I have been advised on the Hannah English, Gynaecology Sister Department and their relationship implications of the result of my review Nominee: Emerging Leader Award to training, supervision and support of the effectiveness of the system

52 53 Annual Report 2013 / 14 Annual Report 2013 / 14

2013 /14 Governance Statement 2013 /14 Governance Statement

Head of Internal Audit Roles and responsibilities The organisation’s Assurance The Head of Internal Audit The overall opinion level categories The range of individual opinions Framework should bring together all used by CEAC as set out on the next Opinion on the Effectiveness The whole Board is collectively Opinion arising from risk-based audit of the evidence required to support page, and are consistent with the of the System of Internal accountable for maintaining a sound assignments, contained within the AGS requirements. The purpose of my annual HoIA assurance level categories assigned system of internal control and is Control at Ipswich Hospital Opinion is to contribute to the to each audit throughout the year risk-based plans that have been responsible for putting in place In accordance with NHS Internal Audit NHS Trust for the Year Ended assurances available to the 2012/13. These assurance levels reported throughout the year. arrangements for gaining assurance Standards and Public Sector Internal Accountable Officer and the Board 31 March 2014 have been developed considering The risk-based plan was constructed about the effectiveness of that overall Audit Standards, the Head of Internal which underpin the Board’s own the Department of Health’s (DH) from the Assurance Framework and system. Audit (HoIA) is required to provide assessment of the effectiveness of an annual opinion, based upon and guidance (Gateway Approval Number: Risk Registers, essential audit coverage The Annual Governance Statement the organisation’s system of internal limited to the work performed, on the 15460) and are embedded in CEAC’s of fundamental systems, other areas (AGS) is an annual statement by the control. This Opinion will in turn assist overall adequacy and effectiveness of quality manual. For the purposes of of client concern, accumulated Accountable Officer, on behalf of the the Board in the completion of its the organisation’s risk management, clarification, the overall opinion of internal audit knowledge and Board, setting out: AGS. control and governance processes (ie Good would be included in the DH’s experience and other risk assessment • how the individual responsibilities the organisation’s system of internal My opinion is set out as follows: definition of Significant Assurance. processes (audit needs assessment). of the Accountable Officer control). This is achieved through 1 Overall opinion; The commentary below provides the The plan is monitored by the Audit are discharged with regard to a risk-based plan of work, agreed context for my opinion and together Committee who have been effective in 2 Basis for the opinion; maintaining a sound system of with management and approved with the opinion should be read in its discharging their duties in accordance internal control that supports the by the Audit Committee, which 3 Commentary. entirety. with the Audit Committee Handbook. achievement of policies, aims and should provide a reasonable level of My overall opinion is that The effectiveness of the controls objectives; assurance, subject to the inherent Satisfactory assurance can be given The design and operation of operating in each system examined limitations described below. • the purpose of the system of as there is a generally sound system the Assurance Framework has been rated according to the scheme set out below. internal control as evidenced The opinion does not imply that of internal control in place in the and associated processes. by a description of the risk Internal Audit have reviewed all areas reviewed, and the controls are There have been no limitations of management and review risks and assurances relating to generally being applied consistently An Assurance Framework has been scope or coverage placed upon processes, including the Assurance the organisation. The opinion is and effectively. However some areas established which is designed and internal audit work during the year. Framework process; substantially derived from the conduct for improvement were identified. operating to meet the requirements of the 2013/14 AGS and to provide • the conduct and results of the of risk-based plans generated from a The basis for forming my opinion is reasonable assurance that there is an review of the effectiveness of the robust and organisation-led Assurance as follows: effective system of internal control to system of internal control including Framework. As such, it is one 1 An assessment of the design and manage the principal risks identified any disclosures of significant component that the Board takes into operation of the underpinning by the organisation. control failures together with account in making its AGS. Assurance Framework and assurances that actions are or will supporting processes; and be taken where appropriate to Rating Explanation of Rating address issues arising. 2 An assessment of the range of There is a sound system of internal control in place, and the controls Excellent individual opinions arising from are being consistently and effectively applied in all the areas reviewed. risk-based audit assignments There is a generally sound system of internal control in place in contained within internal audit Good the areas reviewed, and the controls are generally being applied risk-based plans that have been consistently and effectively, with only minor improvements identified. reported throughout the year. This assessment has taken account of There is a generally sound system of internal control in place in the areas reviewed, and the controls are generally being applied the relative materiality of these Satisfactory consistently and effectively. However some areas for improvement areas and management’s progress were identified. in respect of addressing control weaknesses. There are weaknesses within the system of internal control, and/or Limited key controls are not being applied consistently or effectively in the 3 Any reliance that is being placed areas reviewed, which may adversely impact on the organisation. upon third party assurances. Serious weaknesses in the design and/or, inconsistent or ineffective Carol Bolton, Ear, Nose and Throat Department Unacceptable application of controls in the areas reviewed, which may adversely Highly Recommended: Support Colleague of the Year Award impact on the organisation.

54 55 Annual Report 2013 / 14 Annual Report 2013 / 14

2013 /14 Governance Statement Declaration of Interests

The following table (right) contains Principal Declaration of Interests 1 April 2013 to 31 March 2014 my opinion of the work carried Assurance and Relevant Audit Reports Objective out by Internal Audit during the Ann Tate • Governor of Rattlesden CEVC Primary School year on the effectiveness of the Safe, reliable, Good assurance Chair management of those principal risks personal and Alan Bateman • Paid employee of Sailstone Ltd identified within the organisation’s 13/06 Safeguarding Children responsive Non-executive Director Assurance Framework. On this basis 13/08 Clinical Effectiveness – Evidence-base Practice emergency care, Laurence Collins • Vice Chairman of Gymnastics in Ipswich it is my opinion that for the identified Satisfactory planned care, Non-executive Director (from 01 / 04 / 2013) • Governor of Rushmere Hall Primary School, Ipswich principal risks covered by Internal maternity and 12/09 Patient Property Audit work the Board has the Andrew George • Director of Suffolk Mind children’s care 12/24 Waiting List Management – ALL follow-up Non-executive Director • Interest in a property syndicate (offices in Diss and Eye) following assurance (see table, right): 13/02 CQC Essential Standards – Monitoring • ‘Independent Person’ for various councils in Suffolk Areas that have been reviewed by 13/03 Management of Records Julia Holloway • Paid employee of Geoff Holloway, Independent Financial Advisor Internal Audit through the year but Non-executive Director (to 31 / 05 / 2013) • Trustee – Age UK Suffolk 13/04 Patient Safety – Staffing are not reflected in the Assurance Rajan Jethwa • Chief Executive Officer of Microtest Matrices Ltd Framework are detailed in the 13/16 Cancer Waiting Lists Non-executive Director (from 02 / 09 / 2013) • Sole Director of the Erudite Evaluation Ltd following table. 13/17 Pharmacy – Stocks Management Tony Thompson • Paid employee in Parasol Ltd 13/23 Information Governance Toolkit Non-executive Director • Trustee for the Melton Trust • Elected Councillor and Chair of the Finance, Employment and Risk Management Audit Area Assurance 13/20 Network Review Committee of Melton Parish Council Limited Nick Hulme • Nil 13/14 Serco Baseline Advisory 12/26 Outpatients – Outcome Forms Chief Executive (From 01 / 04 / 2013) Methodology 13/18 Complaints Margaret Blackett • Paid employee / partner and substantial financial interest in Blackett Sharp Ltd Interim Director of Transformation • Member of executive committee and substantial financial interest in Britannia Workforce Satisfactory (to 23 / 08 / 2013) Sailing School Ltd Developments Reliance placed upon third 13/09 Monitoring Sickness Absence Barbara Buckley • Nil Medical Director (from 03 / 02 / 2014) party assurances. Effective Excellent Clare Edmondson • Partner – Badwell Ash Holiday Lodges Financial Account has also been taken of the 12/23 Income Director of Human Resources Management results of work carried out by the Good (Part-time from 27/09/13, full-time from 01/11/2013) Trust’s Local Counter Fraud Specialist 13/05 Car Park Income Julie Fryatt • Motor home rental business trading under the name Sunrise Motor Homes during the year. 13/07 Patient Finances Director of Human Resources (to 31/10/2013) Foundation Trust Director (from 01/11/2103) Name: N Abbott Satisfactory Date: May 2014 Mary Leadbeater • Director of Esther Troy Ltd 12/20 Procurement Interim Director of Finance and • Trustee of Asthma UK Head of Internal Audit 13/11 Payroll Performance (to 07/06/2013) • Member of Asthma UK Finance and Audit Committee 13/13 Clinical Coding • Director of Caxton Foundation • Chair of Caxton Foundation Audit Committee 13/19 Financial systems Rob Mallinson • Nil 13/24 Capital Programme Monitoring Medical Director (from 01/04/2013 to 02/02/2014) Limited Neill Moloney • Director of Casemix Ltd 13/17 Pharmacy Stock – Control Account Chief Operating Officer (from 15/07/13) Paul Scott • Nil Director of Finance and Performance (from 06/06/2103) Lynne Wigens • Visiting Senior Fellow – University Campus Suffolk Director of Nursing and Quality / • Series Editor – Cengage Publishing (Nursing & Healthcare Texts) Director of Infection Prevention and Control

56 57 Annual Report 2013 / 14 Annual Report 2013 / 14

Glossary of Terms Thank You To...

• All the staff of The Ipswich Hospital NHS Trust Glossary of Terms • All our volunteers The Ipswich Hospital NHS Trust • Referred to as ‘the Trust’, ‘the hospital’ or ‘we’ throughout this report. • All our patients and visitors

CCG • Clinical Commissioning Group • Fundraisers throughout the community – individuals, families and organisations NHS • National Health Service • The Ipswich Hospital Band

GP • General Practitioner • The Ipswich Hospital Community Choir • Hospital Radio Ipswich DH • Department of Health • The media – Ipswich Star, East Anglian Daily Times, BBC Radio Suffolk, Heart, Town 102, BBC Look East, ITV Anglia • Health colleagues in the east of England

This report was compiled by the hospital’s Communication team and designed by the Design and Print team.

Sally Matthews, Saxmundham Ward Joint Highly Recommended: Living the Values Award Radiotherapy VERT Team Nominee: Clinician of the Year and Innovator of the Year Award Highly Recommended: Innovator of the Year Award

58 59 Find out more about the hospital by visiting our website at www.ipswichhospital.nhs.uk or find us on Twitter: @IpsHos

Further copies of this report are available from: The Press Office (N057) The Ipswich Hospital NHS Trust Heath Road Ipswich Suffolk IP4 5PD Tel: 01473 704770 Email: [email protected]

This Trust is working towards equal opportunities.

Published: Summer 2014

DPS Ref: 01200-14 © The Ipswich Hospital NHS Trust, 2014. All rights reserved. Not to be reproduced in whole, or in part, without the permission of the copyright owner.