Annual Report and Accounts 2018/19
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ANNUAL REPORT AND ACCOUNTS 2018/19 incorporating the quality account 2018/19 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 University Hospital Southampton NHS Foundation Trust Annual report and accounts 2018/19 incorporating the quality account 2018/19 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 3 ©2019 University Hospital Southampton NHS Foundation Trust 4 TABLE OF CONTENTS Overview and performance report Voluntary disclosures Welcome from our Chair 7 Equality, diversity and inclusion 78 A word from the chief executive 8 Environmental sustainability and climate change 80 Southampton Hospital Charity 84 Overview of the Trust Developments in informatics 85 Statement of purpose and activities 9 Leading research into better care 85 History of UHS 9 Investing for the future 86 Our executive team structure 10 Structure of our services 11 Quality account and quality report 2018/19 Our vision and values 12 Chief executive’s welcome 88 Our priorities, key issues and risks 13 Our approach to quality assurance 90 Our commitment to safety 90 Performance report Duty of candour 91 Going concern disclosure 16 Our commitment to staff 91 Reporting structure 16 Freedom to speak up 94 Key performance indicators 17 Our commitment to education and training 95 How we monitor performance 18 Our commitment to staffing rota gaps 96 Detailed analysis and explanation of the Our commitment to technology to support quality 97 development and performance of UHS 18 Our commitment to the Care Quality Commission 98 Regulatory body ratings 23 Our commitment to improving the environment Environmental matters 24 for our patients 100 Social, community, anti-bribery and Review of quality performance 101 human rights issues 25 Clinical research 101 Review of services 102 Accountability report CQUIN payment framework 103 Members of the Trust Board 27 Data quality 103 Trust Board purpose and structure 31 Participation in national clinical audits and Board meeting attendance record 2018/19 32 confidential enquiries 104 Well-led framework 33 How we are implementing the priority clinical Strategy and finance committee 34 standards for seven day hospital services 105 Quality committee 34 Learning from deaths 106 Audit and risk committee 35 Progress against 2018/19 priorities 109 External auditors 36 Priorities for improvement 2019/20 128 Governance code 36 Conclusion 132 Performance evaluation of Trust Board Responses to our quality account 133 and its committees 36 Statement of directors’ responsibilities 138 Remuneration 36 Independent auditor’s report 139 Countering fraud and corruption 36 Independence of external auditor 37 Quality account appendix Internal audit service 37 Appendix 1: Our quality priorities 2019/20 143 Better payment practice code 37 Appendix 2: Quality performance data 144 Statement as to the disclosures to auditors 37 Appendix 3: CQUIN data 151 Disclosures 37 Appendix 4: Clinical audit and confidential Income disclosures 38 enquiries data 154 Governance disclosures 38 Appendix 5: British Society of Urogynaecology 156 Approach to quality governance 38 Appendix 6: National clinical audit: actions to Council of Governors 40 improve quality 157 Annual remuneration statement 49 Appendix 7: Local clinical audit: actions to Remuneration and appointments committee 52 improve quality 161 Governors’ nomination committee 54 Appendix 8: Shared decision making 173 Staffing report 58 Appendix 9: Registration with the Care Quality Staff survey results 62 Commission 174 Trade union facility time 66 Statement of chief executive’s responsibilities Annual accounts as the accounting officer 69 Statement from the chief financial officer 177 Annual governance statement 70 Foreword to the accounts 178 Independent auditor’s report 179 Financial accounts and notes 186 5 OVERVIEW AND PERFORMANCE REPORT OVERVIEW AND PERFORMANCE REPORT Welcome from our chair 2018/19 was a year of change in the leadership of UHS. Following the departure of Fiona Dalton in March 2018 to run a hospital group in Canada, David French took on the role of interim chief executive officer. On behalf of the Trust Board I would like to thank David for agreeing to do so and also for doing such an outstanding job. During the year we welcomed three new non-executive directors to the Trust; Jane Bailey, Professor Cyrus Cooper and Catherine Mason. Catherine’s talents were also recognised by Solent NHS Trust and she has since left to help lead their organisation as chair. We were delighted to welcome Paula Head as chief executive in September after a rigorous and robust recruitment process. Paula’s experience as chief executive of Royal Surrey County Hospital NHS Trust and, prior to that of Sussex Community NHS Foundation Trust, shone through and we were confident that under her leadership UHS would continue to develop, grow and improve. Demand for our services continues to rise rapidly as the result of a changing demographic and other factors, and at a rate far greater than our income. Despite this our staff continue to deliver exceptional care. I was delighted that this was recognised by the Care Quality Commission in their recent inspection when they again rated us as Good. The revised NHS Long Term Plan will inevitably require us to adapt to the changing pattern of healthcare, but we do so with enthusiasm. This year has shown just how adept we are as an organisation at responding positively to change, not only rising to the challenges it presents, but thriving with it. This is evident in the significant investments we have made in the Trust’s estate this year. Phase one of our new children’s emergency department is complete thanks to the continued support of the Murray Parish Trust. We also approved one of the largest capital investments in our history with the updating and expansion of our general intensive care unit. We recognised that it was as crucial to invest, not just in the physical environment within which we provide healthcare, but within the digital environment too, acknowledging that UHS is an NHS digital exemplar. We have invested significantly in information technology to enhance accessibility and improve both patient and staff experience. We look forward with confidence to helping lead the NHS into a new phase of delivering health and care for the United Kingdom into 2019/20. Peter Hollins Chair 7 OVERVIEW AND PERFORMANCE REPORT A word from the chief executive Since arriving at UHS to take up my position as chief executive officer, I have heard and witnessed some incredible achievements by staff at the Trust. Dr Joanne Horne was named biomedical scientist of the year at the Advancing Healthcare Awards for her work in histopathology; Dr Beth McCausland, quality improvement fellow in dementia care, was named foundation doctor of the year by Royal College of Psychiatrists; Sarah Charters, consultant nurse and mental health lead for the emergency department was awarded an MBE for services to vulnerable adults and her vulnerable adult support team were also winners of a Nursing Times Award in the emergency and critical care category. The medicine for older people therapy team led by Hannah Wood was named most inspiring team at the national #EndPJParalysis awards while Marie Nelson, matron in research and development, and senior research sisters Jane Forbes and Kirsty Gladas won the silver award for clinical research site of the year at the PharmaTimes International Clinical Researcher of the Year Awards. Jean Piernicki, senior nurse manager in occupational health, was awarded the title of Queen’s Nurse in recognition of her high level of commitment to patient care and nursing practice. Fiona Chaâbane, a senior clinical nurse in neurosciences was named winner of the nursing and midwifery award at the BBC’s The One Show Patients Awards. The medicines advice service, led by Dr Simon Wills, picked up the HSJ Value Award for training and development for its medicines learning portal and Matthew Watts, head of news, was named operational services support worker of the year for the south of England at the Our Health Heroes Awards 2018. We were also delighted that the energy and sustainability team collected the clinical NHS Sustainability Award for its green wards project. These are just a few of the individual and team successes achieved this year. Our entire organisation can also be incredibly pleased and encouraged by the outcome of the recent Care Quality Commission (CQC) inspection, which rated UHS ‘good’ overall, with many individual areas being recognised as outstanding by the CQC. You can find full details of the inspection on page 98 of the quality account. Such positive inspection results link to equally positive staff survey results which saw UHS ranked as the second highest acute trust for staff satisfaction and fifth highest for staff recommending the Trust as a place to work and receive treatment. It’s made me incredibly proud to be able to say that I am part of such a driven team and it’s clear that the UHS team share my drive and determination to improve things for patients and staff every day. This is evident in both the successes I have already mentioned, but also in the pioneering work that is taking place across every department. Informatics has been pioneering new digital initiatives which they recently shared with Hadley Beeman, chief technology adviser to the secretary of state and social care. Surgeons Bhaskar Somani and Stephen Griffin have created a ‘twin surgeon’ model that has revolutionised the treatment of kidney stones in children. Dr John Paisey, consultant cardiologist, and his team were among the first in the world to implant and programme a pacemaker using Bluetooth technology. They performed four of the first five procedures in the world. While Professor Mike Grocott and his team created ‘surgery school’ which is transforming the fitness of patients prior to their operations and thereby reducing length of stay.