1. Our Year Royal Devon and Exeter NHS Foundation Trust 1 RoyalAnnual Devon Report andand Accounts Exeter 2012/13 NHS Foundation Trust

Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Royal Devon & Exeter NHS Foundation Trust Annual Report and Accounts 2012/13 Presented to Parliament pursuant to Schedule 7, paragraph 25(4) of the National Health Service Act 2006

2 Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Annual Report and Accounts 2012/13

Presented to Parliament pursuant to Schedule 7, paragraph 25(4) of the National Health Service Act 2006 Contents1. Our Year Royal Devon and Exeter NHS Foundation Trust 3 Annual Report and Accounts 2012/13

Contents

Section 1: Our Year 5 Chairman's Introduction 6 Chief Executive's Introduction 8 About the RD&E 12  Highlights of the Year 14

Section 2: Our Trust 25 Directors' Report 26 Our Business 40 Patient Care and Quality Improvements 42 Our Staff 44 Sustainability Report 51

Section 3: Quality Report 62 Quality Report 2012/13 63 Independent Auditor's Report on the Annual Quality Report 64

Section 4: Our Governance 67 Board Effectiveness and Evaluation 72 The Board of Directors 75 Remuneration Report 80 Audit Committee 89 Compliance with the NHS Foundation Trust Code of Governance 91 Annual Governance Statement 92 Quality Governance Reporting 98 Regulatory Ratings/CQC Reports and Response 98 Disclosure to Auditors and Further Disclosures 100

Section 5: Our Governors and Members 101 Council of Governors 102 Governor profiles 112 Our Governors 2012/13 116 Our Members 121

Section 6: Our Finances 134

4 1. Our Year Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13 Royal Devon and Exeter NHS Foundation Trust 5 Annual Report and Accounts 2012-13 1Our Year 6 1. Our Year Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Chairman's Introduction

Welcome to our new Annual Report, Quality Report and Accounts 2012/13.

I joined the Trust as Chairman at what in the hands of GP Clinical Whole-system is a particularly interesting time for Commissioning Groups, from 1 April the NHS – never before in its 65 year 2013. Innovations in technology and approach history has it faced such significant treatment, an ageing population and Our population demographic in the changes and challenges. increasing expectations mean that the area we serve is older than the UK NHS is being asked to deliver more than This year has been a period of average, so a higher percentage of our ever before. At the same time the health transition as we prepared for new patients are frail, older people, with service has to save £20 billion by 2014 organisational structures, which, often complex health needs, who need and much of this saving will be focused among a raft of changes, included a longer than average hospital stay. This placing the majority of commissioning on acute hospitals like the RD&E. places huge pressure on our capacity, particularly over the winter months. This year, as well as investing in two new wards for frail older patients, we worked with our partners across the health community to take a whole-system approach to meeting the challenge of ensuring sufficient capacity. We know that sometimes people come to the Emergency Department of their local hospital when a pharmacist or GP could help them. At the other end of the patient journey, when people are well enough to leave hospital, and where they may need further rehabilitation in a care home or additional support at home, ensuring they are able to leave acute care in a way that is appropriate and safe is also challenging. Yet we know that supporting patients in this way, when they no longer need to be in an acute hospital setting, is better for them as well as more financially efficient. By planning and responding jointly with our colleagues in primary care, social services and public health, we were able to deliver much more integrated healthcare and make better use of our limited resources. This approach 1. Our Year Royal Devon and Exeter NHS Foundation Trust 7 Annual Report and Accounts 2012/13

served us well for our winter planning, Third, we must start to have honest consequences of evolving policy, for though more remains to be done. debates as to how we will spend example in relation to competition. As stated elsewhere in this Report, increasingly scarce resources. In a We are very fortunate at the RD&E that services were stretched at times over time of austerity, how do we balance we have great clinicians, leaders and the winter period, but not to breaking the attachment some people have to support staff, the vast majority of whom point, as in some hospitals. existing facilities even where these are completely focused on doing their may offer less good clinical outcomes We now need to extend that best for our patients each day. or be delivered more expensively? partnership approach more generally. Choices will need to be made: if there During my tenure as Chairman, I The RD&E has to deliver £17 million of is willingness to maintain such facilities, intend to work with our staff, partners savings year-on-year. That’s a significant what other services will we then need and stakeholders to find innovative sum of money. What’s more, we want to reduce or stop? There are no easy solutions and new pathways that to deliver the savings whilst continuing answers to these questions, but over will deliver the sustainable future to maintain, or ideally improve, the the coming years it is precisely these our patients deserve. There will be level and quality of services we offer. trade-offs that will shape public debate. many bumps along the road but I am It’s just not possible to keep taking In my view, it is best to engage in these confident that we will be able to look money out of services whilst costs and debates openly now to jointly develop back with pride on how we achieved demand are increasing. an approach that is right for the much more for less to the benefit communities we serve and avoid the of our communities, staff and other Meeting the inevitable polarisation that can occur stakeholders. challenges once proposals are put on the table. It is my opinion that the best way to First, we need to dispel the myth that ensure a sustainable future for the NHS financial sustainability and high quality is to take a whole-service and whole- clinical care are somehow divorced or system approach. If we allow clinical James Brent even in competition. To provide high leadership to configure truly integrated Chairman quality and safe clinical services we health and social care services, then need to employ sufficient high quality the by-product will be improved staff to operate in a high quality service, greater efficiency and financial We are very fortunate environment; we can only provide savings. Working more closely with our high quality clinical care sustainably if colleagues in Clinical Commissioning at the RD&E that we we as an organisation are financially Groups will be a step towards this, but have great clinicians, sustainable. we will need to go much further and be bold in embracing radical service leaders and support Second, we need to work hard to redesign. make the system more efficient, not staff. only within the hospital walls but in I am keen that the RD&E plays its part the wider system too - and not only in engaging with our communities, in healthcare but in social care also. through our Governors and If we focus solely on making cuts, Members, to debate how we can for example by reducing the ratio of become more efficient and allocate nurses to patients, then the quality of scarce resources to their benefit and care will decline. And we have already do so in an honest and transparent seen from the Francis Report the manner. We must not allow denial of unacceptable and tragic consequences the challenge to deflect us from dealing that can bring. with it and we must be clear on the 8 1. Our Year Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Chief Executive's Introduction

I have been Chief Executive of the Trust for 17 years now, and I can honestly say that the past year has been the most challenging I have experienced in all that time.

I know from my visits around the Trust and discussions with many of our staff that they too are feeling the pressure more than ever before. We are operating in a context of significant change - we serve an ageing population with increasingly complex health needs, our budget is decreasing in real terms year on year, and the NHS is also currently undergoing a major restructure. The publication of the second Francis Report was a stark reminder to all involved in the delivery of patient care of how important it is, particularly in challenging financial times, to keep our focus on delivering safe compassionate care to all our patients. My own experience at the RD&E is that our staff care passionately about our patients and they take great pride in delivering excellent services – whether that’s in frontline healthcare or support services. Every day, great things happen at the RD&E because of our staff and this view is endorsed by feedback from our patients, their families and carers, as well as our regulators. 1. Our Year Royal Devon and Exeter NHS Foundation Trust 9 Annual Report and Accounts 2012/13

for Older People, and 120 nurses One of the highlights of the past year for me was and allied health professionals. This investment was supported by the launch of our Extraordinary People Awards. It other changes, including a new feels really important to share and celebrate the ambulatory care lounge, a dedicated paediatric assessment unit, more dedication, innovation and achievement of our 7-day working and more escalation beds. We also had investment and staff. We will make awards three times a year, support from our partners in other with an annual ‘winner of winners’ ceremony. parts of the healthcare system to make our emergency services as resilient as possible. The investment One of the categories, the ‘Excellent Care Award’, is open to patients has paid off; even with a particularly and carers to nominate individual staff or volunteers who have made a long and harsh winter, we did not difference to them. I have been moved by some of their comments: experience the problems of the “Jane demonstrated that no amount of procedural format can take the previous two years place of genuine nursing care… Jane took the initiative and showed a • Research is a key element of personal commitment and personal concern for me. Wonderful!” securing sustained quality Mr M, Crediton improvement and it was a great “Alison’s ability to listen, to care and to show that I was important as a delight when President of the Royal patient was amazing!” Mrs T, Exeter College of Surgeons, Professor Norman Williams, officially opened “This hard-working, overworked NHS doctor listened, reassured and the Exeter Surgical Health Services mended me. He has lifted a curtain of depression and pain...” Mr B, Crediton Research Unit (HeSRU). This specialist resource brings together a wealth of clinical knowledge and research to improve the care and For me, the highlights of our year Trust, working together, to develop experience of surgical patients. It included: a plan that would ensure safe has a video link from a seminar and effective delivery of care of • The unprecedented levels of room to operating theatres for emergency and waiting list patients. emergency admissions during the teaching and a clinical consultation I am particularly proud of all our winters of 2010/11 and 2011/12 room. The facility supports work staff who worked so hard to deliver meant that services were severely for the National Institute for two complete new wards in time stretched, with planned operations Health Research and strengthens for winter 2012/13. Board approval cancelled and staff overextended. established links with our academic for the £4.5 million project was We made a decision that we could and research partners granted in June, and Ashburn and not tolerate a third winter of Yealm wards opened in December extreme demands and therefore 2012, creating an additional 48 put in place a whole host of medical beds for older people. To measures to enable us to manage staff the new beds, we recruited an the extra demand on services. Our additional consultant in Healthcare response required all parts of the 10 1. Our Year Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

• The excellence of our stroke service the on-going challenge of year-on- was recognised once again with Consultant urological surgeon, year reductions in income. We have a place on the national shortlist commenced a transformation journey John McGrath, and a research for the stroke category in the to help us tackle this task and redesign Care Integration Awards hosted team at the University of our services to make them as safe and by The Health Service Journal and Exeter recently won a highly efficient as possible. the Nursing Times. RD&E staff prestigious grant from Pay is our single biggest area of developed a successful initiative expenditure. One of the challenges to help patients recover from Intuitive Surgical in California, facing us is how to reward our staff strokes in their own homes instead manufacturers of the da Vinci fairly for the vital work they do, of needing to stay in hospital for surgical robot, to fully fund whilst also ensuring the overall pay treatment. Specialist nursing care budget is sustainable. In partnership and rehabilitation is provided to the provision of a second robot at with other organisations in the South same quality as the patient would the RD&E for nine months. This West, as part of the South West Pay have received in hospital, but in the will be used exclusively to run Consortium, we have explored the comfort and familiar surroundings potential for reform of pay, terms of their home studies looking at differences and conditions of service. This work • We took delivery of a £2.5 million in the mental workload, stress has progressed alongside national state-of-the-art surgical robot in and learning curves of novice negotiations on creating a sustainable December 2012, and are now one and expert surgeons. The reward system linked to the changing of only around 20 hospitals in the service and financial environment the UK using robots in complex surgery findings will help inform the NHS operates in. to target prostate cancers. Research wider NHS about the potential Every time we make a decision, it and clinical tests have already benefits of robotic surgery in will be based on the bottom line of confirmed the benefits and safety continuing to deliver safe healthcare of robotic surgery for patients in training the next generation of for our patients and maximising the certain kinds of complex surgery. surgeons safely, within a timely potential of our staff. We already have These benefits include a faster fashion and with technology a successful track record of doing recovery and reduced blood loss, this. I am proud of all our staff and for example that may help them deal more their achievements and I am delighted effectively with stressful aspects to share some of our successes with of surgical procedures. you through the pages of this annual report. The economic environment remains difficult and, as the Chairman highlights in his introduction, we have some tough decisions to make in order to meet our financial Angela Pedder targets. Making savings has become Chief Executive increasingly difficult and will require more radical approaches than we have previously needed to consider to meet 1. Our Year Royal Devon and Exeter NHS Foundation Trust 11 Annual Report and Accounts 2012/13

Leading RD&E soft tissue lumps, in April 2012, Vikram met with me at an outpatients Surgeon wins NHS appointment. He told me one lump Heroes Award had been found as cancerous, a liposarcoma. Amidst the shock he Consultant plastic and reconstructive reassured me that I was in his care and surgeon, Mr Vikram Devaraj, is not to worry. Within two weeks I had an NHS Hero. Nominated for the a three hour reconstructive excision award by one of his patients, Vikram and flap replacement operation. Mr received his certificate from Trust Devaraj then visited me the following Chairman, James Brent. three mornings (two of which he was off duty) when he checked my NHS Heroes was a recognition scheme award but am acutely aware that as condition, healing and drips. His post- launched to coincide with the NHS’ a tiny cog in a huge wheel this could operative assurance, skill of his team 64th birthday in July 2012. It ran until be given to a number of people who and leadership has an individuality mid-September and was designed to also deserve public recognition for that makes him my hero as I am sure celebrate the extraordinary work that their work in the NHS. I also appreciate he is to all his patients and staff.” staff in the NHS carry out every day. hugely the support my patients and On receiving his award, Mr Devaraj colleagues have given me over the last David May, Mr Devaraj’s nominator, said: “I am delighted to receive this 30 years since I qualified.” said: “Following the excision of two 12 1. Our Year Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

About the RD&E

The Royal Devon and Exeter NHS Foundation Trust serves a core population of 400,000 people in Exeter and East and Mid Devon. For some specialist (tertiary) services, we serve a wider population across the south west region.

Most hospital services are provided services), Cancer Services, Renal Research and Care. We lead local from the Wonford and Heavitree Services, Exeter Mobility Centre and research networks for cancer, stroke Hospitals in Exeter, but in partnership Mardon neuro-rehabilitation centre. and diabetes and have become the with other NHS providers we also leading centre for high quality research We pride ourselves on delivering run some services from community and development in the south west continuous improvement through locations including Axminster, Dawlish, peninsula. innovation and clinical research. Honiton, Okehampton, and Tiverton. We are a founder member of the We have nationally and internationally South West Peninsula Academic Did you know we… recognised excellence in a number of Health Science Network and host the specialist fields including the Princess Peninsula Comprehensive Research • Employ almost 6,800 staff Elizabeth Orthopaedic Centre, the Network, the South West Research including more than 1,760 Centre for Women’s Health (maternity, Design Service and the Peninsula registered nurses and 747 neonatology and gynaecology Collaboration for Applied Health doctors • Spent £350 million delivering healthcare in 2012/13 Our Katie is a true • Have more than 115,000 NHS Hero admissions a year

The scheme gave everyone in England • Hold 450,000 outpatient clinics the chance to acknowledge NHS staff. each year For the first time, patients, their friends • Have 810 inpatient beds and families, work colleagues and (including maternity and professional peers nominated their neuro-rehabilitation) and personal NHS Hero. 80 day case beds RD&E oncology nurse, Katie Williams, was nominated by a patient’s daughter. • Have 92 midwives responsible Melody Floyde, Katie’s nominator, said: “My Dad’s last weeks were spent on for more than 3,000 births a year Yeo Ward. Katie is an outstanding nurse who worked tirelessly to ensure that • Achieved all ‘good’ or Dad was comfortable and well cared for and treated him with such kindness. ‘outstanding’ grades in the 2012 She even worked late on one occasion to get advice on pain relief for Dad Ofsted inspection of our hospital when he was uncomfortable. She was a great source of support for us when school we were going through such a difficult time, ensuring we had tea, biscuits, a bed to sleep on and so many words of comfort. She is a true NHS Hero and I will be eternally grateful to her.” 1. Our Year Royal Devon and Exeter NHS Foundation Trust 13 Annual Report and Accounts 2012/13 14 1. Our Year Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Highlights of the Year

Spring 2012 academic and clinical community to RD&E stroke service at the improve health and patient care. forefront of a research study

Demolition work began at our The demolition of the postgraduate Our stroke service was at the forefront Wonford hospital site to make education centre building took around of a research study to reduce the time way for a world-class research three weeks, to allow the building to it takes for patients to receive vital clot- centre be taken down with consideration busting treatment. for local residents living nearby. Every The study is investigating the whole We are working in partnership with effort was made to minimise noise process of emergency treatment that the University of Exeter to create a new and dust pollution. Over 90% of the follows when a person suffers an Research, Innovation, Learning and old building will be recycled as acute stroke from a blocked artery Development (RILD) Centre on site. building aggregate. Interserve Construction is the principal in the brain. For most patients in contractor for the £19.4 million Once building work started, a time this situation, the earliest possible centre which is due for completion capsule was buried in the foundations. administration (thrombolysis) of a clot-busting drug can greatly improve in autumn 2013. Future generations may discover the their chances of recovery. The drug is capsule which included copies of The centre brings together skills, currently licensed for delivery up to our staff newsletter and our annual education and medical research on the three hours from the onset of a stroke, strategic business plan. hospital site and represents the shared but in that time the patient needs to passion and commitment of Exeter’s call an ambulance, get to hospital, 1. Our Year Royal Devon and Exeter NHS Foundation Trust 15 Annual Report and Accounts 2012/13

have a brain scan, and be assessed by specialists before receiving the treatment. Our acute stroke team, radiology department and Emergency Department colleagues have been working with researchers from the University of Exeter Medical School and the ambulance service. By looking at what happens ‘on the ground’, researchers have been able to create computer simulations that imitate the various permutations of stroke victim identification, transport, arrival at hospital and treatment. Analysis of over 1,400 episodes of care has enabled them to identify the bottlenecks in the system, and take steps to speed up the process of emergency care which can lead to earlier clot-busting treatment. The researchers estimate that earlier treatment could treble the number of people whose outcome after a stroke could be greatly improved.

Outpatients rate servicesDr Martinhighly James,aged 16 years RD&E or older were Consultant asked to •Physician Privacy and dignity and Lead Clinician for Stroke share their views about their hospital • Advice on new medication, We have around 450,000 outpatient experience. correspondence for GPs and who to clinic appointments a year and on the acute stroke unit Patients gave their feedback on contact after leaving the hospital if were delighted to learn that we questions about: worried about their condition. scored highly in a survey on patient satisfaction for theseThe services. study is investigating• Appointments the whole processThere isof always emergency room for improvement treatment that follows though, and this year we started According to independent healthcare • Waiting time in clinic an appointment reminder service regulator, the Carewhen Quality a person suffers an acute stroke from a blocked artery in the brain. For most • Cleanliness of the department to reduce the number of missed Commission, patients rate the appointments and help us to see more outpatient clinic servicespatients and standard in this situation,• Information aboutthe testsearliest and possible administration (thrombolysis) of a clot- people more quickly. of care at the Royal Devon & Exeter treatment hospital highly – placing the RD&E in The CQC survey of adult outpatient busting drug can• Caregreatly and communication improve with their chances of recovery. The drug is currently the top 20% of best performing NHS services involved 163 acute and the doctor and other healthcare Trusts in the country. specialist NHS Trusts. licensed for deliveryprofessionals. up to three hours from the onset of a stroke, but in that time the The Emergency Department (A&E) and fracture clinicspatient were among needs the to call an ambulance, get to hospital, have a brain scan, and be hospital departments where patients assessed by specialists before receiving the treatment.

Our acute stroke team, radiology department and Emergency Department colleagues have been working with researchers from the University of Exeter Medical School and the ambulance service.

By looking at what happens ‘on the ground’, researchers have been able to create computer simulations that imitate the various permutations of stroke victim identification, transport, arrival at hospital and treatment. Analysis of over 1,400 episodes of care has enabled them to identify the bottlenecks in the system, and take steps to speed up the process of emergency care which can lead to earlier clot-

Page 13 16 1. Our Year Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13 1. Our Year Royal Devon and Exeter NHS Foundation Trust 17 Annual Report and Accounts 2012/13 Senior managers served afternoon teas and cakes, and for patients with dementia, our nurses made memory cards with images of Queen Elizabeth to prompt Senior managers served afternoon teas and cakes,discussion and for andpatients recognition with dementia, of this special occasion. All staff on duty on 5th June were our nurses made memory cards with images of Queenoffered Elizabeth a free cupcake to prompt courtesy of the catering service. Over 3,000 individual cakes discussion and recognition of this special occasion.were All baked staff on by dutychef Angelaon 5th June Jones. were offered a free cupcake courtesy of the catering service. Over 3,000 individual cakes were baked by chef Angela Jones.

Summer 2012

The summer of 2012 was one to remember for the whole of the country, as we hosted the Olympics and marked the Queen’s Diamond Jubilee. Staff and patients were involved in both the preparations and the celebration for our summer of fun.

Queen’s Diamond Jubilee Being in hospital did not prevent our patients from being able to join the national celebrations of the Queen’s Diamond Jubilee on Tuesday 5 June 2012. Patients on the Kenn and Bovey wards He was nominated to run with the Olympic torch through his home town of at the RD&E Wonford hospital helped staff make paper chains and bunting in Ilfracombe by his father. Thomas was bowled over by the fantastic support he readiness for the big day. Many of the people on these wards were around received from the thousands of people who lined the streets and cheered him on. for the Queen’s coronation and were able to join the Jubilee celebrations with a tea party on the ward. Senior managers served afternoon tea and cake, and for patients with dementia, our nurses made memory Olympic Imaging Services cards with images of Queen Elizabeth to prompt discussion and recognition of this special occasion. All staff onMatron Torchbearer Julie Vale serves sandwiches on Kenn and Bovey Ward duty on 5th June were offered a free RD&E consultant musculoskeletal radiologist Dr David Silver played a key role in the Inspirational RD&E hospital renal himself into major projects including cupcake courtesy of the catering patient Thomas Hack savoured every charity working for a month in Kenya. service. Over 3,000 individual cakes setting up of specialist imaging services for hundreds of international athletes moment when he was an Olympic were baked by chef Angela Jones. He was nominated to run with the The pop of non-alcoholtorchbearer. Bucks The 19-year-old, Fizz corkswho has couldcompeting be heard in the in the2012 haematology Olympic and and Paralympic Games in London. Olympic torch through his home The pop of non-alcoholic Bucks received his renal dialysis treatment at town of Ilfracombe by his father. Fizz corks could becancer heard in the day casethe unit, RD&E where for the past the two waiting years, was lounge was decked out in bunting and a Thomas was bowled over by the Matron Julie Vale serves sandwicheshaematology and oncancer Kenn day case and unit, Boveydiagnosed Ward at the age of seven with buffet spread was laid on for patients and theirfantastic relatives support heby received the Exeter from the Leukaemia where the waiting lounge was decked a form of tissue death (necropathy) thousands of people who lined the out in bunting and a buffet spread was and his kidneys failed when he was Fund charity. streets and cheered him on. The pop of non-alcohol Bucks Fizz corkslaid on could for patients be and heard their relatives in the haematology17. Thomas has not letand his health by the Exeter Leukaemia Fund charity. challenges get in the way of throwing cancer day case unit, where the waiting lounge was decked out in bunting and a buffet spread was laid on for patients and their relatives by the Exeter Leukaemia Fund charity. Page 16

He was one of many NHS professionals who gave up annual leave to volunteer for

this once in a lifetime experience – providing top class healthcare services for competitors in the pre-games training and during the summer Olympics. Page 16

Page 18 18 1. Our Year Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

regularly undertake activities such as workplace risk assessment, health surveillance, stress counselling and medical advice on sickness absence or early retirements.

Pioneering LINX® procedure for severe acid reflux Consultant Upper Gastro-Intestinal (GI) Surgeon, Mr Saj Wajed, carried out a pioneering new surgical procedure at the Olympic Imaging Services Around 200 athletes a day used the RD&E. We were the first NHS hospital in musculoskeletal medical services the UK to offer this innovative procedure RD&E consultant musculoskeletal in the state-of-the-art ‘polyclinic’ for sufferers of Gastro Oesophageal radiologist Dr David Silver played a in the Olympic village. There was Reflux Disease (GORD), a severe and key role in the setting up of specialist multi-million pound investment in persistent form of acid reflux. imaging services for hundreds of the clinic technology – including two international athletes competing in the Most people will experience MRI scanners, a CT scanner and three 2012 Olympic and Paralympic Games uncomfortable symptoms of acid ultrasound machines. These facilities in London. reflux such as heartburn at some are now part of a lasting Olympics point, especially after a large meal. He was one of many NHS professionals legacy, benefitting local NHS patients. For people living with GORD however, who gave up annual leave to volunteer regurgitation and chest pain are just for this once-in-a-lifetime experience – Accreditation is a SW First! some of the uncomfortable symptoms providing top class healthcare services for they have to deal with on a daily basis. competitors in the pre-games training Exeter Occupational Health Service, Other aggravating symptoms of GORD and during the summer Olympics. which is part of the Royal Devon & Exeter NHS Foundation Trust, provides include nausea, coughing and difficulty LOCOG (London Organising a comprehensive range of occupational swallowing – these symptoms can be Committee for the Olympic Games) health services to the RD&E and other severe and persist over time. asked the British Society of Skeletal regional NHS Trusts. It was the first The new LINX® Reflux Management Radiologists to provide expert service in the South West to achieve System is a small, flexible band of musculoskeletal imaging for all athletes Safe, Effective, Quality Occupational titanium beads with magnetic cores and the wider ‘Olympic family.’ A Health Standards (SEQOHS) that is placed around the oesophagus, project committee was set up four accreditation. just above the stomach. It is designed years ago with elected volunteers who to restore the body’s natural barrier are all Society Members. Dr Silver The accreditation standards were to reflux and eliminate the symptoms was elected to this committee and developed in response to a report by associated with GORD. worked with the other members to National Director for Health and Work, set up imaging facilities throughout Dame Carol Black, which examined Until now, if GORD symptoms were the UK and recruit a 116-strong the health of Britain’s working age not relieved by medication, the only volunteer workforce of radiologists, population and the quality of support other option available was a procedure radiographers and radiographic services currently in place. known as fundoplication. This involves assistants. Occupational health is the promotion altering the anatomy of the stomach and maintenance of health and by wrapping part of it around the wellbeing at work and the team oesophagus. 1. Our Year Royal Devon and Exeter NHS Foundation Trust 19 Annual Report and Accounts 2012/13

New technology to speed up infection diagnosis Young Healthcare The RD&E was the first hospital in the Scientist of the Year South West to trial a new microbiology machine called MALDI-TOF (Matrix Dr Tim McDonald was named the Assisted Laser Desorption Ionization). Young Healthcare Scientist of the Year for his work which transforms diabetes There are just nine of the MALDI-TOF screening in young people. machines in the UK which can analyse and identify up to 200 infections every Clinical Biochemist Tim was presented two hours using laser technology to with his award by the then Secretary map key pathogens found in samples. of State for Health, the Rt Hon Andrew Lansley CBE, and Chief Scientific Officer at the Department of Health, Professor Sue Hill OBE, at Westminster The microbiology team manages more Hall in London. Thousands of children and young people will benefit from than 200,000 samples a year for the his innovative work. Tim developed a urine test which can help identify RD&E hospitals, GPs and community the two per cent of young people with a type of diabetes called MODY hospital services. Typically, samples (Maturity Onset Diabetes of the Young) that results from a single faulty gene. arrive in our microbiology labs where Importantly, the treatment of this type of diabetes may involve tablets instead bacterial cultures are developed on of lifelong insulin injections. Genetic testing can give a definitive answer but agar plates. This process can take up is too expensive to use to test all children with diabetes. Tim has developed to 48 hours to complete. The new a non-invasive screening test that can identify children most likely to have facility allows us to make a diagnosis MODY and who can therefore be selected for genetic testing. Tim, who in a fraction of the time, thus enabling works at both the University of Exeter Medical School on the RD&E Wonford clinicians to provide far more targeted hospital site and the clinical chemistry laboratory, worked out how best to do antibiotic treatments which in turn the diagnostic test and created a test kit for the diagnostic assessment. help patients to make a quicker recovery and return home. 20 1. Our Year Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Autumn 2012 Exeter Surgical Health Services Research Unit officially opened Three hospital wards £34,000 grant for national The President of the Royal College have achieved the research project of Surgeons, Professor Norman Williams, officially opened the Exeter highest standard award RD&E Orthodontic Senior Registrar Surgical Health Services Research Unit Ansa Akram secured the highest grant (HeSRU) in September. in recognition of the available from the British Orthodontic Society to carry out research into This specialist resource brings together quality of nursing care the quality of life of youngsters born a wealth of clinical knowledge and they provide. without adult teeth (hypodontia). research to improve the care and experience of surgical patients. This study follows on from the research In addition, General Recovery and The unit facility has a video link from a she did during her Doctorate in Child and Women’s Health Recovery seminar room to operating theatres for Orthodontics which won the 2011 also got gold for a similar assessment teaching and a clinical consultation room. British Orthodontic Society’s national called RQAT, Recovery Quality It supports work for the National Institute award for postgraduate research. Assessment Tool, which provides a for Health research and strengthens measure specifically of nursing practice Hypodontia is a condition affecting established links with partners, including and standards. 5-8 % of the population where the University of Exeter. babies are born without some of their permanent or adult teeth which Consultant colorectal surgeon Professor RD&E achieves UNICEF’s Baby normally replace their baby teeth. Williams was hosted by RD&E Friendly award consultant surgeons and during his visit This becomes apparent during their The Royal Devon & Exeter Centre he heard first-hand about the latest early teenage years. A predominantly for Women’s Health has achieved surgical research being performed in genetic condition, it can have international recognition with the the unit, including work on the early a significant impact on children prestigious UNICEF (United Nation’s detection of surgical complications, ranging from difficulty in eating and Children’s Fund) Baby Friendly award. speaking to being bullied at school. novel developments in surgical 80% of patients will present to their training as well as improvements in We decided to join forces with UNICEF orthodontist at around 11 years of age, the treatment of skin cancer. UK’s Baby Friendly initiative to increase a time of life when having a full set of breastfeeding rates and to improve teeth is so important. Gold standard care achieved care for mothers at all our maternity units including the RD&E, Tiverton, Three hospital wards have achieved This three-year research project aims Okehampton and Honiton. to establish how we can provide the highest standard award in the best possible quality of care for recognition of the quality of nursing Breastfeeding protects babies our patients using all the treatments care they provide. Associate Director against a wide range of serious available across orthodontics and other of Midwifery and Patient Care, Tracey illnesses including gastroenteritis and dental specialities. The RD&E is leading Reeves, said: “To achieve gold in respiratory infections in infancy, as well the project with six other hospitals the Nursing Quality Assessment Tool as allergies and diabetes in childhood. around the UK participating including (NQAT) each ward must score 95% or We also know that breastfeeding Musgrove Park Taunton. more. We are delighted that Wynard, reduces the mother’s risk of some Abbey and Yarty wards have all got cancers. Many mothers give up gold awards following observation of breastfeeding before they want to. This staff activities, feedback from patients award shows that we provide support and checking documentation.” for women to establish breastfeeding 1. Our Year Royal Devon and Exeter NHS Foundation Trust 21 Annual Report and Accounts 2012/13

and to continue to breastfeed for as The Award, given to the RD&E Centre long as they wish. for Women’s Health after a three-stage assessment by a UNICEF team, has The Baby Friendly initiative, set up shown that recognised best practice by UNICEF and the World Health standards are in place. Organisation, is a global programme which provides a practical and effective way for health services to improve the care provided for all mothers and babies.

RD&E Anaesthetist Barry Nicholls from Taunton. These (a former trainee in Exeter) and Mr courses turned into the South West David Wilkinson (an anaesthetic scoops National Anaesthesia Group, SOWRA, as more practitioner in Exeter). consultants became interested in Teaching Award Dr Conn is currently interested learning newer and better anaesthesia in teaching ultrasound guided RD&E Anaesthetics and Pain techniques. SOWRA now runs a regional anaesthesia, because of the Management consultant, Dr David training course for 40 trainees once a improvement in speed and accuracy Conn has won the “B Braun Medical year and an annual scientific meeting. of this technique. Teaching Award”, presented annually Dr Conn’s commitment to his to a clinician who has shown profession and its development goes excellence in regional anaesthesia above and beyond teaching. He teaching and research within the UK. published a handbook of regional Dr Conn was nominated for the anaesthesia in 2003 with Dr Nicholls award by Dr Oldman, a consultant at and Dr Alice Roberts from the Bristol Derriford Hospital in Plymouth. Anatomy Department. He is currently Dr Conn started twice yearly courses co-authoring a textbook on regional in regional anaesthesia in 1996 for anaesthesia for the Oxford University consultants and senior trainees, with Press with Dr Nicholls, Dr Warman 22 1. Our Year Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Winter 2012 John McGrath and the research team are set to find out. They have won a highly prestigious grant from Intuitive Robotic surgery research taking Surgical in California, manufacturers place in Exeter of the da Vinci surgical robot, to look The RD&E is pioneering new research in at differences in the mental workload, robotic surgery, thanks to a partnership stress and learning curves of novice with academics in the University of and expert surgeons. Exeter. To celebrate the beginning of the research programme, and heralding The RD&E is pioneering the launch of prostate cancer awareness month, members of the public were new research in robotic given an opportunity to try their hand at robotic surgery using a demo robot in surgery. the hospital foyer. The findings will help inform the wider During robot-assisted surgery, the NHS about the potential benefits of surgeon sits at a remote computer robotic surgery in training the next console to operate and control four generation of surgeons safely, within robotic arms that carry out the guided a timely fashion and with technology surgery. The surgeon watches and guides that may help them deal more the whole procedure on a high-definition effectively with stressful aspects of computer screen with 3-D vision. surgical procedures. Research and clinical tests have already confirmed the benefits and safety of robotic surgery for patients in certain kinds of complex surgery. These benefits include a faster recovery and reduced blood loss, for example. However, little is known about the benefits that robotically-assisted surgery may offer the surgeon and the operating team in theatre. That’s what consultant urological surgeon, Mr 1. Our Year Royal Devon and Exeter NHS Foundation Trust 23 Annual Report and Accounts 2012/13

Ground-breaking heart research Launch of new surgery unit at RD&E Researchers at the RD&E are leading a research project to develop a better In January 2013 we launched a physical treatment for an abnormal dedicated surgery unit. The facility on heart rhythm. Knapp Ward follows a huge redesign project to create a ward for all surgical The research project is being run admissions, both in-patient and day- in nine hospitals across the South case. Acting as a hub for planned West, with the RD&E being its main surgery taking place at the RD&E, sponsor site. The research is focussed the new unit has 30 patient spaces on a condition called supraventricular allowing staff to manage 50 daily tachycardia (SVT), a heart problem that inpatient admissions and a further causes the heart to beat very quickly 20 day cases. and affects thousands of people around the world. Providing patients and their families with a calm and professional The aim is to improve the effectiveness environment is also very important. of the initial physical treatment for this Coming in for surgery can often be condition and to reduce the number daunting and many of our patients of patients who need to go on to have have to travel long distances for their emergency drug treatment. The trial procedures. The new unit allows us itself does not use any drugs and only to meet their needs more effectively, takes a few minutes to run for each ensuring that doctors see them in of the 370 patients being invited to a timely manner and that we get take part. patients home as soon as we can, once When patients come to hospital they are well enough. with SVT, they can help to get their The unit was also an important part of heart beat back to normal by doing our plans to ease bed pressures during a physical treatment called a Valsalva the busy winter months, ensuring that Manoeuvre (VM) but often this doesn’t we deliver a more structured approach work. Changing the way the VM is for our surgical patients, provide them done might make it better at stopping with the best possible care during their the SVT. That’s what researchers hope time with us, and reduce the number to find out. of cancellations because of medical The trial is being co-ordinated and run emergencies. through the Peninsula Clinical Trials New facilities include a large day room Unit at Plymouth University Peninsula providing a comfortable environment Schools of Medicine and Dentistry, and for patients and their relatives, as well has been funded by a Research for as two new treatment rooms where Patient Benefit Grant from the National patients can be assessed in very private Institute of Health Research. The surroundings. research has been developed with the help of Arrhythmia Alliance and local Research Design Service. 24 1. Our Year Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13 Royal Devon and Exeter NHS Foundation Trust 25 Annual Report and Accounts 2012/13 2Our Trust 26 2. Our Trust Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Directors’ Report

2012/13 has been one of the most challenging years the RD&E, and indeed the NHS, has faced in many years.

The significant changes that have However, the Board is fully and These changes have had a profound been, and continue to be, made to the unequivocally committed to both impact on the way in which the way that healthcare is organised and sustaining and improving services for RD&E operates in that its principal delivered in England, and the funding both current and future generations. customer - the organisation that allocations to support it, will have a purchases healthcare from us – will In doing this, is it recognised that major impact on the way that the NHS change from the beginning of the the continuing support not only of works now and for the next decade next financial year from NHS Devon our Governors, Members and staff but or more. While the full ramifications to the Northern Eastern and Western also our partners in the local health of the financial squeeze and the (NEW) Devon Clinical Commissioning economy will be required. alterations made to the way the whole Group. Inevitably, as one organisation healthcare system operates are not The Board acknowledges that it is only gives way to another, there are yet known, it has become clear during thanks to our highly committed and opportunities to develop new ways of the last year that the Trust will need to dedicated staff – and our Members, working that better meet the needs transform itself if it is to successfully who display such passion for this of patients. But it is also recognised adapt to the changing landscape of organisation – that the RD&E remains that the new system for procuring healthcare provision. in a strong position to not only respond healthcare is complex and will need to the challenges but also grasp the time to establish itself. In addition, the For the RD&E’s Board, the main opportunities that exist to ever improve wider changes in the way the NHS challenges are to ensure that the Trust: our services. That is why the Board is organised (for example, the new • Continues to provide safe, high has continued to develop and refine National Commissioning Board – NHS quality healthcare delivered with its corporate strategy over the last England – and local area teams, the courtesy and respect in a way that year precisely so that it can improve its changes to the role of Monitor, the meets the needs of patients and the “offer” to the communities it serves involvement of councils in the delivery framework set by our regulators now and into the future. We are of public health) will also take time confident that the RD&E is well-placed to bed in. This, inevitably, leads to a • Transforms the way in which its not only to weather the economic degree of uncertainty and disruption as services are delivered so that it can storm but to emerge stronger and the new system evolves. maintain good quality care in a more effective in serving the needs sustainable way in the future. of our communities, but we do not Delivering 'business as usual', while underestimate the size of the challenge The RD&E is well-placed at the same time making some we and the wider NHS face. not only to weather fundamental changes in how we organise ourselves differently and Context the economic storm how we work with others to be able to maintain quality services into the The Health & Social Care Act 2012 but to emerge stronger future, has been the main focus for and the associated changes in the way and more effective in the Board over the last year. The RD&E that the NHS is structured and run, has Board recognises that this is not going progressively come into force over the serving the needs of our to be an easy road. year. More changes enshrined in the legislation will take effect from communities. 1 April 2013. 2. Our Trust Royal Devon and Exeter NHS Foundation Trust 27 Annual Report and Accounts 2012/13

“We have all been shocked at the stories of individual suffering, neglect and abuse that have, with the publication of the Public Inquiry report on Mid Staffs, now been thoroughly exposed. As a nurse, a senior manager, but above all as a human being, it is impossible not to be affected by the litany of failure that was so starkly set out by the families and loved ones of those who some of the powers of the Council of Governors by setting out the nature of received a level of care that was From the beginning of the next the accountability relationship between completely unacceptable. For financial year, the RD&E will be issued the Board and the Council, as well a licence to operate its services by me and for all of us responsible as conferring some new powers to Monitor. The new licence – which for delivering safe, quality care, Governors on issues such as mergers essentially mandates the key services and acquisitions. The new clarity on the publication of the Francis that the Trust provides within the the role of Governors contained in the Report has triggered a chance to context of Monitor's broader role – Act was welcome and, while there replaces the “terms of authorisation” pause and reflect on what now are some changes required in specific that Monitor had previously issued to needs to be done to ensure that areas, such as when Governors may be providers like the RD&E. involved in significant transactions, the the NHS does not allow this to The new Act contains a clause to hold work we have done with Governors happen again.” Board meetings in public from 1 April over the last few years puts us in a Em Wilkinson-Brice 2013. In anticipation of this legislation, good position to accommodate the Chief Nurse/Executive Director of the RD&E Board decided to embrace changes resulting from the Act. Service Delivery openness and transparency by holding The second Francis Report on the Board meetings in public from June unacceptable failure of care at the 2012. The meetings in public allow Mid Staffs Foundation Trust received any member of the public to see considerable media attention during the Board in action as it transacts the year. The Board discussed not only its core business. The meetings are the key issues from the public inquiry now regularly attended by individual but also reviewed the actions it had Governors and they are able to gain agreed to take forward from the first an insight into how the Board operates Francis Report. This enabled the Board which is proving to be very useful in to assure itself that the actions it had their role of holding the Board – and agreed to take two years ago were individual Non-Executive Directors – to appropriate, followed up and actioned, account. but that it also took into account any of The new Act heralded changes in the key lessons from the second report. 28 2. Our Trust Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13 2. Our Trust Royal Devon and Exeter NHS Foundation Trust 29 Annual Report and Accounts 2012/13

Stewardship on amber-red rating by Monitor. our elective patients, particularly in The Board was mindful that tackling orthopaedics, surgery and cardiology, At the same time as navigating the the backlog of patients who had at a level not seen before. At the same RD&E through an increasingly complex breached the 18 week RTT target time, we experienced problems in external environment and coping involved a great deal of hard work discharging patients who were ready with the year-on-year constraints and dedication by staff to ensure to leave hospital but required ongoing on our finances, the organisation that patients were being treated in a care, in a community hospital or other faced a prolonged winter period with timely way. In examining some of the community setting. attendances at an unprecedented causes of the RTT backlog, the Board high. Reluctantly, but in the interest Public health data confirms there will considered what lessons it needed of patient safety, the Board decided continue to be a significant increase in to learn to prevent a similar backlog that priority had to be given to the number of very elderly people in occurring in the future. Performance emergency and urgent patients and, Devon. These demographic changes information has continued to evolve as a consequence, routine surgery was coupled with the wider changes over the course of the year reflecting cancelled or restricted for a significant in the healthcare and social care changes in the governance structures, period of time. This had a knock-on system means the pressures we are greater clarity about what information effect over a period of months on the experiencing are unlikely to recede in was useful to the Board (particularly Trust's Referral To Treatment (RTT) the short term. Enabling patients who in triangulating data and making targets for admitted patients and are able to move out of the hospital connections between financial resulted in a backlog of patients who in an appropriate way, and ensuring information and quality of service) had already breached the 18 week that the wider health and social care and in some of the detail presented to target. The Trust's failure to achieve community develop alternative services the Board (particularly on the Ward to the 18 week RTT target for admitted to reduce the demand on our services, Board reporting) and subsequent “drill patients placed the Trust in a position remains an issue that we will continue downs”. Over the next year the Board in which it was at risk of regulatory to address, working closely with our will continue to develop and refine the intervention by Monitor. CCG and local authority partners. On performance information it receives. the basis of this analysis, and the need Targets are clearly important but the The Government’s plan for health to ensure the Trust did not add to the Board knew that behind the statistics and social services is for more care to backlog of patients not hitting the RTT were real patients having to wait an be delivered close to home, thereby 18 week target, the Board decided unnecessarily long time to receive the reducing the demand on hospital to progress: treatment they required. The Board services and residential care. As took the view that it would ensure • The redesignation of Lowman ward in other parts of the country, our that substantial effort was placed from a surgical day case/admissions partners are still in the early stages of on managing down the backlog of unit to an inpatient medical ward developing this approach and therefore patients but to do this in an ethical and the recruitment of a permanent there has been no reduction in the way, namely to treat those who staffing complement demand for our services. Rather, there had waited the longest first and was a 14% increase in the numbers • The purchase of a 48-bed those whose conditions necessitated of very elderly patients coming modular unit and recruitment of a more immediate treatment. The through our doors over the last year permanent staffing complement. Board approved a plan, agreed with – particularly in the period October Monitor, to manage the backlog into 2011 to May 2012 and an increase a treatment list that was sustainable in the complexity of their cases. This and it is expected that this would be placed real strains on our systems, and cleared by the autumn 2014. As a had significant knock-on effects for consequence, the RD&E was placed 30 2. Our Trust Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

The modular unit includes a: The new facility opened in December • Reports from the Governance 2012, and has helped the Trust Committee on a range of issues • 28-bed medical ward manage winter 2012/13 in a way that such as the Corporate Risk Register • 20-bed short stay rehabilitation has been more sustainable and better and ensuring that exception ward (based on the model for patients. reporting to the Board took place successfully piloted between if action plans were not effective in Longer term, the focus in our strategy November 2011 and April 2012). controlling risk on providing healthcare at home, on This decision was not taken lightly at a more joined up healthcare service • Receiving and debating the Annual a time of real financial constraints. and, ultimately, a smaller acute service, Infection Control Report and action Identifying an investment of £4.6m remains central to the direction of plan. capital and £6m revenue was not travel for the RD&E. The Board also has a stewardship straightforward, but the Board was As well as overseeing the performance over the Trust’s finances. The Business clear that its key priority was to of the Trust as a whole, the Board’s Review in the Our Finances section ensure that patient safety and quality stewardship role entailed looking at (p.130) sets out more details about the was maintained. a number of issues in more detail Trust’s financial and trading position Getting this additional capacity up including: over the year. and running by December 2012, • Regularly reviewing the Patient and ensuring that it was staffed Engagement and Experience appropriately, was challenging. The quarterly reports and reports from staffing issues involved not only local the Engagement & Experience recruitment but also international Committee recruitment to ensure that the Trust had high quality, well-trained staff to undertake the new roles in the new ward areas. 2. Our Trust Royal Devon and Exeter NHS Foundation Trust 31 Annual Report and Accounts 2012/13

Quality of care patient care at the Trust. The For example: programme sets out an ambitious The Board’s principal purpose is to • We are rolling out Comfort Rounds organisational commitment to ensure ensure that the Trust is governed in where we ensure that each ward that high standards of care are a way that leads to the best possible undertakes a nursing round every applied consistently. The three-year patient care. Improving patient care hour. We believe it is not acceptable programme, which was developed by drives everything that the Board does, for patients to rely on a call bell to the senior leaders, seeks to capture the and everything it does is viewed request assistance. Every patient pride and dedication that our nurses, through the impact decisions may have every hour will be asked by a midwives and AHPs demonstrate on on patients. nurse or midwife whether they are a daily basis. It also emphasises their comfortable and if there is anything The Board receives regular Ward passion to constantly improve patient they need. This regular check will to Board reports which monitor care: good is not good enough – we address essential aspects of patient performance at acute inpatient ward want to be the best we can possibly care including pain management, and divisional level and provide a be for our patients, their families and nutrition and hydration. We also risk-rated outcome indicator for each carers. Representatives of nurses, expect this pro-active approach to area. The report has now become part midwives and allied health professionals reduce the incidence of patient falls of the Integrated Performance Report at the RD&E were involved in the and pressure ulcers that is seen by the Board each month. development of the vision to reinforce The report enables Board Members to their commitment to: • We have always sought to improve take a view on the quality and safety of our services by listening to patient • Providing safe, dignified and work taking place at ward level and to feedback. Now, based on a compassionate care monitor this over time. Where actions successful trial in our orthopaedic are required, this is overseen by the • Being open and honest in their wards, we are systematically Deputy Chief Nurse who holds the lead communication and working in capturing patient feedback whilst nurses accountable. The information partnership with patients and their patients are still in hospital. This is is provided alongside outcomes for families shared at daily team safety briefings the Care Quality Assessment Tool to promptly address any issues or • Recognising specific needs (CQAT) and, with information from concerns that may arise of individuals and providing incidents and complaints, enables personalised care. • Staff morale and satisfaction in the Board to triangulate information. the workplace can mirror patient This innovation has been seen by the The programme of work which sits satisfaction. So, we now have Board as providing a useful insight beneath the Vision includes simple anonymous staff feedback cards to into ensuring that changes in certain innovations, such as ensuring good pick up on themes or issues which indicators can be tracked and that any practice in one area can be rolled out need addressing. repercussions can also be monitored. and applied consistently and reliably The Board also undertakes 'drill downs' across the hospital, and making sure into specific issues as necessary arising that individuals are held accountable. Good is not good from the Ward to Board reports and enough – we want to these are either taken as agenda items in Board meetings or in seminars. be the best we can During the course of the year, possibly be for our the Board approved a new vision to guide the work of the 2,800 patients, their families nurses, midwives and allied health professionals [AHPs] providing and carers. 32 2. Our Trust Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

At the heart of these initiatives – and improving our service. This also sustainable care for our patients within and many others besides – is the puts us at the forefront of evolving an increasingly challenging economic understanding that delivering safe, high quality systems for this group environment. quality care to patients each and every of patients. Over the last year the Trust has time with compassion and dignity must Faced with this challenge, the Board undertaken a considerable amount be the main focus for our work. Whilst is clear that there is a need for of work to improve the experience of targets and financial imperatives are transforming how our services are run, patients who use our services. From important and have their place, they in order to deliver the same or better the moment patients are referred to cannot and must not get in the way of level of healthcare for less money. the RD&E until their transfer home good, decent and compassionate care. While meeting our patients’ needs or to onward care, they are on a Pages 42-43 and the Quality Report comes first, the Board is aware that ‘pathway’ through our services. We detail more of the work we have been to continue to deliver good quality have embarked on a process to look doing during the last year on quality care, the Trust needs to have sound at these pathways in detail with care. finances, be run prudently and in the aim of making every patient’s a sustainable way. Doing more for pathway as smooth and effective as Doing more with less less through efficiency savings is an possible. Increasingly this involves us important component of this and the in integrating our improvements with Overall spending on health is protected Board has been tracking the progress external partners in primary and social by this government, but the Trust’s made by the Trust in delivering year- care. Staff engagement is central in income – like that of other acute on-year savings of around £17m. making these projects work – as it is hospitals – is declining in real terms and Finding ways of making such savings, often those on the frontline who have the demands of us, as a result of ageing without any knock-on impacts on the best ideas about how to change demographics, are increasing. We quality or safety, is not straightforward things for the better. So too is clinical therefore need to do more with less. and, as we look for this level of savings engagement, to ensure that we are • Our like-for-like real revenues are every year, the task becomes ever really delivering valuable change for reducing by 4-5% every year – that harder. The 'easy wins', and even some patients and the RD&E. of the more difficult changes we have means a total reduction of 20-25% During the year, the Trust was part had to make, have been delivered. over five years – and yet we target of a South West Pay Consortium that That is not to say that no further a surplus of only 1% every year. examined potential changes to the efficiency savings can be found and We cannot achieve this level of current pay, terms and conditions that some of the work undertaken over the savings alone whilst meeting our could help safeguard health services last year has streamlined processes and commitments to our communities. and employment in the years ahead. eliminated inefficiencies in a way that We must therefore work closely Joining the Consortium to take on this has improved the service we offer. At with our partners in the local health work was a cost-effective response to the same time, the Board is now aware economy to become more efficient ensure that we received sound advice that, given the current and foreseeable and quickly. about the options open to the Board. pressures on the Trust, more radical • Our staff costs equate to However, it was recognised that the and transformative solutions will be approximately 70% of our total approach did not find favour with a required and within the Trust’s four costs. We must therefore achieve number of unions and this helped walls but particularly in how we and staffing efficiencies as well as in create a period of difficulty and, for the wider NHS work in tandem with other areas such as procurement. some staff, a great deal of insecurity. our partners. The final report from the Consortium • The ageing of our population is Our transformational change set out the significant financial and around 20 years ahead of the programme is designed to enable us service challenges facing the NHS, average for the UK, which will add to deliver clinically safe and financially including the need to: to our challenges in maintaining 2. Our Trust Royal Devon and Exeter NHS Foundation Trust 33 Annual Report and Accounts 2012/13

• Maintain and improve the quality of The report highlighted that staff pay existing patient services remains our largest single item of Our transformational expenditure and it is right and proper • Manage increasing demand due not to ring-fence this area as being change programme is to demographic changes and beyond consideration. The Board advances in medical innovation and designed to enable us to signed up to the work undertaken by technology and cost pressures the Consortium because it believed deliver clinically safe and • Meet the expectations (including that it has a responsibility to consider those of taxpayers and patients) of how taxpayer funding may be more financially sustainable increasing service excellence efficiently used in order to protect both care for our patients the continued delivery of high quality • Cope with year-on-year reductions healthcare and employment. in overall NHS budget, which for the within an increasingly RD&E equates to savings of around challenging economic 4% a year • Respond to growing competition environment. from new providers of NHS services • Meet regulatory standards and targets. 34 2. Our Trust Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Investing in the future Strategic direction Meeting this vision will be challenging and at times unsettling for both our Over the course of the year, the Board At the RD&E we always strive to staff and our community. But we approved a number of new investments provide the very best healthcare to believe that, with concerted and designed to improve the quality and our patients. As described above, in joined-up effort from all of our staff, outcomes of the care provided by the face of major funding constraints, and working with our partners, we can the Trust. Being able to invest in new rising demand, increased patient make the changes needed. In taking services, to ensure that we have the expectations and substantial changes our strategy forward, we will focus on latest technology and to enhance to the NHS, we know that we need three areas. patient experience, is one of the key to rethink what we do and how we rationales for being a Foundation Trust. can deliver it effectively and efficiently We will: whilst providing the best possible Some of the main investments we 1. Ensure we maintain the quality, health outcomes for our patients and have made are set out in the Our Year safety and sustainability of our the wider community. section (pages 12-23) but some of the current healthcare services as well more notable investments included: Over the last few years we have begun as our research and training. What this process of change and we have we do now provides the building • The modernisation of patient record achieved a lot in this time. We have blocks for our future success and management through eNotes sought to listen to staff, to learn from it is essential that we safeguard • The RILD Centre, due for completion their expertise, and take action to what we do well. We recognise October 2013, will bring together improve the care we offer. that sustaining our current services skills, learning and innovation to requires: But it is now becoming clear that we improve patient care in a single need to think and act more radically • New, innovative ways of centre of excellence. Its facilities if we are to achieve our vision of working developed by engaging include clinical research areas and providing safe, high quality, seamless our staff in continuously medical research laboratories, services delivered with courtesy and improving the delivery of offices, meeting rooms, write up respect. safe, high quality, financially areas, primary laboratories and sustainable services to patients specialist laboratory space. The In five years’ time, we want the RD&E facility will also house the new Post to be: • A clear, unambiguous focus Graduate Education Centre (PGEC) on providing safe services that • Offering improved high quality consisting of specialist teaching results in improved health services to more people whether rooms, lecture theatres and seminar outcomes delivered with that is delivered at home, in hospital rooms, social areas and breakout courtesy and respect or in a local setting spaces • Driving forward our ambitions • Providing first rate clinical outcomes • The Exeter Surgical Health Services to continue the delivery of high for our patients delivered in a way Research Unit (HeSRU) - a new quality research and becoming that is sustainable, cost effective specialist resource bringing together a regional hub for academic and more individualised a wealth of clinical knowledge and excellence. research to improve the care and • In tune with and held accountable 2. Work to better integrate seamless experience of surgical patients by the communities we serve care beyond our four walls – either • The Trust's new £2.5 million robotic • Financially sustainable and able to by offering new services or working equipment that is being used in continue reinvesting in improving in partnership with others. surgery to target prostate cancers our care, in line with the priorities of Already we are doing this in a our patients. • The new modular wards. number of areas – in stroke care, in 2. Our Trust Royal Devon and Exeter NHS Foundation Trust 35 Annual Report and Accounts 2012/13

our 'Hospital at Home' project and elsewhere. This work is essential in delivering improved health outcomes and a better patient experience. In many cases, it can be delivered in a more financially sustainable way than at present. Work we are doing on the journey that elderly patients make through the health system – and finding new, more efficient and patient- centred approaches to this journey – will be critical to the RD&E in the future. 3. Provide the quality care associated with the RD&E to more patients in the region and invest in new services to improve health outcomes. Already we are investing in new technologies to improve services – such as robotic surgery – and working in partnership with others to enhance the healthcare offer to patients – for example, working with the University Hospital Bristol NHS Foundation Trust on thoracic surgery. We are also actively developing new partnerships with other organisations to drive quality outcomes as well as extend our service offer to other communities.

We need to rethink what we do and how we can deliver it effectively and efficiently whilst providing the best possible health outcomes for our patients. 36 2. Our Trust Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Over the next five years, we anticipate • Work in partnership to integrate Both Trusts are already committed considerable changes to how healthcare our services as far as possible with to delivering efficient high quality is delivered. more care being provided closer to care that meets the needs of their home local populations. While the two Our aim over this time is simple: it is to organisations already work together ensure that we take bold decisions and • Build on our strong research base in some areas, the Boards of both transform the way we work so that and work in collaboration with the Trusts decided to commission a study we can continue our excellent track South West Peninsula Academic to explore other opportunities to record of providing the best possible Health Sciences Network (AHSN) work in partnership. The overriding healthcare to the population we serve. to develop our research and principle of the Boards of both Trusts innovation agenda The Board is, as a result of the work in pursuing the study will be putting undertaken during 2012/13, much • Maintain a sound and sustainable patients first. The Trusts' Boards will clearer about where we want the financial base continue to explore the improvements RD&E to be in five years’ time. By in quality and economies of scale that • Build and extend our brand 2018, the Trust wants to: partnerships can create, including • Be the employer of choice in the developing relationships with other • Serve a larger population over a region and have an empowered NHS Trusts, hospitals, healthcare wider geographic area and skilled workforce. providers and businesses which have • Be the safest hospital in the region As part of our strategy work, the Board the potential to deliver important • Ensure that patients treated by the has been working with Taunton and benefits for our patients. The study Trust feel cared for Somerset NHS Foundation Trust to will report at the beginning of the next explore the potential of developing a financial year. • Provide a comprehensive range of closer working relationship to secure core health services good quality care for the communities • Work ever closer with our partners to they serve primarily in Devon and enable the smooth flow of patients Somerset. through the NHS system and to avoid admissions where possible 2. Our Trust Royal Devon and Exeter NHS Foundation Trust 37 Annual Report and Accounts 2012/13 38 2. Our Trust Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Frail and older will be like in 2042. Despite these professionals in the patient’s pressures, caring for elderly people home for a maximum period people costs more than the funding received, of 21 days as an alternative and this pressure is likely to get to hospital admission in pilot As people get older they can develop worse within a constrained funding areas complex physical and mental health environment. Added to this is the issues, with social care needs which • Providing education and fact that reduced social care spending are often compounded by isolation training in dementia care per capita in Devon is lower than and discrimination. Hospitalisation across the Trust the national average and focused on entails greater risks for elderly institutionalised care, and that the • Involving patients and carers people, who are more prone to system for managing the care of the in our redesign work. hospital-acquired infections, falls and elderly is fragmented. The challenge delirium, and can become rapidly This project has three key strands: of managing the health needs and dependent and institutionalised. It expectations of this population are • Changing the way we manage also means added pressure on significant now and will become the care of elderly patients acute hospitals. more so in the future. within the Trust including • Frail older patients have new ward arrangements, Meeting this challenge is a key longer admissions active rehabilitation, increased element of the Trust's strategy and ambulatory care, 7/7 working, • High occupancy of inpatient over the last year we have been improving discharge processes beds has a knock-on impact on working on what we can do to and dementia screening the flow of patients through turn this challenge into a strategic the hospital from admission to opportunity. Over time, the Board’s • Working with key partners discharge and this can result aspiration is to develop a new, including improved early in the cancellation of elective innovative model of care, working detection and intervention admissions with our partners to ensure that for dementia, rapid patient frail elderly patients receive the best assessments and partnership • Patients are more likely to possible care and the Trust becomes working with primary care be transferred to the wrong renowned as a centre of excellence. clinicians wards. We have undertaken a detailed • Potential commissioning A recent King’s Fund report on elderly analysis of the pathways that patients changes: understanding care suggests that elderly patients follow and this has helped identify a and discussing with new occupying between 42-55% of bed number of improvements that would commissioners how potential days would be better treated at home. have the biggest impact on frail older changes in commissioning The population served by the RD&E patients including: may impact on elderly care. has a significant proportion of • Providing comprehensive As a result of this ongoing work, elderly frail people, above that of the needs assessment at the while admissions for this group of national average. In one part of East point of presentation to acute patients continue to rise, the length Devon, for example, a demographical hospital of stay has decreased. analysis shows that over 80s make up 5.28% of the population, which is • Providing active treatment the same as what England as a whole by health and social care 2. Our Trust Royal Devon and Exeter NHS Foundation Trust 39 Annual Report and Accounts 2012/13

Engagement currently a gap between ideas and to be held accountable. As a and inventions – and the actual result, our relationship with the The RD&E’s Board takes its widespread adoption of them – so Committee is excellent. engagement work with stakeholders that everyone receiving health and very seriously. We have undertaken a • As part of the new Chairman’s social care can benefit. By closing survey of some of our key institutional induction, a number of meetings this gap, the network believes the stakeholders to work out how we were held with a wide range of health and wellbeing of people can develop our relationships. Some partner organisations throughout living in Somerset, Devon, Cornwall of the changes in the way the NHS is the year, both to enable and the Isles of Scilly can be structured offer up new opportunities relationships to be developed improved. It has decided to focus on: to develop collaborative relationships, as well as to enhance a broader and we have placed emphasis on ➤ Increasing the number of people understanding of the wider stepping up engagement with the new taking part in health research healthcare economy in Devon. Clinical Commissioning Groups and This intelligence, together with the ➤ Making sure that research and GPs. The examples below demonstrate insights and knowledge brought learning becomes best practice some of the key issues in our to the Board table by the Chief collaboration with stakeholders during ➤ Giving the healthcare workforce Executive and other Executive the last year: the right skills and knowledge Directors, has enabled the Board needed to provide high quality to keep in touch with the wider • The RD&E has played a lead role patient care and services external context and the views of in establishing the South West our key collaborators. Peninsula Academic Health Science ➤ Improving what information is Network (AHSN) which aims to collected, used and shared to • The Trust continued to enjoy drive collaborative, cross-sector find and develop innovation and a good relationship with the working to transform research best practice University of Exeter – cemented again this year through the joint delivery and create the most ➤ Building strong links with work on the AHSN. successful AHSN in the country. industry to support innovation The Network Membership consists and best practice in health and of two universities, clinical social care and generate ‘wealth Successful engagement commissioning groups and health creation’ opportunities for local service providers from across economic growth. with our stakeholders Somerset, Devon, Cornwall and the Isles of Scilly. It aims to harness and • The RD&E provided updates to and partners is critical align the capabilities of research Devon County Council’s Health & and we will continue and health services in this region Wellbeing Scrutiny Committee on with the science and technology a number of occasions during the to develop this in the sectors, so that it can maximise year. This enabled councillors on joint opportunities for economic the Committee to ask questions future. growth and prosperity. Local to the Trust’s Chief Executive and authorities, economic development other senior managers about a partnerships and commerce will range of topics, from the RD&E’s be key partners and there will also strategic direction to issues such be opportunities for patients and as car parking as well as key the general public to get involved operational issues. These occasions and make a positive contribution. provide a useful opportunity to It is recognised that there is explain the work the Trust is doing 40 2. Our Trust Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Our Business

2012/13 has been a challenging year for the Trust, both operationally and financially.

The external NHS environment has population demographic profile, which The Trust performed well against undergone significant change with has a percentage of elderly residents other operational targets including the dissolution of Strategic Health 20 years ahead of the rest of England, improvements to its A&E four-hour Authorities and Primary Care Trusts this trend is set to continue into the target and finished the year meeting and the creation of a National future. Ensuring we are best placed to its planned governance rating with Commissioning Board and Clinical deliver services for this group of our the regulator Monitor of amber red. Commissioning Groups amongst patients will be a key focus over the However pressures are emerging other structural changes. The Board next couple of years. Currently the around cancer targets and this of Directors has considered the impact national tariff for emergency patients may have an impact on the Trust's of these changes and the potential is paid at 30% for the number of operational performance in 2013/14. impact on the local health and social patients above the baseline year of Plans are currently being developed to care sector as part of the work it 2008/09, so not only will we seek ensure we can maintain a good service has been undertaking in relation to to ensure that patients are treated for our cancer patients. developing the Trust's strategy. Over in the most appropriate location in Due to the pressures outlined above, the next five years it is likely that the the community or hospital but we the Trust did not meet its planned Trust will expand the population base aim to make these services become surplus during 2012/13, achieving a it currently serves on an acute basis financially sustainable (currently it costs surplus (before extraordinary items) from approximately 420,000 to circa approximately £5m more per annum of £1.3m against a plan of £3.5m. 800,000 and, in addition, will also to deliver this service than we receive Whilst this surplus is lower than seek to develop integrated services in income.) planned, it was sufficient, together across the local community. The Trust In addition the Trust undertook a with other financial performance, will continue its focus on safety and recovery plan to address a backlog in for the Trust to maintain its planned aims to be in the top three of Trusts the number of patients waiting for Financial Risk Rating (FRR) of 3 against across the NHS South region for its treatment for more than 18 weeks. Monitor's compliance framework. safety performance. Furthermore This backlog was created during This benchmarks comparatively with the importance of research and 2011/12 due to a high number of other Foundation Trusts (FTs), as at development to support and further emergency patients occupying the the end of Quarter 3, 49% of FTs our objectives will be strengthened, Trust's available beds and displacing were rated at a FRR of 3. This is the including the completion of a new elective patients. first time in recent years that the Trust £23m research, innovation and has failed to meet the financial plan learning and development facility in The Trust is on track with its plans by more than £500k and, due to a conjunction with the University of to recover its position against this strong cash position, this does not Exeter during 2013/14. target during 2013/14 and has been present any immediate concerns for able to accommodate the additional During 2012/13 the Trust treated more the organisation. However there is activity and extra emergency patients patients than ever before, in particular a need to ensure that the Trust can due to the construction of two new we experienced a rise in the number remain financially sustainable in a modular wards. These were opened of frail elderly patients admitted on an difficult operating environment. For the in December 2012 providing 48 emergency basis (an increase of 6% in next three-five years it is anticipated additional beds (including a short stay the number of medical patients over that the Trust will need to generate rehab facility.) 85 years of age). Given the hospital's approximately £17m (representing 2. Our Trust Royal Devon and Exeter NHS Foundation Trust 41 Annual Report and Accounts 2012/13

approximately 5% of turnover) of cost and productivity gains in each year. It is becoming increasingly more difficult to achieve savings in a traditional way; however the Trust has developed a transformation programme that will support the delivery of these financial requirements whilst at the same time ensuring services are fit to meet our patients' needs. The risk of not achieving this programme remains one of the most significant risks appearing in the Trust's Board Assurance Framework.

We aim to be in the top three Trusts in our region for safety.

During the year the Trust revalued its estate and as a result has reduced the value of its assets by approximately £46m. This exercise is purely a technical one and will ensure the Trust pays an appropriate amount of Public Dividend Capital in future years. However there is a one-off Both the commissioner and the charge against the Trust's income and hospital, as a provider of services, has expenditure account which results in a commitment to make the best use a bottom line deficit for the Trust of of available resources to serve the £21.6m for 2012/13. population of Devon. Looking forward to 2013/14 and beyond, the Trust has developed plans with its new commissioners NEW Devon (eastern locality) for the number of patients to be treated. We will work jointly with the Clinical Commissioning Group to deliver our combined plan to develop services to ensure that patients are treated wherever possible closer to home and are only admitted to hospital, when clinically appropriate. 42 2. Our Trust Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Patient Care and Quality Improvements

Ensuring safe and good quality patient their families through our excellent care delivered with courtesy and Cancer services rated team of specialist nurses and local respect is the organising principle for groups, especially FORCE charity.” the Trust. The progress we have made very highly by adult Lead nurse for cancer services on delivering our quality priorities patients in a national Tina Grose said: “Investigations over the last year and our aim to and treatment for cancer can be continuously improve our services in survey frightening and stressful for our the coming year are summarised in patients and their families. It is our the Quality Report. The Quality Report priority to ensure they know that we contains a number of examples of the are with them every step of the way way in which the Trust has prioritised A detailed annual survey for the and it was particularly heartening that and delivered improved quality and Department of Health was sent to patients said in the survey that they safety outcomes for our patients. 113,000 cancer patients nationally and 1,314 RD&E patients. Seventy two per had confidence in staff and felt they Last year, we put in place a new cent of RD&E patients completed and could discuss any concerns or worries vision to guide the work of the 2,800 returned their survey answers. They with us.” nurses, midwives and allied health received their treatment for cancer There were 160 acute hospital NHS professionals [AHPs] providing patient from the RD&E between September trusts providing cancer services which care at the Royal Devon & Exeter and November 2011 and the results took part in this survey conducted Hospital. More details are included in were published in 2012. by Quality Health on behalf of the the Quality of Care section in the “Our Department of Health. Adult patients Trust” section. Further examples of The survey covered patient experience who took part are aged over 16 improvements we have made during from the time they were referred by years old. The cancer groups involved the year are included in the highlights their GP to the RD&E for diagnostic included breast, colorectal/lower section at the start of the report. tests, through their treatment, and aftercare. Aspects of their experience gastrointestinal, lung, prostate, brain/ The Trust has a Patient Experience included how well they understood central nervous system, gynaecological, Group (PEG) that brings together their results, pain control, side effect haematological, head and neck, patient representative groups and management, respect and dignity, sarcoma, skin, upper gastrointestinal interest groups to ensure that we communication with healthcare and urological. learn from the experiences of patients professionals and the quality of and take into account the particular written information. 89% of RD&E needs of identified groups in the patients rated their care as excellent delivery of good quality care. The or very good. work undertaken by this group feeds into one of our key governance RD&E Clinical Director for Cancer committees: the Engagement & Services Mr John Renninson said: Experience Committee that provides “It is encouraging to see that the both the strategic direction to the overwhelming majority our patients Trust’s engagement activities as well as have had a positive experience of their assuring the Board on issues relating cancer treatment when understandably to patient experience. This Committee they are going through a very difficult includes three Non-Executive Directors time. There are high levels of patient and three Governors as well as satisfaction in the survey with the clinicians and Trust managers. different types of information they receive and we score highly for the support services available to them and 2. Our Trust Royal Devon and Exeter NHS Foundation Trust 43 Annual Report and Accounts 2012/13

Complaints/Patient In October 2012 the Department of as a result of feedback evidencing Health (DH) released implementation that carers sometimes avoid taking Experience – guidance on the Friends and Family care of their own health issues due improvements and Test. The question to be asked is: to concerns about what will happen ‘How likely are you to recommend to their 'cared for' in their absence. key issues our ward/A&E department to friends From February 2013 the Trust has been During the last year complaints and family if they needed similar trialling a monthly 'Staff Carers Health continued to remain stable. Additional care or treatment?’ All adult acute and Wellbeing check' clinic in an office categories have been added to DATIX inpatients (who have stayed at least in the Health Information Centre. (our in-house database) to enable the one night in hospital) and all adult This was started because of the high further analysis of complaints and patients who have attended the number of appointments booked by concerns about quality of care and Emergency Department without staff during Carers’ Week 2012. being admitted or were transferred treatment. The number of enquiries to The Trust continues to see an increase to a Medical Assessment Unit and the Patient Advice and Liaison Service in the number of volunteers recruited then discharged are being asked this (PALS) has increased. and a new area currently being question. Results will be reviewed by developed is a project called ‘Food In August 2012 a revised version the Patient Experience Group as part of Friends’. Volunteers are selected, of the previously named Nursing its system for analysing feedback from trained and assessed as competent Quality Assessment Tool (NQAT) patients through complaints, comment to support mealtimes and assist with was introduced, which has now cards, national surveys, Care Quality the feeding of patients, under the been rebranded as the Care Quality Assessment Tool, 'What Went Well... supervision of the registered nurse. Assessment Tool (CQAT). The CQAT has Even Better If', to identify areas for The purpose of the project is to expanded the audit beyond just the improvement. nursing team and now also involves provide appropriate, directed support medical staff. The Trust’s random note The Carers Group has developed a in preparing patients and the ward review has been incorporated into this poster to be displayed in pre-op areas, environment for mealtimes and ensure method of auditing to help streamline prompting carers to start thinking that selected patients receive the right data collection and involve medical about what will happen to their cared level of support, in a timely way, to colleagues in the data collection. for person when they come into maximise their nutritional intake. The revised tool also includes a staff hospital. This poster was developed survey, which has been informed by the national staff survey, and will help to provide a temperature check of staff experience throughout the year, plus enable correlation of staff and patient views. 44 2. Our Trust Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Our Staff

Health and Wellbeing • We are now reviewing our Improving staff engagement continues Trust-wide annual plan on Health to be fundamental to implementing We encourage staff to lead healthy and Wellbeing to ensure that the the challenges and opportunities set lifestyles by promoting a range of most effective approaches are out in the Trust's Strategic Direction. national and local initiatives. Over the taken to support staff health and Over the past year, we have continued past year there have been a number wellbeing and prevent ill health to embed our staff engagement of new and continuing initiatives strategy 'Enabling Excellence - locally. Our sickness absence rate • Our Occupational Health performance through People' continues to reduce and presently Department achieved one of alongside strategic redesign and our stands at 3.80%. Our staff survey the first SEQOHS, (Safe Effective senior management review, designed demonstrates improvements in staff Quality Occupational Health to strengthen clinical leadership within health. Work pressure felt by staff has Service) accreditations in the South the Trust. improved and the percentage of staff West working extra hours is aligned to the Through Trust-wide staff and • Our staff direct access national average for Acute Trusts. The management development physiotherapy service continues to percentage of staff feeling pressure programmes, the Trust continues deliver early intervention to attend work when ill has only to build capacity and capability to increased by 1% in our full staff survey. • The successful weight loss clinic increase engagement and improve Although staff suffering work-related continues to support a range of patient care. Staff communication has stress has increased slightly, we are still staff across the Trust been enhanced with 'CASCADE', a regular team briefing to encourage in the best 20% nationally and our • The Virtual Gym service is available staff feedback throughout the score of 30% is very close to the best free to all staff and their families of Acute Trusts (28%). organisation. A new reward and recognition scheme ‘Extraordinary • A self-care course designed to People Awards’ has recently been support staff with long term developed and implemented. conditions has had a successful pilot and is being expanded to Summary of Performance other staff. In 2012, the RD&E, as part of its staff Statement of Approach engagement strategy, undertook a full census survey of its staff for the fourth Here at the RD&E we believe that year, and is using this material to track engaged staff have higher morale, trends across the Trust and within are more productive and will deliver individual departments. The response improved patient care. The Trust has rate was 49% for both the full survey identified a priority to improve staff and the sample, which feeds into engagement. Research evidence national CQC survey and key findings identifies this as a pivotal indicator to results. The Trust was in the top 20% achieving the RD&E vision and values of Trusts nationally for five of the key of 'safe, high quality seamless services findings and in the bottom 20% for six. delivered with courtesy and respect' and underpinned by values of honesty, fairness, inclusion and collaboration, respect and dignity. 2. Our Trust Royal Devon and Exeter NHS Foundation Trust 45 Annual Report and Accounts 2012/13

Best 20% • Staff suffering work-related stress in last 12 months • Staff experiencing physical violence from staff in last 12 months • Staff experiencing harassment, bullying from patients in last 12 months • Staff experiencing harassment, bullying from staff in last 12 months • Staff experiencing discrimination at work in last 12 months.

Worst 20% • Staff feeling satisfied with the quality of work and patient care they are able to deliver • Staff agreeing that their role makes a difference to patients • Staff having well-structured appraisals in last 12 months • Staff witnessing potentially harmful errors, near misses or incidents in last month • Staff reporting good communication between senior management and staff • Staff motivation at work. 46 2. Our Trust Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Staff Survey Results

2011/12 2012/13 Trust Improvement/Deterioration Trust Acute Ave Trust Acute Ave % Response rate 50 53 49 49 Decrease

Trust 5 Top Ranking Scores 2012 Trust 2011 Trust 2012 Acute Increase/ Trust Ave 2012 Decrease KF 19 - % staff experiencing 13% 18% 24% 5% decrease harassment, bullying or abuse from staff in last 12 months KF18 - % staff experiencing 8% 22% 30% 14% decrease harassment, bullying or abuse from patients, relatives or the public in last 12 months KF 17 - % staff experiencing physical 0% 1% 3% 1% decrease violence from staff in last 12 months KF 11 - % staff suffering work-related 25% 30% 37% 5% decrease stress in last 12 months KF 28- % staff experiencing 9% 7% 11% 2% increase discrimination at work in the last 12 mths

Trust 5 Bottom Ranking Scores 2012 Trust 2011 Trust 2012 Acute Increase/ Trust Ave 2012 Decrease KF1 - % staff feeling satisfied with 66% 70% 78% 4% increase quality of work and patient care they are able to deliver KF 21- % staff reporting good 25% 20% 27% 5% decrease communication between senior management and staff KF8 - % staff having well-structured 34% 29% 36% 5% decrease appraisals in last 12 months KF2 - % staff agreeing that their role 89% 87% 89% 2% decrease makes a difference to patients KF13- % of staff witnessing potential 33% 38% 34% 5% decrease harmful errors, near misses or incidents The Trust's full survey provided similar responses to the CQC results, though our full staff survey KF1 increased from 69% in 2011 to 71% in 2012. Both results are higher than the CQC sample data. 2. Our Trust Royal Devon and Exeter NHS Foundation Trust 47 Annual Report and Accounts 2012/13

Future Trust Priorities For 2013, we intend to undertake agreed from our Patient Satisfaction further in-depth work towards surveys with Staff Satisfaction results The Trust has a number of ongoing improvements in these areas. There is at Trust and departmental level. A priorities where performance is not as clear evidence of the link between high programme of work is being developed satisfactory as we would wish. We will quality patient care and organisational to monitor improvements from action continue to concentrate on these as culture as demonstrated in the Francis plans within a year. part of our staff engagement strategy. report. We continue to align priorities

KF1 % staff feeling satisfied with the quality of work and patient care they are able to deliver

KF2 % staff agreeing that their role makes a difference to patients

KF8 % staff having well-structured appraisals in last 12 months

KF13 % staff witnessing potentially harmful errors, near misses or incidents witnessed in last month

KF21 % staff reporting good communication between senior management and staff

KF25 staff motivation at work

48 2. Our Trust Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Equality & Diversity • People with a disability are making Our experience and Engagement much better progress through the Committee has reviewed the recruitment and selection process experience of older patients based Achievements and the rate of progress has also on data evidence. 'Patient stories' Overall improved for staff from most (including those from a carer's angle) minority groups illustrate issues in service delivery to • Our 18 grades for the Equality older patients. Delivery System are all at • We have produced new dyslexia 'achieving', or better, apart support resources, including an from two. These have improved, interactive face-to-face training As a result we: package from what was already a good • Produced action plans, covering assessment in the first year of • We continue to develop work ethnic minority and lesbian, gay implementation, with additional experience placements for learners and bisexual patients, based on five grades moving from 'achieving' with disabilities, three of whom consultation to 'excelling' have progressed into employment • Supported policy development with us. Our work was 'showcased' • The staff and patient profile at around alcohol-dependent patients our Trust matches the appropriate to Ben Bradshaw MP, when community benchmarks. he visited one of the training • Supported Carers’ Group, Carers organisations which partners us in Week and produced proposals Staff this activity. for how to support staff who are carers. • Overall, our staff profile represents Patients the adult community we serve • Our major local patient survey • We are among the best 20% of suggests very few equality issues Trusts nationally, for our low level of reported discrimination • We have implemented 'This is Me', a personal information book which • We remain above national average patients or their carers complete to in the staff survey for acting fairly make the patient’s personal history as regards career progression and and interests known to Trust staff, promotion to enable better care • Our proportion of ethnic minority • Patients aged 65+ are now notably staff has increased in line with the less likely than expected to be local community and they report a emergency re-admissions, reversing positive experience of working last year's result with us • Engagement by race, gender, age and disability in our Involving People projects continues to be representative of our patient body as a whole. 2. Our Trust Royal Devon and Exeter NHS Foundation Trust 49 Annual Report and Accounts 2012/13

Key performance indicators (KPIs)

The Equality Delivery System (EDS) is a national NHS system to provide an overview of how well NHS organisations are delivering equality and diversity, through grading against 18 outcomes.

Our grades are as follows:

Undeveloped Developing Achieving Excelling 0 2 10 6

Our priority is to address the outcomes assessed as 'developing', by better considering equality issues when we plan and deliver service change.

Overall staff equality This indicator shows the level of discrimination from patients, public, or colleagues, reported in the 2012 staff survey.

RDE National (acute and specialist Trusts) 2012 7% 11% 2011 9% 13% 2010 10% 13% 2009 6% 7%

Reported discrimination nationally has increased, from 7% in 2009 to 11% in 2011, but our Trust has seen a smaller increase, from 6% to 9-10% and back to 7%. We are in the best 20% of acute Trusts and only 1% short of the best score nationally (6%). 50 2. Our Trust Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Patient Equality example, improvements to discharge), Current situation: it is also possible (due to the low 0.7% in survey taken in 2011 Objectives numbers of emergency re-admissions) that there is some natural variance in Goal: year-on-year improvement. the data year-on-year. Next year, there 1. To continuously improve the This indicator has changed slightly, will be three years’ data available and care of our older patients although hardly significantly, having trends will be clearer. Measures: been 0.7% last year. Such slight The second indicator, involvement in changes are to be expected given Year-on-year improvement in the incidents, has a slightly larger equality the small numbers involved (16 out 'equality gap' for patients aged 65+ in gap, as was the case last year. The of 2,323 respondents reporting relation to emergency re-admissions appointment of a Consultant Nurse for discrimination on the theme of and involvement in incidents. Older People, with a remit to spread disability, one more than last year). good practice, should contribute to a We would expect that the proportion i. % in staff survey saying we reduction in the proportion of older of patients aged 65+ who are have implemented reasonable people involved in incidents, many of emergency re-admissions or involved in adjustments: reported incidents would be the same which involve slips, trips and falls. as the proportion of all patients who Current situation: are in that age group. 71% (Acute Trust benchmark 70%) The situation in the 2012 Equality Data 2. To continuously improve our Goal: to remain well above the Report is as follows: support for staff who have national benchmark. disabilities 2012 2011 This indicator has worsened Measures: % patients from 34% 53% dramatically, falling from 84% in the the 65+ age i. Balance of notably negative and previous year’s staff survey. group who are notably positive findings for staff Casework and data evidence “emergency with disabilities, in the 2011 staff both suggest that people with a re-admissions survey. disability are reluctant to be open % patients who 59% 51% Current situation: about disability issues and ask for are 65+ age adjustments. group in reported notably negative findings: 10 The fall in this indicator could be either incidents notably positive findings: 3 because the Trust has been less willing % of all inpatients 43% 43% score: - 7 to grant the reasonable adjustments who are 65+ age people with disabilities consider group Goal: year-on-year improvement necessary, or because staff are less This represents an improvement since This result of -7 overall has improved willing to ask for adjustments at a time 2011 for the first indicator, with the a little since last year, when the overall of increased pressure to find efficiency equality gap having disappeared, so score was -10. savings. that patients aged 65+ are now less ii. Discrimination reporting rate in likely than expected to be emergency the staff survey on the theme of re-admissions. disability. Whilst significant work is underway to improve services for the elderly which could account for this change (for 2. Our Trust Royal Devon and Exeter NHS Foundation Trust 51 Annual Report and Accounts 2012/13

Sustainability Report

The Trust is committed to becoming a low carbon sustainable organisation.

The regulatory and legislative The Board of Directors approved the the methodology required by the NHS requirements for the NHS to reduce Carbon Reduction Strategy at the Sustainable Development Unit. carbon emissions and to adapt to September 2009 Board meeting and The Trust closely monitors its climate change are taken seriously have continued to receive updates on production of greenhouse gases from by the Trust. The Government is progress. the sources described below. The clear that carbon reduction needs to Trust complies with the following be systematically implemented and Carbon Emissions legal instruments designed to improve more transparently reported. The energy and carbon efficiency: Department of Health has produced a The Trust aims to meet the NHS target framework for the NHS for reporting of reducing its 2007 baseline carbon • Carbon Reduction Commitment sustainability as part of the annual emissions, released through building (CRC) NHS financial reporting process. energy consumption, by 10%, before • European Union Emissions Trading Sustainability information from waste 2015. In 2010 the NHS Sustainable Scheme* (EUETS) production to energy consumption is Development Unit published an also gathered and reported through update supplement to the NHS Carbon • Climate Change Levy (CCL). Reduction Strategy highlighting that the mandatory Estates Return *This year the Trust has 'opted out' Information Collection (ERIC). in 2007 the carbon footprint for NHS England was 21 million tonnes. of the EUETS scheme. This does not The Trust has a Sustainability This is broken down by proportion mean that it has absolved itself of Committee which meets periodically in the three primary sectors of travel responsibilities. The Trust is now part and sets the overall agenda for the (17%), building energy (24%) and of the 'UK Small Emitters and Hospitals Trust’s sustainability strategy. The procurement (59%). Opt Out Scheme'. Reporting energy Trust also has a Sustainability Steering usage and a financial cost to carbon Group, the objectives of which are In April 2011, the Trust had its carbon still apply, but the scheme is simplified to promote the Trust’s sustainable emissions independently verified to the to make it less burdensome than the development framework within which recognised EU standard and may now full EUETS. carbon emissions will be reduced. use the CICS (Complete Integrated Certification Services) Carbon Verified The responsibilities required under This group meets on a monthly basis legal obligations include: and reports to the Sustainability Assurance Mark. The RD&E now joins Committee. In 2010, an action plan only 37 Trusts in England, including • Senior management accountability five other Trusts in the South and West, covering key sustainability areas of the • Monitoring and reporting energy which have received the Assurance Trust’s business was set out. The Trust’s usage carbon reduction strategy sets out Mark. • Paying for energy use and carbon proposals for sustainable development It is important to note that previous emissions. to bring about measurable Annual Reports may contain different improvements aimed at ensuring its information regarding carbon emissions; economic, social and environmental this is because the Trust has previously sustainability. The Trust has consulted used different emissions factors for with its Members on sustainability and calculating carbon dioxide equivalents its social responsibilities. (CO2e). This year the Trust is using 52 2. Our Trust Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

For the year 2012-13 the Trust paid the following in levies designed to incentivise low carbon energy usage:

Scheme £ CRC 80,000 CCL 135,120 EUETS 0 The Trust has managed to keep its EUETS emissions within the target range, so has avoided having to purchase extra allowances. Cost of CRC carbon will rise from £12 to £16 per tonne in 2013/14. Based on 2011/12 energy usage this means a cost increase of £24,384. The Trust’s building energy carbon footprint in 2007 was 19,145 tonnes (April 2007 to March 2008). This is now regarded as the 2007 baseline year for the Carbon Reduction Strategy and the Trust’s target is therefore to reduce its emissions by 10% to approximately 17,231 tonnes by 2015. The emissions rose to 20,240 tonnes in 2008/09 due to increase in the Trust’s activity and building size following the opening of the new Centre for Women’s Health at Wonford Hospital in July 2007. However, in 2009/10 an increase in patient activity and the In 2012 the Estates department there was a reduction in the Trust’s CHP plant being under renovation. employed a full-time Energy and building energy carbon emissions to The increase in energy usage has been Sustainability Manager to reduce the 18,609 tonnes. Although this was somewhat muted due to a warmer amount of energy being used. Projects partly due to weather conditions than normal winter and a cooler than currently underway include a funding the Trust was also able to gain more normal summer, reducing demand bid for £1.1m of Government grant to effective use of its CHP (combined heat on boilers and air conditioning reduce the hospital's annual utilities and power) installation, generating respectively. bill by circa £350,000 and to reduce electricity on-site and producing heat emissions of CO2e by 1636t. There is an ongoing programme to to create steam for the laundry. reduce the Trust’s carbon footprint. The figures for 2012/13 show that The Trust also complies with the BRE the building energy carbon footprint Environmental Assessment Methods, is 20,830 tonnes (see Tables 1 and 2 and all major building projects consider below). This is an increase on previous implications for the Trust’s carbon years. This increase is mainly due to footprint. 2. Our Trust Royal Devon and Exeter NHS Foundation Trust 53 Annual Report and Accounts 2012/13

Waste Management

The Trust has a Waste Management Group. The Group has been working to identify ways to minimise the Trust’s impact on the environment, expand recycling and reduce the cost of waste disposal. In 2012/13 the Trust recycling increased to 14% of the total amount of waste produced. During 2012/13 the following projects were implemented: • A higher percentage of dialysis plastic waste is now being recycled • Wood waste is now being recycled • Review of waste management contracts to gain better value for money and improve recycling.

Sustainable Travel Plan

The Trust has a Staff Travel/Car Parking Group. The Group has been working to promote and identify sustainable travel options to help reduce demand on car parking and vehicle dependence. Staff, visitors and patients are encouraged to consider alternatives to using their car when coming to the Trust’s hospitals. During 2012/13 the following initiatives were implemented: • Increased frequency of park and ride bus service to Wonford • Options for alternative travel The Trust is currently preparing a green Hospital and pilot study for shuttle schemes including additional travel plan for the Wonford site which service between Heavitree and cycle facilities, cycle routes and is expected to be completed during Wonford prospective car share scheme Spring 2013. • Continuation of staff discount • Energy Saving Trust Green scheme on public transport Fleet review of the Trust’s own bus services vehicle fleet. 54 2. Our Trust Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Performance

Table 1 summarises the Trust’s performance with previous years' comparatives:

Metric Tonnes Cost £ Area Stream Disposal Methods 2010/11 2011/12 2012/13 2010/11 2011/12 2012/13 Clinical Offsite incineration 785 769 770 £267,105 £265,127 £272,028 Compaction and Domestic 660 736 770 £66,000 £93,577 £104,905 landfill Paper Collection and recycle 45 1.36 1.36 £700 £800 £840 Confidential Shred and recycle 65 102 114 £21,000 £21,523 £15,906 waste Cardboard Batch and recycle 125 101 110 £2,513 -£1,500 -£1,636

management Metals Collection and recycle 9 9 £0 £0 £0 WEEE Collection and recycle 2.8 0.6 7.44 £1,951 £1,447 £495 Waste minimisation and Waste Other Collection and recycle 0 0 2.5 £0 £0 £293 recyclables

Table 2 Greenhouse Gas Emissions in 2012/13:

Tonnes CO2e Emission Type Description 2010/11 2011/12 2012/13 Scope 1 Direct emissions from sources owned Gas 8,214 7,767 8,340 or controlled by the Trust (e.g. combustion boilers. N.B. does not include fleet travel) Oil 1,189 1,001 990 Scope 2 Indirect emissions from energy supplied by another 10,586 10,779 11,500 party (i.e. grid electricity) Scope 3 Non-fleet business travel 517 501 567 Waste Clinical 1,413 1,384 1,386 Domestic 191 213 223 Recycled 5 5 5 Water Indirect emissions from water supplied to the Trust 200 234 248 2. Our Trust Royal Devon and Exeter NHS Foundation Trust 55 Annual Report and Accounts 2012/13

Future priorities Sustainable Energy acute hospital Trusts the NHS carbon reduction target is very challenging. Key areas of focus for the Trust in Strategy The following carbon reduction 2013/14 will be: schemes are under review in the A sustainable energy strategy is being Sustainable Energy Strategy. • Sustainable energy – produce an developed that will set out options for updated action plan by August technical solutions to reduce carbon 2013 emissions, reliance on mains grid Existing CHP at Wonford energy and make the Trust’s energy (Carbon reduction target 500 • Sustainable travel – calculate the supplies more resilient. The aim is to tonnes per annum). carbon footprint by April 2014 create an optimum balance of energy The Trust has bought a Combined • Waste minimisation sources that will reduce reliance on Heating and Power plant. This had grid energy by on-site generation • Increase recycling been previously run by a private from CHP, combined with other local enterprise but the Trust realised that • Produce a sustainable procurement renewable energy sources and low better value for money could be strategy by April 2014 carbon measures. Our goal is that gained by buying out the contract within three years the Trust will be in • Staff and community engagement and running the plant itself. The a position to generate on-site up to plant is currently being renovated. • Produce green travel plan for the 50% of the peak electricity demand The existing CHP plant has been Wonford site by June 2013. at Wonford Hospital. Nonetheless, operating at a performance index of it is recognised that for all large 78% and reducing carbon emissions 56 2. Our Trust Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

by approximately 350 tonnes per medium temperature hot water September 2013. Estimated cost annum. However, with investment of boilers to steam as a backup for both £1 million. approximately £1 million, it is capable the existing CHP and the proposed of running at a considerably higher pyrolysis unit. All of the Trust’s clinical level of performance index of around waste could then be processed in the Air and ground 117%. pyrolysis unit and converted to heat source heat pumps and vapour. The heat and vapour Action – Our Estates Department is would be used to provide energy to The use of ground source heat pumps currently refurbishing the plant to the new waste heat boiler, provide will be reviewed on a project by project improve efficiency. additional steam to the laundry and basis for each capital development. Wonford site and potentially to a small Second CHP at Wonford 500Kw turbine producing electricity. (Carbon reduction target 500 Pyrolysis is recognised as an Advanced Wind turbines tonnes per annum) Conversion Technology (ACT) by the Due to planning restrictions and local Department of Energy and Climate An additional CHP plant providing weather conditions it is unlikely wind Change (DECC). 1mW of electricity and potentially turbines will play a part in the Trust’s 1.4mW of heat would reduce carbon Action – To complete a technical energy strategy; however their potential emissions by approximately 500 feasibility study on the Wonford site for use will be reviewed in all new tonnes. There would be potential and produce a Strategic Outline Case builds, on a project by project basis. to add more CHP plant up to the (SOC) for the October 2014 Board maximum electrical demand of meeting. Estimated cost £1.2 million. 3.6mW, but the 5mW of resultant Biomass boilers heat produced would need a heat sink (in the form of heating or steam Photovoltaic (PV) The remaining gas-fired boilers would load) which is not currently available be partially replaced by biomass at Wonford. Alternatively the heat and Solar Thermal boilers; these would provide the base produced by CHP could be used to Arrays (Carbon heating load for the main hospital, drive an absorption chiller and reduction target 200 with the variable element provided provide cooling. by gas standby or other energy tonnes per annum) sources, e.g. CHP or pyrolysis. Biomass Action – Pending the result of the boilers require a resilient renewable district heat scheme, a feasibility study The installation of 500Kw of PV energy source, e.g. wood pellet. This for a second CHP plant should be panels on the flat-roofed areas of the technology would therefore only be commissioned. Wonford site for micro-generation possible if there is a sustainable supply of electricity directly into the hospital within the area. It would also attract Energy from waste installation mains supply. This would reduce the a Government Renewables Obligation at Wonford (Carbon reduction maximum electricity demand as well Certificate (ROC) income. target 700 tonnes) as provide low-cost electricity. The installation would attract feed-in tariff Action – Pending the result of the This scheme would involve the and it is anticipated that the payback District Heating feasibility study an installation of a new technology period would be approximately 10 investigation into utilising biomass pyrolysis heat treatment plant in the years. boilers should be undertaken. waste management centre combined with the conversion of the standby Action – To commission a site survey steam boiler into a waste heat boiler at the Wonford site and produce and the conversion of one of the a feasibility study/SOC report by 2. Our Trust Royal Devon and Exeter NHS Foundation Trust 57 Annual Report and Accounts 2012/13

Absorption chillers District heating

It is anticipated that the current system schemes cooling load of the hospital will rise The Trust is currently participating in an significantly over the coming years. initiative with Exeter City Council and Absorption chillers use heat to drive the University of Exeter looking at the a refrigeration process and are ideally potential for both the Wonford and suited to run in conjunction with Heavitree hospital sites being part of, waste heat recovery system boilers as or hosting, a district heating scheme. A described above. Absorption chillers feasibility study has been commission provide a chilled water supply at a by the Council and the outcome looks constant rate and would be used to favourable towards a scheme that maintain the base load of the hospital would result in massive cost savings to cooling system. the Trust and a carbon saving of circa Action – To carry out a feasibility study 16000tCO2. in conjunction with the CHP project mentioned above. No estimated cost at Water Consumption this stage. The Trust is actively tackling water leaks and has recently stopped leaks LED and low energy losing 4.5m3 of water per hour. lighting

Most of the Trust’s fluorescent lighting will be replaced by LED lighting wherever possible. As well as reducing the electrical load, the emergency light fittings are maintenance-free, so will reduce revenue costs. Action – The first priority is E-link corridor. Refurbishments and new builds will be specified to have low energy lighting and controls as standard. 58 2. Our Trust Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012-13

Statistics

Carbon Emissions Expenditure on Energy

£ 25,000 4,000,000

3,500,000 20,000

onnes CO2e 3,000,000 T

15,000 2,500,000

2,000,000 10,000

1,500,000 5,000 1,000,000

0 500,000

2008/09 2009/10 2010/11 2012/13 2008/09 2009/10 2010/11 2012/13 20011/12 20011/12 Oil Air Our energy costs increased by 17% in 2012/13, the Rail Gas equivalent of hip operations. . Road Electricity

Our measured greenhouse gas emissions have increased by 1,350 tonnes this year. 2. Our Trust Royal Devon and Exeter NHS Foundation Trust 59 Annual Report and Accounts 2012-13

Expenditure on Waste

900,000

800,000

700,000 Percentage of Waste Recycled 600,000

500,000 We recover or recycle 244 tonnes of waste, which is 14% of the total waste we produce. 400,000

300,000

200,000

100,000

0 2011/12 2012/13

Waste incinerated / energy from waste Waste Recycled / reused

Waste sent to landfill Total Waste arising 60 2. Our Trust Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Energy Consumption Water Consumption in Cubic Metres

60000 270,000 50000 260,000

h 40000 250,000 MW 30000 240,000

20000 230,000 10000 220,000 0 210,000

2008/09 2009/10 2010/11 2012/13 20011/12 200,000 Electricity Coal 2008/09 2009/10 2010/11 2012/13 20011/12 Other Gas In 2012/13 we spent £1,044,539 on water. Our water Renewables Oil consumption has increased by 8, 243 cubic meters in the last financial year. Our relative energy consumption has changed during the year, from 0.45 to 0.47 MWh/square. Renewable energy currently represents 0% of our total energy use. As of April 2013 we will be purchasing renewable y energy for our smaller sites and will have installed and commissioned a small solar array. 2. Our Trust Royal Devon and Exeter NHS Foundation Trust 61 Annual Report and Accounts 2012/132012-13 62 3. Quality Report Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13 3Quality Report 3. Quality Report Royal Devon and Exeter NHS Foundation Trust 63 Royal AnnualDevon Report and and Accounts Exeter 2012/13 NHS Foundation Trust

Quality Report

Royal Devon and Exeter NHS Foundation Trust Quality Report 3 2012/13 64 3. Quality Report Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012-13

Independent Auditor’s Limited Assurance Report to the Council of Governors of Royal Devon and Exeter NHS Foundation Trust on the Annual Quality Report

We have been engaged by the based on limited assurance procedures, • The Trust’s complaints report Council of Governors of Royal Devon on whether anything has come to our published under regulation 18 of and Exeter NHS Foundation Trust to attention that causes us to believe that: the Local Authority Social Services perform an independent assurance and NHS Complaints Regulations • The Quality Report does not engagement in respect of Royal Devon 2009, incorporate the matters required to and Exeter NHS Foundation Trust’s Q1 and Q2 Nov 2012 be reported on as specified in Quality Report for the year ended 31 Q3 and Q4 May 2013; Annex 2 to Chapter 7 of the FT March 2013 (the ‘Quality Report’) ARM • The 2012 national patient survey and specified performance indicators contained therein. • The Quality Report is not consistent • The 2012 national staff survey in all material respects with the Scope and subject matter • Care Quality Commission sources specified below quality and risk profiles dated The indicators for the year ended 31 • The specified indicators have not 09/02/12, 06/03/12, 10/04/12, March 2013 in the Quality Report that been prepared in all material 06/06/12, 05/07/12, 07/08/12, have been subject to limited assurance respects in accordance with the 05/10/12, 06/11/12, 05/12/12, consist of the following national Criteria. 06/02/13, 06/03/13.; priority indicators as mandated by Monitor: We read the Quality Report and • The Head of Internal Audit’s consider whether it addresses the annual opinion over the Trust’s • The percentage of patients content requirements of the FT ARM, control environment dated 24th receiving first definitive treatment and consider the implications for our May 2013. for cancer within 62 days of an report if we become aware of any urgent GP referral; and We consider the implications for our material omissions. report if we become aware of any • The number of C.difficile infections We read the other information apparent mis-statements or material for patients aged 2 or more contained in the Quality Report and inconsistencies with those documents We refer to these national priority consider whether it is materially (collectively, the 'documents'). Our indicators collectively as the 'specified inconsistent with the following responsibilities do not extend to any indicators'. documents: other information. • Board minutes for the period April We are in compliance with the Respective responsibilities of 2012 to the date of signing this applicable independence and the Directors and auditors limited assurance report (the competency requirements of the The Directors are responsible for the period) Institute of Chartered Accountants in England and Wales (ICAEW) Code of content and the preparation of the • Papers relating to Quality reported Ethics. Our team comprised assurance Quality Report in accordance with the to the Board over the period April practitioners and relevant subject assessment criteria referred to on page 2012 to the date of signing this matter experts. 60 of the Quality Report (the 'Criteria'). limited assurance report The Directors are also responsible for the conformity of their Criteria • Feedback from the Commissioners with the assessment criteria set out dated 24th May 2013; in the NHS Foundation Trust Annual Reporting Manual ('FT ARM') issued by the Independent Regulator of NHS Foundation Trusts ('Monitor'). Our responsibility is to form a conclusion, 3. Quality Report Royal Devon and Exeter NHS Foundation Trust 65 Annual Report and Accounts 2012-13

This report, including the conclusion, basis, of the data used to calculate Monitor. This may result in the omission has been prepared solely for the the specified indicators back to of information relevant to other Council of Governors of Royal Devon supporting documentation users, for example for the purpose of and Exeter NHS Foundation Trust as a comparing the results of different NHS • Comparing the content body, to assist the Council of Governors Foundation Trusts. requirements of the FT ARM to the in reporting Royal Devon and Exeter categories reported in the Quality In addition, the scope of our assurance NHS Foundation Trust’s quality agenda, Report work has not included governance over performance and activities. We permit quality or non-mandated indicators in the disclosure of this report within the • Reading the documents the Quality Report, which have been Annual Report for the year ended 31 A limited assurance engagement is less determined locally by Royal Devon and March 2013, to enable the Council in scope than a reasonable assurance Exeter NHS Foundation Trust. of Governors to demonstrate they engagement. The nature, timing and have discharged their governance extent of procedures for gathering responsibilities by commissioning Basis for Adverse Conclusion sufficient appropriate evidence are an independent assurance report in – the percentage of patients deliberately limited relative to a connection with the indicators. To the receiving first definitive reasonable assurance engagement. fullest extent permitted by law, we do treatment for cancer within 62 not accept or assume responsibility days of an urgent GP referral Limitations to anyone other than the Council of Our testing identified administrative Governors of as a body and Royal Non-financial performance information errors in identifying the end date when Devon and Exeter NHS Foundation is subject to more inherent limitations calculating whether first treatment Trust for our work or this report save than financial information, given the for cancer had occurred within 62 where terms are expressly agreed and characteristics of the subject matter days of the GP referral. As a result, with our prior consent in writing. and the methods used for determining for 3 referrals out of 40 tested, the such information. conclusion drawn over whether the case should be included in the indicator Assurance work performed The absence of a significant body of or whether the target had been met We conducted this limited assurance established practice on which to draw was incorrect. engagement in accordance with allows for the selection of different but International Standard on Assurance acceptable measurement techniques Engagements 3000 Assurance which can result in materially different Conclusions (including adverse Engagements other than Audits measurements and can impact conclusion on the percentage or Reviews of Historical Financial comparability. The precision of different of patients receiving first Information’ issued by the International measurement techniques may also vary. definitive treatment for cancer Auditing and Assurance Standards Furthermore, the nature and methods within 62 days of an urgent GP Board (‘ISAE 3000’). Our limited used to determine such information, as referral) assurance procedures included: well as the measurement criteria and In our opinion, because of the the precision thereof, may change over • Evaluating the design and significance of the matters described time. It is important to read the Quality implementation of the key in the Basis for Adverse Conclusion Report in the context of the assessment processes and controls for paragraph, the percentage of patients criteria set out in the FT ARM and the managing and reporting the receiving first definitive treatment for Directors’ interpretation of the Criteria indicators cancer within 62 days of an urgent GP in [Annex B] of the Quality Report. referral indicator has not been prepared • Making enquiries of management The nature, form and content required in all material respects in accordance • Limited testing, on a selective of Quality Reports are determined by with the criteria. 66 3. Quality Report Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Based on the results of our procedures, nothing has come to our attention that causes us to believe that for the year ended 31 March 2013 • The Quality Report does not incorporate the matters required to be reported on as specified in annex 2 to Chapter 7 of the FT ARM; • The Quality Report is not consistent in all material respects with the documents specified above • The number of C.difficile infections for patients aged 2 or more indicator has not been prepared in all material respects in accordance with the Criteria.

PricewaterhouseCoopers LLP Chartered Accountants Plymouth 29 May 2013 The maintenance and integrity of the Royal Devon and Exeter NHS Foundation Trust’s website is the responsibility of the directors; the work carried out by the assurance providers does not involve consideration of these matters and, accordingly, the assurance providers accept no responsibility for any changes that may have occurred to the reported performance indicators or criteria since they were initially presented on the website. 2 Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

Quality Report 2012/13 Royal Devon and Exeter NHS Foundation Trust 3 Quality Report 2012/13

Contents

Part 1 Chief Executive’s Introduction 5

Part 2 Progress on our 2012/13 Priorities? 9

Our Priorities for 2013/14 30

2012/2013 Quality Schemes 38

Core Indicators 44

Part 3 Quality Indicators 49

Annex 55

A – Statement from the Council of Governors 56

B – Statement of Directors' Responsibilities in Respect of the Quality Report 60

C – National Clinical Audits 62

D – Local Clinical Audits Actions 67 4 Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13 1. Chief Executive’s Introduction Royal Devon and Exeter NHS Foundation Trust 5 Quality Report 2012/13

Chief Executive's 1Introduction 6 1. Chief Executive’s Introduction Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

Chief Executive’s Introduction

Welcome to the Royal Devon and Exeter NHS Foundation Trust’s Quality Report for 2012/13.

Earlier this year, when launching • Delivering safe clinical outcomes his response to the second Francis that meet or exceed patient Report on the Mid Staffordshire NHS expectations and that are delivered Foundation Trust and proposing further efficiently and effectively changes to the health service, the • Investing in developing and Secretary of State for Health, Jeremy maintaining a workforce who care Hunt, talked about the importance of passionately about continuous the NHS having ‘high quality care and improvement and who feel invested compassion’ at its heart. I believe that in, supported and listened to we fulfil this principle. • Ensuring strong and consistent Our Quality Report is a key publication leadership on quality issues and for us. It is the vehicle through which ensuring that we recognise those we reflect and report on progress who make a difference against the past year’s quality improvement targets and focus on • Being open and transparent – where our effort should be directed for learning from what we do well, the coming year. as well as where practice does not meet our expectations Our aim is always to provide the highest Delivering high quality, safe care with possible quality of service for our • Taking part in clinical audit and compassion and respect is what we patients, wherever and however they research of local, regional, national constantly strive to achieve for each come into contact with us. That means: and international significance. We see this as an important way and every one of our patients. Our • Placing patients at the centre of to evidence our commitment to staff, whether on the front line of care all that we do –an individualised improving the quality of care we or in a support function, are the people approach that takes into account offer. During the last year, for who bring this principle alive. I would their medical needs as well as their example, we helped to found the like to extend my own thanks, and wider experience of care is essential that of the Board, to our staff, for their emergent South West Peninsula tireless work to ensure that all of our • Continually reviewing what we Academic Health Science Network, patients receive the best possible care. do, looking for innovation and enhancing our existing research I am proud of what we are able to improvement and focussing on partnerships and collaborations deliver: the passion and commitment evidence-based outcomes and promoting the spread of best practice across the peninsula. demonstrated time and again by our • Being consistent so that the staff – even through challenging times quality offer is the same whenever – never ceases to amaze me. you come into hospital, whatever treatment you require and whomever you encounter – from a receptionist to a consultant 1. Chief Executive’s Introduction Royal Devon and Exeter NHS Foundation Trust 7 Quality Report 2012/13

As this report sets out later, among We must unrelentingly look, and look This year we have piloted the many challenges we face is a local again, at what needs to be done to an electronic document population profile that contains a improve what we do and how we do it higher proportion of over 80-year-olds in the interests of driving forward ever management system. Over than most of the country. Our aim is better patient care and experience. time, this will revolutionise to ensure that we develop new ways Constant improvement involves the way we store and manage of providing the best care we can embedding quality in our culture. for this group of patients. We aim to That is why our transformation project patient records, leading to a develop leading edge approaches that – essentially how we can continue to reduced risk of information will benefit patients locally but may deliver clinically safe and financially being misfiled or mislaid and also be of use to the wider NHS, which sustainable care for our patients within has yet to deal with the demographic an increasingly challenging economic thus reducing the potential pressures we currently face. We are environment – has become the centre impact on safety. Moving away taking a comprehensive approach to piece of our approach to quality. from manually written notes this work – developing a wide range The tightening financial climate has of innovative ways to provide good helped drive a fundamental root and is a massive change for the quality care to this group of patients branch examination of how we work, organisation but its benefits are in tandem with our partners. One of with the joint aim of maintaining or tangible. Using eNotes will give our initiatives is to ensure that all staff improving patient care and experience attend a training session to help them whilst maximising efficiencies. Over clinicians much more reliable better understand the issues facing the coming years we will continue and rapid access to patients’ frail elderly paints and those with to transform our organisation, notes, and already staff in the dementia. Our aim is to sensitise all enabling us to do more for less while of our staff to the issues, so that we maintaining the quality of our services. pilot areas are reporting that can be on the front foot in meeting To the best of my knowledge and they see benefits for patients. the needs of these patients. It is by belief, the information contained in embedding new approaches such as this document is accurate and, on this that we will continue to enhance behalf of the Board, I am confident our quality offer. to stand by its contents. Much of Quality care covers a wide range of the format and structure of this issues and means different things to document is prescribed by Monitor’s different people. This is underlined Annual Reporting Guidance, which by the responses we had from our incorporates the requirements of the Members in the focus groups at the Health Act 2009 and the NHS Quality Members' Say event last September. Account Regulations 2010. We understand that quality involves a multifaceted and integrated approach.

Angela Pedder Chief Executive 8 1. Chief Executive’s Introduction Royal Devon and Exeter NHS Foundation Trust QualityAnnual Report and2012/13 Accounts 2012-13 Royal Devon and Exeter NHS Foundation Trust 9 Quality Report 2012/13

Progress on our 22012/13 Priorities 10 2. Progress on our Royal Devon and Exeter NHS Foundation Trust 2012/13 Priorities Quality Report 2012/13

Governors’ Priorities

Last year our Governors identified three quality improvement issues and requested that these should be a priority during 2012/13. This section provides an update on the work undertaken by the Trust for this period.

1. Managing the • Providing active treatment • Working with key partners by health and social care including improved early detection healthcare needs of professionals in the patient’s home and intervention for dementia, the frail and elderly for a maximum period of 21 rapid patient assessments and days, as an alternative to hospital partnership working with clinicians admission, in pilot areas in primary care Frail older people project • Providing education and training • Potential commissioning changes: We have undertaken a detailed analysis in dementia care across the Trust understanding and discussing of the pathways that frail, elderly with the new commissioners patients follow and this has helped • Involving patient and carers in our how potential changes in identify a number of improvements redesign work. commissioning may impact on that would have the biggest impact on This project has three key strands: elderly care. these patients including: • Changing the way we manage As a result of this ongoing work, • Providing comprehensive geriatric the care of elderly patients while admissions for this group of assessment at the point of within the Trust including patients continue to rise, their length presentation to acute hospital new ward arrangements, of hospital stay has decreased. active rehabilitation, increased ambulatory care, seven-day Our population is changing working, improving discharge processes and dementia screening Many people choose to retire to the South West for the quality of life it offers. This means that the RD&E serves a population whose age curve is ahead of the rest of the UK. Year on year we are looking after more older patients with complex needs. Many of these patients are diagnosed with dementia - a physical condition which comes from the progressive deterioration of the brain tissue and its functions. 2. Progress on our Royal Devon and Exeter NHS Foundation Trust 11 2012/13 Priorities Quality Report 2012/13

Forget me not for both clinical staff and those in • Focus on what the person can do support services. This will continue into and play to their strengths We introduced the Forget Me Not the new financial year. campaign to improve communication • Involve the family in their care – with patients who have any form of As well as highlighting the they will know the person well mental illness. For this campaign, we demographics which make this such and how to respond to things. are working with our colleagues in an important issue for the RD&E, the mental health at Devon Partnership training gave staff some top tips on Observational audits NHS Trust. how to help patients who may be disorientated or confused. Our Nurse Consultant for Older People, Forget Me Not aims to benefit anyone Debbie Cheeseman, introduced a struggling to communicate their Top tips when caring for a person with programme of observational audits needs and preferences, for whatever dementia: covering all clinical areas in the Trust, reason. The new campaign symbol, • Remember that this is a person including theatres and outpatient a Forget Me Not flower, tells staff with dementia and not just departments. Each area receives two that the patient needs a little more symptoms of their condition observations of care: one carried out time, sensitivity and skill to support by Debbie and a Ward Matron and the their journey through services. The • Look for the person behind other carried out by Debbie and an campaign symbol is available in the dementia – try to find out independent observer, who may be a magnetic and sticker form so that something about their life member of staff from another area or it can be placed on the bed, ward • Complete the ‘This is Me’ a student or carer. On each visit, the whiteboard, request forms or notes document with family to give observers watch all patient interactions of any patient displaying symptoms of some insight and information into for an hour. Staff are given immediate cognitive impairment. this person’s life. This can help find feedback about their approach towards patients and the Matron is This initiative aims to: areas for engagement advised of the care observed. • Increase interaction time and • About 90% of communication This has been a very powerful teaching frequency of contact with patients is non-verbal – think about body language, gestures and facial tool for all staff involved. A lot of • Increase the therapeutic quality of expressions excellent care has been seen and interactions feedback given so that staff are aware • Effective communication takes • Improve patient and carer they should continue to role model time and patience experiences that good behaviour. One consistent • Respond to emotions not just observation is how little eye contact • Promote a culture of words – does the person seem patients receive from us unless it’s their person-centred care unhappy or distressed? ‘turn to have care’. This will now form • Reduce staff stress. part of a formal research proposal. • Ensure the person can see you – In the meantime this work is being position yourself at their level and shared at the one hour awareness Training maintain eye contact session ‘Our population is changing’ so Consultant Nurse for Older People, • So called ‘problem behaviour’ that staff are learning how eye contact Debbie Cheeseman, also developed is nearly always an attempt to particularly affects patients who have a a training package for all Trust staff. communicate feelings or needs. delirium or dementia. She held a series of one-hour lectures Rather than trying to stop the throughout February and March 2013, behaviour try to work out what which was in plain English and suitable it means 12 2. Progress on our Royal Devon and Exeter NHS Foundation Trust 2012/13 Priorities Quality Report 2012/13

2. Communication • Were clear beforehand that Care Quality Assessment Tool a member of staff answered Our innovative Nursing Quality between staff and questions about the operations Assessment Tool (NQAT) was or procedure in a way that the patients developed in 2009 to ensure that we patient could understand. systematically used: During 201, patients told us that that Over the last year we have worked they were bothered at night by noise • Record keeping compliance hard on improving the ways in which from other patients. We resolved to people leave hospital in a timely, • Observation of care better understand the issues by talking efficient and safe way. This work was to patients and getting their input to • Feedback from patients reflected in the response to the 2012 a scheme to provide eye masks and survey, where a higher proportion of to identify key priorities to improve ear plugs on request. This has resulted patients told us that: patient care. in a smaller proportion of patients reporting being troubled by noise at • They felt that they were involved Since we first introduced this approach night in our last survey (2012). in decisions about going home we have been constantly developing its effectiveness. For example, over the In the responses we received from • A member of staff explained the last year we have made a number of patients in our National Inpatient purpose of the medicines that they changes to our record keeping so that Survey results last year, a greater were taking in a way that they it now encompasses a wider range of proportion of patients than in previous could understand professionals involved in a patient’s years reported that they: • A member of staff told the patient care, including doctors, nurses and • Could always understand what about medication side effects to therapists. This has helped to ensure was being said to them when they watch out for when they went that everyone involved in patient care had important questions home fully understands what is needed. As a result, our record keeping standards • Had confidence and trust in the • They understood how to take their have improved. In recognition that the doctors and nurses treating them medication when they went home tool has been extended to the care • Were involved as much as they • They were given written or printed provided by doctors and therapists wanted to be in the decisions information about their medicines as well as nurses, we have changed about their care and treatment its name to CQAT – the Care Quality • A member of staff told the patient Assessment Tool. • Were given the right amount of about any danger signals that the information about their condition patient should watch for after they We have also introduced a fourth or treatment went home element into CQAT: staff experience. We know that how staff feel about • Were able to find someone on the • The doctors or nurses gave the their work makes a real difference hospital staff to talk about their patient’s family, or someone close to the experience of patients. That worries and fears to the patient, all the information is why we have introduced a staff they needed to help care for the • Got enough support from hospital feedback element into the tool so that patient staff during their stay we can obtain a better picture about • Hospital staff told the patient • Were clear beforehand that the overall care being offered to our whom to contact if they were a member of staff explained patients. This will enable us to make worried about their condition what would be done during the even more improvements to the quality or treatment after they left the operation or procedure and safety of care we provide. hospital. 2. Progress on our Royal Devon and Exeter NHS Foundation Trust 13 2012/13 Priorities Quality Report 2012/13

As CQAT provides real time patient Staffing at a ward level is complex as 3. Benchmarking feedback, it enables our clinical teams there are a wide range of factors which Current ward staffing levels to work on those areas that patients influence how many staff are required have been compared to national and staff have identified as needing to deliver safe and appropriate care. benchmarks. improvement as quickly as possible. In order to ensure that we fully Results are with the clinical teams appreciate this complexity, during the The result of all of this work is that within 48 hours of an audit taking last year we have undertaken a review we now have a comprehensive place, allowing real and tangible of our clinical teams at ward level. This understanding of our ward changes to be introduced rapidly. The review used three criteria: staffing levels and are confident results of CQATs are also reported that we have the right numbers to the Board as part of the regular 1. Professional Judgement and mix of staff on different wards reporting schedule. to meet the differing needs of Ward Matrons assessed the staff their patients. they required to provide optimal 3. Strengthen nursing care on their individual wards. This leadership at ward information was then reviewed by a senior team (made up of Senior level Matrons or Lead Nurses, and the Deputy Director of Nursing). Last year we said that we would strengthen leadership at ward level by 2. Dependency Review ensuring that ward matrons are given the time to lead and opportunities to Clearly not all patients require the develop their skills. same amount of nursing time in order to receive a high standard We know that if we are to maintain of care. Factors such as the nature high standards of care, it is essential of a person’s illness, their age and that Ward Matrons have the right other disabilities can impact upon skills and sufficient time to provide how dependent a patient is. leadership. During the last year we worked with Plymouth University We use a number of tools to to design and develop a bespoke calculate the dependency of leadership programme for Ward patients within hospital wards. Matrons. This programme aims to build All of these have their limitations on and enhance our Ward Matrons’ so we commissioned an expert existing excellent leadership skills and with extensive experience in the will be delivered from April 2013. development of dependency tools, to develop a bespoke dependency The Trust has also taken steps to tool for our needs. This tool has increase support for Matrons on wards been used to provide us with to ensure that they have dedicated detailed data relating to the time to lead their teams and monitor occupancy and dependency of standards of care. This increases their each ward in the Trust. visibility and makes them more available to patients, relatives and carers. 14 2. Progress on our Royal Devon and Exeter NHS Foundation Trust 2012/13 Priorities Quality Report 2012/13

CASE STUDY Members’ Say: What does 'quality' mean to our Members?

In September 2012 the Trust held the • Consulting Members on different There were five key issues that emerged latest in its series of Members’ Say options we are considering to from this discussion. Comments in bold events. These are opportunities for improve patient experience. were those that were highlighted the around 200 of our Members to spend most by respondents. For our Members Our Council of Governors has a duty a day at the Trust learning from leading quality means: to represent the views of the public clinicians about some of our services, in their role and these events help “First rate outcomes” as well as being able to meet with to shape their views about what is staff representing different aspects of • I get the treatment I need, important to Members. Similarly, our the hospital such as infection control, when I need it, to deal with my Board recognises the need to consult patient nutrition and nursing care. health issue with Members and the wider public Members who come to these events and the outcomes from Members’ • I know I will get access to the also have the opportunity to take part Say events help the Board to fulfil this latest technologies/drugs in a range of interactive activities as obligation. well as attend focus group discussions. • My expectations were met or exceeded. The chance to develop an in-depth Members’ Say – September 2012 dialogue with Members – who broadly “Personalised care” represent the wider public served by In September 2012, the Members’ Say event focused on two themes: • I receive tailored care that is the Trust – is very important to us. The individualised and where I have mix of activities and discussion groups • Elderly care a real say in my own care enables us to really understand, in • Quality and safety. some depth, the views and opinions • I know what is happening, what of Members who have experience of We held six focus group discussions will happen next and some of the the RD&E but also other NHS services on the issues of quality and safety. care options I have locally and nationally. Although These groups consisted of around 10 • I get first rate after-care. there are a number of similarities Members, who discussed a range of between the views of patients and issues for about an hour, facilitated “A positive experience at every our Members, we have found that the in a neutral and independent way, stage” priorities, interests and concerns of by a trained member of staff. These • I am treated well, with respect, Members are different, partly because discussions were very rich and the friendliness, empathy, care and they have broader experiences to results below are based on an in-depth dignity – I feel I am looked draw on and because they have also analysis of the results, picking up some after and that my care really had the opportunity to reflect on their of the common themes that emerged matters to everyone I come into experiences of using the NHS. from the dialogue. contact with The feedback we receive from these • I am confident that there is good, Quality matters events helps to inform both our Board effective communications with and our Council of Governors in The groups were asked to say what me and between staff caring relation to: quality meant to them. The purpose of for me and by all staff from the • The Trust’s developing strategy and this was to help us to understand what receptionist onwards strategic options Members mean when they talk about quality; how important it is to them in • Understanding and improving the comparison to other factors; whether reputation of the Trust their assessment of quality is the same • Member priorities for the Trust in healthcare as in other settings; and what key factors were most important • Improving service delivery in determining and assessing quality. 2. Progress on our Royal Devon and Exeter NHS Foundation Trust 15 2012/13 Priorities Quality Report 2012/13

• My experience of quality includes “Poor communications” “Poor experiences” all that happens to me from • I am patronised, treated • I am stressed because I can’t referral onwards and it includes without respect or dignity, or park my car in time to make my car parking, how I am treated by ignored appointment the receptionist, whether I have to wait for my prescription. • I don’t have the right information • I am disturbed at night when an and don’t know what is inpatient. “All the basics taken care of” happening or might happen to me “Basic standards not met” • The environment is clean and • I don’t understand what is being infection-free - guaranteed • I see poor hygiene and there said to me (or understand the seems to be no clear and • The hospital is efficient, speedy information I am given) regularised approach to infection and the same consistent care is • I don’t know who is a nurse, control provided whenever I need it – doctor, healthcare assistant etc. guaranteed • There are inconsistent “Poor care” standards of care/poor • The service is well funded and training/poor accountability of staffed by good professionals/ • I am not treated as an individual staff. experts – guaranteed individual or receive poor 'customer care' The description of what our Members • The basic care standards are consider to be poor quality care met each and every time – • I lose dignity or privacy because of demonstrates the importance of guaranteed. poor care getting the basics right and treating In this discussion, participants mainly • I don’t see enough of the nursing people as individuals. looked at healthcare issues but were staff. We asked Members if they equated able to draw comparisons on how they “Bureaucratic and inefficient” quality care with safe care. Focus group might assess the 'quality offer' in other attendees said that they expected: areas – such as retail or transport. • I witness poor organisation or The description of what our Members management • To 'always feel safe in hospital' consider to be quality care provides a • I receive appointment letters after • That their 'personal safety was a good overview of what needs to be the appointment given'. delivered continuously and consistently. • I have to wait without knowing Any concerns they had on safety We then asked participants to tell us why and when I will be seen included: how they were able to identify poor quality. Five key issues emerged from • I don’t understand how to • Staffing ratios navigate my way round the this discussion. Comments in bold • Pressure of work leading to safety NHS/social care were those that were highlighted lapses the most by respondents. For our • My operation has been cancelled. participants, poor quality means: • The reliance on the lowest paid staff Members to keep the hospital clean. 16 2. Progress on our Royal Devon and Exeter NHS Foundation Trust 2012/13 Priorities Quality Report 2012/13

Trust Priorities 2012/13

Develop a strong • Recognising specific needs • We have always sought to of individuals and providing improve our services by listening value-based vision personalised care. to patient feedback. Now, based on a successful trial in for Nurses, Midwives The programme of work which sits our orthopaedic wards, we are beneath the vision includes simple and Allied Health systematically capturing patient innovations such as ensuring good feedback whilst patients are still in Professionals practice in one area can be rolled out hospital and sharing this at daily and applied consistently and reliably Over the course of the last year team safety briefings to promptly across the hospital, and making sure we have developed a new vision address any issues or concerns that individuals are held accountable. to guide the work of the 2,800 that may arise. Our approach For example: nurses, midwives and allied health involves the distribution of yellow professionals (AHPs) providing • We are rolling out Comfort cards which simply ask patients patient care at the Trust. The Rounds where we ensure that “What went well” and “What programme set out an ambitious each ward undertakes a nursing would make it even better if …?” organisational-wide commitment to round every hour. We believe These are reviewed by the ward ensure that high standards of care are it is not acceptable for patients team at the end of the shift and applied consistently. The three year to rely on a call bell to request where possible any concerns are programme, which was developed by assistance. We want to pre-empt addressed immediately. Ward senior leaders, seeks to capture the the essential needs of our patients; Matrons collate the responses pride and dedication that our nurses, so every patient every hour will to these questions and display midwives and AHPs demonstrate on be asked by a nurse or midwife publicly on the ward significant a daily basis. It also emphasises their whether they are comfortable and issues that have been identified passion to constantly improve patient if there is anything they need. and addressed. This has been care: ‘good’ is not good enough – we This regular check will address implemented on 25 wards want to be the best we can possibly essential aspects of patient care and departments and will be be for our patients, their families and including pain management, implemented across the Trust by carers. Representatives of nurses, nutrition and hydration. We also June 2013. We will adopt this midwives and allied health professionals expect this pro-active approach approach over the coming year in at the RD&E were involved in the to reduce the incidence of patient line with our Governors’ priorities. development of the vision to reinforce falls and pressure ulcers. We have their commitment to: implemented Comfort Rounding ‘Good’ is not good • Providing safe, dignified and on 15 wards and have a plan to compassionate care see it fully implemented by July enough – we want to 2013 • Being open and honest in their be the best we can communication and work in partnership with patients and their possibly be for our families patients, their families and carers. 2. Progress on our Royal Devon and Exeter NHS Foundation Trust 17 2012/13 Priorities Quality Report 2012/13

We now have anonymous staff At the heart of these initiatives – • Enable the development of feedback cards to pick up on themes and many others besides – is the knowledge and skills which inspire or issues which need addressing understanding that delivering safe, staff to give high standards of care because staff morale and satisfaction quality care to patients each and • Identify and invest in the leaders in the workplace can mirror patient every time, with compassion and for today and the future satisfaction. Therefore we have dignity, must be the main focus for implemented a system of ‘What went our work. Whilst targets and financial • Actively listen and encourage ideas well… even better if’… for staff. This is imperatives are important and have which will improve services. very similar to the process we are using their place, they cannot and must not for patients and works in the same get in the way of good, decent and way. The collated significant issues are compassionate care. displayed by the Ward Matron in staff In order for the vision to be properly areas. This will be fully implemented embedded we understand the across the Trust by May 2013. importance of investing in staff. The vision sets out plans to: 18 2. Progress on our Royal Devon and Exeter NHS Foundation Trust 2012/13 Priorities Quality Report 2012/13 2. Progress on our Royal Devon and Exeter NHS Foundation Trust 19 2012/13 Priorities Quality Report 2012/13

Develop a patient As well as being more efficient, Discharge planning the new electronic process is more As soon as any patient is admitted we discharge service to transparent, giving health and social are already planning for them to leave! care colleagues the opportunity to improve Our experience and good practice from continuously improve. co-ordination and elsewhere underlines the importance delivery of care From April 2013 our Onward Care of having a planned date for discharge team will carry out a daily review of for every patient. Within 24 hours Last year we said we did not want our all patients who are ready to leave following admission, a decision is patients to experience delays when hospital. This will help ensure there are made about the date of discharge they are ready to leave our hospital proper plans in place to enable patients and this is displayed prominently and and to receive the right information to leave at the most appropriate time. discussed on the daily ‘board rounds’ and ongoing care in the community. This daily assessment will enable us so that all clinicians are aware of the and our partners to iron out difficulties plan. Any changes to the planned date Enabling patients to leave hospital in onward care as they arise. are recorded so that we can identify when they are fit and ready to do so and address common themes resulting remains a challenge for the Trust. This Pilot project with Red Cross in delays. is primarily because the onward care in Volunteers the local heath economy is disjointed Better information and the availability of appropriate care In February we introduced a pilot settings for patients either at home, project to use volunteers to assist Good care means that patients need in residential care or in community patients on their return home. to be able to leave hospital when they hospitals is not in place. The Trust is Based on good practice established are well enough to do so, but not working hard with its local partners to elsewhere, Red Cross volunteers before. To enable us to understand address these issues and has also taken have been enlisted to meet and greet some of the underlying issues that the following actions: newly-discharged patients at home, affect timely discharge, we are placing check that they have enough food and considerable effort into recording data Electronic onward care referral provide support with other essentials at ward level and collating discharge form of daily living, if required, such as figures – including time of day. shopping and collecting medication Better information will mean we can Small changes can sometimes make (though not providing direct care). identify ways of enabling patients to the biggest difference. One of the This support is available for up to six leave hospital in an efficient and safe issues that has impeded onward care weeks following a patient’s return way, and spot where extra support was completing the right paperwork. home. So far, the Red Cross project has is required. The data collected is fed One of the barriers to smooth supported seven patients and recruited back to all wards so that each area can onward care was that handwritten and trained 20 volunteers. review its discharge performance for Health Needs Assessment forms took the previous week. anything between two and four hours to complete. Over the last year, in To facilitate the timely discharge of partnership with our health and social patients we are also: care colleagues in primary care, we • Developing a new audit tool have launched an electronic onward to monitor the effectiveness of care referral form. This now takes on ‘board rounds’ average just 30 minutes to complete. • Reviewing our discharge policy • Providing more electronic guidance to ward staff. 20 2. Progress on our Royal Devon and Exeter NHS Foundation Trust 2012/13 Priorities Quality Report 2012/13

Patients with complex needs Pharmacy discharge When ward staff are ready to discharge a patient, they can now use our Patients with complex ongoing needs In the past, one of the factors that held ‘discharge bleep service’. A member require more focused assistance to up patients leaving hospital was the of pharmacy staff will go to the ward enable them to leave hospital. We are delay in being prescribed or obtaining to check the discharge summary. This working with our partners – social medication to take home. As a result, enables face to face communication care, health and the voluntary sector we have redesigned our processes to with medical and nursing staff to – to raise awareness amongst staff, ensure that medication is provided as resolve any issues and ensure the right patients and their carers of the support quickly as possible and any delays dealt items are dispensed, reducing waste services available to people after with as quickly as possible, enabling and drastically reducing any delay. The leaving hospital. patients to go home sooner. drug chart does not leave the ward, contributing to improved patient safety. Average turnaround times are greatly reduced: in January 2013, 70% of drugs to take home were dispensed in less than one hour and 93% in less than two.

Improve patient flow when patients come to the RD&E for planned surgery Last year we said we were looking at all our planned surgical services across the hospital to develop ways of improving patient experience by being more efficient. Our aim was to provide smooth co-ordinated services from diagnosis and preparation of surgery through to recovery and leaving hospital.

Review of bed numbers The RD&E has seen a year on year rise of around 7% in emergency medical admissions. Many of these patients are aged 80 years and over and have complex health problems. Over the last two winters the Trust has struggled to balance the number of emergency admissions with patients being discharged, resulting in bed shortages. The national recommendation is for acute hospitals to run on an average 85% bed occupancy – but we were 2. Progress on our Royal Devon and Exeter NHS Foundation Trust 21 2012/13 Priorities Quality Report 2012/13

running way over this for sustained Ward management project resources. We considered a number periods. This compromised our ability of options and decided to create a We want patients to have the best to admit people for planned surgery dedicated day case unit at Wonford possible experience during their and our ability to meet waiting time for surgical patients. We identified stay with us, with clear, smooth and targets. So between January and April two ward areas suitable for day case timely transfers across wards and 2012 we carried out a detailed review surgery including planned orthopaedics departments for the investigations and of current and future demand and bed and specialist surgery work. There treatments they may need. To enable capacity requirements. are a number of advantages to this this to happen, we have embarked approach: on a major new project to better Modular wards understand and address the journey • We can refer patients to a single Our bed review showed that to achieve that patients take through the hospital. place for all planned surgery 85% occupancy rates in summer we This is currently being piloted in six • The ward is conveniently located would need an additional 66 beds, wards and the aim is to improve the for access to theatres rising to 125 extra beds in winter. journey so that it becomes seamless However, the focus of the NHS is and efficient as well as enhancing • The beds are protected for day shifting, with the intention of providing patient experience. case surgery, and patients are more services to patients in their own less likely to have their operations homes or in their local communities. Making surgery more cancelled when the Trust is facing So as well as reviewing bed capacity, convenient for patients capacity pressures. we carried out a major programme (and more efficient) The new surgical admissions and of work with our commissioners and Since April 2010 we have run day-case unit on Knapp Ward was partner health and social care providers operating theatres in local community officially opened in January 2013. Its to review how we work together to hospitals. By increasing the amount of impact is now being evaluated before manage peaks in demand, especially day case surgery (with no overnight changes are introduced to other over the winter. stay in hospital) carried out in these clinical services including emergency As a result of all this work, we created theatres we have been able to release surgical care. two new wards, Ashburn and Yealm, the main Wonford Hospital theatres for which opened in December 2012. more complex and emergency cases. The £4.5 million new wards provide This is better for us as it is a more 48 additional beds for older people. efficient use of resources; but it is also In January 2013 we also opened a better for patients who do not require dedicated surgical admissions unit an overnight stay. to co-ordinate our day case and Despite carrying out more surgery in elective surgery. local community hospitals, over 43,000 day case patients were still receiving their treatment in inpatient beds at Wonford Hospital. We decided to review how we do this work because we believed we could improve both the patient experience and our use of 22 2. Progress on our Royal Devon and Exeter NHS Foundation Trust 2012/13 Priorities Quality Report 2012/13

Invest in technology therefore available for simultaneous review. Electronic capture of the paper to improve document reduces the chance of management of information being misfiled or lost. patient records Matthew Moore, Orthodontic Consultant explains, “I am finding it Last year we said we planned to invest increasingly useful to be able to go in technology to improve management back and review in the system what of patient records with the aim to: I said for a patient yesterday or last • Support the growing size of case week; and it’s instantly available, which notes is a new way of working”. • Address on-site storage limitations The Health Records Department is now running new eNotes processes • Provide more efficient ways of alongside its traditional operations. working to support 21st Century The system will enable the Trust healthcare. to move towards its goal of a In November 2012, the RD&E paper-light health records service. implemented eNotes, an electronic In the meantime, clinical information document management solution. We generated in Orthodontics and Oral are among only a handful of Trusts in Surgery is scanned and stored. Already the country to do so. shelves in medical secretaries’ offices have been transformed, with no eForms allow clinicians to record need to store notes, and secretaries patient information electronically, have found the system has brought submitting directly into the eNotes efficiencies to their processes. record. This work started with the Orthodontics department and has The system is due to be rolled-out changed the way the clinicians work. Trust-wide over the next two years. Consultants and nurses are using laptops to capture and view patients’ clinical information. In addition barcoded paper forms are also used in clinic. These are completed, then scanned into the system and are 2. Progress on our Royal Devon and Exeter NHS Foundation Trust 23 2012/13 Priorities Quality Report 2012/13

CASE STUDY Patient Safety Thermometer

The NHS safety thermometer is a tool Each month’s figures are reported “The safety thermometer provides developed and implemented nationally to the Board in the ‘Ward to Board’ me with an opportunity to meet to measure ‘Harm Free Care’. ‘Harm report. They also act as an additional with all the matrons across the Trust. free care’ is defined as the absence of cross-check on our existing reporting Their enthusiasm for the 'Safety four ‘harms’: procedures. Thermometer' is amazing. It enables them to focus their attention on a • Pressure ulcers Our overall performance for 2012/13 particular element of care on their was: • Patient falls ward, and to visit and talk to every • 95% harm-free care patient in their care. • Urinary tract infections in patients with a catheter • 97% no new harm. “The feedback from staff has been overwhelmingly positive and patients • New venous thromboembolism Senior Matron, Anita Irwin, explains appreciate the time they get with a (blood clots). the difference that the safety matron. As well as increasing our focus thermometer has made – for patients The NHS is striving to provide ‘harm on safety, I think it’s enhanced our and staff: free care’ as these harms affect over ward communication and leadership 200,000 people each year in England “We’ve been running the safety capacity.” alone, leading to avoidable suffering thermometer programme for a year and additional treatment for patients now and have found it’s a really useful and a cost to the NHS of more than addition to our care quality and safety £400million. toolkit. The Royal Devon and Exeter has “It’s my role to co-ordinate the safety extensive programmes of work tailored thermometer each month. On the to each area to prevent these harms second Tuesday of every month, I visit occurring to patients and has seen every area of the Trust, carrying out improvement in each one. On a single the audit and supporting the matrons day each month, every patient in our in completing their database. If they care is reviewed by a matron or other are reporting anyone with one of the senior nurse to identify if any of these four harms, I’ll validate the information harms have occurred at any point in – and we’ll also discuss whether their care. These spot audits provide any further action is necessary. For our nursing leaders with a really good example, we’ll ask the tissue viability insight into the everyday standards of nurses to review patients with pressure care across their wards. ulcers." Some patients may have already come to harm before they arrived at the RD&E, for example they may have acquired a pressure ulcer at home or in another care setting. We therefore measure two indicators: ‘harm-free care’ for patients across their whole NHS journey, and ‘absence of new harm’ for patients directly in our care. 24 2. Progress on our Royal Devon and Exeter NHS Foundation Trust 2012/13 Priorities Quality Report 2012/13

Zero tolerance This year (2012/13), we have achieved have invasive devices such as drips even more and, at the end of March and catheters. Whilst Staph. aureus approach to avoidable 2013, can report that there have been can cause quite minor infections, health-care associated no hospital-acquired MRSA blood it can also cause serious infections stream infections at the RD&E – with such as wound, chest or urinary tract infections it being 550 days since the last MRSA infections. It can also enter the blood In 2003, the Department of Health blood stream infection was identified. stream and cause septicaemia, which is (DH) set out a clear direction for NHS We continue to apply the a very serious infection. interventions that have made this organisations on actions to reduce Staph.aureus infections are treated reduction possible, and now pursue a hospital-associated infections (HAIs) with a variety of different antibiotics zero tolerance approach to avoidable and to curb the proliferation of depending on the type and severity healthcare-associated infections. antibiotic-resistant organisms (DH, of the infection. Unfortunately, 2003). Each acute hospital trust has MRSA stands for Meticillin resistant some types of Staph. aureus have set targets to reduce hospital-acquired Staphylococcus Aureus (Staph. developed resistance to an antibiotic MRSA blood stream infections. The aureus). This is a common bacterium known as Meticillin and other similar targets are being achieved through a that can live, quite harmlessly, in the antibiotics. Types of Staph. aureus range of prevention strategies such as: nose, throat and sometimes on the that are resistant to Meticillin are • Improved hand hygiene skin of about 30% of healthy people. known as MRSA. It is widely accepted However, Staph. aureus may cause that people who carry MRSA in their • Aseptic technique – a method harm (infection) when it has the nose, throat and on their skin have used to protect wounds and other opportunity to enter other parts of the a significant chance of developing susceptible sites from organisms body. This is more likely to happen in a blood stream infection whilst in that could cause infection people who are already unwell and hospital. • Skin disinfection prior to insertion in hospital, particularly those who of drips • Prompt removal of drips and catheters • Screening to identify people carrying MRSA • Topical treatments to reduce carriage of MRSA whilst in hospital. We also know from our Members that tackling hospital-acquired infections remains a priority for the public. Last year, as a result of these and several other interventions, we reported a 98% reduction of MRSA blood stream infections acquired in the RD&E since 2004/5. 2. Progress on our Royal Devon and Exeter NHS Foundation Trust 25 2012/13 Priorities Quality Report 2012/13 26 2. Progress on our Royal Devon and Exeter NHS Foundation Trust 2012/13 Priorities Quality Report 2012/13

CASE STUDY Pressure ulcers – zero tolerance approach to care-acquired skin damage

Pressure ulcers are a type of injury that breaks down the skin and underlying tissue. They are caused when an area of skin is placed under pressure. They are also sometimes known as 'bed sores' or 'pressure sores'. Pressure ulcers can range in severity from patches of discoloured skin to open wounds that expose the underlying bone or muscle. The damage is usually caused by pressure, the weight of the body pressing down on the skin, and can occur when patients are moved incorrectly or nursed in chairs or on mattresses that are not suitable for their risk. The most common places for pressure sores are over bones that are close to the skin like the bottom, heel, elbow, ankle, shoulder, back and back of * The red line in the graph indicates the Trust's target achievement for the year 2012/13. the ear. Patients are more at risk of developing a pressure ulcer if they: Pressure ulcers cause patients If a patient comes into hospital with • Have difficulty moving and cannot long-term pain and distress and 95% a pressure ulcer or develops damage change position of them are avoidable. As well as whilst a patient, they will be seen • Cannot feel pain over part or all of causing pain and discomfort, pressure by a Tissue Viability nurse who will their body ulcers also result in patients staying in undertake an assessment and ensure • Are incontinent, are seriously ill, or hospital longer than planned. their care is the best we can deliver to resolve the pressure ulcer as soon have had surgery Avoiding pressure ulcers is a key as possible. This may involve specialist indicator of the quality of nursing care. • Have a poor diet and don’t drink equipment, moving and handling, enough water wound management, dietary input and Tackling pressure ulcers • Are very young or very old continence advice. Pressure ulcers are graded according to • Have damaged their spinal cord severity, with grade 1 being the least and can neither move nor feel serious and signalling a precursor to their bottom and legs pressure damage and grade 4 being • Are older people who are ill or the most severe. The Trust has had no have suffered an injury like a grade 4 pressure ulcers in 2012/13. broken hip. The graph above shows the reduction in grade 2 and 3 pressure ulcers. 2. Progress on our Royal Devon and Exeter NHS Foundation Trust 27 2012/13 Priorities Quality Report 2012/13

Avoiding pressure ulcers In February 2013 the Trust launched a new campaign - Pressure Ulcer Collaborative – a year-long initiative to embed the Trust’s ‘zero tolerance’ approach to care-acquired skin OCCUPUT damage. To help us achieve this SHEARING FORCE we have nominated pressure ulcer champions, who regularly come TOES SHOULDER together to share best practice and key BLADES learning in order to help drive change for the rest of the organisation. SACRUM

Develop an integrated SURFACE OF BED discharge service for HEAL ISCHIAL TUBEROSITY patients at the end FRICTION of their life so they die in their preferred place of care wherever possible The palliative discharge team commenced fast-track discharge is possible. The Last year we made a pledge to develop work on this project in April 2012. results so far show that patients are an integrated discharge service for The team now starts discussions with spending less time in hospital than patients at the end of their life, with relatives and carers earlier, so that they would have done previously, and the principle aims: their family member receives the best more people are able to die at home • For patients to die in their possible end of life care, and, wherever with their loved ones around them. As preferred place of care possible, in the setting of their choice. well as offering patients a far better This is often not an acute hospital ward. experience towards the end of their • To engage healthcare professionals life, the project is expected to save the The team co-ordinates care across on their attitude to death and Trust around £150,000 a year. dying health communities and aims to offer same-day referral whenever a • To promote earlier discussion about the wishes, concerns and priorities of patients about the end of their life. 28 2. Progress on our Royal Devon and Exeter NHS Foundation Trust 2012/13 Priorities Quality Report 2012/13

CASE STUDY Safety, clinical effectiveness and patient experience

Patient story, as told by Stephen Dinniss

and once we had decided to proceed, "After thinking I was we were kept abreast of ongoing developments and planning. We were cured, after seven aware of meetings between managers years clear, I was and clinicians as well as involvement of Commissioners and the PCT. As a diagnosed with a result we were asked to meet with the Medical Director to ensure we fully recurrence of bowel understood the significance of our cancer in March 2011. decision; and on his suggestion it was arranged for a surgeon from Denmark, Following further with experience of the operation, to chemo-radiotherapy the tumour be brought to Exeter to be involved. was felt to not be curable and We also met most of the seven no surgical options were felt surgeons and anaesthetists, as well as to be appropriate. However, physios and occupational therapists, following a chance meeting who would be involved, and had the between several clinicians opportunity to ensure all our questions whose opinions I had sought, were answered in advance. and the publication of an The operation itself I remember article in a surgical journal from nothing of, and little of the following Denmark describing a more period. I was aware, though, that radical approach to surgery, I many decisions about where my was offered the opportunity to care was based, and who would consider a hemipelvectomy to lead it were made before the treat the cancer. The operation operation. I subsequently felt secure would mean the amputation of in understanding the plan to remain my right leg and removal of the I understood it represented a huge on ITU before moving to the plastic right hip as well as many of the challenge and dilemma for both surgical ward. pelvic organs. It had never been myself and the hospital and required undertaken in the UK before, significant consideration and planning. I remained in hospital for around with just twelve described in the I was therefore given the opportunity five weeks and throughout that Danish article. to meet with the main clinicians time my care was well co-ordinated involved to aid in making the decision and delivered, a testament to the 2. Progress on our Royal Devon and Exeter NHS Foundation Trust 29 2012/13 Priorities Quality Report 2012/13

The Surgeon’s story, as told by Mr Ian Daniels, Colo-rectal surgeon planning that had occurred prior to “This was a truly exceptional example governance team. Delivering all the the operation. A discharge planning of multi-disciplinary team-working aspects of his care was done with meeting, involving community services across organisational boundaries. almost military precision. His operation, both from the local mobility centre and Managers worked in support of lasting over 11 hours and involving the district nurses, was held on the clinically driven leadership; the consultants from six different specialties, ward to ensure the seamless transition surgeons, anaesthetists, nurses, was supported by the theatre team from inpatient to outpatient care. A physiotherapists, occupational who worked tirelessly with the surgeons further opportunity was also given to therapists from all the different during the operation. both myself and my wife to debrief specialties worked as a single team and The payback for us has been tremendous. and discuss any concerns we had everyone was focussed on achieving Not only is Stephen now free from the about our experiences with the clinical the best care for Stephen. intractable pain he was experiencing, team prior to discharge. We struggled As a surgeon, I felt a huge his quality of life is also greatly improved. to identify areas within which my care responsibility seeing Stephen walk into Within weeks he was driving his car could be improved. the operating theatre, knowing the and playing football on crutches with Overall, my experience, on this most enormity of what lay ahead for him his children. He is living as full a life as difficult challenge I have ever faced, and our responsibility. The surgery itself any of us and that’s a great outcome. was made significantly easier by the was the largest single operation we’ve He will remain under continued excellent planning and co-ordination ever carried out at the RD&E. The follow-up and assessment, but already of my care prior to and during my time team of people involved on the day is attending rehabilitation to fit a in hospital. Now as I plan my return to was easily more than 20; but in total prosthesis. Overall I feel very proud work on my new prosthesis, six months probably 70 or 80 health professionals seeing the efforts of so many staff since the operation, I would like to were involved. here in Exeter support Stephen and his take the opportunity once again to family through a very difficult time and It’s highly intensive and complex thank all Members of the staff involved to demonstrate true multi-disciplinary surgery and not undertaken lightly. In and encourage them to consider care.” fact, we’re not aware of it ever having applying aspects of my experience to been carried out in the UK previously the care of all patients.” for recurrent rectal cancer. It required "We're not aware of precision planning because there are so many specialties involved. this surgery ever having As this was a surgical first for the team, been carried out in the I consulted with the Danish colleagues throughout the planning, and arranged UK before for recurrent for one of the surgeons to attend and rectal cancer." advise during the procedure itself. In this case, we had to ensure Mr Dinniss and his family were psychologically prepared; not just for what the operation and aftercare would involve, but also how it would impact the rest of his life. We had to gain consent and funding from our GP commissioners and tremendous work was done by our planners and 30 2. Our Priorities for 2013/14 Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

Our Priorities for 2013/14

Governors’ priorities

This year Governors 2. 28-day re-admissions in this area. However, for the coming year it was agreed that The Trust is keen to improve its have identified three a question along the lines of ‘is understanding of the issues that there anything we didn’t tell you key quality priorities. can contribute to re-admissions that would have been helpful and is undertaking work on to know?’ will be added to the this over the coming year. This 1. Monitoring of ‘never existing feedback questions of work will include detailed case events'/events leading to ‘What went well... Even better reviews of randomly selected significant harm if...’. These results will be analysed cases to establish whether or not The Trust already reports on these by the Engagement & Experience any re-admissions could have figures, but for the coming year Committee which includes three been prevented by the hospital we have agreed that the Trust Governors. team and to provide better will provide more feedback to understanding of the factors Progress on each of the above the Council of Governors as to relating to the re-admission. priorities will be managed by the Safety the cause of any such event, the & Risk Committee, Transformation learning that has taken place and 3. Communication with patients Programme Board, and Experience & the actions taken to prevent a Engagement Committee respectively. recurrence. Communication has been an issue that the Governors have See Annex A, page 61, later in this often highlighted as a key priority report for the Council of Governors and the Trust has been working commentary on the Quality Report hard on making improvements and explanation of why these priorities were chosen.

Angela Pedder OBE Chief Executive 2. Our Priorities for 2013/14 Royal Devon and Exeter NHS Foundation Trust 31 Quality Report 2012/13

The Trust’s priorities

Transforming what we do: our step change for the future.

Patient safety and the quality of care that by assessing their effectiveness the patient safety programme will we offer remains paramount for the and placing them within a coherent be increasingly integrated within RD&E’s Board. Yet we recognise that framework with explicit priorities, we our work on improving patient continuing to deliver safe, quality could ensure cross-learning as well as pathways weed out duplication of effort. Our care within a constrained financial • Efficient use of resources environment is the single biggest renewed transformation programme challenge facing the Trust. now has six key themes: We will need to continue to identify year on year efficiency • Patient journeys through the For a number of years now we have savings to meet our financial hospital and beyond sought to increase the efficiency and targets. The transformation effectiveness of what we do, whilst From the moment patients are programme will examine a maintaining or even improving quality referred to the RD&E until their wide range of areas – such as and safety. Changing what we do transfer home or to onward care, procurement and back office and how we do it has enabled us to they are on a ‘pathway’ through functions – to ensure that our meet our savings targets without any our services. We have embarked processes are as efficient as compromise to the quality and safety on a process to look at these possible, that we are adopting of the services we offer. Whilst much pathways in detail, with the aim of the use of technology, and that remains to be done to streamline making every patient’s pathway as we identify ways to improve how processes and eliminate inefficiencies smooth and effective as possible. some of our functional areas are within the hospital, the Board has The project aims to achieve a organised taken the view that incremental reduction in delays through the change – whilst important – is unlikely • Communications and system; a better utilisation of our to deliver the type of transformation engagement bed stock; appropriate reductions that will be required to sustain the in the length of stay and to For our transformation programme breadth of services we offer and to ensure that patient outcomes and to succeed, we are engaging deliver them in a sustainable and safe experience are integrated into our with our staff and stakeholders. way. That is why we now have a single improvement work. As well as We want to build a culture of transformational change programme, work within our 'four walls' this continuous improvement so that which is designed to enable us to project will increasingly involve we are able to sustain our high deliver clinically safe and financially integrating our improvements with quality services. Staff engagement sustainable care for our patients within external partners in primary and is central in making these projects an increasingly challenging economic social care work. It is often those on the environment. frontline who have the best ideas • Patient safety One of the first tasks for the new about how to change things for programme was to bring together We have a patient safety the better. Engagement of our the large number of improvement programme to provide a clear clinical staff is vital in ensuring that initiatives that have developed focus on safety issues as well change adds value for patients and over previous years. Many of these as ensuring that a standardised the RD&E. All our transformation individual projects were valuable in approach to safety can be projects are overseen by a small creating change. However, we felt implemented. Over the next year group of clinicians and managers 32 2. Our Priorities for 2013/14 Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

• Leadership development RD&E managers at every level and will be rolling these out during Our leadership programme 2013/14 will focus on creating a single, cohesive leadership team. Our • Management system leaders will embody and evidence development our agreed values and principles. Work is underway to develop They will share our vision and standard operating procedures work together to deliver a that will be relevant throughout single corporate plan. They will the Trust so that we bring a aspire to achieve the 'art of the consistent, coherent and possible' for patients and staff. well-managed approach to They will demonstrate ownership our work. and accountability, engaging, inspiring and motivating those Transforming what we do and how we around them. They will work do it, both within the hospital and with collaboratively with internal our external stakeholders, will present and external stakeholders and us with challenges over the coming peers, devolving decision making years. Our aim, in all that we do, is to and encouraging continuous ensure that we keep patients safe and improvement. They will celebrate provide the best possible quality of success, and effectively manage care. This will remain the key driver in non-delivery. We are currently everything we do. developing core standards for all 2. Our Priorities for 2013/14 Royal Devon and Exeter NHS Foundation Trust 33 Quality Report 2012/13

The Nursing Focus on Cancer Throughout 2013/14 we will hold a series of Cancer Summits. These Midwifery and Allied Services events will pull together all clinical, support and management staff Health Professions Providing the best care to our patients involved in cancer care. Our aim is is the central aim of all we do. For our Vision – Year 2 to place our cancer patients centre cancer patients, it is vital that we pay stage and to review and improve our A number of high profile cases of particular attention to timely access to treatment pathways so that we reduce unacceptably poor care in other services and the ease with which they our waiting times, whilst retaining a organisations have been reported in move along the cancer pathway. We personal and compassionate service for the national media during the last year. want to make sure everyone has the patients and their families. These have caused real public concern. right information and support at each The most significant of these is detailed point on their journey. The outcomes of this work will be in the Report of the Mid-Staffordshire monitored through the operational The National Cancer Strategy seeks NHS Foundation Trust Public Inquiry, performance management framework to improve outcomes for people with published in February 2013. We have and the action plan for improvement cancer as well as improving their reviewed the recommendations in this will be monitored through the Trust’s experience of care. Here at the RD&E report, alongside the earlier outcomes Senior Operational Group. from the first report into this failing we echo that intention. Over the Trust, and have identified the following past 12 months we have experienced areas for further work: challenges in meeting some of the Providing the best care national cancer performance targets. 1. Ensuring we further develop a Our biggest challenge has been to our patients is the culture of openness which means achieving the target to commence central aim of all we do. that anyone who has a concern treatment within 62 days of referral. about care feels able to report it We want to reduce waiting times so 2. As part of that culture of openness that our cancer patients receive timely, we will continue to inform effective and safe treatments. To help patients (and the family or carers clarify and reinforce where to focus where appropriate) if ever we our efforts, we enlisted the help of either cause harm or suspect that the Department of Health’s Intensive we have caused harm to patients Support Team [IST]; a resource we can draw on to provide an objective 3. We will explicitly ensure that we review and critique of our services recruit staff who share the Trust’s and systems. The IST provided us with corporate values. a report outlining their findings and This work will form part of year two of our Trust-wide Cancer Plan will take the work plan of our three year vision account of their recommendations. of the Nursing, Midwifery and Allied Health Professionals Vision. 34 2. Statement of Assurance Royal Devon and Exeter NHS Foundation Trust from the Board Quality Report 2012/13

Review of services Audit – participation The national clinical audits and national confidential enquiries that the During 2012/13 the Royal Devon & in clinical audits Royal Devon & Exeter NHS Foundation Exeter NHS Foundation Trust provided During 2012/13 38 national clinical Trust participated in, and for which and/or subcontracted 42 relevant audits and 5 national confidential data collection was completed during health services. enquiries covered relevant health 2012/13, are listed alongside the number of cases submitted to each The Royal Devon & Exeter NHS services that the Royal Devon & Exeter audit or enquiry as a percentage of the Foundation Trust has reviewed all the NHS Foundation Trust provides. number of registered cases required data available to them on the quality During 2012/13 the Royal Devon by the teams of that audit or enquiry, of care in 42 of these relevant health & Exeter NHS Foundation Trust listed in Annex C. services. participated in 92% national clinical The reports of 10 national clinical The income generated by the relevant audits and 100% national confidential audits were reviewed by the provider health services reviewed in 2012/13 enquiries of the national clinical audits in 2012/13 and the Royal Devon and represents 100% of the total income and national confidential enquiries Exeter NHS Foundation Trust intends to generated from the provision of which it was eligible to participate in. take the following actions to improve relevant health services by the Royal The national clinical audits and national the quality of healthcare provided as Devon & Exeter NHS Foundation Trust. confidential enquiries that the Royal detailed in Annex D. Devon & Exeter NHS Foundation Trust was eligible to participate in during The reports of 31 local clinical audits 2012/13 are listed in Annex C. were reviewed by the provider in 2012/13 and the Royal Devon & Exeter NHS Foundation Trust intends to take the actions to improve the quality of healthcare as detailed in Annex E. 2. Statement of Assurance Royal Devon and Exeter NHS Foundation Trust 35 from the Board Quality Report 2012/13

Clinical Audit • The Management of Diabetic • Emergency Laparotomy – Ketoacidosis (DKA) – this this audit improved the care Prize 2013 demonstrated significant pathway for these patients by Clinical audit is a quality improvements in the clinical care fast tracking radiology reporting, improvement process that seeks of patients with DKA including getting patients to theatre to make improvements in reducing inpatient stay, increasing faster, improving the timeliness patient care. physician review of these patients, of antibiotic administration and improving medication and senior medical review The Clinical Audit Prize 2013 was management for deteriorating patients, held to recognise and celebrate the and introducing new medical • Day Case Tonsillectomies – this achievements made by clinical staff equipment to measure cardiac showed a significant increase through clinical audit and to promote output. All of these actions will in the number of tonsillectomy high quality clinical audit projects. contribute to improving the procedures performed as day Fifteen entries from across the Trust mortality rates for these patients in cases, which in turn increased were received; four were shortlisted the long-term based on both the design of the audit patient comfort and experience and the demonstrable improvements and improved patient flow through • Pregnancy Testing before made in patient care. The shortlisted the day case surgery wards. This Surgery – the audit introduced entries were: also had a considerable cost a new safe surgery checklist benefit to the Trust in terms of which brought about a significant efficiency savings and meeting our improvement in the numbers of Department of Health ‘Payment By women having the possibility of Results’ targets pregnancy excluded by means of a pregnancy test prior to surgery. This in turn improves patient safety. 36 2. Statement of Assurance Royal Devon and Exeter NHS Foundation Trust from the Board Quality Report 2012/13

Clinical research The Royal Devon & Exeter NHS The Royal Devon & Exeter NHS Foundation Trust is one of the highest Foundation Trust collaborates with participation recruiting NHS organisations to clinical Exeter Medical School, hosting the trials in the South West Peninsula. The NIHR Clinical Research Facility for Participation in clinical research Trust was involved in conducting 577 experimental medicine. A total of demonstrates the Trust’s commitment clinical research studies in a wide range 5500 participants were recruited to improving the quality of care we of specialties during 2012/13. During into research studies during 2012/13 offer and to making our contribution this period there were over 300 clinical at this facility. Research focuses on to wider health improvement. Our staff participating in research approved understanding mechanisms of disease clinical staff stay abreast of the latest by a research ethics committee. Over (mainly in diabetes and cardiovascular treatment possibilities and their active 95% of studies were approved within patients) and introducing participation in research leads to 30 days of receiving valid application. improvements to patient care. successful patient outcomes. The Royal Devon & Exeter NHS The high quality of the research at The number of patients receiving Foundation Trust hosts the Peninsula the Trust is demonstrated by the level health services provided or sub- Comprehensive Research Network, the of external grant funding, which in contracted by the Royal Devon & South West Research Design Service and 2012/13 exceeded £5 million. Exeter NHS Foundation Trust in the Cancer, Stroke and Diabetes Local 2012/13 that were recruited during Additionally, in the last three years, 400 Research Networks and the Peninsula that period to participate in research publications have resulted from our Collaboration for Applied Health Research approved by a research ethics involvement in research, evidencing and Care, thus playing a significant role committee was 7,900. our commitment to transparency and in the region for the National Institute of desire to improve patient outcomes Health Research (NIHR). and experience across the NHS.

CASE STUDY Emergency laparotomy – a race against time

Every year, around 160 patients are on best practice issued by the Royal best chance of recovery. We hope admitted to the RD&E requiring College of Surgeons and the that by close attention to all aspects emergency laparotomy. This group National Confidential Enquiry into of each patient’s care we can achieve of patients are often very sick and Peri-Operative Deaths (CEPOD). It was ’incremental gains’ that will result in suffer a high rate of morbidity and designed by the Royal Surrey County improved survival of these patients.” mortality. An audit carried out last Hospital NHS Foundation Trust, which The new pathway adopts a truly year, by anaesthetists Louise Cossey, has one of the lowest mortality rates in multi-disciplinary approach, involving Bruce McCormick and James Pittman, the country for these patients. staff from the Emergency Department, showed that the RD&E’s mortality rate “We know that with emergency Surgery, Anaesthetics, ICU and for these patients was around14% laparotomy patients, we’re in a race Radiology. Key to implementation of – slightly better than the national against time to make a diagnosis and the new pathway is the role of the average, but enough to motivate the commence life-saving treatment as Trust’s four Physicians’ Assistants in team to seek improvement. soon as possible,” said Dr McCormick. Anaesthesia, who provide an on-call As a result of that initial study, the “The key is to identify these patients support service. The pilot is running Trust will now take part in a and intervene with antibiotics for six months before being evaluated multi-centre pilot of a new care and, where indicated, perform for its impact on length of hospital pathway, launched on 3rd December emergency surgery within six hours stay and mortality rates. If, as hoped, 2012. The pathway follows guidance of diagnosis, so that they have the the results show a drop in mortality then the pathway will be adapted for ongoing use. 2. Statement of Assurance Royal Devon and Exeter NHS Foundation Trust 37 from the Board Quality Report 2012/13

Goals Agreed with Commissioners

Use of CQUIN payment framework

A proportion of the Royal Devon & Exeter’s income in 2012/13 was conditional on achieving quality improvement and innovation goals agreed between the Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation (CQUIN) payment framework. Further details of the agreed goals for 2012/13 (detailed below) and for the 12 month period is available electronically at www.rdehospital.nhs.uk. The 2012/13 NHS Operating Framework continued the potential for Trusts to earn additional income, conditional upon achieving quality improvement and innovation goals. The Trust agreed a suite of schemes for which the Trust could earn an additional £6.7 million of income in 2012/13. In 2012/13 the Trust received payment to the value of £6.4 million. In 2011/12 the Trust received payment to the value of £3.8 million. National guidance increased the proportion of contract income that could be earned through CQUIN schemes from 1.5% in 2011/12 to 2.5% in 2012/13. 38 2. 2012/13 Quality Schemes Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

2012/13 Quality Schemes

The Commissioning for Quality 3. Dementia Screening 3c. Referral for Specialist and Innovation (CQUIN) payment This indicator represents the Diagnosis framework enables commissioners Trust’s progress in meeting new The percentage of all patients to reward excellence by linking a national guidelines in relation aged 75 and above, admitted proportion of providers’ income to to the early recognition of as emergency inpatients, who the achievement of local quality undiagnosed dementia. This have had a diagnostic assessment improvement goals. There are four indicator requires that the Trust (in whom the outcome is either nationally mandated CQUIN goals identifies patients who may be 'positive' or 'inconclusive' who (items 1-4) and a number of locally exhibiting symptoms of dementia, are referred for further diagnostic agreed goals. assesses them and refers them on advice or follow up. to appropriate care. 2012/13 Target – 90% A summary of these CQUIN’s is set out 2012/13 – please see update below. Currently the Trust is on track to 3a. Dementia Case Finding below* achieve all of the agreed measures apart The percentage of all patients from the Dementia CQUIN which was * A developmental Dementia CQUIN was aged 75 and above, admitted as agreed with Devon PCT in April 2012. In subject to in-year change (see *below). emergency inpatients, who are May 2012 national guidance was published asked the dementia case finding which indicated payment was only available 1. Venous Thromboembolism following the successful achievement of question within 72 hours of (VTE) Risk Assessment 90% compliance with all three elements of admission, or who have a clinical The percentage of eligible patients the CQUIN across all eligible patients. Devon diagnosis of delirium on initial PCT informed us that this would constitute who were assessed for risk of assessment or known diagnosis a change to the CQUIN. Subsequently it has developing a venous become apparent that not all commissioners of dementia. thromboembolism (blood clot). have applied this guidance and are recognizing 2012/13 Target – 90% the complexity of the development work that 2012/13 Target – 90% 2012/13 – please see update this CQUIN entails. The commissioners have 2012/13 Achieved – 94.6% below* agreed a partial payment in recognition of the significant quality, cultural and systemic 2. Patient Experience improvements that have been achieved for 3b. Dementia Diagnostic patients and carers living with dementia. The This indicator draws together Assessment and Investigation Commissioners have recognized this as partial the response of patients to The percentage of all patients achievement of the CQUIN target. five questions identified by the aged 75 and above, admitted Department of Health that were 4. Patient Safety Thermometer as emergency inpatients, who in the 2012 National Inpatient The Safety Thermometer is a have scored positively on the Survey. The responses form an nationally designed tool which case finding question, or who index-based score. The Trust’s monitors four types of potential have a clinical diagnosis of score of 73.3 compares favourably harm: delirium reported as having had a with national benchmarks and dementia diagnostic assessment • Venous thromboembolism is an increase on last year’s including investigations. (blood clot) achievement. 2012/13 Target – 90% 2012/13 Target – 73.5% • Patient falls 2012/13 please see update below* 2012/13 Achieved – 73.3% • Pressure ulcers 2. 2012/13 Quality Schemes Royal Devon and Exeter NHS Foundation Trust 39 Quality Report 2012/13

• Catheter associated urinary tract infections. Harm-free care is defined as the absence of all four of these harms across the patient pathway. The requirement during 2012/13 was to implement the tool. This was achieved and reports commenced in May 2012 (more information on the Safety Thermometer can be found on page 23). 2012/13 Target – introduce tool and commence monthly reporting from July 2012 2012/13 Achieved – Reporting commenced from May 2012

5. End of Life Care This indicator involved implementing the NICE Quality Standard in relation to End of Life care. This has ensured that best practice is being received by patients who are at the end of their life. 2012/13 Target – Delivery of standards in line with the plan 2012/13 Achieved – Standards achieved

6. Antibiotic Prescribing This indicator has ensured best practice in the prescribing of antibiotics.

6a. Antibiotic Prescribing (Stop dates) Proportion of antimicrobial prescriptions with stop/review date specified on the prescription. 2012/13 Target – 65% 2012/13 Achieved – 76% 40 2. 2012/13 Quality Schemes Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

6b. Antibiotic Prescribing 9. Early Supported Discharge for 10b. Nutrition and Hydration (Indications) Stroke (MUST Assessment) Proportion of antimicrobial This indicator has introduced Percentage of patients for whom prescriptions with an indication innovative practice which reduces treatment plans triggered by specified on the drug chart. the amount of time spent in assessments are fully and correctly 2012/13 Target – 65% hospital for patients who have implemented. 2012/13 Achieved – 82% suffered a stroke. 2012/13 Target – 90% 2012/13 Target – Reduction in 2012/13 Achieved – 100% 6c. Antibiotic Prescribing super spell length of stay (Compliance with Guidelines) 2012/13 – Data not yet available, 11. Nosocomial Pneumonia Compliance with Guidelines or but achievement is anticipated This indicator sees the introduction Documentation of Reason for Use of a series of care interventions that of Alternative Antibiotic Agent. 10. Nutrition and Hydration have reduced the risk of patients 2012/13 Target – 75% This is a two-part indicator. One acquiring pneumonia in hospital. 2012/13 Achieved – 91% part has ensured that patients who are assessed as requiring 11a. Nosocomial Pneumonia (Head 7. Scoping and Implementation additional nutritional support are up Tilt Positioning) of High Impact Innovations receiving the appropriate diet. Percentage of beds with ‘heads up In 2011 the Department of The second part of this indicator positioning’ in identified ‘high-risk’ Health identified six high impact has ensured that patients groups. innovations that would yield awaiting surgery are made ‘nil 2012/13 Target – Achieve agreed productivity gains for the NHS as a by mouth’ appropriately but not trajectory (85%) whole. The Trust has been required starved for an unnecessarily long 2012/13 Achieved – 100% in to scope the implementation of time. identified high risk groups these. 2012/13 Target – Production of a 10a. Nutrition and Hydration 11b. Nosocomial Pneumonia plan for 2013-14 (Implementation of ‘Nil by (Compliance with Naso-Gastric 2012/13 Achieved – Report Mouth’) Tube Placement) submitted to NHS Devon Percentage of patients for Percentage compliance with whom there is Compliance with Placement Bundle (Part 1) to 8. Emergency Department Recommended Timeframes for Reduce Incidence of Nosocomial Patient Flows ‘nil by mouth’ (for patients who Pneumonia. This indicator has tested a series require elective orthopaedic 2012/13 Target – Achieve agreed of changes which have improved surgery, both day case and trajectory (90%) the way in which patients are inpatient, and for paediatric and 2012/13 Achieved – 94% managed in the Emergency adult orthopaedic surgery). Department. Improvements in 2012/13 Target – Achieve agreed 11c. Nosocomial Pneumonia processes have reduced delays for trajectory (compliance with Naso-Gastric individual patients. 2012/13 Achieved – 100% Tube Management Bundle 2012/13 Target – Achieve agreed Percentage compliance with Naso- action plan Gastric Tube Management Bundle 2012/13 Achieved – Tests of (Part 2) to Reduce Incidence of change achieved and 95% access Nosocomial Pneumonia. target achieved 2012/13 Target – Achieve agreed trajectory (90%) 2012/13 Achieved – 99 % 2. 2012/13 Quality Schemes Royal Devon and Exeter NHS Foundation Trust 41 Quality Report 2012/13

Statements from or requirements reported by the Care Quality Commission: the the Care Quality development of an action plan Commission (CQC) approved by the Board of Directors which will enhance documentation The Royal Devon and Exeter NHS processes within theatres and also Foundation Trust is required to register on the wards (a summary of the with the Care Quality Commission inspection can be found on the (CQC) and its current registration status CQC website: www.cqc.org.uk/ is registered in full without conditions. directory/rh801). The Royal Devon The CQC has not taken enforcement & Exeter NHS Foundation Trust action against the Royal Devon and has made the following progress Exeter NHS Foundation Trust during by 31st March 2013 in taking 2012/13. such action: all actions contained within the action plan have been The Royal Devon and Exeter NHS completed by the target date of Foundation Trust has participated in 31st March 2013 and approved special reviews or investigations by the by the Governance Committee CQC relating to the following areas on 8th April 2013. The completed during 2012/13: action plan has been forwarded • 16th July 2012 – This to the CQC, who are planning unannounced review was part to undertake a repeat inspection of the CQC’s routine schedule of to ensure the actions meet the planned reviews. The inspection standards. focused on Mardon House, the Trust’s Neuro-rehabilitation Centre. Update on CQC inspections The CQC found that the Royal detailed in the 2011/12 Quality Devon and Exeter NHS Foundation Account Trust was meeting all the essential • 9th and 10th November 2011 standards of quality and safety – The action plan to improve inspected documentation of personalised • 6th, 7th and 9th November delivery of care was completed 2012 – This unannounced review and signed off by the Governance was part of the CQC’s routine Committee 1st June 2012 schedule of planned reviews. • 21st and 23rd March 2012 Eight standards were inspected – The outcome of the responsive and the CQC found that the Royal review of compliance of all Devon and Exeter NHS Foundation providers of Termination of Trust meet five of the standards Pregnancy Services, following fully and action was required for national concerns, found the three of the standards. The Royal Trust was meeting the regulation Devon & Exeter NHS Foundation in relation to the maintenance of Trust intends to take the following HSA1 form. action to address the conclusion 42 2. Statement of Assurance Royal Devon and Exeter NHS Foundation Trust from the Board Quality Report 2012/13

NHS number and general medical practice code validity

The Royal Devon & Exeter NHS Foundation Trust submitted records during April 2012 – January 2013 to the Secondary Uses service for inclusion in the Hospital Statistics that are included in the latest published data. The percentage of records in the published data:

Which included the patient’s valid NHS number was:

99.7% for admitted patient care 99.7% for outpatient care 96.7% for accident and emergency care

Which included the patient’s valid General Practitioner Registration Code was:

100% for admitted patient care 100% for outpatient care 99.2% for accident and emergency care

Information Governance

The Royal Devon & Exeter NHS Foundation Trust Information Governance Assessment Report overall score for 2012/13 was 68% and was graded green. This score indicates the Trust has satisfied the essential standards for management and use of information, including the handling of patient information. 2. Statement of Assurance Royal Devon and Exeter NHS Foundation Trust 43 from the Board QualityAnnual Report 2012/13

Clinical Coding

The Royal Devon & Exeter NHS Foundation Trust was subject to the Payment by Results clinical coding audit during the reporting period (April 2012 – March 2013) by the Audit Commission and the error rates reported in the latest published audit for that period for diagnosis and treatment coding (clinical coding) were:

Primary Diagnoses 93% correct

Secondary Diagnoses 90% correct

Primary procedures 73% correct*

Secondary procedures 100% correct

The audit was focused on three Health Resource Group (HRG) codes in subchapter of neonatal disorders.

* It should be noted that the sample size of primary procedures was fifteen records with four records incorrectly coded with the same error in all four cases (error has since been addressed, with a repeat audit planned for October 2013). We are confident that the errors detected were unique to neonatal disorders; the Trusts Clinical Coding Assurance Manager (who holds a current NHS Classification Service Approved Clinical Coding Auditor qualification) has undertaken audits in 2012 in General Surgery and General Medicine, scoring 94% and 100% respectively. Due to the small sample size, and nature of the subchapter audited, the error rate should not be extrapolated. The Royal Devon & Exeter NHS Foundation Trust will be taking the following actions to improve data quality: • Improve the information recorded on the maternity system (STORK) to provide better quality information for clinical coding. 44 2. Core Indicators Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

Core Indicators

Indicator Indicator Description Data The Royal Devon The Royal Devon Group and Exeter NHS and Exeter NHS Foundation Trust Foundation Trust considers that this intends to take/has data/percentage is taken the following as described for the actions to improve the following reasons indicator (percentage/ proportion), and so the quality of its services Core 12. The data made SHMI - 0.8993 (as expected) 1. There is a 9 month The Trust will continue Indicators available to the National (11 Trusts higher than expected, 115 as cross over between to monitor this data Health Service Trust or expected and 16 lower than expected) each reporting period. quarterly. NHS Foundation Trust Palliative Coding 0.3% (National 2. As the Trust does by the Health and Social 18.4%) not have palliative care Care Information Centre consultants this number with regard to – April 2011 - March 2012: is higher than Trusts (a) the value and SHMI - 0.8797 (lower than expected) that do. 3. The number banding of the (10 Trusts higher than expected, 116 as is increasing very summary hospital- expected and 16 lower than expected) slightly, however with level mortality Palliative Coding 0.2% (National the significant cross indicator (“SHMI”) 17.9%) over in time periods for the Trust for the this makes it difficult reporting period; January 2011 - December 2011: to draw any useful and SHMI - 0.8663 (lower than expected) conclusion. (10 Trusts higher than expected, 117 as (b) the percentage of expected and 16 lower than expected) patient deaths with Palliative Coding 0.4% (National palliative care coded 17.2%) at either diagnosis or specialty level for the Trust for the reporting period. 2. Core Indicators Royal Devon and Exeter NHS Foundation Trust 45 QualityAnnual Report 2012/13

Indicator Indicator Description Data The Royal Devon The Royal Devon Group and Exeter NHS and Exeter NHS Foundation Trust Foundation Trust considers that this intends to take/has data/percentage is taken the following as described for the actions to improve the following reasons indicator (percentage/ proportion), and so the quality of its services Core 18. The data made “Adjusted average health gain” Results for varicose The Engagement and Indicators available to the from the “EQ-5D index casemix vein surgery are low Experience Committee, National Health Service adjusted health gain” due to the small on behalf of the Trust or NHS Foundation (i) Groin hernia surgery: number of procedures Governance Committee Trust by the Health and Apr-12 to Sep-12 - 0.078 (National undertaken within the will continue to actively Social Care Information 0.091, Lowest 0.017, Highest 0.158) Trust. It is not possible monitor this performance Centre with regard Apr-11 to Mar-12 - 0.11 (National to correlate the figures and take action as to the Trust's patient 0.087, Lowest -0.002, Highest 0.143) for groin hernia surgery appropriate. reported outcome Apr-10 to Mar-11 - 0.061 (National and hip replacement measures scores for – 0.085, Lowest -0.020, Highest 0.156) surgery during Apr-12 (i) groin hernia (ii)varicose vein surgery: to Sep-12 against the surgery, Apr-12 to Sep-12 - N/A (National previous 2 year period 0.093) due to the fact that (ii) varicose vein Apr-11 to Mar-12 - N/A (National it is for a 6 month surgery, 0.094) period only. The data (iii) hip replacement Apr-10 to Mar-11 - 0.114 (National for knee replacement surgery, and 0.091, Lowest -0.007, Highest 0.155) surgery requires further (iv) knee replacement (iii) hip replacement surgery: investigation due to surgery, during Apr-12 to Sep-12 - 0.380 (National the fact that the Trust the reporting 0.437, Lowest 0.333, Highest 0.502) has submitted 256 period. Apr-11 to Mar-12 - 0.458 (National proformas during the 0.416, Lowest 0.306, Highest 0.532) time period, which Apr-10 to Mar-11 - 0.419 (National appear not to be 0.405, Lowest 0.264, Highest 0.503) showing. (iv) knee replacement surgery: Apr-12 to Sep-12 - N/A (National 0.312) Apr-11 to Mar-12 - 0.327 (National 0.302, Lowest 0.18, Highest 0.385) Apr-10 to Mar-11 - 0.293 (National 0.299, Lowest 0.176, Highest 0.407) Core 19. The data made (i) 0 to 14: 1. Numbers (better Performance against this Indicators available to the 2010/11 - 7.70% (National 10.15%) than) national indicator will be managed National Health Service 2009/10 - 7.94% (National 10.18%) performance. through the patient trust or NHS Foundation 2008/09 - 6.81% (National 10.09%) 2. Increase broadly in pathway improvement Trust by the Health and (ii) 15 or over: line with national trend. programme which reports Social Care Information 2010/11 - 10.07% (National 11.42%) to the Transformation Centre with regard 2009/10 - 9.69% (National 11.16%) Programme Board. to the percentage of 2008/09 - 9.16% (National 10.90%) patients aged – (i) 0 to 14; and (ii) 15 or over, readmitted to a hospital which forms part of the Trust within 28 days of being discharged from a hospital which forms part of the Trust during the reporting period. 46 2. Core Indicators Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

Indicator Indicator Description Data The Royal Devon The Royal Devon Group and Exeter NHS and Exeter NHS Foundation Trust Foundation Trust considers that this intends to take/has data/percentage is taken the following as described for the actions to improve the following reasons indicator (percentage/ proportion), and so the quality of its services Core 20. The data made Average weighted score of 5 questions The Trust continues to The Engagement and Indicators available to the relating to responsiveness to inpatients' ask these questions Experience Committee, National Health personal needs (Score out of 100) as part of the Care on behalf of the Service Trust or NHS 2011/12 - 70.8 (National 67.4, Lowest Quality Assessment Tool Governance Committee Foundation Trust by the 56.5, Highest 85) (an ongoing real-time will continue to actively Health and Social Care 2010/11 - 71.3 (National 67.3, Lowest audit). monitor this performance Information Centre with 56.7, Highest 82.6) and take action as regard to the Trust's 2009/10 - 69.8 (National 66.7, Lowest appropriate. responsiveness to the 58.3, Highest 81.9) personal needs of its patients during the reporting period. • Were you involved as much as you wanted to be in decisions about your care and treatment? • Did you find someone on the hospital staff to talk to about your worries and fears? • Were you given enough privacy when discussing your condition or treatment? • Did a member of staff tell you about medication side effects to watch for when you went home? • Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital? 2. Core Indicators Royal Devon and Exeter NHS Foundation Trust 47 AnnualQuality Report 2012/13

Indicator Indicator Description Data The Royal Devon The Royal Devon Group and Exeter NHS and Exeter NHS Foundation Trust Foundation Trust considers that this intends to take/has data/percentage is taken the following as described for the actions to improve the following reasons indicator (percentage/ proportion), and so the quality of its services Core 21. The data made 2012 - 74.121% (4th Quartile - top The general economic To support staff, the Indicators available to the performer), Median 63.256% (acute climate is difficult for Trust has invested National Health Service & acute specialist trusts), Lowest the NHS and what and commenced Trust or NHS Foundation 35.337%, Highest 94.119%. this means for staff implementation in a Trust- Trust by the Health and 2011 - 75%, Average 62% (acute is becoming clearer. wide transformational Social Care Information trusts), Lowest 33.149%, Highest For example in the programme that will Centre with regard 89.464%. South West the pay create a culture which to the percentage of consortium has been engages all staff in staff employed by, high profile and has delivering the changes or under contract to, caused anxiety for staff. required for the future. the Trust during the reporting period who would recommend the Trust as a provider of care to their family or friends. Core 23. The data made Oct12 - Dec-12: 92.1% (National The focus has been on Ongoing work with Indicators available to the 94.1%, Highest 100%, Lowest 84.6%) sustained improvement clinical teams to strive for National Health Jul-12 - Sep-12: 88.3% (National against this target. 100% risk assessment. Service Trust or NHS 93.8%, Highest 100%, Lowest 80.9%) There has been a Further identification Foundation Trust by Apr-12 - Jun-12: 83.5% (National steady improvement in of ineligible cohorts of the Health and Social 93.4%, Highest 100%, Lowest 80.8%) performance over 2012 patients. Improved VTE Care Information Centre Jan-12 - Mar-12: 80.5% (National which has continued event audits to ensure with regard to the 92.5%, Highest 100%, Lowest 69.8%) in the first quarter of that the Trust derives percentage of patients Oct11 - Dec11: 80.5% (National 2013. This has been maximum learning from who were admitted to 90.7%, Highest 100%, Lowest achieved through a adverse events related hospital and who were 32.4%) relentless focus by ward to missed opportunities risk assessed for venous clinical teams to ensure for VTE prophylaxis. This thromboembolism that all eligible patients work will be monitored during the reporting are risk assessed in a by the Infection Control period. timely manner and and Decontamination current performance Group. exceeds the quoted National average. 48 2. Core Indicators Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

Indicator Indicator Description Data The Royal Devon The Royal Devon Group and Exeter NHS and Exeter NHS Foundation Trust Foundation Trust considers that this intends to take/has data/percentage is taken the following as described for the actions to improve the following reasons indicator (percentage/ proportion), and so the quality of its services

Core 24. The data made 2011/12: 38 (National 21.8, Lowest There was no Testing and reporting Indicators available to the 0.0, Highest 51.6) apparent reduction in line with revised DH National Health Service 2010/11: 41.1 (National 29.6, Lowest because during the guidance since April Trust or NHS Foundation 0.0, Highest 71.8) third period a more 2012. Trust-wide change Trust by the Health and 2009/10: 41.1 (National 36.7, Lowest sensitive laboratory in Oct 2012 to use of Social Care Information 0.0, Highest 85.2) test was introduced antibiotics that are less Centre with regard to and therefore case likely to predispose to the rate per 100,000 ascertainment increased C.difficile infection. This bed days of cases of and all cases were work will be monitored C.difficile infection reported. by the Infection Control reported within the and Decontamination Trust amongst patients Group. aged 2 or over during the reporting period.

Core 25. The data made Patient safety incidents reported to the The data uploaded to The Safety and Risk Indicators available to the National Reporting and Learning Service the NRLS continues to Committee will continue National Health Apr12 - Mar13: 8581 (estimated increase as reporting to monitor this indicator Service Trust or NHS position)8581 (data taken from Datix increases. Overall in quarterly to review trends Foundation Trust by the Incident Reporting System) the last 12 months of number of incidents Health and Social Care Oct 12 – Mar 13 : 4605 (data taken there has been a 10% verses level of harm. Information Centre with from Datix Incident Reporting System) increase in reporting. regard to the number Apr12 - Sep12: 3766 (data from NRLS) This is due to increased and, where available, 3976 from Datix Incident Reporting awareness and training rate of patient safety System around incident incidents reported Oct11 - Mar12: 2522 reporting which is within the trust during Apr11 - Sep11: 2421 indicative of a good the reporting period, Safety incidents involving severe harm open reporting culture. and the number and or death percentage of such Apr12 - Mar13: 10/8581 = 0.117% patient safety incidents (estimated position) 10/8581 (data that resulted in severe taken from Datix Incident Reporting harm or death. System) Oct 12 – Mar 13 : 8/4605 = 0.174% (data taken from Datix Incident The NPSA definition Reporting System) of severe harm is used Apr12 - Sep12: 13/3766= 0.345% as per the National (data from NRLS) 2/3976 = 0.050% Framework. This is (data taken from Datix Incident defined as requiring Reporting System) life-saving intervention, Oct11 - Mar12: 19/2522= 0.753% major surgical / Apr11 - Sep11: 5/2421= 0.207% medical intervention, permanent harm or will Compared to all other Acute teaching shorten life expectancy. organisations: Apr12 - Sep12: 850/147776= 0.575% Oct11 - Mar12: 839/125564= 0.668% Apr11 - Sep11: 773/118806= 0.651% Royal Devon and Exeter NHS Foundation Trust 49 Quality Report 2012/13 3Quality Indicators 50 3. Quality Indicators Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

Monitor Dashboard

Monitor Dashboard - March 2013

Position Monitor Risk for Risk for Position Target for Monitor Risk for Risk for Indicator Trend Target Indicator Trend for Quarter Weightin Period Year for Quarter Period Weightin Period Year MON01 max. 67 MON05 Clostridium 9 (17) 1.0 Low Low 90.8% min. 90% 1.0 High High annual RTT Admitted Difficile Monitor Dashboard - March 2013

Position Monitor Risk for Risk for Position Target for Monitor Risk for Risk for Trend MON06 Trend IndicatorMON02 max.Target 2 Indicator for 0Quarter (0) Weightin1.0 PeriodLow YearLow RTT Non- for97.8% Quarter min.Period 95% Weightin1.0 PeriodLow YearLow MRSA annual MON01 Admitted max. 67 MON05 Clostridium 9 (17) 1.0 Low Low 90.8% min. 90% 1.0 High High MON03.I annual RTT Admitted Difficile Cancer 31 Day 86.0% MON07 min. 94% High High 92.8% min. 92% 1.0 Medium Medium Subsequent (26 of 186) RTT Incomplete MON06 MON02Surgery max. 2 0 (0) 1.0 Low Low RTT Non- 97.8% min. 95% 1.0 Low Low MRSA annual MON03.II AdmittedMON08 99.6% 94.8% Cancer 31 Day min. 98% 1.0 Low Low Cancer 31 Day min. 96% 0.5 Medium Low MON03.I (1 of 266) (33 of 630) Subsequent Drug First Treatment Cancer 31 Day 86.0% MON07 min. 94% High High 92.8% min. 92% 1.0 Medium Medium SubsequentMON03.III (26 of 186) RTT Incomplete MON09.I 92.8% CancerSurgery 31 Day 98.4% min. 94% Low Low Cancer 14 Day (192 of min. 93% High Very Low Subsequent (6 of 376) MON03.II GPMON08 Urgent 2664) Radiotherapy 99.6% 94.8% Cancer 31 Day min. 98% 1.0 Low Low Cancer 31 Day min. 96% 0.5 Medium Low (1 of 266) MON09.II (33 of 630) SubsequentMON04.I Drug 80.0% First Treatment Cancer 14 Day 93.0% Cancer 62 Day (65.5 of min. 85% High High min. 93% High Very Low MON03.III Symptomatic (10 of 143) GP Urgent 328) MON09.I 92.8% Cancer 31 Day 98.4% Breast min. 94% 1.0 Low Low Cancer 14 Day (192 of min. 93% High Very Low Subsequent (6 of 376) MON04.II GPMON10 Urgent 2664) Radiotherapy 100.0% Cancer 62 Day min. 90% Medium Medium A&E - 4 Hour 97.1% min. 95% 0.51.0 Low Low (0 of 35) MON09.II ScreeningMON04.I 80.0% Target Cancer 14 Day 93.0% Cancer 62 Day (65.5 of min. 85% High High min. 93% High Very Low Symptomatic (10 of 143) GP Urgent 328) MON11 LearningBreast 1.0 Not applicable Compliant Compliant 0.5 Very Low Very Low MON04.II DisabilityMON10 100.0% Cancer 62 Day min. 90% Medium Medium A&ECompliance - 4 Hour 97.1% min. 95% 1.0 Low Low (0 of 35) Screening Trend graphs run from April 2010Target to current month

MON11 Indicates that the target has been achieved for the quarter Learning Indicates that the target has been achieved for that month but the quarter has not yet finished Monitor Dashboard - March 2013 Not applicable Compliant Compliant 0.5 Very Low Very Low Monitor DashboardMonitor - March DashboardIndicates 2013 that the - Marchtarget has not 2013 been achieved for the quarter Disability Indicates that the target has not been achieved for that month but the quarter has not yet finished Compliance Position Monitor Risk for Risk for Position Target for Monitor Risk for Risk for Indicates that the target is not yet enforced Trend Trend Indicator Position Target MonitorPosition Risk for Risk for MonitorIndicator Risk for Risk for Position Target for MonitorPosition Risk forTarget Risk for for Monitor Risk for Risk for Indicator Indicator Trend Trend for Quarter Target Weightin Period TargetYear Indicator Indicator Trend Trend for Quarter Period WeightinTrend graphsPeriod run Yearfrom April 2010 to current month for Quarter Weightinfor QuarterPeriod Year Weightin Period Year for Quarter Period Weightinfor QuarterPeriod PeriodYear Weightin Period Year MON01 MON01 max. 67 MON05 MON01 Low Low Indicates that the target has been achieved for the quarter High High Indicates that the target has been achieved for that month but the quarter has not yet finished Clostridium 9 (17) max. 67 1.0 max. 67 MON05 MON05 90.8% min. 90% 1.0 Clostridium Clostridium 9 (17) annual 1.09 (17) Low Low 1.0 RTT AdmittedLow Low 90.8% min. 90% 1.090.8% Highmin. 90%High 1.0 High High Difficile annual annual RTT Admitted Indicates thatRTT the Admitted target has not been achieved for the quarter Indicates that the target has not been achieved for that month but the quarter has not yet finished Difficile Difficile Indicates that the target is not yet enforced MON06 MON02 max. 2 MON06 Low Low MON06 Low Low MON02 MON02 0 (0) max. 2 1.0 max. 2 RTT Non- 97.8% min. 95% 1.0 MRSA 0 (0) annual 1.0 0 (0) Low Low 1.0 RTT Non-Low Low RTT Non- 97.8% min. 95% 1.097.8% Low min. 95%Low 1.0 Low Low MRSA MRSA annual annual Admitted Admitted Admitted MON03.I MON03.I Cancer 31 Day MON03.I 86.0% MON07 Cancer 31 Day 86.0% min. 94% High High MON07 92.8% min. 92% 1.0 Medium Medium Subsequent Cancer 31 Day (26 of 186) min. 94% 86.0% High High RTT Incomplete MON07 92.8% min. 92% 1.0 Medium Medium Subsequent (26 of 186) min. 94% RTT IncompleteHigh High 92.8% min. 92% 1.0 Medium Medium Surgery Subsequent (26 of 186) RTT Incomplete Surgery Surgery MON03.II MON08 MON03.II 99.6% MON08 94.8% MON03.II min. 98% 1.0 Low Low MON08 min. 96% 0.5 Medium Low Cancer 31 Day 99.6% 99.6% Cancer 31 Day 94.8% 94.8% Cancer 31 Day Cancer 31 Day (1 of 266) min. 98% 1.0 Low min. 98%Low 1.0Cancer 31Low Day Low Cancer 31 Day (33 of 630) min. 96% 0.5 Mediummin. 96%Low 0.5 Medium Low Subsequent Drug (1 of 266) (1 of 266) First Treatment (33 of 630) (33 of 630) Subsequent Drug Subsequent Drug First Treatment First Treatment MON03.III MON03.III MON09.I 92.8% Cancer 31 Day MON03.III 98.4% MON09.I 92.8% Cancer 31 Day 98.4% min. 94% Low Low Cancer 14 Day MON09.I (192 of min. 93% 92.8% High Very Low Subsequent Cancer 31 Day (6 of 376) min. 94% 98.4% Low Low Cancer 14 Day (192 of min. 93% High Very Low Subsequent (6 of 376) min. 94% GP UrgentLow Low Cancer 14 Day 2664) (192 of min. 93% High Very Low Radiotherapy Subsequent (6 of 376) GP Urgent 2664) Radiotherapy GP Urgent 0.52664) Radiotherapy MON09.II 0.5 MON04.I 80.0% MON09.II 0.5 MON04.I 80.0% Cancer 14 Day MON09.II 93.0% Cancer 62 Day MON04.I (65.5 of min. 85% 80.0% High High Cancer 14 Day 93.0% min. 93% High Very Low Cancer 62 Day (65.5 of min. 85% High High Symptomatic Cancer 14 Day (10 of 143) min. 93% 93.0% High Very Low GP Urgent Cancer 62 Day 328) (65.5 of min. 85% SymptomaticHigh High (10 of 143) min. 93% High Very Low GP Urgent 328) Breast Symptomatic (10 of 143) GP Urgent 1.0 328) Breast 1.0 Breast MON04.II 1.0 MON10 MON04.II 100.0% MON10 MON04.II min. 90% Medium Medium MON10 min. 95% 1.0 Low Low Cancer 62 Day 100.0% 100.0% A&E - 4 Hour 97.1% Cancer 62 Day Cancer 62 Day (0 of 35) min. 90% Mediummin. Medium90% A&E -Medium 4 Hour Medium A&E - 4 Hour 97.1% min. 95% 1.097.1% Low min. 95%Low 1.0 Low Low Screening (0 of 35) (0 of 35) Target Screening Screening Target Target MON11 MON11 Learning MON11 Learning Not applicable Compliant Compliant 0.5 Very Low Very Low Disability Learning Not applicable Compliant Compliant 0.5 Very Low Very Low Disability Not applicable Compliant Compliant 0.5 Very Low Very Low Compliance Disability Compliance Compliance Trend graphs run from April 2010 to current month Trend graphs run from AprilTrend 2010 graphs to current run frommonth April 2010 to current month Indicates that the target has been achieved for the quarter Indicates that the target has been achieved for that month but the quarter has not yet finished Indicates that the target has been achieved for the quarter Indicates that the target has been achieved for that month but the quarter has not yet finished Indicates that the target hasIndicates not been that achieved the target for thehas quarterbeen achieved for the quarter Indicates that the target hasIndicates not been that achieved the target for thathas beenmonth achieved but the forquarter that monthhas not but yet the finished quarter has not yet finished Indicates that the target has not been achieved for the quarter Indicates that the target has not been achieved for that month but the quarter has not yet finished Indicates that the target has not been achieved for the quarter Indicates that the target is notIndicates yet enforced that the target has not been achieved for that month but the quarter has not yet finished Indicates that the target is Indicatesnot yet enforced that the target is not yet enforced 3. Quality Indicators Royal Devon and Exeter NHS Foundation Trust 51 Quality Report 2012/13

Monitor Indicators and CQUIN

The Trust has reduced the number of indicators reported in the Quality Account, reporting only on those indicators which are mandatory, as outlined in the Monitor Reporting Manual 2013. The rationale for this change in approach is to focus on those indicators that are relevant, current and meaningful to the public.

Indicator Group Indicator Description Data Monitor Indicators - Clostridium (C.) difficile – meeting the C. 2012/13 - 46 (target 67) Safety difficile objective 2011/12 - 85 (target 74) Definition: infections relate to patient aged two years 2010/11 - 93 (target 162) old or more; a positive laboratory test result for C Diff recognised as a case according to the Trust’s diagnostic; positive results on the same patient more than 28 days apart are required as separate episodes, irrespective of the number of specimens taken in the intervening period, or where they were taken; and the Trust is deemed responsible. This is defined as a case where the sample was taken on the fourth day or later of an admission to the Trust (where the day of admission is day one) Monitor Indicators - Methicillin-resistant Staphylococcus aureus 2012/13 - 0 (target 2) Safety (MRSA) bacteraemia – meeting the MRSA 2011/12 - 1 (target 3) objective 2010/11 - 2 (target 4) Monitor Indicators - All cancers: 31-day wait for second or 2012/13 - 92.4% Quality subsequent treatment comprising: surgery 2011/12 - 97.9% 2010/11 - 97.0% Monitor Indicators - All cancers: 31-day wait for second or 2012/13 - 99.8% Quality subsequent treatment comprising: anti-cancer 2011/12 - 99.8% drug treatments 2010/11 - 99.7% Monitor Indicators - All cancers: 31-day wait for second 2012/13 - 98.7% Quality or subsequent treatment comprising: 2011/12 - 99.0% radiotherapyy 2010/11 - 94.7% Monitor Indicators - *All cancers: 62-day wait for first treatment 2012/13 - 83.6% Quality from: urgent GP referral for suspected cancer 2011/12 - 85.7% Definition: The indicator is expressed as a percentage 2010/11 - 85.4% of patients receiving first definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer. An urgent GP referral is one which has a two week wait from date that the referral is received to first being seen by a consultant. The indicator only includes GP referrals for suspected cancer (i.e. excludes consultant upgrades and screening referrals and where the priority type of the referral is National Code 3 – Two week wait). The clock start date is defined as the date that the referral is received by the Trust; and the clock stop date is the date of first definitive cancer treatment as defined in the NHS Dataset Set Change Notice. In summary, this is the date of the first definitive cancer treatment given to a patient who is receiving care for a cancer condition or it is the date that cancer was discounted when the patient was first seen or it is the date that the patient made the decision to decline all treatment.

*All cancers: 62-day wait for first treatment from: urgent GP referral for suspected cancer – the assurance review undertaken by PriceWaterhouseCoopers LLP of this indicator has identified clerical errors in the recording of data of the sample tested. These recording errors have been double checked by the Lead Consultant and Manager responsible for the service who have advised that the delivery of patient care has not been affected by these errors. The Trust is currently reviewing the administrative and clerical processes for collecting and recording 62 day wait for first treatment and the training provided to staff, to ensure the correct data is recorded for all patients. 52 3. Quality Indicators Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

Indicator Group Indicator Description Data Monitor Indicators - All cancers: 62-day wait for first treatment 2012/13 - 96.9% Quality from: NHS Cancer Screening Service referral 2011/12 - 93.8% 2010/11 - 96.9% Monitor Indicators - Maximum time of 18 weeks from point of 2012/13 - 88.6% Patient Experience referral to treatment in aggregate – admitted 2011/12 - 93.6% 2010/11 - 94.7% Monitor Indicators - Maximum time of 18 weeks from point of 2012/13 - 98.1% Patient Experience referral to treatment in aggregate – non- 2011/12 - 97.8% admitted 2010/11 - 98.0% Monitor Indicators - Maximum time of 18 weeks from point of 2012/13 -91.9% Patient Experience referral to treatment in aggregate – patients 2011/12 - 84.4% (no target) on an incomplete pathway 2010/11 - 86.5% (no target) Monitor Indicators - All cancers: 31-day wait from diagnosis to 2012/13 - 96.3% Quality first treatment 2011/12 - 98.1% 2010/11 - 97.3% Monitor Indicators - Cancer: two week wait from referral to date 2012/13 - 95.5% Quality first seen comprising: all urgent referrals 2011/12 - 95.3% (cancer suspected) 2010/11 - 97.8% Monitor Indicators - Cancer: two week wait from referral to date 2012/13 - 96.5% Quality first seen comprising: for symptomatic breast 2011/12 - 99.1% patients (cancer not initially suspected) 2010/11 - 98.4% Monitor Indicators - A&E: maximum waiting time of four hours 2012/13 - 96.2% Quality from arrival to admission/transfer/discharge 2011/12 - 95.6% 2010/11 - 97.9% Monitor Indicators - Certification against compliance with 2012/13 - Compliant Patient Experience requirements regarding access to healthcare 2011/12 - Compliant for people with a learning disability 2010/11 - Compliant CQUIN Indicator 1. Venous Thrombo-embolism (VTE) Risk Q1 - 94.7% (Target 90%) Assessment Q2 - 94.7% (Target 90%) Q3 - 91.4% (Target 90%) Q4 - 94.6% (Target 90%) CQUIN Indicator 2. Patient Experience Q1 - N/A (Target N/A) Q2 - N/A (Target N/A) Q3 - N/A (Target N/A) Q4 - 73.3% (Target 73.5%) CQUIN Indicator 3a. Dementia Case Finding Q1 - Implementation Plan agreed between Trust and NHS Devon (Target Plan agreed) Q2 - Plan agreed (No target for Q2) Q3 - Plan agreed (No target for Q3) Q4 - 32% (Target 90%) CQUIN Indicator 3b. Dementia Diagnostic Assessment and Q1 - Implementation Plan agreed between Trust and NHS Investigation Devon (Target Plan agreed) Q2 - Plan agreed (No target for Q2) Q3 - Plan agreed (No target for Q3) Q4 - 40% (Target 90%) 3. Quality Indicators Royal Devon and Exeter NHS Foundation Trust 53 Quality Report 2012/13

Indicator Group Indicator Description Data CQUIN Indicator 3c. Referral for Specialist Diagnosis Q1 - Implementation Plan agreed between Trust and NHS Devon (Target Plan agreed) Q2 - Plan agreed (No target for Q2) Q3 - Plan agreed (No target for Q3) Q4 - 94% (Target 90%) CQUIN Indicator 4. Patient Safety Thermometer Q1 - Reporting commenced from May 2012 (Target Implementation plan) Q2 - Reporting commenced from May 2012 (Target Monthly Reporting) Q3 - Reporting commenced from May 2012 (Target Monthly Reporting) Q4 - Reporting commenced from May 2012 (Target Monthly Reporting) CQUIN Indicator 5. End of Life Care Q1 - Plan agreed (Target Implementation plan agree between Trust and NHS Devon) Q2 - Milestones achieved (Target Achievement of milestones in agreed workplan) Q3 - Milestones achieved (Target Achievement of milestones in agreed workplan) Q4 - Standards achieved (Target Delivery of standards in line with the plan) CQUIN Indicator 6a. Antibiotic Prescribing (Stop dates) Q1 - 72% (Target 50%) Q2 - 71.5% (Target 55%) Q3 - 71.6% (Target 60%) Q4 - 76% (Target 65%) CQUIN Indicator 6b. Antibiotic Prescribing (Indications) Q1 - 66% (Target 50%) Q2 - 71.5% (Target 55%) Q3 - 78.8%(Target 60%) Q4 - 82% (Target 65%) CQUIN Indicator 6c. Antibiotic Prescribing (Compliance with Q1 - Baseline audit complete (Target Baseline audit Guidelines) undertaken) Q2 - Baseline audit complete (Target Baseline audit extended) Q3 - 100% (Target Baseline audit 70%) Q4 - 91% (Target 75%) CQUIN Indicator 7. Scoping and Implementation of High Q1 - Complete (Target Benefits paper) Impact Innovations Q2 - Progress report submitted to NHS Devon (Target Progress report against plan production) Q3 - Progress report submitted to NHS Devon (Target Progress report against plan production) Q4 - Report submitted to NHS Devon (Target Production of a plan for 2013-14) 54 3. Quality Indicators Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

Indicator Group Indicator Description Data CQUIN Indicator 8. Emergency Department Patient Flows Q1 - Action Plan agreed (Target Agree Action Plan) Q2 - Reviewed and developed joint action plan with PCT (Target Agreement of objectives and measures for Q3 and 4) Q3 - Reviewed and developed joint action plan with PCT (Target Agreement of objectives) Q4 - Tests of change achieved and 95% access target achieved (Target Achieve agreed action plan) CQUIN Indicator 9. Early Supported Discharge for Stroke Q1 - N/A (Target N/A) Q2 - N/A (Target N/A) Q3 - N/A (Target N/A) Q4 - Data no yet available, but achievement is anticipated (Target Reduction in super spell length of stay) CQUIN Indicator 10a. Nutrition and Hydration Q1 - Baseline established (Target Production of a baseline (Implementation of ‘Nil by Mouth’) and agree trajectory) Q2 - 55% Hydration, 64% Nutrition (Target 30%) Q3 - 92% Nutrition (Target 60%) Q4 - 95%, 65%, 100% (Targets 90%, 60%, 90%) CQUIN Indicator 10b. Nutrition and Hydration (MUST Q1 - Baseline established (Target Production of a baseline Assessment) and agree trajectory) Q2 - Achieved 90.3% and 87.6% (Target 40%) Q3 - Achieved 89.0% and 83.0% (Target 75%) Q4 - Achieved 98.0% and 100% (Target 90%) CQUIN Indicator 11a. Nosocomial Pneumonia (Head up Tilt Q1 - Approach agreed, baseline identified (Target Agree Positioning) approach and definition of high risk groups) Q2 - 100% in identified high risk groups (Target N/A) Q3 -100% in identified high risk groups (Target N/A) Q4 - 100% in identified high risk groups (Target Achieve agreed trajectory 85%) CQUIN Indicator 11b. Nosocomial Pneumonia (Compliance Q1 - Trajectory agreed (Target Produce baseline and agree with NGTube Placement) trajectory) Q2 - 84% (Target 76%) Q3 - 90% (Target 87%) Q4 - 94% (Target 90%) CQUIN Indicator 11c. Nosocomial Pneumonia (compliance with Q1 - Trajectory agreed (Target Produce baseline and agree Naso-Gastric Tube Management Bundle) trajectory) Q2 - 96% (Target 82%) Q3 - 98% (Target 88%) Q4 - 99% (Target 90%) Additional Indicators Patient Safety – The NHS Safety Thermometer 2012/13 (May12-Mar13) - 94.20% as chosen by Trust Additional Indicators Patient Safety – Incidence of Pressure Ulcers 2012/13 - 0.34% (target 0.80%) as chosen by Trust 2011/12 - 0.58% (target 0.80%) 2010/11 - 0.67% (target 0.80%) 3. Quality Indicators Royal Devon and Exeter NHS Foundation Trust 55 AnnualQuality Report 2012/13 4Annex 56 4. Annex A Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

Statement from the Council of Governors

This report has been prepared on Governors welcome the Trust’s focus 2. Frail older patients behalf of the Council of Governors on using a variety of methods such Governors are aware of the Trust’s by the Patient Safety and Quality as the CQAT for obtaining ‘real-time’ emphasis on all aspects of care for Group (PSQG) - a sub-group of patient feedback and staff experience this vulnerable group of patients, and COG with the particular remit to to identify improvement priorities. some Governors are directly involved focus on issues relating to patient Likewise, the ‘what went well, even in the Frail and Older People Project. safety and quality of care. The better if...’ scheme allows the early The Consultant Nurse leading this COG as a whole is informed and identification of patient concerns as project regularly reports on progress can seek assurance from many well as confirmation of good practice. to the COG. Further details about this information sources including At Board level, Governors are reassured project are provided in Part Three of Board papers; attendance at Board to see actions taken to understand this report. meetings; performance reports and resolve real or potential problems and the results from the Trust’s identified in the ‘ward to board’ participation in national surveys. reports. In addition, COG has received 3. Written communications In addition, three Governors detailed presentations on topics such between staff and patients (including the chair of PSQG) are as the CQAT assessment tool; end Governors have previously commented members of the Engagement and of Life care; dementia care; patient on the many variations in the format Experience Committee and provide pathways; complaints; nursing of hospital letters, and are pleased updates to other Governors at vision; frail and elderly care. These that a working group has been COG meetings. presentations provide the opportunity formed to revise letter formats and for Governors to question senior staff produce draft templates. The Patient about the Trust’s approach to these Experience Group have asked patient areas of patient care. representatives to test the new formats and report on their findings. Progress with Governor priorities 4. Dignity and respect for 2012-13 There is no single measure for this priority, but there are many sources 1. Accessible information of information which relate to these aspects of care including national The Trust’s Equality and Diversity surveys; the Trust’s own CQAT tool; Manager is working with the Patient complaints and commendations; and Experience Group (PEG) on the the ‘what went well - even better if’ production of easy read pamphlets scheme. In addition, senior nursing on eight topics: coming into hospital, staff and members of the Trust information for outpatients, protection executive undertake ‘walk arounds’ and use of information, ‘your where they can directly observe experience counts’, your spiritual whether dignity and respect are health, MRSA screening, colonoscopy preserved by all members of the and anaesthesia. care teams. 4. Annex A Royal Devon and Exeter NHS Foundation Trust 57 Quality Report 2012/13

5. Patient discharge - avoidance 2. 28 day re-admissions relationships with the Trust Board, of delays (Monitor) and the Non-Executive Directors in particular to ensure that all governors Since Governors identified this priority Governors are concerned about can continue to have confidence in the the Trust has undertaken a major re-admissions due to the potential for quality of patient care at the Trust. piece of work looking at all aspects of the Trust to be unfairly penalised for patient discharge and introducing a such events. The Trust has agreed to large number of changes to improve carry out regular audits throughout the process for all patients. Much of the year of randomly selected this work is ongoing, and Governors cases to establish whether or not receive regular reports on progress. any readmissions could have been Jill Gladstone prevented by the hospital team and to Governor priorities provide better understanding of the Public Governor for East Devon, Dorset for 2013 - 14 factors relating to the re-admission. & Somerset Chair Patient Safety and Quality Group As in previous years, all Governors 3. Communication with patients April 2013 were invited to submit suggestions for quality priorities, which together Governors suggested that patients with the findings from the most recent should be asked if there is any Members’ Say event were considered additional information that would have by the Patient Safety and Quality been helpful for them to know, and a Group and discussed with the Trust question about this will be added to executive. For the first time, Monitor the ‘what went well - even better if’ has suggested topics for Governors scheme. to monitor. The agreed topics for the The implementation this year of the coming year are: Health and Social Care Act gives Governors more responsibilities. 1. Monitoring of ‘never events/ These, together with the findings events leading to significant and recommendations from the harm’. (Monitor) Francis Report increase the pressure on Governors as representatives of The Trust already reports on these members and the wider public to be events, but for the coming year we properly assured about the quality have agreed that Governors will be of care at the Trust. There are many provided with more feedback about examples already in this report of a the cause of any such event; the range of examples that demonstrate learning that has taken place and the the high quality of care at the Trust; actions taken to prevent a recurrence. some of the most striking are the patient stories and case histories. In the coming months, the COG will build on the existing good working 58 4. Annex A Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

Statement from the Northern, Eastern and Western Devon Clinical Commissioning Group

The NHS Northern Eastern and hospital can clearly demonstrate the The Eastern Locality Board agrees with Western Clinical Commissioning difference they are making to patients the work reflected in the 2012/13 Group (NHS NEW Devon CCG) when using patient information, which Quality Account and acknowledges founded on 1st April 2013, is now the can be instant for example feedback that the Trust continues to put patient commissioning organisation for many immediately at ward level or used safety and quality of care at the services that the Royal Devon and toward longer term improvements for forefront of the services they deliver Exeter NHS Foundation Trust (The Trust) example, in service redesign. whilst striving to improve at every provides. The Eastern Locality Board, level in order to meet the needs of Initiatives such as the use of the Forget who have delegated authority and the population it serves. We look Me Not for patients who are struggling responsibility from NEW Devon CCG forward to the Trust maintaining the to communicate their needs is a very for commissioning those services, look improvements in the quality of service useful, visual reminder to staff when forward to working in partnership with patients have received in receipt of they are caring for the patient. The the Trust in the coming year to deliver urgent care during 2012/13 and a Consultant Nurse for older people high quality, effective and efficient continuation in the collaborative is addressing the needs of older services that meet the local needs of working which has brought the patients across the whole hospital. their patients and both managers and improvements in the quality of service The demographics for the east coast clinicians from commissioning and the in the Emergency Department. of Devon shows higher numbers of Trust are continuing to work closely in Both organisations have a shared elderly patients than the national determining and improving the services vision with respect to delivering figures who then use inpatient and for 2013/2014. This is a process that innovative care in the areas of first outpatient services therefore this work is well aided by some of the excellent appointment outpatients and follow- is timely and the changes that this will patient-centred work identified in this ups and we look forward to the quality bring in terms of improving the Patient report. improvements this work will deliver. Experience is supported by the Eastern This Quality Report describes the Locality Board. The work for 2013/14 will no doubt bring challenges in order to deliver patient experience. There is a range of CQUIN targets have been achieved safe, cost effective services, however means that allow patients and carers and exceeded this year and have led the Eastern Locality Board on behalf to give their views of the services directly to improved patient care and of NEW Devon CCG looks forward to they have experienced. This enables outcomes. The areas chosen for local working together with the Trust over the Trust to act on the feedback. The improvement relate directly to areas of the coming year importance of patient experience care that impact on patient experience information is how it then influences such as nutrition and hydration, end changes and improves services. The of life care, antibiotic prescribing and nosocomial pneumonia. The Eastern Locality Board acknowledges the hard work that has been undertaken to deliver the 2012/13 CQUIN targets. The zero tolerance approach to healthcare-associated infections and care-acquired skin damage is welcomed. Infection targets will be very challenging over coming months and the Trust is working strenuously to keep patients free from harm. 4. Annex A Royal Devon and Exeter NHS Foundation Trust 59 AnnualQuality Report 2012/13

Statement from the Health and Wellbeing Scrutiny Committee

Commentary on the Royal Devon and Exeter NHS Foundation Trust quality account

Due to Council elections and the timing of its submission for comment, Devon County Council’s Health and Wellbeing Scrutiny Committee has been unable to consider the Royal Devon and Exeter NHS Foundation Trust Quality Account this year. Overview and Scrutiny Committees are well placed to ensure the local priorities and concerns of residents are reflected in a provider’s Quality Account. In line with this approach Devon County Council’s Health and Wellbeing Scrutiny Committee will welcome a continuation of the positive engagement process from The Royal Devon and Exeter NHS Foundation Trust in the coming year. 60 4. Annex B Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

Statement of Directors’ Responsibilities in Respect of the Quality Report

The Directors are required under the In preparing the Quality Report, o The Trust’s complaints report Health Act 2009 and the National Directors are required to take steps published under regulation 18 Health Service Quality Accounts to satisfy themselves that: of the Local Authority Social Regulations to prepare Quality Services and NHS Complaints • The content of the Quality Report Accounts for each financial year. Regulations 2009, dated meets the requirements set out in Q1 and Q2 Nov 2012 Monitor has issued guidance to the NHS Foundation Trust Annual Q3 and Q4 May 2013 NHS Foundation Trust Boards on the Reporting Manual 2012/13 form and content of annual quality o The 2012 national patient • The content of the Quality reports (which incorporates the survey Report is not inconsistent with above legal requirements) and on the internal and external sources of o The 2012 national staff survey arrangements that Foundation Trust information including: Boards should put in place to support o The Head of Internal Audit’s the data quality for the preparation of o Board minutes and papers for annual opinion over the Trust’s the quality report. the period April 2012 to June control environment dated 24th 2013 May 2013 o Papers relating to Quality o CQC quality and risk profiles reported to the Board over the were reported on the following period April 2012 to June 2013 dates 09/02/12, 06/03/12, 10/04/12, 06/06/12, 05/07/12, o Feedback from Governors 07/08/12, 05/10/12, 06/11/12, dated April 2013 05/12/12, 06/02/13, 06/03/13. o Feedback from the Commissioners dated 24th May 2013 o Feedback from Health and Wellbeing Scrutiny Committee dated 23rd May 2013

4. Annex B Royal Devon and Exeter NHS Foundation Trust 61 Quality Report 2012/13

• The Quality Report presents a well as the standards to support balanced picture of the NHS data quality for the preparation Foundation Trust's performance of the Quality Report (available over the period covered at www.monitor-nhsft.gov.uk/ annualreportingmanual). • The performance information reported in the Quality Report is The Directors confirm to the best of reliable and accurate their knowledge and belief they have complied with the above requirements • There are proper internal controls in preparing the Quality Report. over the collection and reporting of the measures of performance included in the Quality Report, and By order of the Board these controls are subject to review to confirm that they are working effectively in practice • The data underpinning the measures of performance reported in the Quality Report is Mr James Brent, Chairman robust and reliable, conforms to 30th May 2013 specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and the Quality Report has been prepared in accordance with Monitor’s annual reporting guidance (which incorporates the Quality Accounts regulations), Mrs Angela Pedder OBE, (published at www.monitor-nhsft. Chief Executive gov.uk/annualreportingmanual) as 30th May 2013 62 4. Annex C Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

Clinical Audit

During 2012/13, 38 national clinical participated in 92% national clinical data collection was completed during audits and 5 national confidential audits and 100% national confidential 2012/13 are listed below, alongside enquiries covered NHS Services enquiries for which it was eligible. the number of cases submitted to each provided by the Royal Devon and audit or enquiry as a percentage of the The national clinical audits and national Exeter NHS Foundation Trust. number of registered cases required by confidential enquiries that the Royal the terms of that audit or enquiry. During that period, the Royal Devon Devon and Exeter NHS Foundation and Exeter NHS Foundation Trust Trust participated in and for which

National Clinical Audit / Confidential Enquiry Title Eligible? Participated % Participation Rate 2012/13 Adult community acquired pneumonia Yes Yes 100% (British Thoracic Society)

Adult critical care (ICNARC CMPD) Yes Yes 100%

Emergency use of oxygen (British Thoracic Society) Yes Yes 100%

Hip, knee and ankle replacements (National Joint Yes Yes 83% Registry)

Non invasive ventilation - adults (British Thoracic Yes Yes Ongoing Society) submission to 31 May

Renal Colic (CEM) Yes Yes 100%

Severe trauma (Trauma Audit & Research Network) Yes Yes 100%

Cardio-thoracic transplantation (NHSBT & UK No No N/A Transplant Registry)

National Comparative Audit of the labelling of Blood Yes Yes 100% Samples

Potential donor audit (NHS Blood & Transplant) Yes Yes 100%

Renal transplantation (NHSBT UK Transplant Registry) Yes Yes 96%

Bowel cancer Yes Yes 100% (National Bowel Cancer Audit Programme)

Head & neck cancer (DAHNO) Yes Yes 100%

Lung cancer (National Lung Cancer Audit) Yes Yes 100%

Oesophago-gastric cancer (National O-G Cancer Audit) Yes Yes 100%

Acute Myocardial Infarction & other ACS (MINAP) Yes Yes 57%

CABG and valvular surgery No No N/A (Adult cardiac surgery audit)

Cardiac arrest (National Cardiac Arrest Audit) Yes Yes 100% 4. Annex C Royal Devon and Exeter NHS Foundation Trust 63 Quality Report 2012/13

National Clinical Audit / Confidential Enquiry Title Eligible? Participated % Participation Rate 2012/13 Cardiac arrhythmia Yes Yes 100% (Cardiac Rhythm Management Audit)

Paediatric cardiac surgery No No N/A (NICOR Congenital Heart Disease Audit)

Coronary angioplasty Yes Yes 100% (NICOR Adult cardiac interventions audit)

Heart failure (Heart Failure Audit) Yes Yes 60%

Pulmonary Hypertension (NHS IC) No No N/A

Peripheral vascular surgery Yes Yes 247 cases submitted (VSGBI Vascular Surgery Database) (denominator unavailable)

Asthma Deaths (NRAD) Yes Yes 100%

Child Health (CHR-UK) Yes Yes On-going data submission to 14th May 2013

Maternal Infant and Perinatal Yes Yes 100%

Patient Outcome and Death (NCEPOD) Yes Yes 100%

Suicide and Homicide in Mental Health (NCISH) No No N/A

Elective surgery (National PROMs Programme) Hernia Yes Yes 28% Hip 93% Knee 94% Vein 32%

Adult asthma (British Thoracic Society) Yes Yes 45%

Bronchiectasis (British Thoracic Society) Yes No 0%

Diabetes (National Adult Diabetes Audit) Yes Yes 762 cases submitted (denominator unavailable)

Diabetes (RCPH National Paediatric Diabetes Audit) Yes Yes 100%

Ulcerative colitis & Crohn's disease (UK IBD Audit) Yes Yes 100%

Chronic pain (National Pain Audit) Yes No 0%

Renal replacement therapy (Renal Registry) Yes Yes 100%

Carotid interventions (Carotid Intervention Audit) Yes Yes 95%

Fractured Neck of Femur (CEM) Yes Yes 100% 64 4. Annex C Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

National Clinical Audit / Confidential Enquiry Title Eligible? Participated % Participation Rate 2012/13 Hip fracture (National Hip Fracture Database) Yes Yes 100%

Parkinson's disease (National Parkinson's Audit) Yes No 0%

Stroke Improvement National Audit Programme Yes Yes 97.6 % (SINAP) (closed 31 December 2012)

Sentinel Stroke National Audit Programme (SSNAP) 100% (began 1 January 2013)

Prescribing in mental health services (POMH) No No 0%

Psychological Therapies No No N/A

Schizophrenia (National Schizophrenia Audit) No No N/A

Childhood epilepsy Yes Yes 100% (RCPH National Childhood Epilepsy 12 Audit)

Fever in Children (CEM) Yes Yes 100%

Neonatal intensive and special care (NNAP) Yes Yes 100%

Paediatric asthma (British Thoracic Society) Yes Yes 100%

Paediatric intensive care (PICANet) No No N/A

Paediatric pneumonia (British Thoracic Society) Yes Yes 100% 4. Annex C Royal Devon and Exeter NHS Foundation Trust 65 Quality Report 2012/13

The reports of 10 national clinical audits were reviewed by the provider in 2012/13 and the Royal Devon and Exeter NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided:

National Clinical Audit / Actions Confidential Enquiry Title National Audit of Epilepsy • Appointment of a paediatrician with a recognised expertise in managing epilepsy to act 12 (Childhood Epilepsy) as service lead • Second paediatrician to complete additional training • Presentation to the Child Health Service Line Meeting and the Paediatric Clinician2Clinician meeting about the need for an epilepsy nurse service. Seek other funding • The need for an epilepsy nurse to be raised in negotiations regarding the community child health contract • Risk Assessment completed re lack of epilepsy nurse (risk level 9 = high). Action plan to be presented at Divisional level • To increase the number of children with an appropriate diagnosis, to be achieved by: o increase in dedicated epilepsy clinics o education for other senior paediatricians. • To increase the number of children with appropriate investigations to be achieved by: o increase in dedicated epilepsy clinics o education for other senior paediatricians (in-house, PET1). BTS Paediatric Asthma Improve education for doctors and nursing staff through teaching by paediatric respiratory nurse specialists at mandatory training sessions and doctor induction sessions on the following areas: • Awareness of availability of information leaflets for parents • Training and assessment in inhaler device techniques • The writing of asthma management plans for patients and communicating these to GPs • Advising patients to visit their GPs within 1 week of discharge or arranging an alternative appropriate follow up at paediatric respiratory nurse clinic • Ensuring the appropriate prescription of antibiotics for emergency treatment of an exacerbation. The Management of • To improve the re-evaluation of pain scores, change in ED practice is planned to enable Pain in Children in the greater nursing input for repeat observations of patients, including pain scores Emergency Department • In order to improve documentation in patient notes, work is planned to increase the (ED) mandatory fields in the electronic ED patient notes. 66 4. Annex C Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

National Clinical Audit / Actions Confidential Enquiry Title The Management of In order to improve the timeliness of antibiotic prescribing and urine output measuring the Severe Sepsis and Septic following actions are planned: Shock in Adults in the • Sepsis checklist to be triggered on the diagnosis of sepsis – unified protocol with acute Emergency Department medicine (ED) • More nursing staff to be requested, especially in majors where there are delays to antibiotics. Consultant Sign Off As the RD&E were high performing in this audit there are few actions required to improve patient care. However, to ensure the maintenance of this standard a mandatory field “consulted with...” in ED electronic patient notes system is planned. National UK Epilepsy • To improve documentation of key elements of patient care/observations it is planned to (NASH) amend the proforma in use in the Emergency Department to provide a prompt to staff • Appointment of an Epilepsy Specialist Nurse is planned. Myocardial Ischaemia • To improve response times after patients call for help a direct link from the Cardiac Care National Audit Project Unit and the ambulance has been established. It is also planned to increase the use of (MINAP) the air ambulance where possible. Acute Stroke (Stroke Actions planned to improve stroke care include: Improvement National • Creation of a new Standard Operating Procedure to ensure that stroke patients have a Audit Programme SINAP/ maximum 3 hour wait in ED before transfer to the acute stroke unit Sentinel Stroke National Audit programme SSNAP) • Introduction of screening for carotid stenosis out of hours from Spring 2013 • Training for stroke nurse practitioners on dysphasia assessment and management • Future provision for early supported discharge scheme in negotiation with the commissioners • Seeking patient user representatives to participate in stroke team governance meetings. Intensive Care National Actions planned as a result of the recommendations form this audit include: Audit & Research Centre • Mortality & Morbidity (M&M) meetings to be held more frequently and in more depth (ICNARC) Case Mix Programme • National Emergency Laparotomy clinical guidelines are being introduced and followed. National Confidential • To improve reporting and monitoring of cardiac arrest incidents, change in practice to Enquiry: Cardiac Arrest report all cardiac arrests through Trust electronic incident reporting system (DATIX) Study, Time to Intervene • To improve the appropriate escalation of treatment, focused work on improving the use of ‘Treatment Escalation Plan (TEP) and resuscitation Forms’. 4. Annex D Royal Devon and Exeter NHS Foundation Trust 67 Quality Report 2012/13

The reports of 31 local clinical audits were reviewed by the provider in 2012/13 and the Royal Devon and Exeter NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided:

Local Clinical Audit Title Actions & Aim Pre-operative Fasting This re-audit demonstrated significant improvements in the provision of information on in Paediatric Surgery fasting times for parents pre-operatively; and also demonstrated reductions in the amount (Re-audit) of time that children are being fasted for. In order to continue to improve the following actions are taking place: Aim: to ensure improvements in communication to patients • Anaesthetists will be required to write last drinking times on drug charts (parents) of appropriate • Education on importance of encouraging drinking to patients, parents and ward staff. fasting times had been achieved. Venous Thromboembolism Compliance with the dosage of Dalteparin was found to be high, but compliance with (VTE) Prophylaxis – dosage the exact timing of the administration of Dalteparin was low. In order to improve this the and timing of Dalteparin following action was planned: Aim: to improve compliance • Creation of a clear Trust clinical guideline on dosage and timing of Dalteparin for VTE. with NICE CG92 to ensure that patients are receiving the appropriate dosage of Dalteparin at the appropriate time. Management of children This audit demonstrated some gaps in compliance with the following areas of clinical with Duchenne Muscular management: growth measurement; physiotherapy assessments; psychological Dystrophy (DMD) assessments; and vaccinations. Actions planned to address these issues are: Aim: to improve all aspects • New clinic procedures to be introduced for growth measurement of the clinical management • Introduction of a standardised physiotherapy assessment scale of children with DMD. • Request to tertiary neurologist to attend DMD clinics • Introduction of a local proforma to improve recording of vaccination and other auditable healthcare surveillance. Management of bacterial Compliance with the NICE CG102 standards were generally high, but the following actions meningitis have been identified to improve patient care: Aim: to improve the • Creation of a local clinical guideline for steroid administration for the treatment of diagnosis, initial treatment, bacterial meningitis and onward clinical • Development of an improved system for audiology referrals. management of children with bacterial meningitis. 68 4. Annex D Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

Local Clinical Audit Title Actions & Aim Local hip surveillance in Compliance with the local guideline was poor and it was felt current research had moved children with Cerebral on. Therefore the following actions were identified to improve patient care: Palsy (CP) • New local guideline on the identification and management of hip displacement in Aim: to improve the children with CP to be produced and agreed identification and • Local guideline to be discussed and agreed at a regional level to gain south-west management of hip consensus displacement in children with a diagnosis of Cerebral Palsy. • Once agreed, clinical guideline to be placed on the Trust intranet to make more accessible to clinicians • Further radiology audit to be undertaken around the specific aspect of gonadal protection in paediatric patients • The Gross Motor Function Classification System (GMFCS) to be introduced and used on a routine basis by physiotherapy and paediatrics • Clinical examinations and documentation to be standardised. Management of Tongue- This re-audit demonstrated that the appropriate referral pathway is being followed. Tied Neonates (Re-audit) Referrals and procedures for this condition had increased by 30%. Follow-up of these patients at 3 months was poor. Therefore the following actions were agreed to continue to Aim: to ensure the improve patient care: appropriate referral pathway and management of • Further education of clinical staff to ensure they are aware that referrals should be only tongue-tied patients is being for patients with feeding problems to reduce unnecessary referrals followed. • Greater liaison with breastfeeding peer supporters to increase 3 month follow ups. Post-natal Mumps, This re-audit demonstrated a 30% improvement in the offer of post-natal MMR vaccination Measles & Rubella (MMR) since 2010 to 95% compliance. There was 80% compliance with the initial recording of Vaccination (Re-audit) rubella susceptibility for pregnant women. Therefore the following changes in process were agreed to improve the robustness of the system: Aim: to ensure improvements to the effectiveness of • Labour Ward midwives to check antenatal hospital and hand-held notes and transcribe processes for screening appropriate information on rubella susceptibility and need for MMR to Management of women for rubella Plan section of postnatal hand-held notes susceptibility and subsequent • Screening Coordinators to follow-up all susceptible women after delivery to find offer of MMR vaccination evidence that MMR has been offered/given. If no record is found the Screening had been achieved. Coordinators will inform the relevant GP. 4. Annex D Royal Devon and Exeter NHS Foundation Trust 69 Quality Report 2012/13

Local Clinical Audit Title Actions & Aim Neurological imaging Partial compliance with the documentation of reasons for the decision taken to not image of children suspected of a child. To improve compliance with the standard the following actions were agreed: being the subject of non- • Further education of paediatricians to improve documentation in patient notes. accidental injury Aim: to ensure all children presenting with suspected non-accidental head injury undergo appropriate neuro- imaging. Use of imaging in the • Standard operating procedures and protocols for the management of adverse events to bowel cancer screening be updated programme • Education of radiographers to scan Buscopan vial stickers onto CRIS to ensure Aim: to improve the administration of Buscopan is documented effectiveness of the CT • Each reporting radiologist to be required to audit their performance on an annual basis – Colonography (Virtual to be added to specialty clinical audit programme. Colonography) clinical pathway for patients with suspected bowel cancer. Surgical Prophylaxis in This audit identified poor compliance and that patients undergoing elective and Patients Colonised with emergency surgery did not have their MRSA status used appropriately to guide the use of MRSA decolonization or the use of appropriate prophylaxis. In order to improve patient care the following actions will be undertaken: Aim: to improve compliance with antibiotic surgical • Increase awareness of surgical antibiotic prophylaxis guidelines by placing antibiotic prophylaxis guidelines for prophylaxis charts in all anaesthetic rooms MRSA positive patients. • Education of anaesthetists to check prophylaxis where resistant organisms are highlighted in the surgical checklists • Findings to be fed back to ‘antibiotic champions’ across the Trust to further raise awareness of issues. Correct patient This audit demonstrated that all patients were correctly identified and had the correct blood identification for the administered. However, all steps of the patient identification process were not followed in Administration of Blood all cases. In order to improve compliance the following actions will be undertaken: Aim: to ensure compliance • Change process from two person independent check, to one person independent check with the process for patient • Change process by removing unnecessary form to be completed and recorded identification prior to the information instead on prescription chart administration of blood products. • Raise the profile of pre-transfusion checking through participation in the national ‘do you know who I am’ campaign. 70 4. Annex D Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

Local Clinical Audit Title Actions & Aim Mineral bone disease Overall this audit demonstrated improvements in the mineral bone disease management of management in haemodialysis patients. The following actions will be undertaken to further improve patient haemodialysis patients care: (Re-audit) • Ensure greater dietician input into this patient group to improve phosphate levels. Aim: to ensure the appropriate management of mineral bone disease for patients on haemodialysis. Cardiovascular Risk in • Exeter Kidney Unit to improve statin prescribing and co-morbidity and complication Renal Transplant Patients recording for all patients. Aim: to ensure the appropriate monitoring and treatment of cardiovascular risk factors for patients after renal transplantation. Appropriate use of Audit demonstrated improvement since previous audit. Further actions required to continue imaging in the Daily improvements in patient care were: Stroke Clinic (Re-audit) • Secretaries to remind doctors when the Vital Signs audit form has missing data Aim: to ensure the • Further education of doctors to ensure they give stroke patients driving advice appropriate use of imaging in stroke patients. • Liaison with radiology to streamline the referral process. Urine tests for feverish Initial audit demonstrated urine testing was poor, actions to improve were: children in the Emergency • Use of nappies to collect urine samples for young children Department (ED) • Improving stock of urine pots in triage rooms Aim: to increase rates of urine testing of feverish • Education for all staff - posters in triage, in the ED and communication folder, lunchtime children in the ED. teaching sessions • Education for parents - posters in waiting rooms. Use of intra-venous (IV) This audit showed poor knowledge of appropriate prescribing and administration of IV PPI. proton pump inhibitors Actions to address were: Aim: to ensure the • Local Clinical guideline to be produced appropriate prescription and • Education and awareness raising (including ‘learning at lunch’ session) of the guideline administration of IV Proton once produced Pump Inhibitors (PPI) for patients with gastric and • Ward pharmacists to check prescribing; educating clinical staff were errors are found. duodenal ulcers. 4. Annex D Royal Devon and Exeter NHS Foundation Trust 71 Quality Report 2012/13

Local Clinical Audit Title Actions & Aim Dietary management The audit demonstrated that not all patients were having dietitian reviews, and that more of cholesterol in Renal could be done to improve patient dietary knowledge. Actions to address: Transplant Recipients • Include on patient appointment letters for transplant clinic that they may be asked to (RTRs) see a dietitian and should therefore leave additional time Aim: to improve the • Set up annual review clinic effectiveness of dietary advice in lowering cholesterol • Use of phone reviews by dietitian for patients who were missed in clinic and improving knowledge of • Improve patient literature re cholesterol lowering advice dietary measures to reduce cholesterol, in RTRs with • Produce posters/ displays for patient waiting room containing cholesterol lowering hypercholesterolaemia. advice. Nutritional management Audit demonstrated good compliance with the renal dietetic standards for haemodialysis of haemodialysis patients patients. Actions to further improve compliance were: Aim: to ensure appropriate • To have dedicated cover by a dietitian to Exeter Kidney Unit and timely nutritional • Increase use of telephone dietitian reviews for HD patients where face-to face review not review and assessment of possible haemodialysis patients. • Dietitians to provide written input to monthly Quality Assurance meetings when not able to attend in person • Patients that are identified as needing review during Quality Assurance meetings are referred to the dietitians by the consultants if dietitians not present. Recording of Verification • Education of new junior doctors to ensure they are aware that death verification at night of Death in Patients’ Notes should be undertaken by the site practitioner Aim: to improve recording • Education of new junior doctors to ensure they understand the importance of recording of the verification of patient all four indicators of death in patient notes. death. Enhancing continuity • A formal weekend care plan sticker produced and used to improve recording of of care for patients at summaries of clinical care to date and anticipated care needs over the weekend. weekends Aim: to improve communication and handover processes to weekend on-call teams to improve continuity of clinical care. 72 4. Annex D Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

Local Clinical Audit Title Actions & Aim Prescription and wearing The audit highlighted some areas of poor practice or misunderstanding about the of Thrombo Embolic appropriate prescription and wearing of TEDS. The following actions have been undertaken Deterrent Stockings (TEDS) to improve patient care: in Surgical Inpatients • Education of ward nursing staff to remind them to reapply TEDS after washing and/or Aim: to reduce risk of other clinical procedures patients experiencing Venous • Education of junior doctors through presentation at surgical audit meeting around need Thromboembolism (VTE) for accurate TEDS prescription complications through improved prescription and • Laminated cards to be produced and displayed on wards on the contraindications for wearing of TEDs. TEDS. Documentation of x-ray • Education of doctors to improve formal review and documentation of plain radiograph. interpretation Aim: to improve documentation of interpretation of x-rays by referring healthcare professionals. Tattooing of polyps at • Joint local protocol between gastroenterologists and colorectal surgeons to be devised colonoscopy • Education of all endoscopy staff to improve compliance with standards and improve Aim: to improve documentation. identification of colonic lesions during laparoscopy to ensure adequate resection in bowel cancer patients. Accuracy of orthopaedic This audit demonstrated poor compliance with the accuracy of discharge summaries. The discharge summaries following actions will be undertaken: Aim: to improve the accuracy • E-discharge system to be developed and introduced of orthopaedic discharge • Different electronic systems to be linked to ensure correct consultant and operation note summaries to ensure patient linked to discharge. safety. Prescription of Normal This audit demonstrated that most patients were not having their normal medications Medication for all Elective prescribed prior to surgery. The following actions will be implemented to improve patient Orthopaedic Admissions safety: Aim: to reduce delays • All doctors to be allocated a day to attend pre-operative assessment to ensure that in the prescription and medications can be prescribed at this stage. administration of patient normal medication for elective orthopaedic patients. 4. Annex D Royal Devon and Exeter NHS Foundation Trust 73 Quality Report 2012/13

Local Clinical Audit Title Actions & Aim Consent in trauma The audit demonstrated that the procedures for obtaining accurate informed consent were patients not being consistently followed. The following actions were implemented to address this: Aim: to ensure informed • Implementation of mandatory consent training on induction for all doctors starting in consent is obtained and trauma and orthopaedics, to be provided by a consultant orthopaedic surgeon documented for all trauma • Ensure all doctors working within the department are offered a ‘trauma week’ during patients. which they have the opportunity to attend theatre to see/ assist on surgeries. Haemoglobin Status The audit demonstrated that no patients required blood transfusion after bimaxillary Pre- and Post-Osteotomy osteotomy procedures. Changes in practice agreed: and Blood Transfusion • Change in Trust protocol in line with national standards to remove bimaxillary osteotomy Requirements in from the Agreed Blood Order Schedule. This will provide significant financial and Orthognathic Surgery efficiency savings for the Trust. Aim: to improve the efficiency of the process for the management of blood loss in Orthognathic Surgical patients. Compliance with Ketovite This audit demonstrated that not all patients were taking the prescribed vitamin in Haemodialysis patients supplements. To improve compliance the following actions have been implemented: Aim: to improve • Ensuring all GPs receive letters instructing them to prescribe vitamins for these patients compliance with taking • To replace Ketovite with an alternative vitamin which needs to be taken less frequently vitamin replacements for and should encourage compliance. haemodialysis patients. Phlebitis Rate Re-Audit This re-audit demonstrated a significant reduction in phlebitis rates since the first round of audit. Actions to further improve include: Aim: to reduce the risk of infection from cannulae. • Greater utilisation of the cannula stickers to increase awareness of patients with cannulae • Education of staff not to cover the site of cannulae with a dressing so that it can be observed and any signs of infection noticed earlier. Central Venous Catheter Actions from this audit include: (CVC) audit • Education of all staff to inform the Vascular Access Team when any short-term central Aim: to reduce the rate of lines are out on the wards especially if placed out of hours so lines that are higher risk of infections in patients with infection are reviewed by the team central venous catheters. • The development of an electronic form to be completed by staff placing CVC lines with prompts for the appropriate actions to be taken to prevent infection. 74 4. Annex D Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13

Local Clinical Audit Title Actions & Aim Vaccination of Actions from this audit included: rheumatology patients on • Production of a vaccination card to be given to patients when they are initially biological therapy counselled by the doctor about starting biological therapy Aim: To ensure that • Production of a letter to be sent to the GPs when their patient is counselled about patients with autoimmune biological therapy. This outlines which vaccines are needed and prompts GPs to amend inflammatory rheumatic their records to invite the patient for annual flu vaccinations disease on biological therapy are appropriately vaccinated. • Development of a database of all rheumatology patients at the RD&E to help to identify patients who require annual vaccines. These patients can then be prompted via a nurse-led phone call to attend their GP surgery for vaccination. 4. Annex E Royal Devon and Exeter NHS Foundation Trust 75 Quality Report 2012/13 3. Quality Report Royal Devon and Exeter NHS Foundation Trust 67 Annual Report and Accounts 2012/132012-13 4Our Governance 68 4. Our Governance Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Our Governance

The role of the Board The Council of Governors consists requirements and contractual of elected public Governors, staff obligations of Directors Governors and appointed individuals • Set the Trust’s strategic aims from key stakeholder organisations (as The RD&E is a NHS Foundation at least annually, taking into defined in the constitution). Governors Trust that is constituted as a public consideration the views of the help bind the Trust to its patients, benefit corporation. Its governance Council of Governors service users, staff and stakeholders. structure is founded on a constitution Governors are unpaid and volunteer • Be responsible for ensuring the that is approved by the regulator, part-time on behalf of the Trust. They quality and safety of healthcare Monitor. The constitution sets out are not Directors and therefore do not services, education, training and how the organisation will operate act in a directorial capacity as their role research delivered by the Trust from a governance perspective and is very different. The Trust Chairman is what arrangements it has in place, • Ensure that the Trust exercises its chair of both the Council of Governors including its committee structures functions effectively, efficiently and and the Board of Directors. and procedures, to enable the Trust economically Governors are the direct representatives to be governed effectively and within • Set the Trust’s vision, values and of local communities. They collectively the legislative framework. The Trust’s standards of conduct and ensure challenge the Board of Directors and constitution incorporates the legal and the Trust meets its obligations to hold them to account for the Trust’s statutory requirements necessary to its members, patients and other performance, as well as representing govern the Trust. In addition, Monitor stakeholders and communicates the interests of Foundation Trust has developed a Code of Governance them to these people clearly which all Foundation Trusts must Members and the public and providing comply with (or explain if they them with information on the Trust’s • Take decisions objectively in the choose not to comply). This details performance and forward plan. interests of the Trust the necessary governance structures Governors have a range of statutory • Take joint responsibility for every and processes that Foundation Trusts powers as well a significant influence decision of the Board, regardless of should have in place. over the Trust. their individual skills or status Essentially, there are three basic The Board of Directors of the RD&E is • Share accountability as a unitary components of the Trust’s governance ultimately and collectively responsible Board structure: for all aspects of the performance of the Trust. The Board of Directors’ role • Constructively challenge the • The Membership is to: decisions of the Board and help • The Council of Governors develop proposals on priorities, risk • Provide effective and proactive mitigation, values, standards and • The Board of Directors. leadership of the Trust within a strategy. framework of processes Members of the RD&E consist of members of the general public who • Develop procedures and controls choose to apply for membership, which enable risk to be assessed and Trust staff (unless they opt out). and managed Members are located in a defined • Take responsibility for making sure number of constituencies that are the Trust complies with its terms set out in the Trust’s constitution. of authorisation, its constitution, Members elect Governors and can also mandatory guidance issued stand for election themselves. by Monitor, relevant statutory 4. Our Governance Royal Devon and Exeter NHS Foundation Trust 69 Annual Report and Accounts 2012/13

The Board of Directors has both In carrying out their role, Directors The Directors are paid Executive and Non-Executive Directors need to be able to deliver focused (NEDs) with a majority of independent strategic leadership and effective for their skills, time and Non-Executive Directors. It is a scrutiny of the Trust’s operations, and expertise in leading the unitary Board which means that both make decisions objectively and in the Executive and Non-Executive Directors interests of the Trust. The Board of Trust both strategically share the same liabilities and joint Directors will act in strict accordance responsibility for every decision of with the accepted standards of and operationally, the Board. The Chief Executive is the behaviour in public life, which include as well as for taking nominated Accounting Officer and is the principles of selflessness, integrity, responsible for the overall organisation, objectivity, accountability, openness, responsibility for the management and staffing of the NHS honesty and leadership (The Nolan Foundation Trust, for its procedures Principles). performance of the Trust in financial and other matters, and The Board of Directors is legally for offering appropriate advice to and being accountable accountable for services provided by the Board on all matters of financial the Trust and is responsible for setting propriety and regularity. in the event of failures. the strategic direction, having taken account of the views of the Council of Governors, and for the overall management of the RD&E. The Board is led by the Non-Executive Chairman. There are six Non-Executive Directors who, together with the Chairman, form a majority on the Board. The six Executive Directors manage the day-to-day operational and financial performance of the Trust. The Board of Directors works on a unitary basis, being collectively responsible for the performance of the NHS Foundation Trust and exercising all the powers of the Trust. In so doing, Board Members bear full legal liability for the operational and financial performance of the Trust. The Board normally meets to conduct its core business at least ten times a year. At these meetings it takes strategic decisions and monitors the operational performance of the Trust, holding the Executive Directors to account for the Trust’s achievements. 70 4. Our Governance Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Board Meetings The framework within which decisions The Chairman and all Non-Executive affecting the work of the Trust Directors meet the independence The papers for the monthly Part 1 are made are set out in the Trust’s criteria laid down in Monitor’s Code Board meeting and the approved published Standing Orders, Standing of Governance (Provision A.3.1). minutes of the previous meeting are Financial Instructions and Scheme of The Board is satisfied that no direct published on the Trust’s website in Delegation, copies of which may be conflicts of interest exist for any advance of the Board meeting. In viewed on the Trust’s website (www. member of the Board. There is a full advance of the legislation compelling rdehospital.nhs.uk) or on request from disclosure of all Directors' interests NHS Foundation Trusts to hold their the Foundation Trust Secretary. in the Register of Directors’ Interests, Board meetings in public, the RD&E which is available upon request from The composition of the Board decided in June 2012 to move to open the Foundation Trust (FT) Secretary. is in accordance with the Trust’s Board meetings that were accessible Directors and Governors may appoint Constitution and the Policy for the to the public. These are meetings advisors to provide additional expertise Composition of NEDs on the Board. that take place in the public arena on particular subjects if required. The Board considers it is appropriately rather than public meetings, although composed in order to fulfil its The Board of Directors is accountable members of the public have the statutory and constitutional function to the membership via the Council of opportunity to ask questions at the end and remain within Monitor’s Terms Governors. The Chairman informs the of the public section of the meetings. of Authorisation. In consultation Council of Governors about the work Items of a confidential nature are with Governors, it has, through its and effectiveness of the Board at each discussed by the Board in private recruitment of NEDs, been able to Council Meeting. in a monthly ‘Part 2’ meeting. The maintain a good quality and effective issues discussed in the closed sessions The business of the Trust is conducted Board that is appropriately balanced tend to be commercial in confidence in an open manner and annual and complete. issues that may impede the conduct schedules of meetings for the Board of of the Trust’s business if they were to There is a clear division of responsibility Directors and Council of Governors are be aired publicly. The 1960 Act on between the Chairman and the Chief published twelve months in advance. admissions to public meetings is used Executive. The Chairman heads the by the Board to help determine which Board, providing leadership and topics are discussed privately and, over ensuring its effectiveness in all aspects the course of the year, the Board has of its role, and sets the Board agenda. sought to discuss the majority of its The Chairman ensures the Board business in open session. receives appropriate information to ensure that Board Members can In addition to its ten formal Board exercise their responsibilities and make meetings, the Board also holds a well-grounded decisions. The Chief number of development and strategy Executive is responsible for running sessions as well as briefing meetings all operational aspects of the Trust’s and seminars. It also has increasingly business, assisted by the team of used task and finish groups to tackle Executive Directors. key issues. 4. Our Governance Royal Devon and Exeter NHS Foundation Trust 71 Annual Report and Accounts 2012/13

Outside interests There are also express duties for each Director to avoid conflicts of interest. The Board regularly updates its The Constitution has to be revised to register of interests to ensure that take into account the need to avoid each member discloses details of such conflicts. The new Act includes company directorships or other other provisions relevant to Directors material interests in companies which including: may conflict with their management • Supplying Governors with meeting responsibilities. Board Members also agendas prior to their meetings have an opportunity at the start of and minutes as soon as practicable each meeting to declare any interests after meetings which might impede their ability to take part in discussions and Directors • Constitution must be amended to are aware that such a declaration provide for meetings to be open would be permissible at any time to the public and may provide for during a meeting, dependent on the exclusion of the public for special issue being discussed and the potential reasons for any conflict of interest to arise. • Obligation to promote the NHS The Directors’ Register of Interests is Constitution to members of the available for inspection from the FT public in discharging the Trust’s Secretary (01392-402993) or on the functions Trust website http://www.rdehospital. nhs.uk/trust/ft/documents.html and • Ensure that the Governors are Directors can be contacted via email at equipped with the skills and [email protected] knowledge required to discharge their duties • Accountability to Governors (all Impact of the Health Directors) for performance of & Social Care Act 2012 their functions and duties and the requirement to attend at Council, The new Act changes some of the if requested by Council, to supply duties of Board Directors. Directors information and answer questions now have individual as well as a regarding their functions and collective responsibility to promote performance of their duties. the success of the Foundation Trust, so as to maximise the benefits for the Members and the public. More importantly, Board members may also face personal liability (with claims for financial losses) under insolvency legislation, where a non-designated provider continues to trade when likely to become insolvent. 72 4. Our Governance Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Board effectiveness and evaluation

The RD&E Board has continued on its Board has tried out different ways of The review focused on a collective development journey during the year. operating – for example by keeping analysis of the effectiveness of the Collectively, the Board understands verbal introductions to Board papers to main Board (rather than committees that to conduct its business effectively a minimum, and adopting a new Board and other governance structures) and to ensure that it fulfils its paper template – to ensure that it is using feedback forms the Board itself obligations as the body responsible being as effective as possible. had undertaken through an online for all aspects of the performance self-evaluation survey, independent Over the year, the Board has also of the Trust, it needs to maintain an observation of the Board meeting, focused its attention on developing approach of continuous improvement seminar and a review of its key the Board Assurance Framework (BAF) in what it does, how it does it and the materials, and a seminar conducted in order to focus on understanding culture and behaviours that underpin with Board Members. The purpose of and mitigating risks to the corporate performance. undertaking an external evaluation strategy as well as using the BAF to was based on good practice drawn Over the year, the Board uses the drive the Board agenda. from the direction set out in the UK time it has available to transact its Some of the issues the Board Corporate Governance Code (2010) core business as a Board but also to addressed in these development/ which recommends that all FTSE 350 spend time ensuring that it has the strategy sessions included: companies undertake an externally opportunity to consider, reflect on facilitated Board evaluation at least and improve its own performance; to • Annual Plan and contracting issues every third year. have more wide-ranging discussions • Changes to the compliance about issues that are impacting on The evaluation concluded that the framework and implications the Trust within the context of the Board compares well with similar Trust’s corporate strategy; and to • Developing the Trust’s Corporate organisations: “The RD&E Board is an receive briefings on key issues or Strategy engaged and well-functioning Board that compares favourably to its peers developments in the NHS and in • The Board Assurance Framework healthcare more generally. within the NHS and other listed or • Board effectiveness privately owned organisations. We To enable this to happen, the Board were struck by the how well the Board held four development/strategy days • A seminar on E-Notes. works together as a team, with the during the year (as well as a joint In January 2013 the Board Board Members all having air-time session with the Council of Governors). commissioned a consultancy (Board to question and provide constructive In addition to this, the Board agreed Intelligence) to undertake an external input to agenda items. There was that from May 2012 it would move evaluation of Board effectiveness and a positive atmosphere in the Board its Board meetings to the afternoon what lessons could be learned to meeting and we observed a healthy to enable the whole of the morning continue the ongoing development of dynamic between Board members." sessions to be devoted to strategic the Board. discussions and Board development. This has undoubtedly helped the Board "The RD&E Board focus its attention on maintaining a strategic approach to its work and is an engaged and reasonable balance with the necessary well-functioning Board" work it undertakes on performance, operational issues and compliance. As well as re-balancing its schedule, the 4. Our Governance Royal Devon and Exeter NHS Foundation Trust 73 Annual Report and Accounts 2012/13

This fundamental strength sets the reactive performance management to stakeholder interaction, Corporate RD&E Board apart from many other more proactive, forward-looking and Social Responsibility (CSR), key risks, Boards and provides an enviable strategic thinking, although the Board and peer innovation & learning. platform upon which to build a strong noted that further work is required here. The Board also wanted to see an system of governance. All Directors improvement in the quality of The Board feels that it is functioning recognise and value the progress the performance reporting, and noted the well as a unitary Board, with individual Board has made over the past few Integrated Performance Report (IPR) Directors taking better collective years (in particular, many referenced ‘task & finish’ group that has been set responsibility, yet there remains the appointment of the new up to progress this. appetite to continue to strengthen Chairman) and the commitment of the individual contribution and the Finally, the Board would like to see an Directors and their continued appetite expertise represented on the Board. improvement in the way business cases for improvement was notable. are presented to help avoid repetition, The report produced by Board Briefing materials to allow the Board to focus on the key Intelligence captured some of the points and any new issues. Business key improvement themes based on The Board noted recent improvements cases are currently presented to the the self-assessment. These key issues to the Board reports, though there Board as a preliminary case, which is included: were requests for improvement, then built into a full business case, namely making the papers more but the process can be unnecessarily relevant, focused and concise, with Board dynamic & Director laborious and result in duplication. less data and more insightful variance contribution analysis so that the Board does not get The Board felt that the new Chairman lost in the detail. has greatly improved the overall Directors would like a wider scope of effectiveness of the Board, the information, including a systematic openness within which it operates and review of progress of strategic the quality of challenge, debate and initiatives and the transformation decision-making. The new Chairman programme and greater visibility of has also encouraged a shift away from 74 4. Our Governance Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Governance Infrastructure The recommendations and The Chief Executive undertook a observations highlighted by Board similar process with the Executive The Board is keen to build on its Intelligence sought to support the Directors and these discussions were relationship with Governors by Board in developing further and enhanced by seeking the views of clarifying the role of the Governors achieving best practice. the NEDs in examining performance and the desired focus of interaction and identifying future development between the Board, management The Chairman met regularly needs. The outcome of the appraisals and Governors, in order to improve with individual NEDs to discuss is fed back to the Executive Director communication between these their personal development and Remuneration Committee (EDRC). different groups. performance issues. These discussions The Chief Executive was appraised focussed on issues such as continuing On the basis of the review, the by the Chairman, with the outcome professional development and consultants identified a clear Board reported to the EDRC. The process for capacity-building to enhance personal mandate – essentially being focused the appraisal of the Chairman is led by performance. A new appraisal process on the contribution the Board makes the Senior Independent Director and was agreed during the year by the to the governance of the Trust. The is also reported to the Nominations Appraisals Working Group made up essence of this mandate was to clarify Committee and then to the Council of of Governors, the Senior Independent the ways in which the Board’s agenda Governors. Director and the Chairman. This was can be split into its core stewardship implemented for the year’s Director and supervisory responsibilities linked appraisals. The new approach helped to strategy, operational performance to focus on performance and add and governance. real value to appraisal discussions, It was felt that aligning the Board’s although it became clear in the work programme around this matrix course of undertaking the appraisals would enable the Board to enhance its that the system required additional effectiveness and be clear what was development. The outcomes of Non- expected of it. Executive Director appraisals (carried out by the Chairman) were reported to the Nominations Committee when considering re-appointment, and were reported annually to the Governors. 4. Our Governance Royal Devon and Exeter NHS Foundation Trust 75 Annual Report and Accounts 2012/13

The Board of Directors

Brief details of each Director and their record of attendance at Board meetings are shown below.

James Brent, Chairman Accountants in England and Wales and setting the vision for the technology, James was an investment banker for a graduate of the University of Reading. people and the process change 25 years and established Akkeron His 27 years of experience in finance necessary to modernise the BBC’s Group LLP which has key business is extensive covering investment, production capabilities. Michele has activities in hotels, urban generation commercial and consumer banking, more recently served for three years as and large scale agriculture. He also securities and fund management. Most a Non-Executive Director on the Board owns a controlling stake in the Devon- recently he was the Group Head of of Salisbury NHS Foundation Trust. based surf wear brand Saltrock. He Operational Risk for Standard Chartered She continues to travel internationally has combined his commercial ventures Bank. His career has involved working through her consultancy business. with a desire to contribute in a range in London, Luxembourg, Hong Kong, of public sector settings as well, for Singapore, Tokyo and New York. Andrew Willis, Non-Executive Director example as Chairman of Plymouth City His charity sector interests include Andy joined the Board in February Development Company. More recently Sightsavers, Vision Fund International 2011. Previous Board experience he has invested in Plymouth Argyle and Seeing is Believing. includes service on two NHS acute Football Club and is the new club provider Boards and in the housing chairman. David Robertson, Non-Executive sector. A corporate lawyer by Director profession, he has worked for City and Brian Aird, Vice-Chairman David joined the Trust in October regional law firms and now specialises Brian joined the Trust in April 2008. 2010 and is a Fellow of the Institute in legal training. He is also a Leadership He has considerable previous NHS of Chartered Accountants in Associate of the King's Fund, focusing experience as a Chief Executive of England and Wales and a graduate on corporate governance and NHS a NHS Trust and a Health Authority. in Business Studies. He was Finance Board/Director development. Andy is He was previously a Non-Executive Director of Viridor Limited, the waste Chair of the Governance Committee. Director of Trent Strategic Health management subsidiary of Exeter Authority, and more recently has based Pennon Group plc, until March David Wright, Non-Executive Director, run his own company offering 2011. He was with the Pennon Group Senior Independent Director organisational development and for 20 years, prior to which he was David joined the Trust in April 2008 executive coaching services. He is with KPMG for 14 years. He is also and is now retired but spent the also a trustee of United Response, a trustee of South West Lakes Trust. majority of his career with Save the a national charity providing services David is Chair of the Audit Committee. Children UK, where he was a Country to people with learning difficulties Programme Director for various areas and mental health needs. Appointed Michele Romaine, Non-Executive both in the UK and abroad. He was Vice-Chairman in May 2010, Brian Director also Chairman of Swindon PCT and a also chairs the Trust’s Organ Donation Michele joined the RD&E Board in Non-Executive Director with Wiltshire Committee and the Engagement and September 2012. She has held a NHS Community Trust. David became Experience Committee. number of senior roles in public sector the Senior Independent Director in organisations, including the BBC as its February 2011. Peter Knott, Non-Executive Director Director of Production. Ten years ago Peter joined our Board in July 2012. He Michele helped steer the course for the is a Fellow of the Institute of Chartered BBC in a time of significant change, 76 4. Our Governance Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Non-Executive Directors not in Mr Martin Cooper, Joint Medical Suzanne Tracey, Director of Finance post at year end Director and Business Development Martin was appointed to the RD&E in Suzanne joined the Trust in August Angela Ballatti, Chairman 1988 as a Consultant General Surgeon 2008 from Yeovil District Hospital NHS Angela joined the Trust as Chairman with an interest in Upper GI and Breast Foundation Trust, where she held the in May 2006. She was previously disease. He had previously worked as a post of Director of Finance/Deputy the Chair of County Durham and Lecturer and Senior Lecturer in Bristol Chief Executive. Darlington Acute Hospitals Trust. and spent 18 months at the University She has an extensive background of Chicago. In addition to his clinical Em Wilkinson-Brice, Chief Nurse/ in business management and role, Martin has a major interest in the Executive Director of Service Delivery governance, having worked, among management of cancer, acting as the Em joined the RD&E as Director of others, as a senior consultant for Clinical Director of Cancer Services Nursing & Patient Care in July 2010. Coopers Deloitte and been a senior from 1995 until taking up his current After qualifying from nursing in Exeter, tutor at the University of Durham position in 2009. Regionally, he was she subsequently worked in Oxford Business School. the Medical Director of the Peninsula specialising in critical care. She was Cancer Network from 2000 to 2007. Director of Nursing at Derby Hospital John Rackstraw, Non-Executive Director before joining the RD&E. A Board member since August Dr Vaughan Lewis, Joint Medical 2006, John spent his career in the Director Executive Directors not in post construction industry. He is a Chartered Vaughan joined the Board as Joint at year end Director and past Chief Executive and Medical Director on 1st April 2011. Deputy Chairman of Pearce Group Ltd. He joined the RD&E in February Elaine Hobson, Chief Operating Officer He has lived in Somerset for over thirty 2002 as a Paediatrician with interest Elaine is a trained nurse and has held years and has extensive knowledge of in Neonatology and Paediatric a number of positions at the RD&E, the local community and a range of Nephrology. He served as Lead becoming Director of operations in local and national contacts. Clinician in Child Health from 2004 December 2000 and Chief Operating and was promoted to Clinical Director Officer in 2008. Executive Directors of Child & Women’s Health in 2009.

Angela Pedder, OBE, Chief Executive Lynn Lane, Human Resources Director Angela joined the NHS in 1975. She Lynn joined the RD&E in July 2006 was Chief Executive of St Alban’s & as HR Director, with over 20 years Hemel Hempstead NHS Trust before HR experience, having held senior taking up her post as Chief Executive at management positions at both the the RD&E in 1996. Angela was awarded BBC and NHS in Oxford. the OBE in the New Year Honours Lists 2007 for services to the NHS. 4. Our Governance Royal Devon and Exeter NHS Foundation Trust 77 Annual Report and Accounts 2012/13

Non-Executive and Executive Directors Of The Board – 2012/2013

Name Designation Appointed Left Trust/Post Voting Mr Brian Aird Vice-Chairman – NED 1 April 2008 N/A Y Ms Angela Ballatti Chairman NED 1 May 2006 30 April 2012 Y Mr James Brent Chairman – NED 1 May 2012 N/A Y Mr Martin Cooper Joint Medical Director 2009 N/A Y (ditto) Ms Elaine Hobson Chief Operating Officer December 2000 30 September 2012 Y Mr Peter Knott NED 16 July 2012 31 March 2013* Y Mrs Lynn Lane Director of Human Resources July 2006 N/A Y Dr Vaughan Lewis Joint Medical Director 1 April 2011 N/A Y (1 vote) Mrs Angela Pedder Chief Executive 1996 N/A Y Mr John Rackstraw NED 1 August 2006 31 July 2012 Y Mr David Robertson Chair, Audit Committee – NED 1 November 2010 N/A Y Ms Michele Romaine NED 1 September 2012 N/A Y Mrs Suzanne Tracey Director of Finance and Business August 2008 N/A Y Development Mrs Em Wilkinson-Brice Director of Nursing and Patient Care/ July 2010 31 November 2012 Y Acting Chief Operating Officer Mrs Em Wilkinson-Brice Chief Nurse/Executive Director of 1 December 2012 N/A Y Service Delivery Mr Andrew Willis Chair, Governance Committee – NED 1 February 2011 N/A Y Mr David Wright Senior Independent Director – NED 1 April 2008 N/A Y

* Peter stepped down at the end of March 2013. 78 4. Our Governance Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Attendance

Board Attendance for 2012/13 was as follows:

NAME Apr May Jun Jul Sep Oct Nov Jan Feb Mar B Aird * * * A * A * * * * A Ballatti * ------J Brent - * * * * * * * * * Mr M Cooper * A * * * * * A A * E Hobson^ A A A A A - - - - - P Knott - - - * * * * * * * L Lane * * * * A * * * * * Dr V Lewis * * * * * * * * * * A Pedder * * * * * * * * * * J Rackstraw * * * * ------D Robertson * * * * * * * * * * M Romaine - - - - * * A A * * S Tracey * * * * * * * A * * E Wilkinson-Brice * * * * * * * * A * A Willis * * * * * * * * A * D Wright * * * * A * * * * * * present A Absent - Not applicable ^ Elaine Hobson was absent due to ill health in the period April-September 2012 4. Our Governance Royal Devon and Exeter NHS Foundation Trust 79 Annual Report and Accounts 2012/13

Non-Executive Director Appointments

The Chairman and Non-Executive Directors are appointed by the Council of Governors (COG) acting on the recommendation of the Nominations Committee, which is a committee of the COG.

The Chairman chairs the Committee John Rackstraw finished his second when appointing Non-Executive Directors. term during the financial year. The Membership of the committee can Board acknowledged the contribution be found in the Governors section made by Mr Rackstraw in his time with on page 116. The Chairman and the Trust. The Nominations Committee, Non-Executive Directors are initially which is chaired by the Chairman with appointed for three year terms, as a membership drawn from Governors, approved by the COG. Re-appointment undertook a recruitment process to fill for a further three year term can be two vacancies: one from the previous made, subject to satisfactory appraisal financial year (Mr J. Gaisford) and and the approval of the Governors. the one arising from Mr Rackstraw’s Consideration of extension beyond six departure. In advance of this process, years is subject to rigorous review, in the Board undertook a review of the line with the agreed processes. ‘Policy for the Composition of NEDs on the Board’ to ensure the necessary Although the new Trust Chairman, mix of skills and experience on the James Brent, was appointed during Board and this was then discussed with the last financial year, he took up his the Nominations Committee. On the position from the beginning of May basis of a very successful recruitment 2012. He replaced Angela Ballatti who campaign, two new NEDs were left the Trust at the end of April 2012, appointed during the year: when her second term came to an end. • Mr Peter Knott • Ms Michele Romaine. Details of their start dates are included in the table on page 77. 80 4. Our Governance Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Remuneration Report

The Executive Director Remuneration Committee (EDRC) comprises the Chairman and all the Non-Executive Directors.

The Chief Executive and Director remuneration for Executive Directors, the policy as a whole should be set of Human Resources are invited to once again this year, the Committee aside. In particular, the elements of the attend the meetings in an advisory has, in effect, suspended the application current framework that relate directly role and are excluded on issues directly of the policy. This was on the basis to internal relativities between the relevant to them by the Chairman of that the political and economic context Chief Executive and Executive Directors the Committee. The Committee is meant that it was not possible to move was felt to be unnecessary and could chaired by David Wright, the Senior the remuneration packages of the potentially impede the Trust’s ability to Independent Director. The Committee Directors towards the median point. appoint the best candidate. As a result, is supported by the Trust Secretary. In reviewing salary levels during the the Committee decided to take steps year, and taking into consideration the to replace the existing policy with a The Committee’s main purpose is prevailing external policy environment new set of principles to help guide its to set rates of remuneration, terms and using the evidence gained from decision-making. These new principles, and conditions of service for the the updated comparator information, which are currently being developed, Chief Executive, Executive Directors the Committee took the view that will draw on those elements of the and Directors, i.e. those persons in there would be no adjustments made existing policy framework that are senior positions having authority or to the salary levels of the Executive considered to be of use. For example, responsibility for directing or controlling Directors. In doing so, the Committee the continued use of a comparator the major activities of the Trust. were cognisant that the benchmarking group of similarly sized Trusts outside The Committee’s work is guided by data again demonstrated salaries were the South East (a group which has a policy framework for Executive significantly below the peer group. expanded over the year) was felt to Director remuneration and conditions. Despite this, and in view of the pay provide a useful barometer against The policy sets out a framework by freeze for all other staff groups, the which to compare remuneration rates. which the EDRC will manage the policy was, in effect, suspended. The Committee received the results remuneration and terms of service In taking this view, the Committee of the appraisals process for Executive of the Chief Executive and Executive recognised the low comparative salary Directors that was taken forward by Directors. The policy details the levels exposed the Board to a degree the Chief Executive. On the basis of approach that the Committee will take of risk in a competitive employment 360-degree feedback from Executive to executive remuneration, how the market and the approach may not be colleagues and Non-Executive policy will be applied, and the duties sustainable in the future. Directors, the Committee was briefed and responsibilities of key staff. The on the performance of each of the policy allows a reasonable level of Given that the Committee reached the Executive Directors in their role as flexibility on which the members of view that it had not been possible to Board members and details of relevant the committee will apply their best implement the policy for the previous continuing professional development. judgements in reaching conclusions two years, Committee members about the remunerations of Executive raised some searching questions as During the course of the year the Directors. Although the policy to whether the policy framework was Trust has embarked on a Senior provides a framework for determining therefore fit for purpose and whether Management Review (SMR) as part 4. Our Governance Royal Devon and Exeter NHS Foundation Trust 81 Annual Report and Accounts 2012/13

of its transformation programme. The Committee agreed the reshaped • The establishment of a single, The Senior Management Review has portfolios of the Executive team during full-time Medical Director is a focused on assessing whether the the year. The main changes were: move away from the existing senior management structure was: arrangements, in which the Trust • The reduction in the number of has a single post filled through 1) enabling as efficient delivery as Executive Directors from five to a job share. This was felt by the possible of current patient services four posts Committee to be an important 2) capable of delivering the future • The establishment of a change in ensuring that greater strategy. The scope of the review new Executive Director of capacity could be applied to the included some Band 7 roles up to, Transformation and Organisational leadership necessary for the clinical and including, the Executive Team. Development to drive the new staff in the Trust. This post was ways of working both within the advertised and recruited during the The EDRC welcomed the SMR because Trust and beyond its four walls, to year and the new post-holder will the Committee was keen to ensure ensure that the services offered take up the position in the next that the senior leadership team had by the Trust are delivered to a financial year. the right capacity and capability good quality, meet the needs of to maintain its 'business as usual' In addition to the changes made at patients and are undertaken in a performance but also transform the Executive Director level, the financially sustainable way. This the way the organisation meets its Committee also helped develop new role includes some functional objectives, so that it is able to deliver proposals for the tier below Executive areas linked to the transformation good quality services that meet the Directors. To support the new Chief agenda such as Organisational needs of patients in a financially Nurse/Executive Director of Service Development, Human Resources sustainable way. The EDRC have been Delivery the supporting sub-structure and Communications and clear that achieving these goals during has been re-organised and an Engagement. This post was a time of austerity was mission-critical Operations Director role has been advertised during the year and the but, given the volume and complexity established. Mr Peter Adey took up this post will be taken up during April of the work underway, represented role in March 2013. 2013 perhaps the biggest challenge that The clinical and operational structure had faced the Trust in a generation. The • Bringing together a new within the Trust has also been reviewed Committee engaged in developing the role encompassing nursing, and proposals are currently subject senior management review in relation to: performance and operations, to staff consultation. Within the patient safety, quality and • Ensuring that the revised portfolios proposal structure the focus has been engagement, and governance in of the Executive Director team was on streamlining lines of reporting a Chief Nurse/Executive Director appropriate and fit for purpose and enhancing engagement in the of Service Delivery. This role was leadership of the Trust. The structure • Ensuring that, in the design of the taken up by Em Wilkinson-Brice will establish three new clinical SMR, there was sufficient capacity from the 1st December 2012. divisions, replacing the current five, and capability in the rung below The Committee considered the each headed by a Divisional Director. the Executive Directors appropriate remuneration for this The remuneration for the new new role based on relativities with • To either make any changes to the Divisional Director roles will be set other ED portfolios. On the basis structure cost-neutral or to reduce by the EDRC. The establishment of a of this comparison, the Committee expenditure. re-organised supporting management took a view about the appropriate tier was to extend the number of level of compensation and this is posts that fall within the remit of the reflected in the accounts. Committee. 82 4. Our Governance Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

The Committee accepted that Elaine Attendance at EDRC meetings 2012/13 Hobson, the Trust’s Chief Operating Officer, would leave the Trust as her NAME Sept 12 Nov 12 Dec 12 - Jan 13+ post had become redundant under J Brent * * * the senior management review. Elaine stepped down from the role at the B Aird * * * end of September 2012 after working P Knott * * * at the Trust since 1985 and with a M Romaine * A * career in the NHS stretching back some D Robertson * * * 37 years. The Board acknowledged Elaine’s significant contribution in A Willis * * * a number of roles during this time D Wright * * * and thanked her for her hard work, * present determination and resilience. A Absent NHS Pension Scheme provisions apply to + This was a single agenda item meeting that took place on four separate all Executive Director posts, with the level occasions. As a result attendance varied during this time but the meeting was of employer contribution determined always quorate. nationally. Executive Directors are on permanent, pensionable contracts, subject to standard NHS terms and conditions of service and their current notice periods are:

Chief Executive 12 months Chief Operating Officer 3 months Director of Finance and 6 months Business Development Director of Human 6 months Resources Director of Nursing 6 months & Patient Care/Chief Nurse/Executive Director of Service Delivery Medical Directors* 3 months

* The Medical Directors are on permanent clinical contracts with the Trust. This period relates to the Medical Director appointment only.

The EDRC has determined that, over time and upon recruitment, it will move all EDs to a uniform notice period. 4. Our Governance Royal Devon and Exeter NHS Foundation Trust 83 Annual Report and Accounts 2012/13

Salary, Pension and Other Information

A full declaration of salary, benefits in kind, real increase in pension and related lump sum at age 60, total accrued pension and cash equivalent transfer values are stated in full on page 84.

The accounting policy for pensions is As part of the Review of Tax set out in Note 7.0 to the accounts. Arrangements of Public Sector Appointees published by the Chief The total of salaries, allowances and Secretary to the Treasury on 23 May non-cash benefits in kind paid to 2012, departments and their arm’s Non-Executive Directors and senior length bodies including Foundations managers for this and the previous Trusts are required to publish year are: information in relation to the number 2011/12 2012/13 of off payroll engagements – at a cost of over £58,200 per annum – that £1,097,000 £1,358,000 were in place on 31 January 2012. The EDRC Committee agreed that In relation to off payroll engagements Elaine Hobson would leave the at a cost of over £58,200 per annum Trust as her post had become there were four in place as of redundant under the Senior 31 January 2012 all of which came Management Review. Compensation to an end. for loss of office was agreed under nationally-agreed arrangements for Furthermore, the Trust must report which Treasury/Monitor approval all new off-payroll engagements was required. between 23 August 2012 and 31 March 2013, for more than £220 per Signed day and more than six months. In this period, there were three engagements and assurance has been requested and received in relation to their tax A M PEDDER OBE, Chief Executive obligations in all three cases. 30 May 2013 84 4. Our Governance Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Directors' Remuneration Salary and Pension entitlements of senior managers

Name and Title Salary Other Golden hello / Benefits Remuneration compensation in kind for loss of office

(bands of £5000) (bands of £5000) (bands of £5000) (Rounded to the nearest £100)

£000 £000 £000 £ 2012/13 J Brent Chairman (appointed 1 May 2012) J Brent 40 - 45 A Ballatti Chairman (resigned 30 April 2012) A Ballatti 0 - 5 - - - B Aird Non-Executive Director B Aird 10 - 15 - - 300 P Knott Non-Executive Director (appointed 16 July 2012 and resigned 31 March 2013) P Knott 5 - 10 - - - J Rackstraw Non-Executive Director (resigned 31 July 2012) J Rackstraw 0 - 5 - - 600 D Robertson Non-Executive Director D Robertson 10 - 15 - - 100 M Romaine Non-Executive Director (appointed 1 September 2012) M Romaine 5 - 10 - - - A Willis Non-Executive Director A Willis 15 - 20 - - 2,800 D Wright Non-Executive Director D Wright 10 - 15 - - 700 A Pedder Chief Executive A Pedder 170 - 175 - - 8,500 M Cooper Joint Medical Director M Cooper 70 - 75 90 - 95 - - E Hobson Chief Operating Officer (redundant 30 September 2012) E Hobson 125 - 130 - 245 - 250 - L Lane Director of Human Resources L Lane 85 - 90 - - 700 V Lewis Joint Medical Director V Lewis 65 - 70 90 - 95 - - S Tracey Director of Finance & Business Development S Tracey 125 - 130 - - 100 E Wilkinson - Brice Chief Nurse / Executive Director of Service Delivery E Wilkinson - Brice 125 - 130 - - -

Other Remuneration shows the salary that is attributable to clinical duties. The post of Chief Operating Officer was declared redundant as part of the Senior Management Review. Compensation for loss of office was agreed under nationally-agreed arrangements for which Treasury / Monitor approval was required The contractual hours of L Lane are 0.8 of a whole time equivalent. The benefit in kind for A Pedder relates to the provision of a lease car. The remaining benefits in kind relates to the mileage allowance paid over and above the HM Revenue Customs and Excise allowance. 4. Our Governance Royal Devon and Exeter NHS Foundation Trust 85 Annual Report and Accounts 2012/13

Name and Title Salary Other Golden hello / Benefits Remuneration compensation in kind for loss of office

(bands of £5000) (bands of £5000) (bands of £5000) (Rounded to the nearest £100)

£000 £000 £000 £ 2012/13 J Brent Chairman (appointed 1 May 2012) J Brent 40 - 45 A Ballatti Chairman (resigned 30 April 2012) A Ballatti 0 - 5 - - - B Aird Non-Executive Director B Aird 10 - 15 - - 300 P Knott Non-Executive Director (appointed 16 July 2012 and resigned 31 March 2013) P Knott 5 - 10 - - - J Rackstraw Non-Executive Director (resigned 31 July 2012) J Rackstraw 0 - 5 - - 600 D Robertson Non-Executive Director D Robertson 10 - 15 - - 100 M Romaine Non-Executive Director (appointed 1 September 2012) M Romaine 5 - 10 - - - A Willis Non-Executive Director A Willis 15 - 20 - - 2,800 D Wright Non-Executive Director D Wright 10 - 15 - - 700 A Pedder Chief Executive A Pedder 170 - 175 - - 8,500 M Cooper Joint Medical Director M Cooper 70 - 75 90 - 95 - - E Hobson Chief Operating Officer (redundant 30 September 2012) E Hobson 125 - 130 - 245 - 250 - L Lane Director of Human Resources L Lane 85 - 90 - - 700 V Lewis Joint Medical Director V Lewis 65 - 70 90 - 95 - - S Tracey Director of Finance & Business Development S Tracey 125 - 130 - - 100 E Wilkinson - Brice Chief Nurse / Executive Director of Service Delivery E Wilkinson - Brice 125 - 130 - - -

Other Remuneration shows the salary that is attributable to clinical duties. Ratio between highest paid director and median remuneration The post of Chief Operating Officer was declared redundant as part of the Senior Management Review. Compensation for received by employees of the Trust 2012/13 2011/12 loss of office was agreed under nationally-agreed arrangements for which Treasury / Monitor approval was required

The contractual hours of L Lane are 0.8 of a whole time equivalent. Band of highest paid Director - as above 170 - 175 170 - 175 The benefit in kind for A Pedder relates to the provision of a lease car. Median remuneration received by employees within the Trust 26.8 28.2 The remaining benefits in kind relates to the mileage allowance paid over and above the HM Revenue Customs Ratio 6.4 6.1 and Excise allowance. 86 4. Our Governance Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Pension Benefits

Name and Title

£000 £000 £000 £000 £000 £000 £000

A Pedder Chief Executive A Pedder (0.0 - 2.5) (5.0 - 7.5) 80.0 - 85.0 240.0 - 245.0 1,681 1,590 8

M Cooper Joint Medical Director M Cooper 0.0 - 2.5 0.0 - 2.5 60.0 - 65.0 190.0 - 195.0 - - -

E Hobson Chief Operating Officer E Hobson 0.0 - 2.5 5.0 - 7.5 60.0 - 65.0 180.0 - 185.0 1,252 1,069 63

L Lane Director of Human Resources L Lane 0.0 - 2.5 2.5 - 5.0 10.0 - 15.0 30.0 - 35.0 211 176 26

V Lewis Joint Medical Director V Lewis 0.0 - 2.5 5.0 - 7.5 25.0 - 30.0 80.0 - 85.0 419 359 41

S Tracey Director of Finance & Business Development S Tracey 0.0 - 2.5 0.0 - 2.5 20.0 - 25.0 60.0 - 65.0 318 286 18

E Wilkinson-Brice Director of Nursing and Patient Care E Wilkinson-Brice 0.0 - 2.5 2.5 - 5.0 35.0 - 40.0 105.0 - 110.0 513 455 34

As Non-Executive members do not accrued in their former scheme. Real increase in CETV - This reflects receive pensionable remuneration, The pension figures shown relate to the increase in CETV effectively funded there will be no entries in respect of the benefits that the individual has by the employer. It takes account of pensions for Non-Executive members. accrued as a consequence of their the increase in accrued pension due total membership of the pension to inflation, contributions paid by the A Cash Equivalent Transfer Value scheme, not just their service in a employee (including the value of any (CETV) is the actuarially assessed senior capacity to which the disclosure benefits transferred from another capital value of the pension scheme applies. The CETV figures, and the pension scheme or arrangement) and benefits accrued by a member at a other pension details, include the uses common market valuation factors particular point in time. The benefits value of any pension benefits in for the start and end of the period. valued are the member's accrued another scheme or arrangement benefits and any contingent spouse's which the individual has transferred pension payable from the scheme. to the NHS pension scheme. They also A CETV is a payment made by a include any additional pension benefit pension scheme, or arrangement to accrued to the member as a result secure pension benefits in another of their purchasing additional years pension scheme or arrangement of pension service in the scheme at when the member leaves a scheme their own cost. CETVs are calculated and chooses to transfer the benefits within the guidelines and framework prescribed by the Institute and Faculty of Actuaries. 4. Our Governance Royal Devon and Exeter NHS Foundation Trust 87 Annual Report and Accounts 2012/13

Real Real Total Total Cash Cash Real increase in increase in accrued accrued Equivalent Equivalent Increase in pension at pension pension at related lump Transfer Transfer Cash age 60 related sum age 60 at 31 sum at age Value at 31 Value at 31 Equivalent (bands at age 60 March 2013 60 at 31 March 2013 March 2012 Transfer £2,500) (bands (bands of March 2013 Value at 31 £2,500) £5,000) (bands of March 2012 £5,000)

£000 £000 £000 £000 £000 £000 £000

A Pedder Chief Executive A Pedder (0.0 - 2.5) (5.0 - 7.5) 80.0 - 85.0 240.0 - 245.0 1,681 1,590 8

M Cooper Joint Medical Director M Cooper 0.0 - 2.5 0.0 - 2.5 60.0 - 65.0 190.0 - 195.0 - - -

E Hobson Chief Operating Officer E Hobson 0.0 - 2.5 5.0 - 7.5 60.0 - 65.0 180.0 - 185.0 1,252 1,069 63

L Lane Director of Human Resources L Lane 0.0 - 2.5 2.5 - 5.0 10.0 - 15.0 30.0 - 35.0 211 176 26

V Lewis Joint Medical Director V Lewis 0.0 - 2.5 5.0 - 7.5 25.0 - 30.0 80.0 - 85.0 419 359 41

S Tracey Director of Finance & Business Development S Tracey 0.0 - 2.5 0.0 - 2.5 20.0 - 25.0 60.0 - 65.0 318 286 18

E Wilkinson-Brice Director of Nursing and Patient Care E Wilkinson-Brice 0.0 - 2.5 2.5 - 5.0 35.0 - 40.0 105.0 - 110.0 513 455 34

Cast Equivalent Transfer Values (CETV) are not available for members that have reached the normal retirement age of 60 or who have commenced drawing their pension. No CETV is therefore available, as at 31 March 2012 and 31 March 2013, for M Cooper. 88 4. Our Governance Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Non-Executive Director Remuneration Committee

The Non-Executive Director Remuneration Committee (NEDRC) comprises five elected Governors and is chaired by the Lead Governor, Council of Governors.

The Committee is supported by the prevailing and that the Trust had had HR Director and the Trust Secretary. no issues in recruiting high quality Recommendations for any changes NEDs as a result of a salary level to remuneration for the Chairman that was uncompetitive. Ad-hoc and other Non-Executive Directors are evidence from Committee members made by the NEDRC for consideration suggested that the rates of pay by the Council of Governors at a for the Chairman and NEDs were general meeting. The Committee met broadly in line with similar FTs in the once – in March 2013 – to review region. The Committee decided not its terms of reference, welcome to recommend any change to the new members to the Committee, basic level of remuneration for Non- and to decide whether it wished to Executive Directors and Chairman receive external consultancy support and consequently, in line with the in reviewing the salaries of NEDs in policy agreed by the Council of relation to similar posts elsewhere in Governors in April 2010, increases in the NHS. remuneration to the Chairman and Non-Executive Directors were limited The Committee made some minor to reflect increases in the cost of alterations to its terms of reference living only. to ensure that it was updated and also considered the need for external Membership and attendance at the NEDRC assistance in understanding the going rates for NEDs in other FTs. Monitor’s NAME Code of Governance (E 2.3) says that Richard May Lead Governor and Chairman of the NEDRC 1/1 Governors “should consult external professional advisers to market-test the Tony Cox Staff Governor 0/1 remuneration levels of the chairman Geoff Barr Exeter & South Devon 1/1 and other non-Executives at least Cynthia Mid, North, West Devon & Cornwall 1/1 once every three years and when they Thornton intend to make a material change to Linda Vijeh East Devon, Dorset & Somerset 1/1 the remuneration of a non-Executive.” Having considered the arguments for and against seeking the advice of external consultants the Committee took the view that it would not take this step at this stage bearing in mind the overall economic conditions 4. Our Governance Royal Devon and Exeter NHS Foundation Trust 89 Annual Report and Accounts 2012/13

Audit Committee

The Audit Committee is a formal, statutory committee of the Board of Directors, chaired by Mr David Robertson (a Non-Executive Director with a financial background).

Four Non-Executive Directors Auditors, PricewaterhouseCoopers constituted the membership of the (PwC), Internal Audit and the Counter Committee, although one member Fraud Service. only served up to January 2013. The Audit Committee met five A replacement for that Member times during 2012/13. The names is currently being recruited. The of members and their attendance at Committee is also attended by 2012/13 meetings, are as follows: representatives of the External

Date of committee David Peter John Michele David Robertson Knott Rackstraw Romaine Wright 25 April 2012 Y – Y – Y 28 May 2012 Y – Y – Y 30 July 2012 Y – Y – N 31 October 2012 Y Y – Y Y 30 January 2013 Y Y – N Y 90 4. Our Governance Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

A full description of the duties and • Review the work and findings of business plans, are subject to responsibilities of the Audit Committee the external auditor appointed by review as to completeness and can be found on the Trust’s website: the Governors and consider the accuracy of the information www.rdehospital.nhs.uk. Some of the implications and management’s provided to the Board Committee’s key areas of responsibility responses to their work • Provide a written report are to: • Review the adequacy of all risk highlighting the key issues arising • Review the establishment and and control-related disclosure from the Committee to the maintenance of an effective system statements together with any meeting of the Board of Directors of integrated governance across accompanying head of internal that directly follows the Audit the whole of the organisation’s audit statement, external audit Committee. activities (both financial and opinion or other appropriate It is the responsibility of the Trust’s non-financial), that supports the independent assurances, prior to Directors to produce the Annual achievement of the organisation’s endorsement by the Board Accounts included in this report. The objectives • Review the adequacy of the policies external auditors provide an independent • Utilise the work of internal audit, and procedures for all work related opinion on the Trust’s accounts and external audit and other assurance to fraud and corruption as set out also audit the overall position of the functions to assess the overarching in Secretary of State Directions and Trust’s management and performance, systems of integrated governance, as required by the Counter Fraud including an opinion on the quality risk management and internal and Security Management Service of the system of internal control. The control, together with indicators of outcome of this work is reported in • Oversee the work of other their effectiveness the Audit Opinion included with the committees within the accounts in this report and the Annual • Ensure that there is an effective organisation, whose work can Management Letter to the Board. internal audit function established provide relevant assurance to the by management that meets Audit Committee’s own scope of For the year under report, the external mandatory NHS internal audit work. This will particularly include auditor provided an unqualified standards and provides appropriate the Governance Committee and opinion on the Trust’s accounts and independent assurance to the its management of the Trust’s expressed themselves satisfied with the Audit Committee, Chief Executive corporate risk register Trust’s management procedures and and Board control processes. • Monitor the implementation of • Make recommendations to the Policy on Standards of Business Council of Governors in relation to Conduct for members and staff the appointment, re-appointment (the Codes of Conduct and and removal of the external auditor Accountability). This will include and to approve the remuneration the arrangements by which staff and terms of engagement may, in confidence, raise concerns about possible improprieties in • Give consideration to the major matters of financial reporting and findings of internal audit work control, clinical quality, patient (and management’s response), and safety or other matters ensuring co-ordination between the internal and external auditors • Ensure that the systems for to optimise audit resources financial reporting to the Board, including those of budgetary control and the preparation of 4. Our Governance Royal Devon and Exeter NHS Foundation Trust 91 Annual Report and Accounts 2012/13

Compliance with the NHS Foundation Trust Code of Governance

The Code of Governance published in September 2006 (last updated 1st April 2010) contains recommended best practice to be followed by FTs in areas of corporate governance.

The Code contains main and supporting It was reported to the Board in April principles, which are subject to ‘comply’ 2013 that the Trust had maintained or ‘explain’ reporting procedures. Any compliance with all the provisions provisions with which the Trust does not of the Code for the current year. As comply must be disclosed in the explained in the section on Executive Annual Report. Director remuneration (see page 80) the EDRC, confirmed by the Board, In last year’s Annual Report, the have extended the definition of senior following provisions were reported management to include the tier of under the ‘explain’ category: management below Executive Directors E.2.2 Definition of senior and that the terms and conditions for management – which states that “the this category of Very Senior Managers Remuneration Committee should be taken out of AfC and be considered have delegated responsibility for by the Executive Director Remuneration setting remuneration for all Executive Committee. Directors, including pension rights Therefore, the Board has declared and any compensation payments. The that it is fully compliant with all the committee should also recommend provisions set out in the Code of and monitor the level and structure of Governance. remuneration for senior management. The definition of ‘senior management’ should be determined by the Board but should normally include the first layer of management below Board level.” The Trust’s explanation for non- compliance with this provision was that the Board has defined ‘senior management’ to be limited to Board Members only. All other staff were covered by the Agenda for Change scheme of nationally agreed terms and conditions. 92 4. Our Governance Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Annual Governance Statement

1. Scope of Trust, to evaluate the likelihood of risk is delegated to the appropriate those risks being realised and the level from Director through to responsibility impact should they be realised, local management through the and to manage them efficiently, divisional management teams. As Accounting Officer, I have effectively and economically. The All Directorates have Governance responsibility for maintaining a system of internal control has Groups which meet regularly. sound system of internal control been in place in the Royal Devon There are established Governance that supports the achievement & Exeter NHS Foundation Trust for Co-ordinator posts to support of the NHS Foundation Trust’s the year ended 31 March 2013 the Directorates in implementing policies, aims and objectives, and up to the date of approval of robust risk and governance whilst safeguarding the public the Annual Report and Accounts. processes. Directorate Governance funds and departmental assets Groups report and escalate for which I am personally concerns to the five Governance responsible, in accordance with 3. Capacity to sub-committees. Strategic risks the responsibilities assigned to me. are managed via the Board-owned I am also responsible for ensuring handle risk Board Assurance Framework. This that the NHS Foundation Trust 3.1 During 2010/11 the Board of document lists all risks that could is administered prudently and Directors commissioned a review of prevent the Trust from achieving its economically and that resources the Trust’s governance framework strategic objectives. are applied efficiently and and agreed a development effectively. I also acknowledge my 3.4 The Board has appointed a plan which resulted in a revised responsibilities as set out in the Senior Independent Director to governance architecture with effect NHS Foundation Trust Accounting be available to Governors and from October 2011. An interim Officer Memorandum. Members if they have concerns, review undertaken by Internal which contact through the normal Audit in July 2012 reported “the channels of Chairman, Chief governance structure has been 2. The purpose of the Executive or Director of Finance strengthened greatly”. A full has failed to resolve, or for which system of internal review is currently underway and is such contact is inappropriate. due to be reported in April 2013. control In addition the Trust has a 3.2 The Audit Committee monitors Whistleblowing Policy to protect The system of internal control and oversees both internal control staff who raise issues of concern. is designed to manage risk to issues and the process for risk a reasonable level rather than 3.5 All staff joining the Trust are management. Audit Southwest to eliminate all risk of failure required to attend Corporate (internal audit) and PWC (external to achieve policies, aims and Induction, which covers key auditors) attend all Audit objectives; it can therefore elements of risk management. Committee meetings. The Audit only provide reasonable and This is further enhanced at Committee reviews all reports of not absolute assurance of departmental induction. Training the Internal and External Auditors effectiveness. The system of courses are run on a regular and reports regularly to the Board. internal control is based on an basis and provide staff with ongoing process designed to 3.3 Risk issues are reported through the skills needed to undertake identify and prioritise the risks to the Governance Committee via the risk management duties. Staff the achievement of the policies, Safety and Risk Committee and are trained and equipped to aims and objectives of the Royal the Trust’s management structure. manage risk in a way appropriate Devon & Exeter NHS Foundation Management and ownership of to their authority and duties. 4. Our Governance Royal Devon and Exeter NHS Foundation Trust 93 Annual Report and Accounts 2012/13

Risk management is included in 4. The risk and 4.3 The Audit Committee is a the Trust’s mandatory training Non-Executive Committee of the programme and follow up control framework Board of Directors and reviews the refresher training. The Trust’s establishment and maintenance of 4.1 The Board of Directors is risk management policies and an effective system of integrated responsible for the strategic procedures are available on the governance across the whole of direction of the Trust. The Board Trust’s intranet, IaN. the Trust’s activities that supports of Directors has reviewed and the achievement of the Trust’s 3.6 In June 2011, the Trust approved a revised Risk Strategy objectives. The Committee implemented Datix web, an and updated, amended and provides assurance to the Board electronic Governance System, approved the Board Assurance of Directors that the governance which has the ability to record Framework accordingly. The Board system is functioning in accordance and monitor incidents, complaints Assurance Framework identifies with the framework agreed by the and risks. Since its implementation the key risks and mitigations Board. the reporting and management related to the Trust's strategic of incidents has improved. The objectives and key priorities. The Specifically, the committee reviews complaints and risk register Board Assurance Framework the adequacy of: module were implemented in is reviewed by the Board of • All risk and control-related December 2011 and January 2012, Directors on a quarterly basis. disclosure statements together and the legal claims module was The Corporate Risk Register is with the Head of Internal Audit implemented in October 2012. reviewed by the Governance Opinion and external audit Committee each time it meets. The 3.7 Senior clinical staff and opinion (ISA 260 report) prior to Governance Committee reports to Governance Co-ordinators endorsement by the Board the Board of Directors quarterly. are trained to conduct Serious The Audit Committee considers • The annual audit plans (and Incidents Requiring Investigation the Assurance Framework when approves these) (SIRI). The Risk Management Team setting Internal Audit’s annual co-ordinates SIRIs and adverse • The data assurance process work plan. incidents which are reported and underpinning the Trust’s Quality managed through the Incident 4.2 Any material gaps in controls of Report Review Group (a sub group of the assurance are highlighted and • The underlying assurance processes Safety and Risk Committee) and reported to the Board of Directors. that indicate management of learning points are made available When identified, risks to the Trust’s risks that may impact the degree to all relevant staff. All SIRIs and strategic objectives that cannot be to which achievement of the action plans are shared with the immediately eliminated are placed corporate objectives is secured, Trust’s lead commissioner, NHS on the corporate register and together with the effectiveness Devon. action plans put in place to address of the management of principal any gaps. The Board of Director’s risks and the appropriateness of risk and control framework is disclosure statements supported by the Audit Committee and Governance Committee which • The policies and procedures provide assurance to the Board for all work related to fraud of Directors on risk and control and corruption as required by management issues. the counter fraud and security management service 94 4. Our Governance Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

• The Trust’s self assessment process Other specialist Groups led by a is the failure to deliver the for assessing compliance with Care Director or senior clinician include: recurrent annual £17 million Cost Quality Commission Regulations for Improvement Programme (CIP). • Clinical Audit and Guidelines the period April 2012 to March 2013. Controls and plans are in place but Group the risk is not fully mitigated. 4.4 The Governance Committee is • Medical Devices Group chaired by a Non-Executive Director 5.3 The Trust maintains a and provides leadership to the • Medicines Management Group comprehensive Corporate Risk risk management process. The Register covering both clinical and • Medical Gases Group Committee takes a comprehensive organisational risk. There are 33 oversight of the quality and safety • Patient Safety Programme Group current risks on the Corporate Risk of care provided by the Trust and Register. All identified risks have • Radiation Safety Group provides assurance to the Board clear mitigation plans in place. Of of Directors. The work of the • Trust Infection Control and the Trust’s eight highest scoring Governance Committee is supported Decontamination Assurance Group risks, four relate to a diagnostic test by five key sub-committees: • Drugs and Therapeutics ordering and result communication system, one relates to storage of • Integrated Safeguarding Committee. medical records, one relates to Committee administrative staffing within one • Clinical Effectiveness Committee 5. Risk Identification area of the Trust, one relates to the installation of a tracking system • Workforce and Diversity and evaluation for medical equipment and one Committee 5.1 The Trust has a risk management relates to the care of an individual • Safety and Risk Committee strategy which has been approved patient. These risks are assigned • Engagement and Experience by the Board of Directors and clearly to an appropriate executive lead Committee. sets out the process for identifying and manager who are responsible and managing risk. It incorporates for ensuring that the risk is These five committees are a standard methodology in which either eliminated or managed responsible for monitoring and risk is evaluated using a likelihood- appropriately. A robust system is in managing specific types of risk. consequence matrix. The roles place to monitor progress of action plans. This is undertaken by both 4.5 The Adverse Events Forum is and responsibilities of staff in chaired by a consultant clinical lead managing risk are defined and key the Head of Governance and the and reviews all adverse incidents, posts highlighted. The strategy also Divisional Governance Groups to Clinical Audits and Mortality and includes the governance reporting ensure that risks are proactively Morbidity Reviews. The Incident structure and the terms of reference managed down to their end target Review Group is chaired by the of the Governance Committee and score. A detailed report is produced Deputy Chief Nurse and Patient all the committees reporting to the by the Head of Governance to the Care and reviews all Serious Audit Committee and Governance Safety and Risk and Governance Incidents Requiring Investigation Committee. Committee each time they meet. (SIRI) and action plans. 5.4 5.2 The Board has developed a revised The Trust has Directorate-level Board Assurance Framework; it risk registers which feed into focuses on risks, controls and the Corporate Risk Register. At plans to address gaps in control Directorate level, the risk registers that might impact on the delivery contain lower-level localised risks, of the Trust's strategic objectives. which can be managed by the The highest strategic risk identified relevant Directorate. The Corporate 4. Our Governance Royal Devon and Exeter NHS Foundation Trust 95 Annual Report and Accounts 2012/13

Risk Register contains the 5.6 Information Governance and 5.10 The Board of Directors receive higher-level risks and Trust-wide data security is managed by assurance that we are meeting our risks. This ensures that risks are the Information Governance legal obligations with regard to identified, managed and escalated Steering Group lead by the equality and diversity, through an appropriately at all levels of the Director of Finance and Business annual report received, on behalf organisation. Risk assessments, Development, the Trust’s of the Board of Directors, by the including Health and Safety and nominated Senior Information Risk Governance Committee. Infection Control are undertaken Owner. Information Asset Owners Full evidence of legal compliance throughout the Trust. All areas for critical systems have been is also published on the Trust's of the hospital have trained Risk identified; system risk assessments external website. Management Officers and the Risk and Information Risk Management Management Department and training is undertaken annually. The Trust uses an NHS-designed Head of Governance facilitate risk tool, the Equality Delivery System 5.7 An Information Security Forum, surgeries to provide support and (EDS), to ensure compliance with chaired by the Medical Director training and to ensure consistency legal obligations and enable as Caldicott Guardian, deals with in approach. continuous improvement. all aspects of information security 5.5 Other methods to identify risks and data confidentiality. Risks to 5.11 As an employer with staff entitled include: information security are reported to membership of the NHS Pension directly to the Information Security Scheme, control measures are • Complaints, Care Quality Forum (a sub-group of the in place to ensure all employer Commission and Health Service Information Governance Steering obligations contained within the Ombudsman reports and Group) and recorded on the Scheme regulations are complied recommendations Corporate Risk Register. The Trust with. This includes ensuring that • Inquest findings and reports from has completed the Information deductions from salary, Employer’s HM Coroner Governance Tool Kit assessment contributions and payments into • Health and Safety Executive and and the Audit Committee and the the Scheme are in accordance regulatory body compliance Board of Directors has received with the Scheme rules, and inspections a report regarding its system for that Member Pension Scheme control of Information Governance. records are accurately updated in • Medico-legal claims and litigation accordance with the timescales reports 5.8 The Trust is green-rated on the detailed in the Regulations. Information Governance Toolkit, • LiNKs and Health Scrutiny achieving a level 2 on all 45 5.12 The Trust has undertaken risk Committee reports requirements. assessment and Carbon Reduction • Incident reports and trend analysis Delivery Plans are in place in 5.9 Control measures are in place to (via Datix software, identification accordance with emergency ensure that all the organisation’s of hot spots) preparedness and civil contingency obligations under equality, diversity requirements, as based on UKCIP • Internal and external audit reports and human rights legislation are 2009 weather projects, to ensure • Quarterly Performance Reviews complied with. As a public sector that this organisation’s obligations organisation, the Trust has legal • Feedback from Governors and under the Climate Change Act obligations as regards equality and Members and the Adaptation Reporting diversity through both the Equality requirements are complied with. • Ward to Board Framework, Clinical Act and the Public Sector Duty. Quality Assessment Tool (CQAT) • Safety Thermometer. 96 4. Our Governance Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

6. Quality Report with the Trust’s commitment to 7. Review of economy, openness and transparency, the 6.1 The Trust is fully registered with data included is not just limited to efficiency and the Care Quality Commission good performance and is publicly effectiveness of the and remains compliant with the reported at least on a quarterly requirements of registration. basis. The Audit Committee use of resources undertakes a review of the data 6.2 The Directors are required under 7.1 The Trust's Annual Plan, including assurance underpinning the Quality the Health Act 2009 and the financial, performance, quality Account. Through this process and National Health Service (Quality and governance targets was other reviews of data, the Board of Accounts) Regulations 2010 to approved by the Board of Directors Directors is assured that the Quality prepare Quality Accounts for each in May 2012. Overall performance Account represents a balanced financial year. Monitor has issued is monitored via an integrated view. guidance to NHS Foundation performance report at the monthly Trust Boards on the form and 6.5 During 2011/12, as part of meetings of the Board of Directors. content of annual Quality Reports the three-year audit cycle, a Operational management and the which incorporate the above programme to assess quality coordination of Trust services are legal requirements in the NHS systems and data (similar to that delivered by the Executive Directors Foundation Trust Annual Reporting in place for our financial systems), and Trust Management Committee, Manual. was agreed with our internal which comprises the Executive auditors and built into the Internal Directors, Clinical Directors and 6.3 The content of the Trust’s Quality Audit plans for future years. This Divisional Managers. Performance Account for 2012/13 builds on will be an ongoing process and of individual clinical and support the 2011/12 report. It has been the Board of Directors will use the Directorates is monitored informally agreed by the Board of Directors recommendations from this work on a monthly basis and formally on and incorporates the views and to further improve the robustness a quarterly basis via the quarterly priorities of Governors and the of the process underpinning the review process. views of Trust Members in setting Quality Accounts. priorities for improvement in 7.2 The Trust’s Internal Audit Plan 2013/14. The development of the and External Audit Management report is led by the Chief Nurse/ Letter include commentary on the Executive Director of Service economical, effective and efficient Delivery. The views of NHS Devon, use of resources. The findings of as lead commissioner, Healthwatch internal and external audit are Devon and Devon County Council reported to the Board via the Audit Health Scrutiny Committee have Committee. been sought. 7.3 I can confirm that the Trust 6.4 The Trust uses the same systems complies with the cost allocation and processes to collate, validate, and charging requirements set out analyse and report on data for in HM Treasury and Office of Public the annual Quality Account as Sector Information guidance. it does for other clinical quality 7.4 Internal Audit has conducted and performance information. reviews against the Care Quality The data is subject to regular Commission regulations, records review and challenge at specialty, management, data quality, and Directorate and Trust levels. In line 4. Our Governance Royal Devon and Exeter NHS Foundation Trust 97 Annual Report and Accounts 2012/13

information governance. Reviews 8.2 The processes applied in • Performance monitoring by are conducted using a risk-based maintaining and reviewing the the Board of Directors of the approach. In addition they have effectiveness of the system of Trust’s strategy and operational annual reviews of the Trust’s risk control include: milestones to achieve internal and management and governance external targets • The maintenance of a view of arrangements. the overall position with regard • National patient and staff survey to internal control by the Board results and development of 8. Review of of Directors through its routine targeted action plans reporting processes and its work on • Delivery of the health and safety effectiveness corporate risk action plan • Review of the Board Assurance 8.1 As Accounting Officer, I have • The Trust’s compliance with the Framework and receipt of Internal responsibility for reviewing the Hygiene Code effectiveness of the system of and External Audit reports to the internal control. My review of Audit Committee • The Trust’s unconditional registration with the CQC. the effectiveness of the system of • Personal input into the controls internal control is informed by the and risk management processes 8.3 My review of the effectiveness of work of the internal auditors and from all Executive Directors, Senior the system of internal control has the Executive Managers within the Managers and clinicians been presented and approved by NHS Foundation Trust who have the Board of Directors. The Board • The review of the Trust’s risk and responsibility for the development of Directors and the Audit and internal control framework is and maintenance of the internal Governance Committees have been supported by the Annual Head of control framework. I have drawn kept informed of progress against Internal Audit opinion which states on the content of the quality action plans throughout the year. report attached to this annual that significant assurance can be report and other performance given, that there is a sound system information available to me. of internal control and that controls 9. Conclusion My review is also informed by are generally being applied There are no significant internal control comments made by the external • Evidence gathering for core Care issues (i.e. issues where the risk could auditors in their external audit Quality Commission regulations not be effectively controlled) I wish management letter and other and registration reports. I have been advised on to report in respect of 2012/13. I am • Self assessment against the Care the implications of the results of satisfied all internal control issues raised Quality Commission’s Essential my review of the effectiveness of have been, or are being, addressed by Standards for Quality and Safety the system of internal control by the Trust through appropriate action (reviewed by internal audit) the Board, the Audit Committee, plans and that implementation of these Internal Audit, the Divisional • Self assessment against Monitor’s plans is monitored. Manager of Corporate Affairs Code of Compliance and Monitor's Signed and Communications, the Head Governance Framework of Governance and External • Clinical Negligence Scheme for Audit. The system of internal Trusts level 2 accreditation for its control is regularly reviewed and maternity services Angela Pedder OBE Chief Executive plans to address any identified weaknesses and ensure continuous • NHS Litigation Authority level 1 improvements are put in place. accreditation for all other services 98 4. Our Governance Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Quality Governance Reporting

We have put in place a rigorous There are no material inconsistencies approach to governing the quality between the Annual Governance of our services. More details about Statement, Board statements required these arrangements are included in by the Compliance Framework, the our Quality Report (see page 58) – Quality Report and Annual Report. The which is a sub-section within the main Board, through its sub-committees, Annual Report as well as in the Annual regularly reviews the effectiveness of Governance Statement (see page 88). the Trust's system of internal controls.

Board Assurance Framework

The Board Assurance Framework (BAF) assurances that adequate controls Audit, undertaken in March 2013, is a Board-owned document whose are operating to reduce these risks to has declared: ‘Overall we are of the primary role is to inform the Board acceptable levels. Over the past twelve opinion that the redesigned BAF is fit about the totality of risks or obstacles to eighteen months the BAF has been for purpose’. Since that opinion, some that may impede it from achieving on an evolutionary journey, in parallel further work has been undertaken to its strategic objectives as outlined with the redevelopment of the wider enhance the working of the BAF and in the Trust’s long-term Strategy governance arrangements within the to ensure it remains a living document document. The BAF also provides Trust. A review of the BAF by Internal which informs the Board agenda.

Regulatory ratings/CQC reports and response

Monitor assesses the performance Deriving the financial risk rating Deriving the governance risk of the Trust using Key Performance rating The financial risk rating is weighted Indicators, designated as average of financial criteria scores, Monitor includes the following Regulatory Ratings. There are two which are: elements within the governance ratings: risk rating: • Achievement of plan • Financial Risk Rating assessed on a • Service performance scale from 1 (high risk) to 5 • Underlying performance • Third party reports (low risk). • Financial efficiency • Failures to comply with board • Governance assessed on a scale of • Liquidity green/amber-green/amber-red. statements • Annual Plan 4. Our Governance Royal Devon and Exeter NHS Foundation Trust 99 Annual Report and Accounts 2012/13

Analysis

Quarter 1 Quarter 3 Quarter 4

Two of the Monitor targets were Two of the Monitor targets were Four of the Monitor indicators not met for Quarter 1 resulting not met for Quarter 3 resulting assessed on a quarterly basis were in Monitor giving an amber-red in Monitor giving an amber-red not met for Quarter 4. governance rating. governance rating. • All cancers: 31-day wait for second • Non-achievement of the Maximum • Non-achievement of the Maximum or subsequent surgical treatment. time of 18 weeks from point of time of 18 weeks from point of The position for the quarter was referral to treatment in aggregate referral to treatment in aggregate 85.3% against a target of 94%. for admitted patients target was for admitted patients target was • All cancers: 62-day wait for first reported. The Trust’s position reported. The Trust’s position treatment from urgent GP referral against the target of 90% was against the target of 90% was to treatment. The position for 86.7%, 85.5% and 84.4% for 89.9%, 90.1% and 91.7% for the quarter was 80.3% against a April, May and June respectively. October, November and December target of 85%. respectively. As this target is • Non-achievement of the Maximum assessed on a monthly basis the • All cancers: 31-day wait from time of 18 weeks from point of non-achievement of the target in diagnosis to first treatment. The referral to treatment in aggregate October means the target was not position for the quarter was for patients on incomplete met for the quarter. 94.4% against a target of 96%. pathways target was reported. The Trust’s position against the • Non-achievement of the Cancer • All cancers: 14-day wait from target of 92% was 86.1%, 88.8% 62 Day Waits for first treatment referral to date first seen for all and 92.8% for April, May and (urgent GP referral for suspected cancers. The position for the June respectively. cancer) was reported. The Trust’s quarter was 92.8% against a position against the target of 85% target of 93%. was 83.6% for the quarter. Quarter 2

One of the Monitor targets was not met for Quarter 2 resulting in Monitor giving an amber-red governance rating. • Non-achievement of the Maximum time of 18 weeks from point of referral to treatment in aggregate for admitted patients target was reported. The Trust’s position against the target of 90% was 86.0%, 87.4% and 88.2% for July, August and September respectively.

Annual Plan Q1 2011/12 Q2 2011/12 Q3 2011/12 Q4 2011/12 2011/12 Financial risk rating 3 3 4 3 3 Governance risk rating amber-red amber-green amber-green amber-red amber-red Annual Plan Q1 2012/13 Q2 2012/13 Q3 2012/13 Q4 2012/13 2011/12 Financial risk rating 3 3 3 3 3 Governance risk rating amber-red amber-red amber-red amber-red amber-red 100 4. Our Governance Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Disclosure to auditors and further disclosures

So far as each Director is aware, there The Counter Fraud Service for Royal is no relevant audit information of Devon and Exeter NHS Foundation which the RD&E’s External Auditor Trust is provided by Audit South West is unaware. Each Director has taken (ASW) via the services of a Local all the steps that they ought to have Counter Fraud Specialist (LCFS) taken as a Director in order to make The LCFS’ time during 2012/13 was themselves aware of any relevant audit predominantly spent on: information and to establish that the RD&E’s external auditor is aware of • promoting an Anti-Fraud Culture; that information. • intelligence gathering; After making enquiries, the Directors • raising awareness of current fraud have a reasonable expectation that scams; the RD&E has adequate resources to continue in operational existence • giving advice in respect of fraud for the foreseeable future. For this risks, attempted scams, procedures reason, they continue to adopt the and policies; going concern basis in preparing the • dealing with case referrals; and accounts. • conducting local proactive There were no Serious Incident exercises Requiring Investigation (SIRI) relating to data losses or breaches in patient The Trust also participated in the Audit confidentiality during the course of the Commission’s National Fraud Initiative financial year. data matching exercise using Payroll data. The data matching reports were If management wishes to use the received in January 2013 and the services of the Trust’s external auditor resulting matches are under review. for any non-audit purposes, we demonstrate why this is appropriate. The Director of Finance and Business Development will provide professional advice on the appropriateness of such an arrangement and the Audit Committee develop, implement policy and review the engagement of the External Auditor to supply non- audit services, taking into account relevant ethical guidance regarding the provision of non-audit services by the external audit firm. This safeguard is in place to ensure independence. PwC also need to confirm that they would be able to carry out any non- audit work without impacting on their independence. 4. Our Governance Royal Devon and Exeter NHS Foundation Trust 101 Annual Report and Accounts 2012/132012-13

Our Governors and 5Members 102 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Our Governors and Members

Council of Governors Governors themselves define their core link between the Trust’s governance role as follows: structure and the Governors. The The Council of Governors (CoG) groups are accountable directly to • Representing the interests is an important part of the Trust’s the Council of Governors and the of the Members and partner governance structure. Individual convenors report on progress and organisations in the local health Governors and the Council as a whole outcomes to every CoG meeting. economy have continued to add real value to the The Governor’s Coordinating Group, Trust during the course of the year. As • Holding the Board collectively to which comprises the Chairman, the a long-standing Foundation Trust, the account for the performance of Lead Governor (and Deputy), the work of the Governors has evolved, the Trust convenors of the three task groups, and continues to evolve over time. The • Feeding back information about a staff governor representative and work undertaken by the Governors the Trust to constituencies and FT secretariat staff, meets every two themselves in shaping their own role stakeholder organisations. months and focuses on coordinating over the last few years has gone a long the work of the CoG and ensuring way in enabling the Council to play an As reported last year, to take forward that progress is being made against important role, acting as both a critical its key functions, the Governors the plan and facilitating co-operation friend and a conduit of member views. established three new task groups on: between the CoG and the Board of This increasing maturity as a collective a. Enhancing the effectiveness Directors. body is demonstrated best in the way of CoG in which the CoG has become much During 2012/13, these groups have more central in conducting its own b. Patient Safety and Quality aligned been busy implementing programmes affairs, ensuring that it is playing an to the Engagement and Experience of work linked to Governors' key roles effective role and holding individual Committee work programme and stated priorities. Governors and Groups accountable. c. Member and Public Engagement. The focus on implementation marks In spending time on clarifying its These groups are responsible for a significant transition from a time purpose and how the role will be put when Governors worked hard to better into practice, the Trust’s Governors identified elements of the agreed consolidated CoG business plan and understand the role and how they have effectively done a great deal could contribute, to a position now to foreshadow the subsequent provide a Governor perspective on key issues within the groups’ remit in which the more inward-looking clarification of the Governor's role processes have been replaced by much that has emerged through the Health (i.e. they do not undertake executive functions that are the remit of the greater clarity and a determination to & Social Care Act 2012. This has put add value. the RD&E’s CoG in a good position Trust). to continue its own development in The groups have a convenor and a core The following section sets out some line with the new powers provided to group but are open to any member of of the key highlights for each of these Governors in the new Act. CoG that wishes to participate. The groups over the year. task groups’ convenors are the three Governors who currently represent the CoG on the Engagement & Experience Committee providing an essential 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust 103 Annual Report and Accounts 2012/13

Enhancing the • Attendance monitoring to ensure • The Group also worked with staff that all Governors play an active Governors to see if there were Effectiveness of CoG role in the work of the Council specific initiatives to maintain the interests and commitment of staff working group • Working with the Trust secretariat Governors as well as promoting the to work on the agenda This group works on ensuring that concept to staff within the Trust and outcomes for the joint the CoG’s own processes are fit for development day with the Board • The Group commissioned a purpose. It undertakes the necessary and planning for the new Board refreshed Governors' Reference housekeeping involved in managing a to Council meeting scheduled for File group of volunteers to maximise their later in 2013 contribution to the work of • The Group reviewed the the Governors. • The group tasked the Nominations information that currently goes Committee with reviewing its own to the CoG following the issues It also has a remit of continuous Terms of Reference and developing identified in the evaluation of CoG improvement – ensuring that it a policy for the removal of a effectiveness. The Group found assesses what the Governors are doing Chairman, to be completed by that Governors are generally and ways in which these processes or October 2013 happy with the information projects could be improved. presented but also highlighted • The Group also considered Over the course of the year the group the importance of requesting proposals to make changes to the has progressed a number of work additional data if useful. Although Nominations Committee processes streams including: the information relates to a quarter and membership in light of lessons that occurred a relatively long time • Agreeing its terms of reference learned following the recruitment ago, it does outline the Board and and developing a comprehensive of two new NEDs during the year Monitor’s update and what was work plan for the year. The Group • The Group also considered the actually done, and most recent out- also ensured that other working consequences of the Health and turn information is also given. groups and Committees reviewed Social Care Act and the likely and updated their terms of knock-on impact for the Trust reference Constitution • Identifying the key lessons from • The Group set up a rota for the CoG Effectiveness Review and Governors attending open ensuring that these issues were Board meetings prioritised and acted on in the year • Working on how the Board and CoG work together and in particular how the CoG can better hold the Board of Directors accountable 104 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Member and at a younger audience (under 50s) • A member of the group also held be held in the first half of 2013. a talk on membership at a school Public Engagement The Group agreed that a survey on the Devon/Dorset border – working group of members from this age group Colyton Grammar School. This would be undertaken to help was an exploratory meeting to This group exists to develop and design such an event in the best develop a better understanding implement the Trust’s membership way possible to meet the needs of what the Trust would need to strategy and to contribute to the and interests of this group do to encourage greater numbers Trust’s work on wider stakeholder of members of members – and indeed and public engagement. engagement – from younger • The Group has run a significant people, a group that is currently The Group agreed three core number of membership under-represented in the Trust’s objectives for the year: recruitment activities in the membership. The visit confirmed hospital restaurant and in other • To maintain and increase our belief that young people are locations in the hospital in order membership, targeting the 'hard interested in health issues, albeit to maintain overall membership to reach' groups identified by the from a perspective of enhancing numbers. It was agreed to report on membership their own future careers and alternate Oasis sessions with personal development. The • To engage members of the public outpatient locations (Medical encouraging number of recruits with the activities of the Trust Outpatients and Orthopaedic has helped to balance the overall Outpatients). The Group also • To educate and involve the age of our membership and discussed undertaking recruitment public in the development and Governors also welcomed one of at various supermarket locations implementation of the Trust the students as an observer at our and doctors' surgeries but these strategy. January CoG meeting initiatives are likely to be taken up Over the course of the year the later in the year • The Group agreed that the series Group undertook the following of talks - Medicine for Members - • Tracked membership numbers activities: should be re-introduced during the over the year as well as receiving year as these were popular with a • The Group established terms of and analysing a report on the good number of members reference and a work plan to meet Trust’s membership which detailed its objectives demographics, geography and • The Group considered whether • Contributing to the design and other relevant indicators there was a need for membership cards as this might incentivise implementation of the Trust’s • A visit by three public Governors membership and could also Members' Say activities (see to a community coffee morning be potentially used for local page 125). Members' Say was held in Cullompton’s newly discounts. However, on the basis seen as one of the main ways in refurbished Community Centre of costs, the Group decided that which the Governors could better in October. This provided an cards should not currently understand member concerns and opportunity to talk to 80 people be issued. priorities. Following September ranging in age from 96 years to a 2012’s Members' Say event, the mother with a 4 week-old baby. Group discussed the pros and The event was attended by over cons of running one annual event 70 people and a small number of alongside the Annual Members' members were recruited Meeting in autumn 2013 and that a different type of event – aimed 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust 105 Annual Report and Accounts 2012/13

Plans for the coming year include: Patient Quality and • Agreeing guidance on the process that any Governor should use • An extension of the Governor Safety working when they want to inform the recruitment sessions within the Trust of any quality issues of which hospital to Medical Outpatients group they become aware, either from and within the community The Group exists to act as a focal point contact with members or through to a local supermarket and a for Governors on issues concerning their own experience. Business Community Health Centre patient safety and quality. Over the cards have also been provided • To develop a contact with Exeter year the Group has: for all Governors so they can let College and possibly other members know who they are, and • Agreed how the Group will Institutes of Further Education how to contact the Trust if they be managed and how it will have specific complaints or issues • An evening event that is designed communicate as well as agreeing they want taken up to attract members in the under its terms of reference 50s age group • Liaising with the Engagement • Focused on meeting one of its and Experience Committee • ‘Members' Say’ combined with the main tasks - namely contributing a to undertake any relevant Annual Members Meeting (AMM) Governor perspective to the Trust’s work relating to patient safety in September. Quality Report and identifying and quality which might be: Governor priorities on quality that commissioned by the Committee; it wanted to see reflected in the and/or following on from report Members' Say events or other • Contributed to the quality part surveys. of the agenda of Governor Development Days 106 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Constitution Review Self-assessment The Group looked at the responses in detail and discussed the areas which In the autumn of 2012, the Trust’s Evaluation needed action. constitution was amended in line with Monitor state in their Code of the elements of the Health & Social Governance that it is good practice for Holding to Account care Act 2012 that came into force on a Council of Governors to assess its Overall the responses were positive, 1st October. collective performance and its impact but with some work required on the The Trust made amendments to on the Foundation Trust. following: the constitution as directed by As reported in last year’s Annual • Role Clarity – the concept of Monitor. The changes – which were Report, Governors agreed that they strategic v. operational. The Group administrative in nature but enabled would conduct a self-assessment considered that the work being the constitution to be compliant with review to assess their effectiveness undertaken on role clarity would the new Act – were discussed and and identify areas for improvement. assist tackling this issue. approved by the Governors and the As mentioned above, Governors have It was also agreed that the Board and subsequently approved by spent a lot of time reviewing their role, pre-election information around Monitor. and it was therefore agreed that the the role commitment and Further changes to the constitution are formal process would focus on specific paperwork could be reviewed to required as a result of the outstanding areas, namely: better inform the membership elements of the Act that will be • Holding to account interested in standing for election. introduced in April 2013 and the Constitution Working Group will be • Engagement and direction Engagement and Direction meeting over the next few months • CoG dynamics to ensure that these changes and Overall the responses were positive any other necessary changes are • Training and development. with the following issues needing further action. incorporated into the constitution. The survey – which was designed by the CoG Effectiveness Group – was • 50% of respondents only slightly designed to capture views on the two agreed that the CoG effectively key roles for Governors – holding the engaged with its members; this Board to account and engagement and despite the success of Members' direction. It also asked questions on Say. The Group felt it important CoG dynamics and Governor training to distinguish that Governors and development needs. A survey are representatives rather than was also sent to the Board asking for delegates their views on holding to account and • Influencing direction – it was less engagement and direction. surprising that the answers were not The key issues highlighted by the as positive here, though there are results are described below: tangible examples where this has been done (annual report, strategic 16 out of the 24 Governors in post plan). Appointing the Chairman responded (66%). The response rate and NEDs was also a very important was deemed to be disappointing example of where Governors do with questions raised as to what the influence the Trust’s direction. Work reasons might be for Governors not is needed to ensure all Governors responding. make this connection. 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust 107 Annual Report and Accounts 2012/13

CoG Dynamics Director Responses The responses here are again positive, 9 out of the 12 Directors in post though the point is raised as to responded (75%). whether all Governors feel comfortable to contribute at meetings. Holding to Account Actions required are: The areas for consideration are: • New Governor induction to be • CoG not understanding the role of followed by a 6-month follow-up holding to account with the FT team and a 1:1 with the Chairman • CoG not asking questions relevant to a Director’s portfolio. • Reinforce the Governor Buddy system. Engagement & Direction

Training & Development Generally Directors feel that Governors have not had much influence on future Once again, the responses were direction. This perception is perhaps in positive. A clear area for further part due to the complexity and length consideration is whether the CoG of the recent strategic review. The needs to do an annual training needs following action is suggested: analysis. • Governors to produce an ‘Annual Areas for action are: Report’ of their year to be • Role clarity – issue of visiting submitted to the Board. clinical areas • Have a Members' Say session on Governors • Information to Governors on the organisational structure and services provided. 108 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

The role of The following overview provides The main differences are: the key elements of the agreement • The establishment of a statutory Governors following between the Governors and Directors duty for Governors rather about how the directions set out under the Health & Social than advice. This suggests that the Act would be taken forward. In Governors must now legally fulfil Care Act 2012 some areas, it was agreed that current this duty The 2012 Act confirmed that the practice was sufficient; in others it • The CoG exercises its Council of Governors has a duty to hold was felt that current practice needed accountability duty in relation to the Non-Executive Directors, individually to be tweaked or more substantially individual NEDs and the wider and collectively, to account for the amended; in others, it was agreed Board. The NEDs must account to performance of the Board of Directors. that a new approach needed to be established. the CoG for the performance of It also has the duty to represent the the Board interests of the Members and the Accountability for the • The accountability is focused on public. Additional rights and powers, performance of the Board the performance of the Board including approving any application to rather than the performance of enter into a merger or acquisition and Holding the Non-Executive Directors, the Trust. the approval of any proposed increase individually and collectively, to account in private patient income of 5% or for the performance of the Board of The Act clarifies that the accountability more in any financial year, were also Directors is a new statutory duty for relationship concerns the performance contained in the Act. the Council of Governors. of the Board in carrying out its duties rather than the performance of the Over the course of the year the Although the 2006 Act does not Trust as a whole. Governors considered the statutory directly refer to accountability between powers contained within the new Act the CoG and Board, the current This will help to avoid, though not and looked at its current practices to Monitor Code of Governance (pre eradicate, the idea that Governors see if they were compliant with it; or 2012 Act) interprets this element of oversee the performance of the Trust whether additional modifications were the role of the CoG to be: in the way that Directors are legally required to ensure that the clarified “The Board of Governors should hold obliged to do. powers were being enacted. This process the Board of Directors to account for This is, as mentioned earlier, consistent involved a negotiated outcome with the the performance of the Trust, including with the work that Governors have Directors at a joint development day. ensuring the Board of Directors acts been involved with at the Trust over In agreeing an initial overview of how so that the Foundation Trust does not a number of years in better defining the powers would be enacted, both the breach the terms of its authorisation.” their role. Governors and Directors stressed that any agreement would need to be subject to regular reviews to ensure that it was fit for purpose. 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust 109 Annual Report and Accounts 2012/13

The tables below set out the ways in which the CoG currently puts its accountability duties into action and what additional reforms were necessary to enable the CoG to fulfil its statutory role:

1. Confidence that the Board is effectively discharging its role in ensuring that the organisation is performing effectively Existing New options/requirements • The Board having effective quality, safety and • Annual CoG-Board meeting to allow the Board to performance assurance mechanisms in place and has provide an overview of its key activities, concerns, acted on any concerns in relation to issues concerning actions and development agenda (and vice-versa) Trust performance • Rota of NEDs meeting with the CoG on a regular basis This is gained from reading Board papers and Board to enable them to explain their role, their view on minutes, observing the Board in its open session, and having key challenges for the Board and to be questioned by access to regulatory reports on performance. Governors • Receiving an overview at CoG meetings of the Trust’s • Receiving regular updates on the Quality Account performance overall, and the focus and actions taken priorities by the Board in relation to any concerns to assure the • The Board specifically drawing to the attention of CoG that the Board is operating effectively CoG changes in the Trust’s Annual Plan and relevant This is gained from receiving a quarterly performance report performance risks/or any other issues that might that provides an overview of Trust performance and which concern regulators describes the role of the Board’s focus and attention during • Governors having regard to relevant information from this period. other organisations about the Trust including NHS • Holding a regular open question and answer session Devon, Healthwatch Devon, Devon Link, regulatory with the Chief Executive as well as regular updates from reports etc. Executive Directors Mandatory requirements • Understanding the role of NEDs. This currently takes • Before each Board meeting, the Board of Directors must place by having regular slots on CoG agendas for NEDs send a copy of the agenda to the Council of Governors to discuss their role as Chairs of Committees • After the meeting, the Board of Directors must send a • Receiving the Annual Report copy of the minutes to the Council of Governors. • Receiving an overview from the external auditors at the Annual Members Meeting • Receiving the external audit of the Trust’s Quality Account. 110 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

2. Being satisfied that the Board has the right people with the right mix of skills to perform their role effectively Existing New options/requirements • Working with the Board to identify priorities for the • Receiving an annual overview of Board development skills and experience required to maintain an effective from the Chairman Board • Receiving any external analysis on Board effectiveness The Nominations Committee has the delegated authority to from external parties develop and run recruitment processes that require approval by the CoG. • The CoG has the power to remove the Chairman or NEDs This power can be used if the CoG comes to a collective view that individuals in question are not performing effectively or not adding value to the effectiveness of the Board. • Receiving an overview of the relative effectiveness of the NEDs (from the Chairman) and Chairman (from the Senior Independent Director) through detailed feedback to the Nominations Committee (as well as broader feedback to the CoG as a whole) • Determine the pay and conditions of NEDs by having a NED Remuneration Committee that proposes changes to NED Remuneration for approval by the CoG • Approving the appointment of the Chief Executive

CoG duty to represent the changing role of Monitor, is clear emerging healthcare context. This interests of the Members of the in the new powers granted to the latter change results from the shift in Trust CoG in relation to issues such as Monitor’s role in which it will no longer mergers and acquisitions, private have a compliance function. The duty to represent the interests of patient income, and significant Members of the Trust and the wider The CoG duty to represent the transactions public is new. However, as above, the views of the public is currently current Code of Governance states that • The CoG has a brief to represent addressed via Members' Say and the CoG is “responsible for representing the views of the public (and not other research mechanisms (on the the interests of NHS Foundation Trust just members). basis that the current membership is Members and partner organisations in the broadly representative of the wider The statutory duty and the associated local health economy in the governance community). powers imply that the CoG has a of the NHS Foundation Trust.” role both in representing the views These research methods along with The main differences are: of the members and public to the other planned activities to reach out Trust but in addition, that it has to under-represented groups would • The most significant change, powers designed to ensure that the appear to be reasonably well covered which relates to the greater focus interests of members/public are taken currently. on local accountability given the into consideration within the newly 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust 111 Annual Report and Accounts 2012/13

The tables below set out the ways in which the CoG currently puts its representative duties into action and options for consideration on what else might enable the CoG to fulfil its role.

3. Representing the interests of Members of the Trust and the wider public Existing New options/requirements • Contributing to the Trust’s member and public • Identifying other specific Trust projects for Governors to engagement work including Member Say events, contribute such as elderly care surveys etc. • Taking part in the Trust’s Engagement & Experience Committee • Feeding back 'experiential' issues of a generic nature to the Trust based on the views of members of the public • Taking part in focused activities relating to patient experience such as Patient Environment Action Team, ward redesign, and car parking

4. Ensuring that the interests of Members/public are taken into consideration within the newly emerging healthcare context Existing New options/requirements • Providing opportunities for the CoG to contribute to Mandatory requirements the development of the Trust’s forward plans through • Mergers, acquisitions, separation or dissolutions require discussions on strategy and Annual Plans the support of more than half of the CoG • Having a process that enables Governors to appoint or • Major transactions – which need to be defined in the remove the Trust’s auditors Trust’s Constitution – between the Trust and other organisations require the support of more than half of the CoG • The Trust must include in its forward plans proposals to carry out any non-NHS activities. The CoG will then take a view on whether they agree that these activities will not significantly interfere with the Trust’s NHS activities. Where non-NHS activities account for 5% or more of total income, this must be approved by at least half of the CoG • Changes to the Constitution require the approval, of at least half of the CoG and the Board of Directors. Where changes to the Constitution affect the powers or duties of Governors then Members must be given an opportunity to vote on the changes at the next Annual Members’ Meeting. The proposed amendments must be presented by a Governor. 112 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Governor profiles

Kate Caldwell, Exeter & South Devon, Governor since 2007

I was born and brought up in Devon, I am also a keen bowls player, and What do you see as a central before training as a nurse and midwife Captain of the Outdoor Exonian part of your role? in the South East. I returned to Bowling Club. As an elected Governor I feel I must the county in 1990 as Director of honour those votes through my Midwifery at the old RD&E Maternity Why did you become a commitment to the role. I feel that Unit on the Heavitree site – it was a Governor? my job is to be a representative of my very exciting time in midwifery, with a area. I think you have to be yourself as real focus on links into the community, I became a Governor really to keep a Governor, but by listening you can be and I was very proud to be a part of it. my hand in with the RD&E and the local community, which has played a the vehicle for passing on and sharing I retired from the RD&E in 2002, and big part in my life. My father actually the views of your community. after several years as Non-Executive laid one of the foundation stones of Director of Exeter Primary Care Trust, I the previous hospital and was involved What do you enjoy about being became a Governor. In my spare time in the transition to this site, so it is a Governor? I am also involved in giving money really part of my history. Hopefully I actually really love being a Governor. to the disadvantaged in the area, my experience and knowledge from I am involved in many of the sub- through my role as Chairman of Exeter working in healthcare also means I can committees that have specific Municipal Charities, and also to the give something back. Trust as Treasurer for the RD&E branch responsibilities, for example the of the League of Friends. Nominations Committee, who were involved in the recruitment of the new Chairman, the Non-Executive Director Remuneration Committee, as well as giving support to the Board’s Audit Committee. These are all roles that I have carried out in the past, when I was heavily involved with the Royal College of Midwives, and I think that my familiarity with these subjects is an advantage. I really enjoy the lively discussions we have had as a group in formulating the Council of Governors and coming to agree on our role within the organisation.

Is there anything you would change about being a Governor? It can be difficult getting all the Governors together in the room at the same time because we have other commitments but I think this is when I feel we are at our most effective. 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust 113 Annual Report and Accounts 2012/13

Keith Broderick, Exeter & South Devon, Govenor since 2008

Why did you become a Governor? I retired early as an accountant working in the public sector. Some years later I became a member of the RD&E Foundation Trust and offered myself for election as a public Governor, hoping to be able to use my experience and knowledge to help towards improving what I thought of as patient care, where the patient should be the main focus in practice as well as in policy theory. This arose from experiences as a visitor in hospitals both here and elsewhere in England, where practice fell short of what patients and carers should reasonably expect, mostly, but not entirely, in non-clinical support and in links with outside bodies.

What do you see as a central part of your role? Foundation Trust Public Governors represent the members who elected them, but their main role on behalf of members is to ensure that the Board complies with the Trust’s terms of authorisation laid down by the takes into account, particularly when Is there anything you would FT Regulator called Monitor. It is making decisions affecting services to change about being a sometimes difficult to balance more be provided. Changes are inevitable, Governor? detailed user perspectives with the and can be made more effective for If there were anything I would change strategic overview Governors have to patients if their views are represented, about being a Governor it would take in holding the Board to account while managing expectations as be in making more opportunities to for the Trust’s performance. techniques and treatments change. I meet constituency members. This is have been fortunate to be nominated partly because they elected me, and or elected on to some Governor What do you enjoy about being partly because direct contact helps working groups, the former Trust a Governor? inform the ways in which Governors working group on Ward Redesign, and both challenge and support the Trust As a Governor, I enjoy being able to now, with two other Governors, on the in dealing with often unexpected help represent the views of members, Board’s Engagement and Experience changes in demand for services. patients and carers that the Trust Committee. 114 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Election results

The following Governors were elected at the annual elections in September 2012:

Public Governors

East Devon, Dorset & Somerset Linda Vijeh re-elected. The turnout was 42.3%. Exeter and South Devon Richard May re-elected. Geoff Barr elected. The turnout was 38.6%. Mid, North West Devon & Cornwall Penny Lobb and Anne Stobart elected. The turnout was 37.5%.

Staff Governors

Medical and Dental Mike Jeffreys re-elected unopposed Non-Clinical Staff Loveday Varian re-elected unopposed

The Board confirms that all elections to the Council of Governors are held in accordance with the election rules as stated in the Constitution. Governors can be contacted via email at [email protected] The Governors’ Register of Interests is available for inspection from the FT Secretary (01392 402993) or on the Trust website. 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust 115 Annual Report and Accounts 2012/13 116 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Our Governors 2012/13

East Devon, Dorset & Somerset Andrew Kyle (Sep 2013) and trustee for the local museum, with responsibility for fundraising. Linda sits Vivien Dibling (Sep 2014) Andrew lives in Exmouth and is a on the Patient Safety & Quality Group. retired teacher. During his career he Vivien lives in Axminster. She trained was involved in teacher education and as a nurse and has also worked as a one of his responsibilities was helping Lynne Wright (Sep 2013) medical secretary and care assistant. NHS staff improve their teaching Vivian was elected for a three year Lynne trained as a secretary. After skills. He has long-standing family term in 2011. working at executive level within connections with the NHS and is industry, for senior partners in legal committed to community involvement firms and a barrister, she moved into Jill Gladstone (Sep 2014) in decision-making. He has a special office management and financial interest in communication. Andrew sits Jill enjoyed a nursing career, mainly control and has over thirty years on the CoG Effectiveness Group. in acute and emergency medicine. commercial experience. She was a She has an MSc in healthcare and long term member and secretary has published research into drug Nicholas Morse (Sep 2013) of the League of Friends of a South administration errors. More recently Warwickshire cottage hospital, and Nicholas lives on the edge of Exmoor she established the team that supports is now retired and living in Budleigh near Dulverton, and is retired from a clinical audit in the district hospital. Salterton. She is Secretary to the Board 40-year career in Communications, Prior to retirement she worked as a of Trustees of a Warwickshire charity. Advertising and Marketing. He worked nursing adviser to the Health Service Lynne sits on the Member & Public on many well-known accounts Ombudsman and was a member of Engagement and Patient Safety & at London West End Advertising the local Research Ethics Committee. Quality Groups. Agencies and in the Media scene with Jill was re-elected for a second term the Guardian Newspaper and House in 2011. Jill chairs the Patient Safety & & Garden. Nicholas sits on the CoG Quality Group and also sits on the CoG Effectiveness Group. Coordinating and Engagement and Experience Committees. Linda Vijeh (Sep 2015)

Peter Hull (Sep 2013) Linda has lived and worked in South Somerset for over 20 years. She has Peter qualified as a Master Mariner extensive experience in the media and spent most of his working life in and hospitality industries, both in the Shipping Industry. After extensive the public and private sectors, with treatment at the RD&E, Peter is keen to a particular emphasis on customer support the Trust and help it maintain service, and social responsibility within its reputation as a place of excellence, the licensing trade. Linda also holds and indeed one of the best hospitals a number of positions within the in the country. Peter also sits on the voluntary sector, including her role as Patient Safety & Quality Group. District Councillor, Publicity Officer for Samaritans, Ilminster Town Councillor and Chairman of Somerset Schools Forum, Governor of two local schools 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust 117 Annual Report and Accounts 2012/13

Exeter & South Devon Rachel Jackson (Sep 2014) Geoff Barr (Sep 2013) Keith Broderick (Sep 2014) Rachel was an NHS clinical Geoff was elected for a term of physiotherapist for 42 years and one year in September 2012. Geoff Keith is an accountant who took early managed a large physiotherapy service. taught politics and other social studies retirement from the public sector Previously a Governor for six years, at Exeter College for many years; in 2005. He lives in Exeter and was Rachel was elected again in 2011 however, he has now moved on to re-elected in 2011. Keith is Chairman after a year’s break. Rachel sits on the teach at the Open University and The of the CoG Effectiveness Group, Member & Public Engagement and University of Exeter Medical School. a member of the Engagement & Patient Safety & Quality Groups. He is an active member of the St Experience and CoG Coordinating Leonard’s Practice Patient Participation Committees and Constitution Review Group and the practice research Working Group. Richard May (Sep 2015) team. Alongside this Geoff is an active Richard, who lives in Exeter, is a member of Keep Our NHS Public and Janice Cackett (Sep 2013) chartered civil engineer and latterly 38 degrees. Geoff sits on the Member ran a waste management company & Public Engagement Group. Janice worked in the Health Service providing a range of services within for 35 years, as a ward Sister and then Exeter and the surrounding areas. in nurse education. She moved to Richard is the Lead Governor on the Devon in1988 to amalgamate three Council of Governors. Richard chairs Schools of Nursing, retiring in 1993. the CoG Coordinating Committee and Janice was ordained a Deacon in the also sits on the Constitution Review Church of England in1999 and a Priest Working Group. in 2000. She was appointed part-time Priest in Charge of the Parishes of East Budleigh and Otterton in 2003 Terry Roberts (Sep 2013) and retired from this position in 2010. Terry is a retired Police Chief Inspector She lives in Topsham. Janice chairs the who lives in Exeter. He has been Membership & Public Engagement involved in working with Social Group and also sits on the CoG Services, his local Alzheimer’s Society Co-ordinating and Engagement and and with the Peninsula College of Experience Committees. Medicine and Dentistry’s doctor selection panel. Terry was previously a Kate Caldwell OBE (Sep 2013) Governor between 2006-07 and was elected again in 2011. Terry sits on the Kate was Director of Midwifery Member & Public Engagement Group. and Deputy Director of Nursing at the RD&E until 2002. She was a Non-Executive Director of Exeter PCT until 2006 and was Treasurer of the Royal College of Midwives. She is a Trustee of the Exeter Municipal Charity and Treasurer of the Royal Devon & Exeter League of Friends. Kate sits on the Patient Safety & Quality and Constitution Review Groups. 118 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Mid North West Devon & Healthcare Practice. Cynthia sits on the Staff Governors Cornwall Member & Public Engagement Group. Mike Jeffreys, Medical and Dental David Giles (Sep 2013) (Sep 2015) Penny Lobb (Sep 2015) Following spells in the Royal Navy Mike has been a Consultant Physician and in hospitals in the South East, Penny was elected for a term of three in Exeter since 1994. During this time David was a GP for 30 years in North years in September 2012. Penny he was a member of the Executive Cornwall. With a keen interest in regards it as a pleasure and privilege Committee of the Exeter Primary Care healthcare quality, David was Chairman to be involved with the governance Trust. Previous medical training was of the Healthcare Accreditation of the Trust going forward. She has carried out at Guy’s Hospital London, Programme for three years. He lives in experience overseas in a multi-cultural, Western Australia, Southampton, Bude. David sits on the Patient Safety religiously diverse military environment, Manchester and Cardiff. & Quality Group. sitting on military boards of enquiry and medical committees. In the UK Alison Wootton, Nursing and private sector Penny has experience Dianah Pritchett-Farrell (Sep 2013) Midwifery (Sep 2014) of working with hospitals towards Dianah is a retired University Lecturer, accreditation and production of Alison is a Lead Nurse for the Medical Examiner, Quality Standards Assessor guidance manuals. Penny sits on the Directorate at the RD&E, with 25 in social care and Senior Probation Patient Safety & Quality Group. years of nursing experience behind Officer, with a research background in her. Alison sits on the Patient Safety & doctor-patient communication, criminal Quality Group. Anne Stobart (Sep 2015) justice, child protection and mental health. She is currently an International Anne was elected as a Governor in Loveday Varian, Admin, Clerical & Assessor to the Care Council in September 2012 and will serve until Managers (Sep 2015) Wales. Dianah was elected Chairman August 2015. She has lived in Mid- of the Foundation Trust Governors Devon since 1990. Anne has taught Loveday has worked for the NHS as Association in August 2011 and is in adult education, colleges and a hospital-based medical secretary actively involved in national Governor universities for over thirty years. Anne for the past thirty years. She joined development and research. Dianah sits has clinical, research and management the RD&E over five years ago and is on the CoG Co-ordinating Committee experience in complementary health a medical secretary within the renal and also the CoG Effectiveness and sciences, most recently in the School team. Loveday sits on the Member & Constitution Review Working Groups. of Health and Social Sciences at Public Engagement Group. Middlesex University and she retired from there in August 2010. Anne sits Cynthia Thornton (Sep 2014) on the Patient Safety & Quality Group. Cynthia lives in Willand. She has had wide nursing experience, including ten years as a district nursing sister. She has a PGCEA and an MSc. in Care, Policy and Management. She held University teaching and research posts in London and Reading. Her published work focused upon Primary Healthcare for People with Learning Disabilities and Innovation and Change in 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust 119 Annual Report and Accounts 2012/13

Appointed Governors

The following people have been appointed by the organisations listed to serve as Governors: Mrs Rebecca Harriott, NHS Devon (Primary Care Trust) (Jul 2013) Professor Steve Thornton, University of Exeter Medical School (Jan 2014) Cllr Andrew Leadbetter, Devon County Council (Jan 2015)

The following people were also Members of the Council of Governors during 2012/13: Public constituency area: Mid, North, West Devon & Cornwall Martin Perry (until Sep 12) Staff Governors Tony Cox, Staff-Allied Health Professionals (until Mar 13) Appointed Governors Professor Mark Overton, University of Exeter Medical School (until Dec 12) 120 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Attendance at CoG 2012/13

Attendance at Council of Governor meetings from April 2012 onwards for Governors currently in post

April 2012 July 2012 Oct 2012 Jan 2013 AMM Part I Part II Part I Part II Part I Part II Part I Part II Geoff Barr * Y Y Y Y Y Keith Broderick Y Y Y Y Y Y Y Y Y Janice Cackett Y Y Y Y Y Y Y Y Y Kate Caldwell # Y Y Y Y A Y Y Y Y Vivien Dibling DNA DNA Y Y Y Y Y DNA DNA David Giles Y A Y Y A Y A A A Jill Gladstone Y Y Y Y Y Y Y Y Y Rebecca Harriott A A A A A A A DNA DNA Peter Hull Y A Y Y Y Y Y Y Y Rachel Jackson Y Y Y Y Y A A Y Y Mike Jeffreys # DNA DNA DNA DNA A Y Y Y Y Andrew Kyle Y Y Y Y Y Y Y Y Y Andrew Leadbetter # Y Y Y Y Y A A Y Y Penny Lobb # A Y Y Y Y Richard May #* Y Y Y Y Y Y Y Y Y Nicholas Morse Y Y Y Y Y A A Y Y Dianah Pritchett-Farrell Y Y A A Y Y Y Y Y Terry Roberts Y Y Y A A Y Y Y Y Anne Stobart Y Y Y Y Y Cynthia Thornton* Y Y Y Y Y Y Y Y Y Steve Thornton Y Y Loveday Varian Y Y A A A Y Y Y Y Linda Vijeh #* Y Y A A Y Y Y A A Alison Wootton Y Y Y Y Y Y Y Y Y Lynne Wright Y Y Y Y Y Y Y Y Y

AMM Annual Members' Meeting Y Present # indicates membership of Nominations A Apologies Committee DNA Did Not Attend * indicates membership of NED Remuneration Committee 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust 121 Annual Report and Accounts 2012/13

Our Members

The Trust is a public benefit corporation that exists for the sole purpose of providing healthcare services to the population it serves.

All Foundation Trusts are obliged, under statute, to have members and NRS Socio-economic Distribution – Public Constituency

Monitor – the sector regulator – takes 60% the view that a FT's membership should be of a reasonable size. The 50% Board of Directors are obliged to keep in touch with the opinions of 40% members and the wider public as key stakeholders. Membership is a 30% distinguishing feature of FTs, which brings with it substantial benefits. As 20% a membership organisation, the RD&E % of population endeavours to reach out to inform 10% members about what is happening 0% at the Trust, as well as listening to ABC1 C2 D E their concerns and opinions on service delivery, on how to improve patient NRS category experience and on influencing its  Membership  Local Area longer-term strategy.

About our members Gender Distribution – Public Constituency

On the whole, the Trust’s membership 60% broadly reflects the average profile 50% for the wider community served

by the Trust. Key findings from an 40% analysis undertaken of our members in comparison to the wider community 30% showed that members are: • Similar to the social- 20% demographic groups found in

our constituencies. The majority % of population 10% of members are, on the whole, 0% comfortably well off Male Female NRS category  Membership  Local Area

122 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

• Representative of the ethnic that genuinely allows for influence and This makes it even more important, diversity within the wider public boundary setting (e.g. options which therefore, that we have a membership members would find unpalatable). This base that corresponds ever more • Older than the general public proactive and timely way of engaging closely with the demographics of the served by the Trust with members is far preferable as a broader population served by the • Marginally more likely to be way of enabling genuine stakeholder Trust. The analysis undertaken of our female than male. engagement and influence than membership base shows that the Trust the more orthodox approach taken needs to do more to encourage: For research purposes, engaging elsewhere in public service. Under this with members about their priorities, • Members from lower type of model, changes are made or concerns and ideas for healthcare socio-economic groups/more formulated by a public body and then provides a 'good enough' correlation urban settings views taken through consultation – with the broader community. This sometimes post-hoc. That is not to • Members who are younger than means that in our engagement with say the methodology deployed by the the current membership profile members, we can be confident that RD&E is perfect and it is important to the views we hear can be said to be • More men to become members. ensure that we guard against asking sufficiently overlapping with what the same set of people all the time, These shortcomings in the members of the public generally would and also to occasionally test whether representativeness of our membership say. This provides a useful rationale for the views of members do correspond base do require work. However, they membership for Foundation Trusts. to the views of the public more are insufficiently significant to skew the Having a membership base allows a generally. research undertaken with Members, meaningful relationship to be developed which we consider to be sufficiently The ongoing conversation with our between members and the Trust. representative of the wider community. members – expressed primarily through The above points provide some priority Developing this engagement helps our Members Say events – is a very areas for more targeted recruitment by us to deepen our understanding of important aspect of the Trust’s work the Member and Public Engagement their views and opinions which we that provides genuine added value in working group. can correlate to the views of the wider informing its work – whether that is community. Developing an ongoing in a relatively minor operational detail, dialogue with members provides an potential service change, ways to opportunity for the Trust to develop its improve services in the best interests of thinking, test ideas, and give members patients/public, or on bigger and more an overview of potential future strategic issues. strategic options, which it can then engage with members on in a way 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust 123 Annual Report and Accounts 2012/13

Age Distribution - Public Constituency

1%1% 3% 6% 24%

9%

30% 26%

0-16 30-39 60-74 17-21 40-49 75+ 22-29 50-59 Not stated

Local Area

11% 18%

19% 6%

9%

13% 10%

14% 124 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Membership Members’ Say views of the membership and thus the wider public and therefore provide a overview The Members' Say meetings continue 'good enough' basis for analysis. As to provide a good way of developing a methodology for engagement and Our membership now stands at 18323, a productive dialogue with Members dialogue with Members, these events made up of 12398 public Members and offering something to Members will remain, with some refinements, a and 5925 staff Members. to recognise and reward their status as core element of the Foundation Trust Anyone aged 12 or over who lives in 'shareholders' of the Trust. work plan going forward. the area we service, or who works for The events provide an opportunity The Members' Say approach enables the Trust on a permanent contract or for that group of Members who have the Trust to identify, explore and one of 12 months or more, has the the most interest in the Trust to be understand the views, opinions, right to become a Member of the informed of some of the work we pre-conceptions and concerns of Trust. are doing, as well as to take part Members on aspects of healthcare. The three public constituencies, with in interactive activities and focus As the profiling of our Members on a membership numbers as at 31st March groups. The model works well as a range of indicators mirrors that of the 2013, are: way of engaging a particular group of wider population (being somewhat Members, and the outcomes of the older and somewhat wealthier than the broader population), the views of East Devon, Dorset & activities and focus groups provides Members can, with some caveats, be Somerset – 4407 useful research data on the perceptions and views of Members (and thus the seen as representing the broader views Exeter & South Devon – 4793 public) on specific topics. This can help of the population serviced by the Trust. inform the development of strategic Understanding the views of Members – Mid, North, West Devon issues, changes in service delivery and, at as key stakeholders – in some depth is & Cornwall – 3198 an operational level, helping us benefit important because it can: from knowing the views of the public. The boundaries of the Trust’s public • Help in the design of service membership include Cornwall, Devon, It is worth noting at the outset that changes. This may include Somerset and Dorset. Members who attend the event are understanding what changes self-selecting and the results of the people would want to see research undertaken on the day implemented but also, critically, needs to be viewed in this light. what tolerance there may be to a Nevertheless, as a whole, the Trust’s sub-optimal solution membership largely mirrors that of the • Help contribute to the wider population served by the Trust. development and implementation While there is not a direct correlation of organisational strategy between the views expressed at these events and those of the population • Help understand views on a range at large, it is reasonable to assume of related, but important, matters that the results provide an insight that are likely to become more into the opinions of a diverse group prominent over future years (such who have knowledge and experience as on branding, for example) of healthcare services. In considering • Help test out lines of argument in the outcomes of the event, it can be a relatively safe way on issues on assumed that they represent the best which gauging potential public possible interpretation of the broader opinion could be a critical risk factor 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust 125 Annual Report and Accounts 2012/13

• Provide a litmus test on what It is also worth noting that the views matters most to those who are of patients and members are not already receiving healthcare or are interchangeable. Clearly patients likely to use these services in are the RD&E’s most important the future stakeholders and the Trust has a range of mechanisms to understand and • Provide Members with the analyse their views. While a significant opportunity to give voice to their proportion of members are or have views and influence the Trust in a been patients, they offer a different number of different ways in line perspective; people who have had time with the ethos of a Public Benefit to reflect on their experiences often Corporation. across a range of different services; In addition, Members’ Say events people who can compare services in provide part of the rationale for the RD&E with health services offered membership of the Trust - having by other public and private providers; the opportunity to attend an event people who may need the services is part of the benefit that being a of an acute hospital in the future – member entails. Holding such events potential patients; people who have demonstrates to existing and potential friends and family with a wide range future members that membership of different experiences that have means something and offers those coloured their view; people who that want it a way of becoming more represent the wider opinions of the actively engaged. local community as taxpaying citizens within a framework that is based on a degree of accountability between a FT and the population it serves. 126 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Members’ Say – May 2012

The Members’ Say event at the end of May 2012 was attended by around 170 Trust members offering them the opportunity to attend lectures, take part in interactive activities, browse the health marketplace and have their say in focus groups and through questionnaires. Around 80% of those that attended felt the event was worthwhile. The focus for this Members’ Say event was on the provision of elderly care and this was reflected in the activities, lectures and focus groups. The views on care settings and on some of the issues that elderly patients and carers face as they move through the health and social care system will be invaluable information as we work last resort and there is a view that out how we can better integrate the Overall this exercise suggested that while healthcare needs may be met, care offered to this group of patients. people have a good understanding communication issues can cause Members were able to give their views of some of the options for healthcare frustration to patients. The position on what the hospital does well, what settings for elderly people. But there of community hospitals is more mixed we could improve on and some of the is a need to draw clear distinctions and worthy of more exploration. issues they thought needed attention between the healthcare needs of individuals and how these are best in areas such as outpatient services, The six focus groups focused on met. There is likely, for example, to discharge and facilities. Members participant views on care setting be real scepticism about encouraging were also able to advise the Trust on options, particularly for the elderly. more widespread care of people at the values that underpin the RD&E’s In particular distinctions were drawn home if their healthcare needs might reputation. Members also provided between the positive and less positive not be adequately met in this situation. feedback to Governors on their aspects of care provided in the A crude policy of more care at home expectations of the role. following settings: would need to be sufficiently nimble Videos of two elderly people with to ensure that the individual needs of • Community Hospitals different health and social issues were patients are being adequately met. • Residential/Care Homes used to illustrate some of the difficult There is also, perhaps surprisingly, a choices facing this age group and • Personal Home members were invited to consider positive view being expressed about • Acute Hospitals. where they were most likely to receive residential care settings, albeit that this the best care – at home, in residential setting came out in a more negative care, in a community hospital or an light for patients who could be cared acute hospital. for at home. Acute hospitals, under these scenarios, are the options of 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust 127 Annual Report and Accounts 2012/13 128 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Community Hospital • More reliable than a 'package' • Why are community hospitals that may need to be argued for being run out of Barnstaple? Setting and arranged to enable people to Surely it would be more return straight to home – even if straightforward if the RD&E was From the transcripts of the this was preferable. doing this. This was coupled with conversations, a dominant theme a view that the larger acutes had of strong and widespread support Despite potential under-utilisation a role in ensuring maximum use of for community hospitals emerged. in some community hospitals, community assets. These settings were seen as more there also seemed to be an issue of personalised, less frenetic, and less beds not always being available in This underlined that while there was institutionalised than acute hospitals. the community hospitals and this strong support for the community They allowed a good standard of dichotomy was hard to understand. hospital concept, in reality members care to be delivered close to home at The consensus was that by providing exhibited a degree of caution as to the patient’s (and their families and elderly patients in particular the whether the strands of care offered friends) convenience. It was apparent opportunity to be closer to their homes would be acceptable and, in a few cases, from the conversations that there and their own recognised environment, concerns that this type of provision may was an element of nostalgia – a large it would facilitate the recovery of an be unaffordable going forward. proportion of those who undertook individual in a timelier manner. Family the focus group conversations gave and friends would have better chances considerable support to the community of being able to visit, and it could be Care Homes 'cottage' hospitals as a means to seen as a ‘half way’ house for the The discussions that took place around aid a quicker recovery. In general, patient, thus promoting a level of residential care were more mixed participants viewed community emotional and positive wellbeing. although the majority of recorded hospitals as: views and comments were supportive Despite the perceived support for of residential care. Issues that emerged • Being able to tackle the community hospitals a number of in the discussions included: communication issues which issues were raised including: often cause larger acute hospitals • The costs of residential homes, • What provision and standard of problems. This was seen as being both in regards to variety of care would be available in smaller a result of the smaller size but homes available and cost of community hospitals? also culture. Staff had more time staying over time (this was a and placed a greater emphasis on • Who would have the responsibility distinct concern evident across all patient communication of managing these hospitals? of the focus groups) • Worthy of trust as venues where • How would community hospitals • Concerns over the quality of care they would be offered appropriate be monitored for effectiveness? on offer. This was often linked to treatment or convalescence • At what stage of recovery would it concerns about the quality of staff (and, in some cases, their abilities • An in-between stage between be appropriate for an individual to to speak English) acute care and going home, transfer to a community hospital? and therefore an essential part • Are they cost effective? • A degree of uncertainty on of the patient journey (for some whether residential homes would conditions) • Are community hospitals being be able to properly support those used as effectively as they might? who suffered from a range of • Part of a wider NHS offer and not complex medical issues. In some the place for treating everyone cases, respondents talked about the fact that complex cases were 'palmed off' to acute Trusts 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust 129 Annual Report and Accounts 2012/13

• A lack of choice in residential The general consensus was that hospital. Some of the issues raised that homes. The issue of choice, and there is no substitute for the level of concern them about the acute hospital the difficulties in obtaining good care that could be given at home, included: quality and reliable information to providing that adequate support and • Perception of poor communication inform choices between different assessments were undertaken to between patient and professional residential care homes, was seen facilitate that care. This included: staff (both while at hospital and in as a big obstacle in this sector. • What the patient wanted written communications); between A number of people spoke positively professional staff themselves; and • How much contact would be about their experiences of residential between the hospital and GPs required care – for example patients being well • Can be impersonal cared for, respected and looked after • How much clinical care could be even when they had complex provided • Lack of consistency of care health needs. between departments • Appropriateness of available On a related issue, there was a resources • Too few staff overnight high degree of confusion about the • If an individual’s home could • Hospital seen as expensive option standards of care on offer in residential be adapted for their particular homes, who was responsible and who • Acute Trusts seen to be under requirements regulated this sector. This uncertainty pressure because of changing was exacerbated by the perceptions of • The level of funding that could be demographics and public high variability in quality. made available. expectations of healthcare. Concerns were expressed that, in an Care at Home environment of cost control, patients would be sent home either before Considerable support was given for medically appropriate or without the individuals being treated at home. This right package of support to enable was widely felt to be the best place for them to stay well at home. This was people to recuperate or to receive help/ coupled with uncertainty about who medical input for long-term conditions. was responsible for providing care However, a small number of at home and, therefore, who was participants felt that the home was the accountable. wrong place to receive ongoing care. These smaller number of participants highlighted issues of concern as being: Hospital Setting • Ongoing potential for isolation Participants clearly took the view (particularly when there was no that the acute hospital was the supporting infrastructure in place, right place for receiving a range of including family and friends) medical interventions, but was not an ideal setting for elderly people with • Bad examples cited of rushed or complex health needs. The general inconsiderate care delivered at perception of the RD&E was very home positive. Nevertheless, for elderly • Potential to be forgotten/ people with long term conditions a insufficiently linked into the number of participants expressed views system. on the appropriateness of the acute 130 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

The future Less positive responses included: • Poor communication with the In all of the focus groups, participants hospital may be transferred if the were asked about whether the Trust became involved elsewhere RD&E should expand its services for the elderly. There was positive and • Concern that staff from the negative feedback on this. hospital site may be moved elsewhere For many participants, having the quality hallmark of RD&E involvement • Waiting time seen by some as in services beyond the hospital was causing problems for the RD&E seen as being a positive move. The brand issues that made people positively • Car parking – clearly an issue that disposed towards this were: bothers very many respondents • RD&E’s reputation for high quality • Concerns that hospital care and high standards management, staff and resources • RD&E has good consultants and may be spread too thinly staff • Concerns expressed over • May help to promote a more temporary staff cover, particularly integrated approach to health and for nurses, if this was the result. social care • RD&E is pretty efficient and can produce a uniformity of care/ I would like somewhere for standardisation to all advice when it comes to • RD&E seen as good administrators choosing a Care Home. in a way that GPs were not, and therefore more likely to be able to run efficient services • Patient care is seen as a strong There is a definite need for ethos for the RD&E community hospitals. It brings • Like the idea of NHS/RD&E the patient back towards family branded services outside the and friends. hospital – "you know what you are getting”.

I'm frightened about the cost of my future care. 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust 131 Annual Report and Accounts 2012/13 132 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/13

Members’ Say - More details on these sessions are Angela Pedder, Chief included in the Quality Report. September 2012 Executive Safe Care The Members’ Say event last “Members’ Say events have September was attended by around become an important part of our Focus group attendees said that they 180 of our members who heard talks agenda as a hospital. It is our expected: on a theme of elderly care, as well chance to ask Members about • To “always feel safe in hospital” as being involved in discussions on their views, to listen to them and hospital nutrition. discuss their opinions, and for us • That their “personal safety was a given”. As in previous events, attendees were to take these views away to help able to take part in a number of inform our strategy or improve Any concerns they had on safety interactive activities and join in focus our services. Our Board and our included: Governors have a duty to ensure group discussions. Members also • Staffing ratios heard from the Trust Chairman, Chief that we understand and meet • Pressure of work leading to safety Executive, Lead Governor and the the needs of the communities we lapses Trust’s auditors as part of the RD&E’s serve and, given that members Annual Members Meeting. The event broadly represent the wider public, • The reliance on the lowest paid staff was a great success and the vast Members' Say events are a great members to keep the hospital clean. majority of people (over 80%) who way of doing this.” Discussions also focused on whether attended found it informative, useful there needed to be changes in the way and stimulating. Quality Care the NHS operated to ensure continued good quality of care at a time of James Brent, Chairman of The focus groups looked in detail financial constraint. the Trust at issues concerning quality and safety. This was useful to understand The views expressed in these sessions “These events are always very members’ priorities on these issues. will inform our quality and safety enjoyable. There is a real buzz It will also feed into the issues the priorities over the next year. about the place that comes from Governors decide to focus on in the lively discussions and interaction Trust’s Annual Quality Report. Visiting hours for patients with from our Members, who are dementia What does good quality mean to you? deeply committed and passionate Members were asked about visiting about the NHS and our Trust. For “First rate outcomes” times for patients with dementia me, it is a real privilege to meet “Personalised care” and whether any changes should be our Members, to hear their views “A positive experience at every stage” considered to better meet their needs. and take these on board as we “All the basics taken care of”. navigate the hospital through some Their views will be considered in challenging times.” How do you recognise poor quality? reviewing the visiting hours for patients “Poor communications and with dementia. information” “Care is not delivered well” Money, money, money “Bureaucratic and inefficient” Attendees were given £50 of fake “Poor experiences” money and were asked how they would prioritise how this should “Basic standards not met”. be spent. 5. Our Governors and Members Royal Devon and Exeter NHS Foundation Trust 133 Annual Report and Accounts 2012/13

Visiting hours for patients with dementia Members' Priorities, Members Say! September 2012

9% 13% 18%

15% 13%

23% 27% 82%

 Visitors should be allowed at any time  Time spent whilst waiting at the hospital  They should be longer (12-6.00pm)  Cleanliness of the hospital  They should remain the same  Time between being referred by GP and being seen by hospital doctor  Reducing hospital infections  Being treated with respect  Being informed

“Very well organised and so very helpful”

“My first ‘Members' Say’ I learned a lot - it gave me food for thought. Thank you very much - till next year, good luck!”

“Very well organised but in this age of cuts, could cheaper paper, simpler refreshments be better so that money can go to needy hospital?”

“Very well organised with a friendly relaxed atmosphere”

“I really think you should charge about £2 for the ticket which would entitle you to lunch”

“Far more focus group opportunities i.e. a direct opportunity to discuss topics with RD&E staff” 134 5. Our Governors & Members Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts 2012/132012-13 6Our Finances 3. Our Finances Royal Devon and Exeter NHS Foundation Trust 135 6 Annual Report and Accounts 2012-13 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST

ANNUAL ACCOUNTS

YEAR ENDED 31 MARCH 2013 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

INDEX

Page

STATEMENT OF THE CHIEF EXECUTIVE'S RESPONSIBILITIES AS THE ACCOUNTING OFFICER 2

INDEPENDENT AUDITORS’ REPORT TO THE COUNCIL OF GOVERNORS 3

FOREWORD TO THE ACCOUNTS 5

STATEMENT OF COMPREHENSIVE INCOME 6

STATEMENT OF FINANCIAL POSITION 7

STATEMENT OF CHANGES IN TAXPAYERS' EQUITY 8

CASH FLOW STATEMENT 9

NOTES TO THE ACCOUNTS 10

Page 1 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

Statement of the Chief Executive's responsibilities as the Accounting Officer of the Royal Devon and Exeter NHS Foundation Trust

The National Health Service Act 2006 ("2006 Act") states that the Chief Executive is the Accounting Officer of the NHS Foundation Trust. The relevant responsibilities of the Accounting Officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by the Independent Regulator of NHS Foundation Trusts (“Monitor”).

Under the 2006 Act, Monitor has directed the Royal Devon and Exeter NHS Foundation Trust to prepare for each financial year a statement of accounts in the form and on the basis set out in the Accounts Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of the Trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year.

In preparing the accounts, the Accounting Officer is required to comply with the requirements of the NHS Foundation Trust Annual Reporting Manual and in particular to:

- observe the Accounts Direction issued by Monitor, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis;

- make judgements and estimates on a reasonable basis;

- state whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual have been followed, and disclose and explain any material departures in the financial statements; and

- prepare the financial statements on a going concern basis.

The Accounting Officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the Trust and to enable her to ensure that the accounts comply with requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities.

To the best of my knowledge and belief, I have properly discharged the responsibilities set out in Monitor's NHS Foundation Trust Accounting Officer Memorandum.

Signed:

Angela Pedder - Chief Executive

Date: 29 May 2013

Page 2 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

Independent Auditors’ Report to the Council of Governors of Royal Devon and Exeter NHS Foundation Trust We have audited the financial statements of Royal Devon and Exeter Foundation Trust for the year ended 31 March 2013 which comprise the Statement of Comprehensive Income, the Statement of Financial Position, the Statement of Cash Flows, the Statement of Changes in Taxpayers’ Equity and the related notes. The financial reporting framework that has been applied in their preparation is the NHS Foundation Trust Annual Reporting Manual 2012/13 issued by the Independent Regulator of NHS Foundation Trusts (“Monitor”).

Respective responsibilities of directors and auditors As explained more fully in the Statement of the Chief Executive’s responsibilities as the Accounting Officer of Royal Devon and Exeter NHS Foundation Trust set out on page 2 the directors are responsible for the preparation of the financial statements and for being satisfied that they give a true and fair view in accordance with the NHS Foundation Trust Annual Reporting Manual 2012/13. Our responsibility is to audit and express an opinion on the financial statements in accordance with the National Health Service Act 2006, the Audit Code for NHS Foundation Trusts issued by Monitor and International Standards on Auditing (ISAs) (UK and Ireland). Those standards require us to comply with the Auditing Practices Board’s Ethical Standards for Auditors.

This report, including the opinions, has been prepared for and only for the Council of Governors of Royal Devon and Exeter NHS Foundation Trust in accordance with paragraph 24 of Schedule 7 of the National Health Service Act 2006 and for no other purpose. We do not, in giving these opinions, accept or assume responsibility for any other purpose or to any other person to whom this report is shown or into whose hands it may come save where expressly agreed by our prior consent in writing.

Scope of the audit of the financial statements An audit involves obtaining evidence about the amounts and disclosures in the financial statements sufficient to give reasonable assurance that the financial statements are free from material misstatement, whether caused by fraud or error. This includes an assessment of: whether the accounting policies are appropriate to the NHS Foundation Trust’s circumstances and have been consistently applied and adequately disclosed; the reasonableness of significant accounting estimates made by the NHS Foundation Trust; and the overall presentation of the financial statements. In addition, we read all the financial and non-financial information in the Annual Report and Accounts to identify material inconsistencies with the audited financial statements. If we become aware of any apparent material misstatements or inconsistencies we consider the implications for our report.

Opinion on financial statements In our opinion the financial statements: - give a true and fair view, of the state of the NHS Foundation Trust’s affairs as at 31 March 2013 and of its income and expenditure and cash flows for the year then ended; and - have been prepared in accordance with the NHS Foundation Trusts Annual Reporting Manual 2012/13.

Opinion on other matters prescribed by the Audit Code for NHS Foundation Trusts In our opinion: - the part of the Directors’ Remuneration Report to be audited has been properly prepared in accordance with the NHS Foundation Trusts Annual Reporting Manual 2012/13; and - the information given in the Directors’ Report for the financial year for which the financial statements are prepared is consistent with the financial statements.

Matters on which we are required to report by exception In our report on the Quality Report we have issued an adverse conclusion on the percentage of patients receiving first definite treatment for cancer within 62 days of an urgent GP referral indicator due to errors in the calculation of the indicator. Other than this matter we have nothing to report in respect of the following matters where the Audit Code for NHS Foundation Trusts requires us to report to you if: - in our opinion the Annual Governance Statement does not meet the disclosure requirements set out in the NHS Foundation Trust Annual Reporting Manual 2012/13 or is misleading or inconsistent with information of which we are aware from our audit. We are not required to consider, nor have we considered, whether the Annual Governance Statement addresses all risks and controls or that risks are satisfactorily addressed by internal controls; or

Page 3 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

- we have not been able to satisfy ourselves that the NHS Foundation Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources; or - we have qualified, on any aspect, our opinion on the Quality Report.

Certificate We certify that we have completed the audit of the financial statements in accordance with the requirements of Chapter 5 of Part 2 to the National Health Service Act 2006 and the Audit Code for NHS Foundation Trusts issued by Monitor.

Heather Ancient (Senior Statutory Auditor) For and on behalf of PricewaterhouseCoopers LLP Chartered Accountants and Statutory Auditors Plymouth

Page 4 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

FOREWORD TO THE ACCOUNTS

These accounts for the year ended 31 March 2013 have been prepared by the Royal Devon and Exeter NHS Foundation Trust in accordance with paragraphs 24 and 25 of Schedule 7 to the National Health Service Act 2006 in the form which Monitor has, with the approval of the Treasury, directed.

The Royal Devon and Exeter NHS Foundation Trust Annual Report and Accounts are presented to Parliament pursuant to Schedule 7, paragraph 25(4) of National Health Service Act 2006.

Signed:

Angela Pedder - Chief Executive

Date: 29 May 2013 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

STATEMENT OF COMPREHENSIVE INCOME FOR THE YEAR ENDED 31 MARCH 2013

2012/13 2011/12 Note £000 £000

Income from activities 3 300,852 287,244 Other operating income 4 66,156 63,350 Operating income 367,008 350,594

Operating expenses - excluding property impairment charge 5 (358,414) (339,647) Property impairment charge 5 & 16.5 (22,839) - Operating (deficit) / surplus (14,245) 10,947

Finance costs Finance income 10 268 279 Finance expense 11 (950) (1,018) PDC dividends payable 14 (6,653) (7,178) Net finance costs (7,335) (7,917)

(Deficit) / surplus for the year (21,580) 3,030

Other comprehensive income

Revaluation (losses) on property, plant and equipment 16.5 (23,459) - Total comprehensive (deficit) /surplus for the year (45,039) 3,030

The above property impairment charge of £22.839m has arisen due to the revaluation of the Trust's land and buildings. This expense is a technical accounting adjustment and has no detrimental impact on the Trust's cash reserves. Excluding the property impairment charge, and the revaluation reduction of £23.459m, the Trust would have achieved a surplus of £1.259m for the year ended 31 March 2013.

Page 6 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

STATEMENT OF FINANCIAL POSITION AS AT 31 MARCH 2013

31 March 2013 31 March 2012 Note £000 £000 Non-current assets Intangible assets 15 1,071 1,190 Property, plant and equipment 16 209,243 240,055 Trade and other receivables 18 944 960 Total non-current assets 211,258 242,205

Current assets Inventories 17 4,459 4,081 Trade and other receivables 18 22,048 13,950 Cash and cash equivalents 23 41,233 49,621 67,740 67,652

Current liabilities Trade and other payables 19 (31,929) (23,456) Borrowings 20 (1,270) (1,270) Provisions 21 (265) (1,392) Other liabilities 19 (1,899) (2,835) Total current liabilities (35,363) (28,953)

Total assets less current liabilities 243,635 280,904

Non-current liabilities Borrowings 20 (17,672) (18,943) Other liabilities 19 (9,036) - Provisions 21 (352) (347) Total non-current liabilities (27,060) (19,290)

Total assets employed 216,575 261,614

Financed by taxpayers' equity Public dividend capital 149,736 149,736 Revaluation reserve 15,597 58,953 Income and expenditure reserve 51,242 52,925 Total taxpayers' equity 216,575 261,614

The notes on pages 10 to 32 form part of these accounts.

The Accounts were formally approved by the Board of Directors and were signed on its behalf by:

Angela Pedder - Chief Executive

Date: 29 May 2013 Page 7 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

STATEMENT OF CHANGES IN TAXPAYERS' EQUITY FOR THE YEAR ENDED 31 MARCH 2013

Income and Public dividend Revaluation expenditure capital reserve reserve Total £000 £000 £000 £000

Taxpayers' equity at 1 April 2011 149,715 60,772 48,076 258,563

Surplus for the year - - 3,030 3,030 Transfers to the income and expenditure account in respect of assets disposed of - (15) 15 -

Public Dividend Capital received 21 - - 21 Transfer of the excess of current cost depreciation over historical cost depreciation to the income and expenditure reserve - (1,804) 1,804 - Taxpayers' equity at 31 March and 1 April 2012 149,736 58,953 52,925 261,614

Surplus for the year excluding property impairment charge - - 1,259 1,259 Property impairment charge - - (22,839) (22,839) Revaluations - property - (23,459) - (23,459) Transfer revaluation reserve element included in impairment charge - (17,600) 17,600 - Transfer of the excess of current cost depreciation over historical cost depreciation to the income and expenditure reserve - (2,297) 2,297 - Taxpayers' equity at 31 March 2013 149,736 15,597 51,242 216,575

Public dividend capital ("PDC") PDC represents the excess of assets over liabilities at the time of establishment of the Trust. It also includes new PDC received to fund capital expenditure on schemes supported by the Department of Health central capital budgets. PDC has no fixed capital repayment period.

Revaluation reserve The reserve reflects movements in the value of purchased property, plant and equipment and intangible assets as set out in the accounting policies.

Income and expenditure reserve The reserve is the cumulative surplus / (deficit) made by the Trust since its inception. It is held in perpetuity and cannot be released to the Statement of Comprehensive Income.

Page 8 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

CASH FLOW STATEMENT FOR THE YEAR ENDED 31 MARCH 2013

Note 2012/13 2011/12 £000 £000

Cash flows from operating activities Operating (deficit) / surplus (14,245) 10,947

Non-cash income and expense Depreciation and amortisation 12,605 12,015 Impairments 22,839 - (Increase) in trade and other receivables (7,623) (2,921) (Increase) / decrease in inventories (378) 511 Increase / (decrease) in trade and other payables 6,654 (1,510) Increase in other liabilities 8,100 1,360 (Decrease) / increase in provisions (1,122) 25 Increase / (decrease) in tax liability payable 19 (704) (Gain) / loss on disposal of property plant and equipment (378) 103 Net cash generated from operations 26,471 19,826

Cash flows from investing activities Interest received 268 279 Purchase of intangible assets (101) (888) Purchase of property, plant and equipment (26,098) (13,472) Sale of property, plant and equipment 405 14 Net cash used in investing activities (25,526) (14,067)

Cash flows from financing activities PDC received - 21 Loans repaid (1,271) (1,270) Interest paid (950) (1,018) PDC dividend paid (7,112) (7,454) Net cash used in financing activities (9,333) (9,721)

(Decrease) in cash and cash equivalents (8,388) (3,962)

Cash and cash equivalents at 1 April 49,621 53,583

Cash and cash equivalents at 31 March 23 41,233 49,621

Page 9 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES

Monitor has directed that the accounts of the Trust shall meet the accounting requirements of the NHS Foundation Trust Annual Reporting Manual which shall be agreed with HM Treasury. Consequently, the accounts have been prepared in accordance with the 2012/13 NHS Foundation Trust Annual Reporting Manual issued by Monitor. The accounting policies contained in that manual follow International Financial Reporting Standards (IFRS), EU endorsed, and HM Treasury's Financial Reporting Manual to the extent that they are meaningful and appropriate to NHS foundation trusts. The accounting policies have been applied consistently in dealing with items considered material in relation to the accounts.

The accounts have been prepared under the historical cost convention modified to account for the revaluation of non current assets at their value to the business by reference to their fair value.

The directors have a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they consider it appropriate to continue to adopt the going concern basis in preparing the accounts.

1.1 Income recognition

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

Revenue relating to patient care treatments (also known as spells) that are part-completed at the year end are apportioned across the financial years on the basis of length of stay at the end of the reporting period. Where income is received for a specific activity which is to be delivered in the following financial year, that income is deferred.

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

Page 10 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS 1. ACCOUNTING POLICIES (CONTINUED)

1.2 Expenditure

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

1.3 Intangible assets

Recognition

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

Intangible assets are capitalised when they are capable of being used in the Trust's activities for more than one year and have a cost of at least £15,000.

Internally generated intangible assets

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

Measurement

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

Subsequently intangible assets are measured at fair value. Revaluation gains and losses and impairments are treated in the same manner as for property, plant and equipment (see note 1.4).

Amortisation and impairment

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

The carrying value of intangible assets is reviewed for impairment if events or changes in circumstances indicate the carrying value may not be recoverable.

Software

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

Purchased computer software licences are capitalised as intangible assets where expenditure of at least £15,000 is incurred and amortised over the shorter of the term of the licence and their useful lives.

Asset category Useful life (years) Software licences 4 - 7

Page 11 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

1.3 Intangible assets (continued)

Research and development

Expenditure on research is not capitalised.

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

- the project is technically feasible to the point of completion and will result in an intangible asset for sale or use;

- the Trust intends to complete the asset and sell or use it;

- the Trust has the ability to sell or use the asset;

- how the intangible asset will generate probable future economic or service delivery benefits, e.g. the presence of a market for it or its output, or where it is to be used for internal use, the usefulness of the asset;

- adequate financial, technical and other resources are available to the Trust to complete the development and sell or use the asset; and

- the Trust can measure reliably the expenses attributable to the asset during development.

Expenditure which does not meet the criteria for capitalisation is treated as an operating cost in the year in which it is incurred.

Where possible the Trust will disclose the total amount of research and development expenditure charged in the Statement of Comprehensive Income separately. However, where research and development activity cannot be separated from patient care activity it cannot be identified and is therefore not separately disclosed.

Other property, plant and equipment assets acquired for use in research and development are amortised over the life of the associated project.

1.4 Property, plant and equipment

Recognition

Property, plant and equipment are capitalised where:

- it is held for use in delivering services or for administrative purposes;

- it is probable that future economic benefits will flow to, or service potential be provided to, the Trust;

- it is expected to be used for more than one financial year;

- the cost of the item can be measured reliably and;

- has an individual cost of at least £15,000; or

- the items form a group of assets which individually have a cost of more than £250, collectively have a cost of at least £15,000, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or

- form part of the initial equipping and setting-up costs of a new building or on refurbishment, may also be "grouped" for capitalisation purposes.

Page 12 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

1.4 Property, plant and equipment (continued)

Measurement and revaluation

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

Property assets

The fair value of land and buildings is determined by valuations carried out by professionally qualified valuers in accordance with the Royal Institution of Chartered Surveyors (RICS) Appraisal and Valuation Manual. The valuations are carried out primarily on the basis of depreciated replacement cost for specialised operational property based upon providing a modern equivalent asset. Existing use value is used for non-specialised operational property. For non- operational properties, including surplus land, the valuations are carried out at open market value. The frequency of revaluation is dependent upon changes in the fair value of property assets however, in line with Monitor's view, the frequency of property asset revaluations will be at least every five years.

Assets under construction are valued at cost and may subsequently be revalued by professional valuers when brought into use or when factors indicate that the value of the asset differs materially from its carrying value.

Non-property assets

For non-property assets the depreciated historical cost basis has been adopted as a proxy fair value. Non-property assets acquired up to 31 March 2008 were revalued through an annual uplift by the change in the value of the GDP deflator. These revalued assets are included in the non-property assets valuation, but further indexation of these assets has ceased.

Additional alternative open market value figures have only been supplied for operational assets scheduled for imminent closure and subsequent disposal.

Subsequent expenditure

Expenditure incurred after items of property, plant and equipment have been brought into operation, such as repairs and maintenance, is normally charged to the Statement of Comprehensive Income in the period in which it is incurred. In situations where it can be clearly demonstrated that the expenditure has resulted in an increase in the future economic benefits expected to be obtained from the use of an item of property, plant and equipment, and where the cost of an item can be measured reliably, the expenditure is capitalised as an additional cost of that asset or as a replacement.

Depreciation

Items of property, plant and equipment are depreciated on a straight-line basis over their remaining useful lives in a manner consistent with the consumption of economic or service delivery benefits.

Useful lives are determined on a case by case basis. The typical lives for the following assets are:

Asset category Useful life (years) Freehold property - buildings 10 - 42 Freehold property - dwellings 32 - 47 Plant and machinery 5 - 15 Equipment - transport 5 - 7 Equipment - information technology 3 - 7 Equipment - furniture and fittings 5 - 10

Freehold land is considered to have an infinite life and is not depreciated.

Page 13 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

1.4 Property, plant and equipment (continued)

The excess depreciation on revalued assets over the historical cost is released to the income and expenditure reserve. On disposal of an asset any remaining revaluation reserve balance is released to the income and expenditure reserve.

Impairment

The carrying values of property, plant and equipment assets are reviewed for impairment when events or changes in circumstances indicate their carrying value may not be recoverable.

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

Decreases in asset values that are due to a loss of economic benefits or service potential in the asset are charged to operating expenses. A compensating transfer is made from the revaluation reserve to the income and expenditure reserve of an amount to the lower of (i) the impairment charged to operating expenses; and (ii) the balance in the revaluation reserve attributable to that asset before the impairment.

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

Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income.

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

1.6 Inventories and work in progress

Inventories and work in progress are valued at the lower of cost and net realisable value. Cost is determined using a first in, first out method.

Work in progress comprises goods in intermediate stages of production.

Provision is made where necessary for obsolete, slowing moving and defective inventories and work in progress.

1.7 Provisions

The Trust provides for legal or constructive obligations that are of uncertain timing or amount at the Statement of Financial Position date on the basis of the best estimate of the expenditure required to settle the obligation. The Trust uses HM Treasury's pension rate of 2.35%, in real terms, as the discount rate for early retirement and injury benefit provisions.

Page 14 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

1.7 Provisions (continued)

Clinical negligence costs

The NHS Litigation Authority (NHSLA) operates a risk pooling scheme under which the Trust pays an annual contribution, which, in return, settles all clinical negligence claims. Although the NHSLA is administratively responsible for all clinical negligence cases, the legal liability remains with the Trust. The total value of clinical negligence provisions carried by the NHSLA on behalf of the Trust is disclosed at note 21. The provision relates to the excess payable on each of the Trust's cases administered by the NHSLA.

Non-clinical risk pooling

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

1.8 Expenditure on employee benefits

Short-term employee benefits

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

Pension costs

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

Employers pension cost contributions are charged to operating expenses as and when they become due.

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

1.9 Value Added Tax

Most of the activities of the Trust are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable.

Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of non-current assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.

1.10 Contingent liabilities

The Trust may have contingent liabilities in respect of NHSLA legal claims arising in the normal course of activities. Where the transfer of economic benefits in respect of legal claims is possible the Trust discloses the estimated value. There were no contingent liabilities realting to legal claims at the year end (2012 - £nil).

1.11 Third party assets

Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since the Trust has no beneficial interest in them. The Trust held no cash or cash equivalents relating to monies held on behalf of patients at the year end (2012 - £nil).

Page 15 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

1.12 Critical accounting estimates and judgements

In the application of the Trust’s accounting policies, management is required to make judgements, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical experience and other factors that are considered to be relevant. Actual results may differ from those estimates and the estimates and underlying assumptions are continually reviewed.

Accounting judgement - Modern Equivalent Asset valuation

The majority of the Trust's estate is considered to be specialised assets as there is no open market for an acute hospital. The modern equivalent asset valuation is based on the assumption that any modern equivalent replacement hospital would be built on an alternative site within the Exeter locality.

1.13 Leases

Operating leases

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

Leases of land and buildings

Where a lease is for land and buildings, the land component is separated from the building component and the classification for each is assessed separately.

1.14 Public dividend capital

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

A charge, reflecting the forecast cost of capital utilised by the Trust, is paid over as public dividend capital dividend. The charge is calculated at the rate set by HM Treasury (currently 3.5%) on the average relevant net assets of the Trust.

Relevant net assets are calculated as the value of all assets less the value of all liabilities, except for donated assets and cash held with the Government Banking Service. Average relevant net assets are calculated as a simple means of opening and closing relevant net assets in the pre-audit version of the accounts.

1.15 Financial instruments and financial liabilities

Recognition

Financial assets and financial liabilities which arise from contracts for the purchase or sale of non-financial items (such as goods or services), which are entered into in accordance with the Trust’s normal purchase, sale or usage requirements, are recognised when, and to the extent which, performance occurs i.e. when receipt or delivery of the goods or services is made.

All other financial assets and financial liabilities are recognised when the Trust becomes a party to the contractual provisions of the instrument.

De-recognition

All financial assets are de-recognised when the rights to receive cash flows from the assets have expired or the Trust has transferred substantially all of the risks and rewards of ownership.

Financial liabilities are derecognised when the obligation is discharged, cancelled or expires.

Classification and measurement

Financial assets are categorised as ‘loans and receivables’. Financial liabilities are classified as ‘other financial liabilities’.

Page 16 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS

1. ACCOUNTING POLICIES (CONTINUED)

1.15 Financial instruments and financial liabilities (continued)

Loans and receivables

Loans and receivables are non-derivative financial assets with fixed or determinable payments that are not quoted in an active market. They are included in current assets.

The Trust’s loans and receivables comprise: cash and cash equivalents, NHS receivables, accrued income and ‘other receivables’.

Loans and receivables are recognised initially at fair value, net of transactions costs, and are measured subsequently at amortised cost, using the effective interest method. The effective interest rate is the rate that discounts exactly estimated future cash receipts through the expected life of the financial asset or, when appropriate, a shorter period, to the net carrying amount of the financial asset.

Interest on loans and receivables is calculated using the effective interest method and credited to the Statement of Comprehensive Income.

Other financial liabilities

Other financial liabilities are recognised initially at fair value, net of transaction costs incurred, and measured subsequently at amortised cost using the effective interest method. The effective interest rate is the rate that discounts exactly estimated future cash payments through the expected life of the financial liability or, when appropriate, a shorter period, to the net carrying amount of the financial liability.

They are included in current liabilities except for amounts payable more than 12 months after the statement of financial position date, which are classified as non-current liabilities.

Interest on financial liabilities carried at amortised cost is calculated using the effective interest method and charged to finance costs. Interest on financial liabilities taken out to finance property, plant and equipment or intangible assets is not capitalised as part of the cost of those assets.

Impairment of financial assets

At the Statement of Financial Position date, the Trust assesses whether any financial assets are impaired. Financial assets are impaired and impairment losses are recognised if, and only if, there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset.

For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset’s carrying amount and the present value of the revised future cash flows discounted at the asset’s original effective interest rate. The loss is recognised in the Statement of Comprehensive Income and the carrying amount of the asset is reduced through the use of a bad debt provision that is determined specifically on individual assets.

1.16 Corporation tax

The Trust is a Health Service Body within the meaning of s519A of the Income and Corporation Tax Act 1988 and accordingly is exempt from taxation in respect of income and capital gains within categories covered by this. There is a power for HM Treasury to dis-apply the exemption in relation to specified activities of an NHS foundation trust (s519A (3) to (8) of the Income and Corporation Taxes Act 1988). Accordingly, the FT is potentially within the scope of corporation tax in respect of activities which are not related to, or ancillary to, the provision of healthcare, and where the profits there from exceed £50,000 per annum. Until the exemption is dis-applied then the FT has no corporation tax liability.

1.17 Non-current assets held for sale

Non-current assets are classified as assets held for sale when their carrying amount is to be recovered principally through a sale transaction and a sale is considered highly probable. They are stated at the lower of carrying amount and fair value.

1.18 Consolidation of NHS charitable funds

The Trust is the Corporate Trustee of the Royal Devon and Exeter NHS Foundation Trust General Charity. The Charity has not been consolidated within these annual accounts as HM Treasury has granted a dispensation to the application of IAS 27 in relation to the consolidation of NHS charitable funds for 2012/13. Further information relating to transactions between the Trust and the Charity is disclosed in note 25.

Page 17 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS

2. Segmental analysis

Operating segments are reported in a manner consistent with the internal reporting provided to the chief operating decision maker. The chief operating decision maker, who is responsible for allocating resources and assessing performance of the operating segments, has been identified as the Trust's Board of Directors.

The Trust's income and activities are for the provision of health and health related services within the United Kingdom. The services provided by the Trust are designated between directorates. Details of the services provided within each of the Trust's main clinical directorates are included below. The information is a summary of activity by directorate level, similar information is provided to the Trust's Board of Directors each month.

Segmental information by assets and liabilities has not been disclosed as this information is not reported to the chief operating decision maker.

2.1 Segmental analysis - explanation of the services provided by directorates

Directorates Examples of services provided within each directorate: -

Medicine (Specialist and General) Cardiology, Dermatology, Diabetes, Endocrinology, Emergency Department, Elderly Care, Acute Admissions Unit, Gastroenterology, Neurology, Neurophysiology, Page 18Page Renal, Respiratory and General Medicine.

Critical Care Anaesthetics Pain Service, Intensive Care Unit.

Orthopaedics Orthopaedics, Trauma and Rheumatology.

Surgery 1 Breast surgery, Colorectal surgery, General surgery, Thoracic and Upper Gastrointestinal surgery, Vascular surgery and Urology.

Specialist Surgery Ear Nose and Throat surgery Ophthalmology, Oral and Maxillofacial surgery, Orthodontics, and Plastic and Reconstructive surgery.

Women and Child Health Clinical Genetics, Gynaecology, Obstetrics and Midwifery, Neonatology, and Paediatrics.

Cancer Services Clinical Haematology, Oncology and Radiotherapy.

Diagnostics Elements of Blood transfusion, Cellular Pathology, Clinical Chemistry, Cytopathology, Haematology, Histopathology, Immunology, Microbiology, Mortuary, and Diagnostic imaging services, - where these services are offered direct to patients and not as part of the care delivered by other specialties within the hospital.

Professional Services Includes Exeter Mobility Centre and elements of Dietetics, Occupational Therapy, Physiotherapy.

Other Included within the "Other" heading is the Patient Transport Service and other financial adjustments such as non payment for emergency readmissions. ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS

2. Segmental analysis (continued) Reconciliation to figures reported 2.2 Segmental analysis 2012/13 on the Statement of Comprehensive Income see explanation below Specialist Women and Cancer Professional Medicine Critical Care Orthopaedics Surgery 1 Surgery Child Health Services Diagnostics Services Other Trust Difference Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £000 £000

Patient Income -PbR 73,747 952 34,153 32,761 25,647 27,575 10,989 19 1 - 205,844 Patient Income - Non PbR 30,609 7,498 1,504 1,541 4,745 16,642 16,578 8,966 10,892 (3,969) 95,006 Trading income 5,582 344 1,142 2,072 1,526 2,066 967 - 67 - 13,766 Total Clinical Income 109,938 8,794 36,799 36,374 31,918 46,283 28,534 8,985 10,960 (3,969) 314,616 Note 1 1 314,617

Admin Secretarial Support 1,602 131 571 204 1,310 2,747 1,379 - 3 - 7,947 Anaesthetics 248 - 2,365 2,357 2,165 1,263 18 - - - 8,416 Devices 3,352 - 2 13 287 103 - - - - 3,757

Page 19 Page Other Departments 5,775 555 1,506 1,238 2,038 5,067 1,333 196 607 23,479 41,794 Diabetes services 1,083 ------1,083 Dialysis 6,890 5 ------6,895

Medical Staffing 22,093 1,272 5,394 7,320 7,805 9,055 2,218 - - - 55,157 Mobility Centre ------8,378 - 8,378 Nuclear Medicine 116 - 52 242 67 26 103 2 39 - 647 Oncology Centre ------2,840 - - - 2,840 Professions Allied to Medicine 3,313 158 522 739 429 356 127 - 1,617 - 7,261 Pathology 4,408 329 428 1,683 457 2,172 1,812 5,892 24 - 17,205 Pharmacy 9,878 380 1,718 1,158 3,633 1,222 9,935 7 363 - 28,294 Radiology 4,475 373 1,400 1,778 510 469 593 1,447 142 - 11,187 Health Records 694 21 1,439 199 318 249 181 - 95 - 3,196 R.T. Physics ------1,376 - - - 1,376 Theatres 6,889 809 12,790 9,406 7,035 2,855 90 - - - 39,874 Wards / Nursing 40,805 4,675 6,918 8,971 5,244 20,314 3,960 2 - - 90,889 Total Expense 111,621 8,708 35,105 35,308 31,298 45,898 25,965 7,546 11,268 23,479 336,196 Note 2

Surplus / (Deficit) (1,683) 86 1,694 1,066 620 385 2,569 1,439 (308) (27,448) (21,580) Agrees to the deficit reported in the Margin % (2%) 1% 5% 3% 2% 1% 9% 16% (3%) 692% (7%) Statement of Comprehensive Income

Notes:

1 - Total clinical income recorded in the Accounts is £300,852 and £13,765 of other income included within "Other operating income" note 4. 2 - Expenditure reported in the Service Line Report document nets other operating income against expenditure. 3 - The "Other" Directorate includes impairment expenditure of £22.8m. ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS

2. Segmental analysis (continued) Reconciliation to figures reported 2.3 Segmental analysis 2011/12 on the Statement of Comprehensive Income see explanation below Specialist Women and Cancer Professional Medicine Critical Care Orthopaedics Surgery 1 Surgery Child Health Services Diagnostics Services Other Trust Difference Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £000 £000

Patient Income -PbR 64,004 1,465 31,911 31,070 24,957 28,618 6,634 75 2 - 188,736 Patient Income - Non PbR 27,746 7,805 2,204 1,216 4,276 14,990 18,199 9,057 10,995 1,202 97,690 Total Clinical Income 91,750 9,270 34,115 32,286 29,233 43,608 24,833 9,132 10,997 1,202 286,426 Note 1 818 287,244

Admin Secretarial Support 2,827 79 1,012 1,280 916 1,725 640 - - - 8,479 Anaesthetics 215 - 1,915 2,078 1,783 1,103 18 - - - 7,112 Devices 4,620 471 3,402 287 467 123 - - - - 9,370 Page 20 Page Other Departments 4,860 447 954 783 1,285 5,378 918 426 773 814 16,638 Diabetes services 1,110 ------1,110 Dialysis 5,984 5 ------5,989 Medical Staffing 14,122 1,216 4,777 4,896 6,514 8,504 2,471 - - - 42,500 Mobility Centre ------8,032 - 8,032 Nuclear Medicine 107 1 55 290 56 31 174 24 38 - 776 Oncology Centre ------2,978 - - - 2,978 Professions Allied to Medicine 2,765 175 617 695 437 351 129 - 1,459 - 6,628 Pathology 3,513 376 474 1,761 507 1,841 1,967 6,293 33 - 16,765 Pharmacy 7,231 464 1,856 1,232 3,293 909 8,358 2 239 - 23,584 Radiology 4,529 266 947 1,652 744 551 1,392 511 229 - 10,821 Health Records 686 24 764 181 311 264 178 - 101 - 2,509 R.T. Physics ------1,278 - - - 1,278 Theatres 5,932 478 9,258 8,186 7,376 3,070 183 - - - 34,483 Wards / Nursing 36,107 4,179 6,127 9,904 5,277 18,940 3,804 6 - - 84,344 Total Expense 94,608 8,181 32,158 33,225 28,966 42,790 24,488 7,262 10,904 814 283,396 Note 2

Surplus / (Deficit) (2,858) 1,089 1,957 (939) 267 818 345 1,870 93 388 3,030 Agrees to the surplus reported in the Margin % (3%) 12% 6% (3%) 1% 2% 1% 20% 1% 32% 1% Statement of Comprehensive Income

Notes:

1 - Total clinical income recorded in the Accounts is £818,000 higher than the value reported on the Service Line Report (SLR), the difference relates to road traffic accident income netted against expenditure reported in the SLR. 2 - Expenditure reported in the Service Line Report document nets other operating income and RTA income against expenditure. ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS

3. Income from activities 2012/13 2011/12 £000 £000

Elective income 81,215 76,585 Non-elective income 91,525 89,805 Outpatient income 55,594 55,232 Other NHS clinical income 61,047 54,618 A & E income 10,522 10,009 Private patient income 925 970 Other non-protected clinical income 24 25 300,852 287,244

Income from mandatory services 299,903 286,249 Income from non-mandatory services 949 995 300,852 287,244

NHS Injury Scheme income is subject to a provision for doubtful debts of 12.6% to reflect expected rates of collection based upon historical experience.

3.1 Income from activities - by source 2012/13 2011/12 £000 £000

NHS foundation trusts 22 25 NHS trusts 19 37 Primary care trusts 298,991 285,301 Non-NHS - private patients 925 970 Non-NHS - overseas patients (non-reciprocal) 111 94 NHS injury scheme 761 792 Non-NHS - other 23 25 300,852 287,244

3.2 Private patient income

The statutory limitation on private patient income in section 44 of the 2006 Act was repealed with effect from 1 October 2012 by the Health and Social Care Act 2012. The accounts disclosures that were previously provided are no longer required.

4. Other operating income 2012/13 2011/12 £000 £000

Research and development 14,254 12,936 Education and training 13,765 13,901 Charitable and other contributions to expenditure 320 123 Non-patient care services to other bodies 24,447 22,722 Staff recharges 6,437 6,070 Profit on disposal of property 390 - Profit on disposal of plant and equipment 15 10 Other 6,528 7,588 66,156 63,350

Included within "Non-patient care services to other bodies" are laundry services, transport services, payroll services, procurement services, IT services, finance services, estates services, pathology services, pharmacy services and drug sales totalling £14.5 million (2011/12 - £14.4 million).

Included within "Other" income above is catering income of £2 million, (2011/12 - £2 million), car parking income of £1.6 million (2011/12 - £1.5 million), nursery/crèche income of £1 million (2011/12 - £0.9 million) and staff accommodation income of £0.7 million (2011/12 - £0.6 million).

Page 21 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS

5. Operating expenses 2012/13 2011/12 £000 £000 Services from other NHS foundation trusts 2,039 1,807 Services from NHS trusts 2,132 1,394 Services from other NHS bodies 1,466 2,627 Employee expenses - executive directors (see note 5.1) 1,218 957 Employee expenses - non-executive directors (see note 5.1) 140 140 Employee expenses - staff 213,708 202,659 Drug costs 33,976 30,090 Supplies and services - clinical (excluding drug costs) 39,193 37,148 Supplies and services - general 5,116 5,107 Establishment 3,161 2,973 Research and development 13,059 12,144 Transport 487 633 Premises 15,158 15,258 Increase in bad debt provision 52 94 Depreciation 12,385 11,773 Amortisation of intangible assets 220 242 Impairments 22,839 - Audit fees - statutory audit 79 79 Other auditors' remuneration 164 48 Clinical negligence 6,113 5,667 Losses, ex gratia and special payments 133 206 Loss on disposal of plant and equipment 27 113 Other 8,388 8,488 381,253 339,647

Operating expenses - excluding property impairment charge 358,414 339,647 Property impairment charge - note 16.5 22,839 - 381,253 339,647

Included within "Other" expenditure above is consultancy costs of £2.3 million (2011/12 £1 million), consultancy costs includes various services received in particular assisting with transforming future services to enable the Trust to operate more effectively and efficiently, academic health science network fees incurred by the Trust and proportionally recharged to other NHS Trusts, property condition and utilisation surveys, and pathology services review. It also includes Patient travel costing £1.3 million (2011/12 - £1.1 million), training courses and conferences costing £0.7 million (2011/12 - £0.8 million) and operating lease expenditure of £1.6 million (2011/12 £1.8 million).

The total employer's pension contributions are disclosed in note 6.1.

Staff costs reported in note 6.1 is higher than the employee expenditure reported above. The difference is due to some employee expenditure being reported within the above research and development expenditure heading.

5.1 Directors' remuneration and other benefits 2012/13 2011/12 £000 £000 Aggregate directors' remuneration 1,272 992 Employer's contribution to pension scheme 86 105 Total 1,358 1,097

In the year ended 31 March 2013 six directors accrued benefits under defined benefit pension schemes (2011/12 - seven).

5.2 Other auditors' remuneration

The audit fee for the statutory audit including quality accounts in 2012/13 was £79,000 (2011/12 - £79,000) including VAT not recoverable. This was the fee for an audit in accordance with the Audit Code issued by Monitor in October 2007. In addition to this, payments made to the auditors for non audit work in 2012/13 amounting to £164,000, excluding VAT Non audit fees in 2011/12 were £48,000. The non-audit work in 2012/13 relates to providing support in reviewing the frail and elderly care pathway.

5.3 Auditors' liability

The Board of Governors appointed PricewaterhouseCoopers LLP (PwC) as external auditors for the financial year ending 31 March 2013. The engagement letter signed on 4 March 2013, states that the liability of PwC, its members, partners and staff (whether in contract, negligence or otherwise) shall in no circumstances exceed £1 million in the aggregate in respect of all services (2011/12 - £1 million).

5.4 Operating leases 2012/13 2011/12 £000 £000 Operating lease payments recognised in expenses 1,596 1,757

Lease expenditure relates to minimum lease payments and is charged to the Statement of Comprehensive Income on a straight line basis over the term of the lease.

Future aggregate minimum lease payments due under non-cancellable operating leases are as follows:

2012/13 2011/12 Land and Land and buildings Other Total buildings Other Total £000 £000 £000 £000 £000 £000 No later than 1 year 294 385 679 517 478 995 Later than 1 year and no later than 5 years 1,040 451 1,491 1,101 108 1,209 Later than 5 years 3,143 - 3,143 3,374 - 3,374 4,477 836 5,313 4,992 586 5,578

Page 22 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS

6. Staff costs and numbers

6.1 Staff costs 2012/13 2011/12 £000 £000 Salaries and wages 174,418 168,910 Social security costs 13,136 12,699 Employer contributions to NHSPA 20,585 20,291 Termination benefits 901 706 Agency and contract staff 9,554 4,822 218,594 207,428

6.2 Average number of persons employed including directors Permanent Other 2012/13 2011/12 employees employees total total Number Number Number Number Medical and dental 619 10 629 616 Administration and estates 1,229 2 1,231 1,241 Healthcare assistants and other support staff 546 - 546 495 Nursing, midwifery and health visiting staff 2,004 6 2,010 1,935 Scientific, therapeutic and technical staff 684 - 684 673 Bank and agency staff - 340 340 219 Total 5,082 358 5,440 5,179

6.3 Staff exit packages 2012/13 2011/12 Exit package cost Number Number Less than £10,000 4 15 £10,000 to £25,000 2 4 £25,001 to £50,000 5 13 £50,001 to £100,000 4 2 £100,001 to £150,000 2 - £150,001 to £250,000 1 - Total number 18 34

2012/13 2011/12 £000 £000 Total exit package expense 901 706

Exit packages relate to staff that left the employment of the Trust under a Department of Health mutually agreed voluntary scheme and also redundancies. The exit package expense includes employer's NIC. Exit packages in respect of senior managers are disclosed in the Directors' remuneration report and are not included in the above note.

7. Pensions

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

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

The last published actuarial valuation undertaken for the NHS Pension Scheme was completed for the year ending 31 March 2004. Consequently, a formal actuarial valuation would have been due for the year ending 31 March 2008. However, formal actuarial valuations for unfunded public service schemes were suspended by HM Treasury on value for money grounds while consideration is given to recent changes to public service pensions, and while future scheme terms are developed as part of the reforms to public service pension provision due in 2015.

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

The next formal valuation to be used for funding purposes will be carried out as at March 2012 and will be used to inform the contribution rates to be used from 1 April 2015.

8. Retirements due to ill-health

During 2012/13 there were 9 (2011/12 - 8) early retirements from the Trust agreed on the grounds of ill-health. The estimated additional pension liabilities of these ill-health retirements will be £731,000 (2011/12 - £466,000). The cost of these ill-health retirements will be borne by the NHS Pensions Agency.

9. The late payment of commercial debts (Interest) Act 1998

In 2012/13 the Trust did not incur expenditure (2011/12 - £nil) arising from claims made under this legislation.

10. Finance income 2012/13 2011/12 £000 £000 Interest on cash and cash equivalents 268 279

Page 23 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS

11. Finance expense 2012/13 2011/12 £000 £000 Loans from the Foundation Trust Financing Facility 940 1,007 Unwinding of discount on provisions 10 11 Total 950 1,018

12. Better Payment Practice Code

2012/13 2012/13 2011/12 2011/12 Number £000 Number £000 Total non-NHS trade invoices paid in the year 98,777 132,343 92,381 120,249 Total non-NHS trade invoices paid within target 94,806 124,281 84,433 108,360 Percentage of non-NHS trade invoices paid within target 95.98% 93.91% 91.40% 90.11%

Total NHS trade invoices paid in the year 3,821 37,868 3,087 28,806 Total NHS trade invoices paid within target 3,365 34,629 2,576 24,759 Percentage of NHS trade invoices paid within target 88.07% 91.45% 83.45% 85.95%

The Better Payment Practice Code requires the Trust to aim to pay all valid non-NHS invoices by the due date or within 30 days of receipt of goods or a valid invoice, whichever is later.

13. Losses and special payments 2012/13 2012/13 2011/12 2011/12 Number Value Number Value £000 £000 Losses 92 45 104 77 Special payments 82 88 66 129 Total losses and special payments 174 133 170 206

Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed regulation. By their nature they are items that ideally should not arise. They are therefore subject to specific control procedures compared with the generality of payments. They are divided into different categories, which govern the way the individual cases are handled. Losses and special payments are charged to the relevant functional headings in expenditure on an accruals basis, including losses which would have been made good through insurance cover had NHS trusts not been bearing their own risks (with insurance premiums then being included as normal revenue expenditure).

The losses and special payments note is compiled directly from the losses and compensations register which reports on an accruals basis with the exception of provisions for future losses.

14. Public dividend capital

A charge, reflecting the cost of capital utilised by the Trust, is payable as public dividend capital dividend. The charge is calculated at the rate set by HM Treasury (currently 3.5%) on the average relevant net assets of the Trust during the financial year. Relevant net assets are calculated as the value of all assets less the value of all liabilities, except for donated assets and cash held with the Government Banking Service.

15. Intangible assets Software licences 15.1 Intangible assets at 31 March 2012 £000 Fair value at 1 April 2011 1,397 Additions - purchased 888 Fair value at 31 March 2012 2,285

Accumulated amortisation at 1 April 2011 853 Provided during the year 242 Accumulated amortisation at 31 March 2012 1,095

Net book value Purchased at 31 March 2012 1,183 Donated at 31 March 2012 7 Total at 31 March 2012 1,190

15.2 Intangible assets at 31 March 2013 Fair value at 1 April 2012 2,285 Additions - purchased 101 Fair value at 31 March 2013 2,386

Accumulated amortisation at 1 April 2012 1,095 Provided during the year 220 Accumulated amortisation at 31 March 2013 1,315

Net book value Purchased at 31 March 2013 1,069 Donated at 31 March 2013 2 Total at 31 March 2013 1,071

Page 24 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS

16. Property, plant and equipment

16.1 Property, plant and equipment at the statement of financial position date comprise the following elements:

Freehold land Freehold Freehold Assets under Plant and Transport Information Furniture and Total buildings dwellings construction machinery equipment technology fittings excluding and payments dwellings on account

£000 £000 £000 £000 £000 £000 £000 £000 £000 Cost or valuation at 1 April 2012 32,780 181,636 2,400 10,984 37,426 1,076 7,859 45 274,206 Additions - purchased - 490 - 26,570 360 45 113 - 27,578 Additions - donated - 2 - 224 94 - - - 320 Reclassifications - 5,099 - (9,344) 4,018 161 66 - - Impairment ------Revaluation (17,015) (41,259) (100) (1,974) - - - - (60,348) Disposals - (47) - - (1,710) (146) (5) - (1,908) Total at 31 March 2013 15,765 145,921 2,300 26,460 40,188 1,136 8,033 45 239,848

Accumulated depreciation at 1 April 2012 - 6,901 51 - 21,385 452 5,320 42 34,151 Provided during the year - 7,094 51 - 3,708 143 1,388 1 12,385

Page 25 Page Impairments 5,232 15,569 64 1,974 - - - - 22,839 Revaluation (5,232) (29,517) (166) (1,974) - - - - (36,889) Impairment ------

Eliminated on disposals - (47) - - (1,683) (146) (5) - (1,881) Accumulated depreciation at 31 March 2013 - - - - 23,410 449 6,703 43 30,605

Net book value Purchased at 31 March 2013 15,765 143,158 2,300 26,303 16,272 678 1,328 2 205,806 Donated at 31 March 2013 - 2,763 - 157 506 9 2 - 3,437 Total at 31 March 2013 15,765 145,921 2,300 26,460 16,778 687 1,330 2 209,243

16.2 Analysis of property, plant and equipment

Protected assets at 31 March 2013 13,960 138,019 ------151,979 Unprotected assets at 31 March 2013 1,805 7,902 2,300 26,460 16,778 687 1,330 2 57,264 Net book value 15,765 145,921 2,300 26,460 16,778 687 1,330 2 209,243

There were no assets held under finance leases, hire purchase contracts or private finance initiative (PFI) at the statement of financial position date.

Protected assets are designated as protected in the Trust's Terms of Authorisation (ToA). Condition 9 of the ToA defines property as protected if it is required for the purposes of providing mandatory goods and services. Protected assets are limited to land and buildings owned by the Trust, assets such as equipment are not regarded as protected assets.

The Trust's land, buildings and dwellings were revalued as at 31 March 2013. The valuation was undertaken by the District Valuer, in accordance with International Financial Reporting Standards and also complies with HM Treasury's requirements to value land and buildings on the basis of utilising modern equivalent buildings that would give the same service potential as is provided by the actual estate that the Trust owns, note 16.5 provides further details. ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS

16. Property, plant and equipment (continued)

16.3 Property, plant and equipment at the prior year's statement of financial position date comprised the following elements:

Freehold land Freehold Freehold Assets under Plant and Transport Information Furniture and Total buildings dwellings construction machinery equipment technology fittings excluding and payments dwellings on account

£000 £000 £000 £000 £000 £000 £000 £000 £000

Cost or valuation at 1 April 2011 32,780 173,214 2,400 11,421 35,914 988 6,587 51 263,355 Additions - purchased - 627 - 12,035 295 14 72 - 13,043 Additions - donated - - - 123 - - - - 123 Reclassifications - 7,795 - (12,595) 3,447 153 1,200 - - Disposals - - - - (2,230) (79) (6) (2,315)

Total at 31 March 2012 32,780 181,636 2,400 10,984 37,426 1,076 7,859 45 274,206 Page 26 Page Accumulated depreciation at 1 April 2011 - - - - 20,018 425 4,092 41 24,576 Provided during the year - 6,901 51 - 3,480 106 1,228 7 11,773

Eliminated on disposals - - - - (2,113) (79) - (6) (2,198) Accumulated depreciation at 31 March 2012 - 6,901 51 - 21,385 452 5,320 42 34,151

Net book value Purchased at 31 March 2012 32,780 171,932 2,349 10,934 15,550 610 2,534 3 236,692 Donated at 31 March 2012 - 2,803 - 50 491 14 5 - 3,363 Total at 31 March 2012 32,780 174,735 2,349 10,984 16,041 624 2,539 3 240,055

16.4 Analysis of property, plant and equipment

Protected assets at 31 March 2012 30,975 166,451 ------197,426 Unprotected assets at 31 March 2012 1,805 8,284 2,349 10,984 16,041 624 2,539 3 42,629 Net book value 32,780 174,735 2,349 10,984 16,041 624 2,539 3 240,055

There were no assets held under finance leases, hire purchase contracts or (PFI) at the statement of financial position date. ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS

16.5 Impairment and revaluation of land, buildings and dwellings

The Trust's land, buildings and dwellings were revalued by the District Valuation Office as at 31 March 2013. The Trust's specialised buildings and associated land have been valued using the depreciated replacement cost method, based upon providing a modern equivalent asset (MEA). A fundamental principal of MEA valuations is that a hypothetical buyer would purchase the least expensive site that would be suitable and appropriate for the existing operations. The valuation of the Trust's specialised land and buildings has therefore been based upon the Trust hypothetically being located on a suitable alternative site away from the city centre, where the cost of the land would be significantly lower, but where the Trust would still be able to re-provide its services. Applying these MEA revaluations has resulted in a net overall decrease of £46.3m in the value of the Trust's Estate. This reduction in value of the Trust's Estate is recorded in the property plant and equipment note 16.1. £22.8m has been recognised as an impairment charged to the Statement of Comprehensive Income and the remaining £23.5m has been recognised as a reduction to the revaluation reserve.

17. Inventories

17.1 Inventories held at year end 31 March 2013 31 March 2012 £000 £000 Drugs 1,567 1,282 Work in progress 53 55 Consumables 2,111 1,863 Energy 330 304 Inventories carried at fair value less costs to sell 398 577 Total inventories 4,459 4,081

17.2 Inventories recognised in expenses 2012/13 2011/12 £000 £000

Inventories recognised in expenses 49,854 43,029 Write-down of inventories recognised in expenses 37 68 Total inventories recognised in expenses 49,891 43,097

18. Trade and other receivables 31 March 2013 31 March 2012 £000 £000 Current NHS receivables 13,809 8,277 Non-NHS receivables 2,427 1,847 Provision for impaired receivables (67) (68) Prepayments 2,591 2,318 Accrued income 2,293 942 Other receivables 334 241 PDC dividend receivable 473 14 VAT receivable 188 379 Total current trade and other receivables 22,048 13,950

Prior to signing the accounts x% of NHS receivables had been paid since the year end.

Non-current Accrued income 944 960 Total trade and other receivables 22,992 14,910

Provision for impairment of receivables At 1 April 68 27 Increase in provision 52 94 Unused amounts reversed (53) (53) At 31 March 67 68

The provision for impairment of receivables relates to specific receivables over 3 months old.

18.1 Analysis of impaired receivables 31 March 2013 31 March 2012 £000 £000 Ageing of impaired receivables Over three months 143 173

18.2 Ageing of non-impaired receivables

Up to three months 2,534 1,674

Page 27 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS

19. Current trade and other payables 31 March 2013 31 March 2012 £000 £000 NHS payables 2,564 1,661 Trade payables - capital 3,276 1,476 Other trade payables 5,615 2,384 Other taxes payable 4,398 4,379 Other payables 2,938 2,688 Accruals 13,138 10,868 31,929 23,456 Other liabilities

Other deferred income 1,899 2,835

19.1 Non-current other liabilities

Other deferred income 9,036 -

Relates to income received from the University of Exeter towards their part of the construction of the Research, Innovation, Learning and Development building.

20. Borrowings

Current 31 March 2013 31 March 2012 £000 £000 Loans from Foundation Trust Financing Facility 1,270 1,270

Non-current Loans from Foundation Trust Financing Facility 17,672 18,943

Total borrowings 18,942 20,213

Amounts falling due within: - In one year or less by instalments 1,270 1,270 Between one and five years by instalments 5,084 5,084 Over five years by instalments 12,588 13,859 18,942 20,213 Two loans are repayable to the Secretary of State for Health.

The first loan of £17 million, was entered into in the year ended 31 March 2006. It is a repayable over a 20 year period, ending 30 March 2026, by equal quarterly instalments. The interest rate of the loan is fixed at 4.55% per annum.

The second loan of £10 million, was entered into in the year ended 31 March 2007, and is repayable over a 25 year period, ending 30 March 2032, by equal quarterly instalments. The interest rate of the loan is fixed at 5.05% per annum.

21. Provisions Early Legal Other Total retirements claims £000 £000 £000 £000 At 1 April 2012 120 211 1,408 1,739 Arising during the year 11 206 9 226 Utilised during the year (11) (108) (15) (134) Reversed unused - (69) (1,155) (1,224) Unwinding of discount 3 - 7 10 At 31 March 2013 123 240 254 617

Expected timing of cash flows: 31 March 2013 31 March 2012 £000 £000 In one year or less 265 1,392 Between one and five years 96 92 Over five years 256 255 617 1,739 Legal claims relate to employee and public liability claims.

The "Other" category relates to injury benefit claims against the Trust.

There were no contingent liabilities relating to legal claims.

The NHS Litigation Authority is carrying provisions as at 31 March 2013 in relation to the Existing Liabilities Scheme and in relation to the Clinical Negligence Scheme on behalf of the Trust of £39,056,000 (2012 - £24,329,000).

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NOTES TO THE ACCOUNTS

22. Prudential Borrowing Limit 31 March 2013 31 March 2012 £000 £000 Total long term borrowing limit set by Monitor 68,800 66,700 Working capital facility agreed by Monitor - 18,000 Total Prudential Borrowing Limit 68,800 84,700

Long term borrowing at beginning of year 20,213 21,483 Repayment in year (1,271) (1,270) Long term borrowing at the end of year 18,942 20,213 During the year the Board decided that the working capital facility was no longer considered necessary.

Financial ratios 2012/13 2012/13 2011/12 2011/12 Actual Minimum Actual Minimum ratios PBL ratios PBL (restated) Dividend cover 2.9x >1x 3.0x >1x Interest cover 21.2x >3x 22.0x >3x Debt service cover 9.1x >2x 9.6x >2x Debt service to revenue 0.6% <2.5% 0.7% <2.5%

The Trust is required to comply and remain within the prudential borrowing limit.

The maximum cumulative amount of long-term borrowing this is set by reference to the four ratio tests set out in Monitor's Prudential Borrowing Code.

23. Cash and cash equivalents

31 March 2013 31 March 2012 £000 £000 At 1 April 49,621 53,583 Net change in the year (8,388) (3,962) At 31 March 41,233 49,621

Broken down into:

Cash at commercial banks and in hand 55 18 Cash with Government Banking Service 41,178 49,603 Cash and cash equivalents as in Statement of Financial Position and Cash Flow Statement 41,233 49,621

Cash and cash equivalents represents cash in hand and deposits with any financial institution with a short term maturity period of three months or less from the date of the acquisition of the investment.

24. Capital commitments

Commitments under capital expenditure contracts, which relate to property, plant and equipment, at the statement of financial position date were £11,928,000 (2012 - £27,479,000). The majority relates to the new Research, Innovation, Learning and Development building, Approximately 70% of the cost of this building will be funded by contributions from the University of Exeter.

25. Related party transactions

The Trust is a public benefit corporation established under the NHS Act 2006. Monitor, the Regulator of NHS foundation trusts has the power to control the Trust within the meaning of IAS 27 'Consolidated and Separate Financial Statements' and therefore can be considered as the Trust's parent. Monitor does not prepare group accounts but does prepare separate NHS Foundation Trust Consolidated Accounts. The NHS Foundation Trust Consolidated Accounts are then included within the Whole of Government Accounts. Monitor is accountable to the Secretary of State for Health. The Trust's ultimate parent is therefore HM Government.

The Trust is under the common control of the Board of Directors.

Directors' remuneration and other benefits are disclosed within the operating expenditure, note 5.1.

Page 29 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS

25. Related party transactions (continued)

The Royal Devon and Exeter NHS Foundation Trust is the Corporate Trustee of the Royal Devon and Exeter NHS Foundation Trust General Charity ("Charity"), registered charity number 1061384, registered office Bowmoor House, Barrack Road, Exeter, EX2 5DW. The Trust has received during the year £57,000 (2011/12 - £57,000) revenue income and £320,000 (2011/12 - £123,000) capital contributions from the Charity. At 31 March 2013 the Trust was due £219,000 (2012 - £119,000) from the Charity. The Charity's most recent audited accounts were for the year ended 31 March 2012. The Charity reported a reduction in reserves of £123,000 and held aggregated reserves of £1,684,000.

During the year the Royal Devon and Exeter NHS Foundation Trust has had a significant number of material transactions with the Department of Health ("DoH") , and with other entities for which the DoH is regarded as the parent of those entities. Income from activity - by source (note 3.1) and the operating expense (note 5) provides details of revenue transactions with those entities. Below are considered to be the significant material transactions.

Income Expenditure Receivables Payables £000 £000 £000 £000 2012/13 Bristol Primary Care Trust 36,592 - 1,543 - Department of Health (excludes PDC dividend) 13,033 10 1,060 11 NHS Devon Primary Care Trust 247,303 1,284 6,422 362 Northern Devon Healthcare NHS Trust 9,423 1,882 2,469 775 Somerset Primary Care Trust 6,587 2 - 3 South West Strategic Health Authority 14,044 52 27 - Torbay Primary Care Trust 5,004 - 39 -

2011/12 Bristol Primary Care Trust 21,028 - 906 - Department of Health (excludes PDC dividend) 11,135 - 264 - NHS Devon Primary Care Trust 249,123 2,297 1,940 (21) Northern Devon Healthcare NHS Trust 9,201 1,183 2,426 227 Somerset Primary Care Trust 7,276 40 (29) 39 South West Strategic Health Authority 14,271 14 2 - Torbay Primary Care Trust 5,308 3 168 -

26. Financial instruments A financial instrument is a contract that gives rise to both a financial asset in one entity and a financial liability or equity instrument in another entity. IFRS 7, Financial Instruments: Disclosures, requires disclosure of the role that financial instruments have had during the period in creating or changing the risks an entity faces in undertaking its activities. The financial assets and liabilities of the Trust are generated by day to day operational activities rather than being held to change the risks facing the Trust in undertaking its activities.

Credit risk Credit risk arises when the Trust is exposed to the risk that a party is unable to meet its obligation to the Trust in respect of financial assets due.

Financial assets mainly comprise monies due from primary care trusts for services rendered by the Trust in fulfilment of service agreements, and cash balances held on deposit. It is considered that financial assets due from primary care trusts pose low credit risk as these entities are funded by HM Government. A significant proportion of the Trust's cash balances are held on deposit with the Government Banking Service, and as such the credit risk on these balances is considered to be negligible. Cash balances are regularly transferred to a commercial bank, from deposit with the Government Banking Service, in order to make payments. Whilst lodged with the commercial bank said deposits pose a credit risk if the commercial bank were to become insolvent during the period from receipt of monies to subsequent payment of suppliers. However, as payments are structured to minimise the period of credit risk exposure, the Trust considers that it has reduced the credit risk to an acceptable level.

Liquidity risk Liquidity risk arises if the Trust is unable to meet its obligations arising from financial liabilities. The Trust's financial liabilities mainly arise from net operating costs, which are mainly incurred under legally binding annual service agreements with local primary care trusts, and liabilities incurred through expenditure on capital projects. Other liquidity risks are loans repayable to the Foundation Trust Financing Facility.

Income from contracted activities with primary care trusts is based upon a nationally set tariff, which under Payment by Results is paid to the Trust in twelve monthly instalments throughout the year; any performance in excess of agreed targets is paid in accordance with the terms of the relevant contract. Payment by instalments allows the Trust to accurately forecast cash inflows and through the preparation and review of cash flow forecasts, as well as the controls in place governing the authorisation of expenditure, ensures that the Trust maintains sufficient funds to meet obligations as they fall due.

Market risk Market risk arises when the Trust is exposed to the risk that the fair value or future cash flows of a financial instrument will fluctuate because of changes in market prices. Market risk comprises three types of risk: currency risk, interest rate risk and other price risk.

Page 30 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS

26. Financial instruments (continued)

Currency risk The Trust receives income denominated in sterling. The Trust, on occasion, does enter in agreements to make payments in non- sterling denominated currencies. Non-sterling payments are principally short term liabilities and for non-significant amounts. Given this, the Trust does not consider that it is exposed to any material currency risk and therefore has elected not to hedge its exposure.

Interest rate risk The Trust does not enter into contracts where cash flows are determined by the use of a variable interest rate.

Other price risk The Trust enters into legally binding contracts with both its customers and suppliers that stipulate the price to be paid. As such it does not consider itself exposed to material other price risk.

26.1 Financial assets by category Loans and receivables £000

NHS receivables 8,277 Accrued income 1,902 Other receivables 2,020 Cash and cash equivalents 49,621 Total at 31 March 2012 61,820

NHS receivables 13,809 Accrued income 3,237 Other receivables 2,694 Cash and cash equivalents 41,233 Total at 31 March 2013 60,973

An analysis of any impairment of receivables is provided in note 18.1.

26.2 Financial liabilities by category Other financial liabilities £000 Borrowings 20,213 NHS payables 1,661 Other payables 5,072 Accruals 10,868 Capital payables 1,476 Provisions under contracts 1,739 Total at 31 March 2012 41,029

Borrowings 18,942 NHS payables 2,564 Other payables 8,553 Accruals 13,138 Capital payables 3,276 Provisions under contracts 617 Total at 31 March 2013 47,090

26.3 Fair value

For all of the financial assets and liabilities at 31 March 2013 and 31 March 2012 the fair value is equal to book value.

Page 31 ROYAL DEVON AND EXETER NHS FOUNDATION TRUST - ANNUAL ACCOUNTS 2012/13

NOTES TO THE ACCOUNTS

27. Accounting standards issued and not adopted

The accounts have been prepared in accordance with the 2012/13 NHS Foundation Trust Annual Reporting Manual (FT ARM) issued by Monitor. The accounting policies contained in that manual follow International Financial Reporting Standards (IFRS) and HM Treasury's Financial Reporting Manual to the extent that they are meaningful and appropriate to NHS foundation trusts. Below is a list of recent standards issued but not yet adopted in the NHS. It is not known or it is reasonably estimated that when these accounting standards are adopted they will not materially affect the Trust's annual accounts.

IFRS 7 - Financial Instruments: Disclosures

IFRS 9 - Financial Instruments: classification and measurement

IFRS 10 - Consolidated Financial Statements

IFRS 11 - Joint Arrangements

IFRS 12 - Disclosure of Interests in Other Entities

IFRS 13 - Fair Value Measurement

IAS 12 - Income Taxes amendment

IAS 1 - Presentation of financial statements, on other comprehensive income (OCI)

IAS 27 - Separate Financial Statements

IAS 28 - Associates and joint ventures

IAS 19 - (Revised 2011) Employee Benefits

IAS 32 - Financial Instruments: Presentation

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