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Annual report and accounts 2012/2013 . Northern and Goole 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 1

. Contents 1 Forewords by the chairman and chief executive

4 About the Trust

4 • Our hospitals

4 • Our history

4 • What is a Foundation Trust

5 • Our services

6 Review of the year

6 • Medicine group, and Goole

7 • Medicine group,

8 • Surgery and critical care group

10 • Women’s and children group

11 • Community and therapy services group

14 • Directorate of diagnostics and therapeutics

19 • Path Links NHS Pathology

20 • Central operations group

22 Chief nurse directorate

28 Facilities directorate

32 Organisational development and workforce directorate

38 Clinical quality and assurance directorate

41 How the Trust is run

44 • Board of Directors

52 • Council of Governors

58 • Membership strategy

59 Annual Governance Statement

69 Head of internal audit opinion on the effectiveness of the systems of internal control 71 Financial reports and accounts

74 • Income and expenditure

79 • Remuneration report

82 • Regulatory ratings report

84 Independent auditor’s report to the Board of Governors of Northern Lincolnshire and Goole Hospitals NHS Foundation Trust 87 The Trust annual accounts

135 Annual Quality Account 2012/2013 Review of the year 1

. Chairman’s foreword

It is always a great pleasure to write the introduction to the annual report not least because it provides an opportunity to thank, in public, the Trust’s staff for the commitment and the care that they deliver on a daily basis and which is so important to the safety of our patients and the quality of the care patients receive in our hospitals. Recognition of the dedication and professionalism of our staff is even more important at a time when the changes to NHS structures and systems are gathering pace, as the financial pressure on the NHS mounts and as the NHS comes under increased scrutiny from patients, the press and the public generally in response to the report of the Francis inquiry.

This is the context for the past 12 months, which have This is an unprecedented savings target and can only undoubtedly been a very significant challenge. However, the be achieved by working in close partnership with the Trust has continued to focus on ensuring the safety and quality commissioners and the other providers to determine how of the services we provide to the communities of Northern the quality of healthcare provision can be improved and Lincolnshire and Goole while at the same time responding made more cost effective. It may be that services in the future to increasing demand for those services and maintaining a look different to how they do now with, for example, care sustainable financial position. being delivered in a community setting closer to patients’ The quality of patient care and the safety of our patients own homes. We don’t know yet the exact make-up of service remains our top priority. Despite the financial pressures, we delivery but we will continue to keep our communities have continued to invest in all three hospitals, for example informed every step of the way. in MRI scanning at Goole, haematology, oncology and It continues to be the case that the future success of the Trust rheumatology at Grimsby and the Blue Sky Imaging suite at and the quality, safety and sustainability of the Trust’s services Scunthorpe. These developments and many others are a real depends upon the skills, dedication and professionalism of all credit to the staff who have made them happen and to the of our staff. would therefore like to thank the doctors, nurses, support which the Trust has received from commissioners and allied healthcare professionals and all of the other workers in others within the local community. the Trust for their hard work and dedication over the past year. I While I feel we should be confident in the overall quality and would also like to take this opportunity to thank our governors safety of our services, I appreciate there is a shared concern and and members and the hundreds of volunteers who selflessly disappointment across the Trust about being identified as an give their time freely to support and enhance our services. outlier in terms of mortality and subsequently being included There is no room for complacency about the scale of the in Sir ’s review. However, I also know there is a challenges which we face but I am confident that by continuing shared determination to improve our mortality performance to work in partnership with staff, patients and governors and both within the hospitals and in the wider community. Linked with our commissioners and partners in the community, the to this commitment we are also determined to ensure that we quality and sustainability of the Trust’s services will be assured. understand and then incorporate all of the lessons learned from the Francis inquiry into our approach to governance and management for the future. As many people will know, nationally the NHS is required to achieve efficiency savings of £20 billion over the four year period to 2014, this is the so-called Nicholson Challenge. The national savings target translates into the need to find significant savings within the local health economy; the Trust itself expects to be required to generate savings of approximately £60 million over the course of the next four years. Dr Jim Whittingham, chairman

1 1

. Chief executive’s foreword

This year has been particularly challenging for the Trust as we continue to tackle the unprecedented efficiency savings that we and the rest of the NHS are required to achieve. While making these savings, we must ensure we provide quality, responsive, compassionate and effective healthcare services for our patients across our three hospitals. During the past year, we have been identified as an outlier in the national Summary -Level Mortality Indicator (SHMI) statistics. These figures are an issue for the whole local health community, not just the hospital trust, and as such we are working with our commissioners and other health and social care providers to make sure that all possible factors affecting this are addressed. The new state-of-the-art Blue Sky Imaging Suite, which cost £3.17 million, was opened at Scunthorpe General Hospital. Within the Trust we have established a formal sub-committee and an operational mortality task group which is investigating Goole and District Hospital has seen the expansion of its every area where there is a possibility of a higher mortality endoscopy service and ophthalmology services, as well as the ratio. introduction of a mobile MRI and CT scan service. Our work in this area is having a positive impact and we are We want to reassure everyone that positive and high quality patient seeing a gradual improvement in our monthly mortality ratio experience is at the heart of everything we do and we aim to figures. Further information about the SHMI and the work the continue with our focus on delivering high quality care for all our Trust is undertaking can be found in the Quality Report. patients. In February 2013 it was also announced that we would be one This priority is reflected within our organisational structure, of 14 NHS trusts whose mortality rates would be reviewed culture and our day-to-day work on the frontline – how by Sir Bruce Keogh. We welcome this decision as it will assist doctors and nurses treat the people in their care. It is therefore us with all of the work we have already done to improve our important that I take this opportunity to publicly thank our mortality position and provide us with an additional learning dedicated staff, at all levels, for their determination in providing opportunity to find out more what we can do to improve the safe, high quality care to patients in all of our hospitals. quality of care that we provide. I would also like to take this opportunity to recognise the We have continued to liaise closely with our regulators during multitude of health and social care organisations across the the last year and will continue to do so, especially with both area, both public and private, which have worked with the Monitor and the Care Quality Comission (CQC) in ensuring that Trust to provide integrated service provision for the local we are complying with all of our registration requirements. communities we serve. We continue to strive to ensure that the clinical safety in our hospitals is high and patients can be assured of receiving high quality treatment though we recognise there is still more work to do. In the past year we have also made great strides forwards in service delivery including: £4.4 million refurbished haematology/oncology and rheumatology unit at Grimsby’s Diana, Princess of Wales Hospital. Karen Jackson, chief executive

3 About the Trust

Northern Lincolnshire and Goole Hospitals NHS What is a Foundation Trust? Foundation Trust employs more than 7,000 staff NHS Foundation Trusts have been created to devolve and serves a local population of around 443,000 decision-making from central government to local people. organisations and communities so they are more responsive to the needs of local people. Local people, patients and staff can have a real say Our services: in the Trust’s decisions by becoming members of the The Trust runs the following hospitals: Foundation Trust. Members elect the Trust’s Council of Governors, which represents the local population. • Scunthorpe General Hospital NHS Foundation Trusts remain fully part of the NHS. • Grimsby’s Diana, Princess of Wales Hospital regulator Monitor, which is directly • Goole and District Hospital. accountable to Parliament, oversees the Trust to ensure it is acting properly as an NHS Foundation We also provide community health services in Trust. North and from a variety of locations. To find out more about becoming a member of our Foundation Trust, please see page 58.

Our history The Trust was established as a combined hospital and community Trust on April 1 2001 and achieved Foundation status on May 1 2007. community services transferred to the Trust in April 2011 under the Government’s Transforming Community Services. The Trust works in partnership with the Hull York Medical School and Medical School providing comprehensive undergraduate teaching for year three, four and five medical students.

4 Scunthorpe Diana, Princess Goole & District Community Community Our services General hospital of Wales Hospital Hospital N. Lincolnshire N. E. Lincolnshire

Medicine Accident and Emergency *Minor Injury Unit Cardiology/coronary care unit Diabetes/endocrinology Respiratory, rheumatology, neurology *rheumatology Oncology, haematology Rehabilitation medicine Dermatology Immunology Acute medicine Stroke services Surgery Lower and upper GI Day case surgery Breast ENT and ophthalmology Gastroenterology Head and neck Vascular surgery outpatient Urology Gynaecology *orthopaedic Trauma and orthopaedic surgery surgery only Maxillo-facial and oral surgery ITU and HDU Women’s and children Maternity and gynaecology Neonatal services Paediatrics *outpatients only Diagnostics Pharmacy, audiology, ultrasound, medical engineering, diagnostic IM&T General radiology, CT, MRI Breast diagnostics, nuclear medicine, physiological measurments, medical illustration Community & Therapy Community dental service Rehabilitation medicine service Adult nursing -planned (district nursing) Community specialist nursing service Children’s nursing – health visiting & school nursing Family nurse partnership Nutrition & dietetics Occupational therapy Physiotherapy Podiatry Speech & language sherapy Wheelchair service Community equipment service

Visiting consultants also provide: plastic surgery; nephrology; cardio-thoracic; specialist paediatrics and clinical genetics. 5 Review of the year

Medicine group, Scunthorpe and Medicine Goole hospitals In September 2012 the Trust achieved provisional accreditation for stroke services at all three hospital General medicine at Scunthorpe and Goole sites. Scunthorpe provides level 2 stroke care hospitals consists of teams including: acute care, which includes acute stroke, thrombolysis and cardiology, respiratory medicine, diabetes and rehabilitation; Goole provides level 4 stroke care endocrinology, gastroenterology, care of the which is rehabilitation. The Trust now offers extended elderly medicine including geriatrics and specialist hours for thrombolysis at Scunthorpe and Grimsby stroke services. and has plans in place to make this a 24/7 service in The group also includes Trust-wide medical early 2013/14. specialties consisting of: haematology, oncology, A third cardiologist, Dr Ramkumar Ramachandra, rheumatology, clinical immunology, dermatology joined the cardiology team in February 2012. Dr and neurology. Ramachandra has an interest in interventional The group has performed highly across a range of key cardiology and is undertaking percutaneous performance indicators; including 18-week referral to coronary intervention (PCI) sessions in addition to Dr treatment times and cancer waiting times. Joseph John and Dr Sudipta Chattopadhyay. Acute medicine continues to expand at Scunthorpe with the opening of a 10-bed short stay ward. Emergency medicine The service will continue to expand with the During 2012/13 the accident and emergency implementation of ambulatory emergency care in the department joined a telemedicine pilot to benefit near future. burns patients. The hi-tech system allows patients to receive remote consultation with Wakefield’s Pinderfields Hospital and Sheffield’s Northern Medical specialties General Hospital’s burns units. A portable video The Trust has extended its immunology service to conferencing telecart – which includes a camera Goole hospital with clinics commencing on a monthly and a television – enables clinicians to share high basis. definition images of the injury. They are also able to discuss the management of the patient. Previously Dermatology services have continued to expand with the patient would have needed to travel to a the increase in community clinics and development specialist burns unit for care and treatment. of light therapy services at Goole. A second clinical nurse specialist and a part-time specialty doctor have also been appointed to dermatology.

6 Medicine group, Emergency medicine Grimsby hospital The Emergency Care Centre (accident and ) provides a 24-hour urgent care service General medicine at Grimsby hospital consists with both emergency medicine and GP out-of-hours of teams including: acute care, cardiology, service in situ. It also now accommodates a paediatric respiratory medicine, diabetes and endocrinology, assessment unit dedicated to children’s emergency care. gastroenterology, care of the elderly medicine including geriatrics and specialist stroke services. The group also includes Trust-wide medical Medicine specialties consisting of: haematology, oncology, rheumatology, clinical immunology, dermatology In line with the national Stroke Strategy we are and neurology. working with local commissioners and the stroke network to develop stroke services within Northern Delivering high quality care services is our main Lincolnshire to expand on the current service objective and to support this we have embarked on provided by the specialist stroke unit at Grimsby a programme to redesign the inpatient environment, hospital. including building a new high dependency unit, acute medical unit, and a new haematology/ In September 2012 the Trust achieved provisional oncology/rheumatology inpatient, outpatient and accreditation for stroke services at all three hospital day case unit all of which opened in 2012. sites. Grimsby hospital provides level 2 stroke care which includes acute stroke, thrombolysis and Work was due to start in May 2013 to build an rehabilitation. integrated cardiology ward including a critical care unit. Two additional cardiologists have been We have extended the current stroke thrombolysis recruited with an expertise in cardiology devices service and plan to extend this to a 24/7 service and work was planned to start in July 2013 to build within the year. a cardiology day case unit to enable the highest We are looking to expand our consultant team standard of cardiology service to be delivered locally. and have recruited a consultant physician with a The consultants and clinical administration support specialist interest in respiratory medicine. With team (CAST) are located near the wards/outpatient the reconfiguration and updating of inpatient and areas to offer convenient access and assistance to outpatient facilities we hope to improve our patients’ patients and staff. experience and support our patients to access specialist services where required to ensure the best Most patients are seen for their first appointment possible clinical outcome. within a six-week target meeting the 18-week national target for referral to treatment and we also provide two-week wait appointments where GPs have made a specific request for urgent referrals. Medical specialties We recognise within the current constraints of Trust-wide medical specialty services and emergency the financial climate this will be a challenging care are currently delivered through outpatients, year to come for the team to realise these new inpatients and community outreach teams supported developments and implement these changes but by onsite diagnostic services. we are committed to work together to continue to deliver excellent standards of care.

We have extended the current stroke thrombolysis service and plan to extend this to a 24/7 service within the year.

7 Review of the year

Surgery and critical care group The surgery and critical care group provides Patients needing joint replacement care within the following specialties across the surgery are recovering quicker three hospital sites: general surgery; trauma and being sent home sooner than and orthopaedics; urology; ear, nose and throat traditionally with the introduction of (ENT), ophthalmology; maxillo facial services and a new way of working. anaesthetics and chronic pain. Regular outpatient services are also provided across a number of community and settings. In 2012/13 the specialties delivered approximately: Examples of just some of the clinical improvements in 2012/13: • 8,500 emergency reviews • 148,000 outpatient appointments Improved access to lower GI • 41,000 outpatient procedures physiological unit at Scunthorpe • 29,500 patient operations. hospital In the last 12 months the group has made significant The unit relocated from the main hospital to the improvements for patients in a number of different Lancaster Suite, which is near the Church Lane main areas including: entrance and has its own parking facilities. It was • Quality and governance of our services. This has officially opened by Trust chief executive Karen Jackson been demonstrated by a reduction in the number of in February 2013. complaints, Patient Advise and Liaison Service (PALS) The service provides outpatient clinics, investigations issues, incidents and claims across the surgery and and treatment for patients suffering from benign critical care group problems such as incontinence, constipation, prolapse • A significant improvement in waiting times. All and irritable bowel syndrome. Investigations include specialties now meet 18-week referral to treatment anorectal manometry and endoanal ultrasound and and cancer targets. The waiting times for treatment treatments include biofeedback, percutaneous tibial within surgical specialties are among some of the nerve stimulation (PTNS) and rectal irrigation. lowest in the region Joint replacement patients recovering • Improvements in clinical and administrative booking processes has meant that there have been significant quicker at Scunthorpe and Grimsby reductions in the number of cancelled or re- hospitals arranged operations or appointments for patients Patients needing joint replacement surgery are • A continued improvement in the standards and recovering quicker and being sent home sooner than quality of care for patients on our wards – including traditionally with the introduction of a new way of patient observation, management of falls, food and working. People admitted to Scunthorpe and Grimsby nutrition and infection control. hospitals for hip and knee replacements are taking part In addition the group has developed strategic plans in an enhanced recovery after surgery programme setting out where and how services are delivered across which aims to help people recover quickly and safely the hospital sites for the next three years. The group will after surgery. need to deliver efficiency and productivity savings in line This programme of care hinges on patients being active with the Trust’s financial requirements. This will be done participants before, during and after their surgery. to ensure safety and quality of care is maintained and Patients are often anxious about undergoing major improved while being delivered more efficiently. surgery and the pain they will experience. However, the programme ensures they receive clear education and information in and at their pre- assessment, and they are advised of their estimated length of stay in hospital and their date of discharge. In the past, stays in hospital after joint replacement were between 10 to 14 days. On average they are now four to five days but with this new programme they can be as low as two to three days.

8 Eye clinic expansion at Goole hospital More intensive care capacity at The ophthalmology suite at Goole underwent a radical Scunthorpe hospital expansion following the investment of over £200,000 in The intensive care unit was due to open another bed equipment and infrastructure. The unit now has state-of- and increase staffing to cope with the increased need for the-art equipment and is a centre for innovative surgical care for our local population. procedures and diagnostic imaging.

In addition, it now provides services within a new framework which integrates primary and secondary care. By involving local opticians and GPs, together Chronic pain services in the community with nurse practitioners and technicians from the In collaboration with the Trust’s community care Trust, the unit has developed a more efficient patient colleagues, the Trust has successfully won the tender for pathway, reducing the number of visits through a one- providing chronic pain services to Northern Lincolnshire stop approach and at the same retaining high quality patients. consultant-led care. This will mean more clinics based in the community, provided by multi-disciplinary professionals including physiotherapists, clinical psychologists and chronic pain Stone services consultants. The Trust can now offer our patients treatment for small kidney and ureteric stones without having to undergo surgery with the help of the new extracorporeal shock wave lithotripsy (ESWL) facility available at Grimsby hospital. With the help of this technology the small stones can be shattered by shockwaves as a day case without anaesthesia or surgery. Patients are also benefiting from percutaneous nephro lithotomy (PCNL), which is keyhole surgery. Large stones can be removed from the kidney, avoiding major surgery. In the past these patients were referred to other hospitals outside the Trust. And coming in 2013/14:

The opening of a surgical assessment unit at Grimsby hospital The hospital is currently reconfiguring wards and improving the timeliness of care for emergency surgical patients. Once the work is completed patients will have access to dedicated and senior medical and nursing assessment outside of the accident and emergency department. This will ensure more timely and appropriate decision making from specific clinicians and a shorter length of stay for patients.

Glaucoma monitoring unit at Grimsby hospital Patients at risk of glaucoma will have shorter waiting times for investigations and fewer visits to the hospital in 2013/14. The ophthalmology department is using the skills of nursing and technician staff to administer investigations, whilst using technology to ‘virtually’ assess a patient’s condition and ensure the right patients are escalated appropriately to consultants.

9 Review of the year

Women and children’s Service developments services group Children services has built on the model of care piloted in Scunthorpe in 2011/12 by developing it The women and children’s services group provides further in Grimsby and has invested in a four-bed a range of inpatient, outpatient and community medically-led assessment area in the emergency care services covering the following specialties: centre. maternity, gynecology, neonatal and paeditrics across all three of the Trust’s hospitals. It means children can be triaged and immediately seen by a paediatric middle grade and trained nurse. Throughout 2012/13 group has continued to work with colleagues in primary care and local This has reduced the number of times a child needs to authorities to provide services that are equitable and be seen by various professionals, and combined with sustainable. Services are continuing to provide short the beds for observation, allows the time to assess waiting times for both first appointments, diagnosis children without necessary admitting them to a and treatment in all specialties, including cancer, and hospital ward. the group strives to ensure that care is delivered in Public Health enabled a pilot to be undertaken where such a way that it supports care in the community. women were able to be offered a flu vaccination Communication and dialogue between health within maternity rather than having to make an professionals and patients aims to be open and appointment with their GP. transparent at all times. This year has seen the This saw vaccinations for the area go up, and 96 per implementation of an advice line for GP’s in cent of women rating the service as excellent. gynaecology at Scunthorpe hospital (which will be rolled out across the group in 2013/14) to help reduce Public Health also supported the service in outpatient appointments that could be avoided. purchasing carbon monoxide monitors to help the service emphasise the importance of stopping The services are further developing collaborative smoking, something that is a challenge locally. working. The benefits of this approach can be seen in the length of stay and emergency readmissions The women and children’s group continued to look continuing to be below their peers in some areas. for ways it could develop staff and was successful in The genuine commitment to ensuring that access to being awarded funding for training and for training services is optimised ensures funding is equipment, including simulation mannequins, to spent in the right place at the right time across the teach all staff emergency scenarios. health community. It also received funds from the Department of Health to improve and upgrade birth environments for mothers and their partners at Scunthorpe hospital, Accreditations improving their privacy and dignity, and to support staff to encourage active involvement of fathers, Maternity services achieved the Clinical Negligence building on the Parliamentary award won in 2011. Scheme for Trusts (CNST) Level 1 demonstrating its services have the policies and guidelines in place that minimise risk. It was also awarded UNICEF Baby Friendly Initiative Stage 1, which is awarded when Health promotion information pathways are clear and informative, The gynaecological cancer team built on its previous and highlights the commitment to improving the years of continued excellence in meeting national numbers of women who breastfeed. targets, and continued to promote awareness of The contraception and sexual health team was gynaecological cancers through promotion locally awarded Your Welcome accreditation, showing it on national gynaecological awareness month in the considers young people’s views and experiences to media, in public stands, and through fundraising. help shape its service developments. The children’s It also developed a new support group for women, diabetes, audiology and cancer services all received their families, carers and friends to meet up, talk and excellent feedback from their respective reviews. share their experiences. A family fun day at Scunthorpe’s Glanford Park was held in August 2012 to celebrate the 20th anniversary of the opening of the newborn intensive care unit at Scunthorpe hospital, and highlighted the important work that neonatal services continue to do.

10 Community and Notable achievements during the year have been: therapy services group • Integration of the care pathway for therapy services for adults in North East Lincolnshire The community and therapy services group through joint working with the Care Plus Group delivers therapy services for the population of North Lincolnshire, North East Lincolnshire and • Integration of therapy services and community Goole as well as community nursing services in nursing services with adult social care into North Lincolnshire and Trust-wide community co-located locality teams covering North dental services and the clinical psychology service. Lincolnshire Commissioners, staff and the people we serve all • Restructuring of the nutrition and dietetic service, recognise the importance of people being able to including the creation of a dedicated team for achieve and maintain their independence/health and children regain this as quickly, and as far as possible, whenever • Substantially reducing the waiting time for North it has been compromised. East Lincolnshire residents requiring a wheelchair The community and therapy services group works assessment with people of every age and most of our work is • Preparing for a new community based model delivered by working with other partner agencies for the management of chronic pain in line with in a variety of settings - health, social care and commissioner requirements (via the Any Qualified educational settings, as well as in people’s homes. Provider model) – this new service will create a therapeutic approach to helping people develop techniques for better management of their pain Therapy services • Development of therapy/nurse-led beds within Work was undertaken in 2011/12 to create multi- Grimsby hospital as part of the step-down disciplinary teams in North East Lincolnshire and process for people returning home following a North Lincolnshire/Goole – as a result, we now have stroke a children’s therapy team, acute therapy team (for • Establishment of our first therapy consultant inpatient services), community rehabilitation team post which will help to drive excellence in clinical and extended therapy team at both ends of the practice patch. • Securing external resources to support AHP The newly remodeled teams, which came into being research and a fully funded PhD post for in May 2012, have brought together the following occupational therapy. services: nutrition and dietetics, occupational therapy,

physiotherapy, podiatry and speech and language therapy. Community nursing services The changes mean that, in conjunction with partner Adult nursing services include the district nursing organisations, we are able to look at how we use service, specialist nursing teams such as Macmillan, the whole workforce to improve quality of care, continence and chronic wound and the rapid tackle variability in outcomes for people and work as response service. efficiently and flexibly as possible. The changes in our population means that people are For service users, this integration means an improved living much longer and often have a combination of response to their needs and less requests to repeatedly health conditions which affect their daily life. give information and deal with a number of separate services. Collectively, our nursing services have an increasingly vital role to play in providing care to people to All the therapy teams have been engaged in working improve and maintain their overall health and enable in partnership with other agencies – in particular, them to care for themselves as much as possible. with partners in the local authorities and other health/social care providers. Of particular note is the work our teams do in supporting people with long term health conditions and the end of life care which we provide for people The changes in our population who wish to die at home. means that people are living much longer and often have a combination of health conditions which affect their daily life.

11 Review of the year

Notable achievements during the year have been: • Adoption of the wider community team by Macmillan – this includes the home • The integration of community nursing with healthcare team which provides personal care to therapy services and adult social care to create five people at home in the final stage of life. This is the locality teams across North Lincolnshire. The first first team of this type to be adopted by Macmillan locality team was established in May 2012 covering and, therefore, recognises the important role they the Barton and Winterton area; the second team offer. covering the area came into being in early 2013. Plans are in place for the roll out of the remaining three teams. This has been a significant change for the service and has been achieved at Children’s nursing services a time of considerable increase in referrals as the Our services for children include health visiting and teams have undertaken 30 per cent more visits school nursing, both of which work with children, during the last two years young people and their families to achieve the best • Improvements in pressure care management. health outcomes possible. They achieve this through Staff have been working with care homes across programmes such as screening, developmental North Lincolnshire to provide training which checks and immunisation as well as supporting will promote earlier recognition of pressure care families when children have an identified need. damage and knowledge of how to reduce the risks of such damage

12 Notable achievements during the year have been: Trust-wide developments • The family nurse partnership, which supports new The community and therapy services group has been parents with additional needs, has been judged as successful in securing five apprenticeships across one of the best performing teams in the country its services. These offer opportunities for people to in terms of the targets and outcomes for the 100 gain essential work based skills and they will make an families recruited to the programme increasing contribution to the care we offer through our • The additional health visiting resources which services. have been made available through the national programme ‘Call for Action’ means we are now able to provide ante-natal visits for some Recognition for our services families – this is important in improving the local rates of breastfeeding and reducing smoking in As a Trust we continue to promote the work we do pregnancy, both of which are cause for concern at a regional and national level in order to share among our local population best practice and recognise the work of the staff we employ. During 2012/13, our staff have been • The school nursing service has reviewed its recognised through a number of national awards: systems of working to improve its ability to provide a responsive service. As a result of these changes, • The Communication Aids Resource Team there is no longer a delay in responding to new (CART) has been recognised as a model of good referrals (which have increased by 40 per cent), practice in the national commissioning guidance waiting times for the enuretic clinic have been produced for communication aid provision significantly reduced and vaccination targets have • The Foundation Certification for Rehabilitation been exceeded. and Reablement, which involves facilitators from both the Trust and local authority staff, was a Community dental service finalist in the national training awards scheme in The community dental service has successfully the category of ‘Macro Employer of the Year’ completed the dental survey for all children aged five • The Respect programme, which involves across North and North East Lincolnshire. This survey speech and language therapists working with will provide important information on which to plan magistrates, police and the youth offending services for the future and has required significant service to reduce the number of young people in additional work by the team to ensure it was the criminal justice system, won the top award in completed on time. the national Shine a Light scheme • Our specialist physiotherapist in adult learning disability has been invited to join the National AHP Clinical pyshchology service (Allied Health Professionals) Clinical Expert database which recognises the most eminent individuals in The service as been successful in the recruitment of their field. staff to posts which will support people following a stroke. This will prove to be extremely beneficial for patients and their families. Recuitment to other newly funded posts are also anticipated.

We have introduced apprentices in many areas and have taken a pride in seeing these new staff integrate into the departments and NHS life.

13 Review of the year

Directorate of diagnostics and community and reduced length of stay in hospital by seven-day working. therapeutics The directorate has supported this challenge Diagnostic services, pharmacy and Path Links are by following a continuous process of service collectively known as the directorate of diagnostic reconfiguration and modernisation. The key to and therapeutic services. It provides a range of meeting the challenge is to increase productivity services including: general radiology; ultrasound levels at a lower unit cost ie diagnostic and (obstetric and non obstetric); CT; MRI; audiology; therapeutics must be able to maintain services physiological measurements; medical illustration; and service quality, keep pace with rising demand medical engineering; nuclear medicine, breast while delivering real reductions to pay and non-pay diagnostics and pharmacy. expenditure. The directorate wishes to acknowledge the continued The year in diagnostic and therapeutics has therefore hard work and efforts of staff at all levels that concentrated on further challenge to traditional ways have achieved service improvement over the past of working and the introduction of more flexible and year. Work of staff continues to raise the profile of responsive service provision. The need to support diagnostic and therapeutic services and we strive to seven-day work with a responsive workforce has offer an efficient, consistent high quality service to therefore being a pivotal focus. We have introduced patients. apprentices in many areas and have taken a pride in seeing these new staff integrate into the departments Diagnostics and therapeutics are now required and NHS life. to continue to build relationships with new commissioners and support the Trust in achievement The diagnostic management team has presented of a strategy to improve quality of which is also information to the workforce and Trust management supportive of successive cost improvement that allows the directorate to ensure the sustainability requirements. We have continued to see the overall of future diagnostic and therapeutic services in the demand for diagnostic services increase and they locality and develop a three to five year plan. are now required to be more accessible in order A core element to our ‘reshaping’ work has been to contribute towards improved diagnosis in the targeted at: • Workforce redesign • Process redesign • Service management changes • Consistent (regulated) quality. Diagnostics The following services are provided: • General radiology • Ultrasound (obstetric and non obstetric) • CT • MRI • Audiology • Physiological measurements • Medical illustration • Medical engineering • Nuclear medicine • Breast diagnostics • Diagnostic IM&T • Pharmacy.

14 General radiology, Grimsby hospital The use of electronic systems by referrers has allowed faster turnaround times for the booking of patient The patient flow through the general radiology appointments and has facilitated speedier patient department has been greatly improved through ultrasound appointments. redesign of the main waiting area, including more comfortable seating, new blinds and windows, and a Ultrasound, Grimsby hospital TV and a water cooler for the patients. We have also installed a separate three bayed, curtained trolley While continuing to maintain an efficient, fast area with individual call bells giving greater privacy responding ultrasound service this year, the and dignity for patients waiting on beds/trolleys. department has focused on professional development including extension of skills of qualified sonographers Two radiographers have been awarded Post in addition to training two student sonographers. The Graduate Certificates in Forensic Radiology and two student sonographers have already qualified in several other radiographers have moved from the obstetrics and are undertaking general abdominal and main radiology department to take up training gynaecological modules. posts in cross sectional imaging; this has resulted in the recruitment of four new radiographers to the We have an active clinical supervisor who is also department. a NVQ assessor overseeing the practical/ongoing training of sonographers and assisting in the NVQ General radiology, Scunthorpe hospital qualifications of healthcare assistants. Activity in the general department continues to see a This year two sonographers have obtained the PG year-on-year increase and we have performed more Certificate in musculo-skeletal (MSK) imaging and now than 65,000 patient examinations in year. There is currently run their own MSK lists. This has supported virtually no waits experienced in this area and the the capacity in MSK ultrasound provision, of which has majority of patients are seen on the day of request. been a growth area this year. The team has also further We continue to work 24 hours, seven days a week improved the skill mix within breast diagnostics by and work closely with the accident and emergency enabling a sonographer to perform interventional department and the medical admissions unit to work including aspirations and biopsies. provide a responsive service to trauma patients and Staff working in obstetric ultrasound have undertaken emergency admissions. nuchal translucency training through the Fetal Medicine Foundation and now provide the women of General radiology, Goole hospital the surrounding area with an enhanced detection rate This team continues to provide a responsive local for Down’s syndrome at an early gestation. service to the GPs, the minor injuries unit and The sonographers have invested time in training inpatients, although it is acknowledged that activity and supporting several chest physicians to provide in general x-ray in Goole has dropped slightly from a bedside ultrasound guided chest drainage service. last year. We are working closely with local GP’s This will enable the Trust to be one of the first sites and providing responsive services for the local area. in the country to offer a physician-led interventional Examples of developments include mobile MRI and thorax ultrasound service in line with NICE guidance. CT provision and community ultrasound. The team is also preparing to improve access to Ultrasound, Scunthorpe hospital inpatients, DVT (deep vein thrombosis) and carotid patients at weekends and ‘out of hours’ service for GP The service moved in August 2012 to the Blue Sky Imaging direct access patients working closely with the local Suite which provides excellent ultrasound facilities in a Clinical Commissioning Group (CCG) to implement calming environment for patients and staff. the NICE guidance for suspected DVT and pulmonary There are three dedicated ultrasound rooms embolism (PE) patients. offering greater flexibility of service for both in and The team has formed a structured work experience outpatients. programme for local sixth form students interested in Within three months of opening the suite the routine a career in the health professions and are extremely ultrasound waiting list had reduced drastically and proud of providing a busy service while investing we have provided more than 19,000 non-obstetric in training and continual professional development scans this year which is an increase on last year. (CPD) for staff. The ultrasound team has ‘gone mobile’ offering scans not only at Scunthorpe and Goole but also at Barton and from the end of March in Holme on Spalding Moor; and in some GP surgeries, providing greater community access to services closer to the patients home.

15 Review of the year

CT and MRI, Scunthorpe hospital to bed pressure alerts, and to reduce the wait for our cancer scans. It has been a challenging and very productive year for this team and we have opened the new Blue Sky Despite the 12 per cent increase in CT, and the 16 per Imaging Suite, which completed on time, and both cent increase in MRI, we are managing to maintain an CT and MRI have been operational seven days per attractive waiting lists position. week since we opened in August 2012. The opening of the new CT scanner has significantly increased our capacity, due to a combination of faster CT and MRI, Goole hospital technology and more efficient working, with patients Mobile services for CT and MRI in Goole began in now being prepared, cannulated, and having their mid-March. We have publicised this service to GPs cannula removed in a dedicated area, freeing up scan and commissioners via direct communication and room time. media coverage and we had very positive responses The opening of the first static MRI unit at Scunthorpe from patients and GPs about the service. We aim to has also gone extremely well, with a small focused team evaluate the demand after three months. of our own staff being supplemented by experienced locums during the training period. Recruitment has been a challenge, but we now have CT and MRI, Grimsby hospital a full team of staff in place. We have recruited some This very busy MRI service is now providing a seven- excellent experienced staff from neighbouring areas, day service and has seen a reduction in the waiting as well as allowing the opportunity for some of our time to four weeks and it is hoped that this will be own general radiographers to rotate into CT and MRI sustained by the seven-day working week. At times to extend their competencies. throughout the year we have supplemented capacity The first cohorts of in-house trained MRI radiographers by the use of a mobile MRI van but the expectation is are almost through their training programme, and we that we will not need to use the services of the mobile are starting now to train the next group of staff. unless extenuating circumstances present in the next financial year. As is often the case with new facilities, our demand has risen dramatically in all areas, the most significant We have delivered more than 22,000 CT scans rises being inpatient and 31/62 cancer referrals. To this year and the waiting list is averaging 10 days. cope with this we have been able to reopen the old CT We have offered a six-day service and plan for the scanner and run it as well as the new scanner, reacting department to open seven days a week following staff consultation.

16 Audiology has made a significant contribution to the Trust- wide equipment procurement group which is A more robust procedure for booking patients responsible for evaluating, challenging, prioritising and managing them on the ‘Auditbase’ patient and approving all capital and charitable funded management system has reduced 18-week breaches equipment purchases. to zero at Grimsby hospital over the last six months. There has been further growth in the range of During the past year the therapeutic support offered equipment provided by the equipment library, to patients with disabling tinnitus has grown and including new ambulatory syringe drivers and we offer approximately 15 hours per week to this syringe pumps with significantly improved patient service. The service offers additional support, safety features. diagnosis and even relaxation sessions. The tinnitus handicap questionnaire shows over two thirds of patients report an improvement in the perception of their tinnitus in just a few visits. This service is now Nuclear medicine offered via GP or ear, nose and throat (ENT) referral at The department continues to flourish and Grimsby, Scunthorpe, Goole and Louth hospitals. benchmarking with other Trusts shows that the An external New Born Hearing Screening Programme department makes excellent use of the resources (NHSP) quality assessment visit for paediatric hearing available. services was not deemed necessary for this year We are working to a high standard and has been based on evidence supplied to the NHSP team, this complimented by an external regulatory audit for offers extremely pleasing assurance. its management of radiation protection and . Physiological measurements Nuclear medicine is a small specialty and the Service improvements have been implemented within department has always been keen to train its own the neurophysiology section as two new pieces of staff. One of our student technologists graduated equipment have been purchased for undertaking with a first class honours degree, obtained her nerve conduction studies and electromyography professional body qualification and now works as a (muscle tests). senior technologist. Another student is hoping to The team will also be enhanced by the on-site graduate in summer 2013. presence of a consultant neurophysiologist, who will undertake some highly specialist diagnostics in these areas. This means that patients can undergo local Breast diagnostics diagnostics and are seen by the clinician in the same setting to be given the results. It has now been a year since we acquired digital mammography. The process of learning a new Our neurophysiology student qualified in June 2012 imaging technique has been challenging, however all and gained the student of the year award. She has the staff have embraced the new technology which is since taken up a substantive post with us and is producing high quality images and streamlining the consolidating her learning with the support of the patient journey through the breast imaging process. more experienced staff. Two members of staff have passed modules at Medical engineering masters level at Leeds University: one staff member has achieved a PGcert in Mammography and a second The department has continued to develop the range has completed a breast ultrasound MSC module and is of services offered over the past year, these include currently in the process of completing an MSc. a partnership agreement with Philips Medical to maintain gamma cameras and further expansion We are currently supporting training in breast MRI of the service to support radiology and ultrasound in order to deliver a double reporting function that equipment, which has led to cost savings and provides further assurance in this modality. improvements to the service provided to equipment users. A service for testing and verifying community based dental decontamination equipment across North Lincolnshire has been established. The department

17 Review of the year

Diagnostic information management and the Yorkshire and Humber Health Innovation and Education Cluster (HIEC) and the Scunthorpe technology (IM&T) hospital medicine group on embedding behaviour WebV is an in-house developed ‘clinical portal’ that change with medicines reconciliation. This work was allows clinicians to view defined information about presented at the ‘Safety in Numbers Patient Safety individual patients in a ‘virtual’ electronic patient Innovation’ conference organised by HIEC and was record drawn from information held in different awarded joint runner-up prize. clinical systems. Easier access to this information To improve the efficiency of medicines reconciliation supports improved care delivery and decision making pharmacy staff have now obtained mobile electronic and patients can be reassured that clinical staff have access to the Connecting for Health Summary Care the information they have prioritised for safe care. Record, which contains information about patients’ The clinical portal itself is not a single product. It current medicines and allergies. This can be reviewed at is delivered by joining together a complex series the bedside while the medicines reconciliation process of products and services which work together to is undertaken. provide information for clinicians. During the year the pharmacy management team WebV is already in use by more than 2,000 users across initiated the formal tendering process which resulted the Trust providing easy access to patients’ diagnostics in Lloyds pharmacy opening community pharmacy results and continues to be developed to provide premises at both Grimsby and Scunthorpe hospitals seamless access to all clinical information. It also to dispense prescriptions for patients attending provides additional modules such as ward management hospital outpatients. and electronic patient observations - National Early This began in January 2013 and will deliver improved Warning Score (NEWS) - and work is underway to release turn-around times in the dispensing of outpatient an integrated electronic discharge module. prescriptions. The WebV project is led by the diagnostics and In December 2012 we started the implementation of therapeutics IM&T team who work closely with Trust the eMedicines management service, which allows IT colleagues and continue to work with departments the electronic transfer of prescription orders from across the Trust in helping to achieve an electronic wards to the pharmacy for dispensing. This is an health record. essential step required for the future implementation of electronic prescribing. At the end of the year the clinical pharmacy service Pharmacy was reconfigured to provide greater support to Following the implementation of the Trust-wide clinicians on wards and greater integration in to the pharmacy-led medicines reconciliation service ward-based clinical teams. last year the team undertook further work with

18 Medicines management with a proposed reconfiguration for the Scunthorpe blood sciences laboratory. Throughout the year the lead nurses for medicines management have been implementing the actions The microbiology laboratories have continued to required to improve the security of medicines on wards. work with the NHS improvement team, undertaking a Shingo self-assessment to promote a ‘lean’ way A new ‘medicines returns bin’ was introduced to of working. Some tests previously sent to reference improve the security of medicines waiting to be laboratories have been brought back in-house to returned to pharmacy and a very successful trial of an improve turnaround times. electronic/mechanical locking system for medicines cupboards has resulted in a proposal for Trust-wide The histology department has successfully become one implementation. of six national exemplar sites created as part of the NHS Improvement Pathology exemplar site programme. The raised profile of medicines security has shown a significant improvement in most areas, but further A number of laboratories from NHS Trusts around the UK work is still a priority. have now visited the department with the aim of sharing areas of good practice and promoting improvements in During the year the Trust appointed a small team to productivity and efficiency. lead the implementation of electronic prescribing. The department has developed and is implementing The team includes a , pharmacy a plan to use biomedical scientists to perform further technician, nurse and doctor who are working specimen dissection up to including complex cancer towards Trust-wide introduction of electronic cases. This has the aim of releasing consultant prescribing and medicines administration. pathologist staffing resources. It is anticipated that the work will be completed The cytology department has successfully implemented in spring 2014. During the year it was also agreed HPV testing to undertake the NHS Cervical Cancer that the same system will be used for electronic Screening triage and test of cure protocol for prescribing for chemotherapy. gynaecological cytology samples. The department The Trust, working in partnership with primary care continues to deliver a service that meets and exceeds the in North Lincolnshire and North East Lincolnshire, has national 14 day turnaround national target. formed the Northern Lincolnshire Area Prescribing All departments have been re-visited by Clinical Pathology Committee. The committee has delegated authority Accreditation (CPA) inspection teams to confirm that from each organisation to make prescribing policy changes made since the last inspection are still in place. decisions and can make commissioning/contract decisions at the same time. The Area Prescribing This was a successful visit and laboratories continue to Committee is responsible for managing the medicines hold full accreditation status. Quality and governance formulary, which is shared by all three organisations. systems continue to be developed with a focus on training during the year. Training competency documents and standard operating procedures have Path Links NHS Pathology been revised and updated. In 2012 NHS Midlands and East launched a ‘Transforming Path Links has continued its four-year ‘Reshaping Pathology Services’ open procurement of direct access Pathology’ plan, previously ratified by Trust pathology services across the East and West Midlands to Management Boards at Northern Lincolnshire and drive quality and efficiency improvements. Goole Hospitals NHS Foundation Trust and United Lincolnshire Hospitals NHS Trust (ULHT), which Effectively this allows any interested party to bid for covers all aspects of pathology services. primary care pathology services and the impact on Path Links could be the loss of GP pathology samples from Blood science laboratories, comprising haematology, Greater Lincolnshire. chemical pathology and blood transfusion, have developed further with the appointment of additional In response to this tendering process, Path Links biomedical assistant staff (band 3) to replace reductions has opened a chief executive-led dialogue with in biomedical scientist posts at band 6 and 7. neighbouring pathology services. Additional work by the Path Links Continuous These will continue in 2013 but the proposal is Improvement team has seen reconfiguration of to form a new Pathology Alliance across the East laboratory space and working practices in Lincoln and Midlands encompassing two business units. Boston. Reduction in the laboratory footprint at Boston Path Links laboratories would be incorporated has allowed an area of the building to be returned to into the ‘Path Links+’ business unit which would ULHT for use by the diabetic retinopathy department. include laboratories in Path Links plus Peterborough, Continuous improvement work will continue in 2013 Sherwood Forest, Chesterfield, and Derby.

19 Review of the year

Central operations group To mark all of the hard work of the health records team, it has received the employee of the month The central operations group is now fully embedded award from the medical director’s office. Lastly, the within the Trust structure. The group continues to team has set up a project board and work streams to provide support functions for the operational and develop the electronic patient record. corporate groups to enable the Trust to provide high quality and timely care to patients. Operation centres at Scunthorpe Health records and Grimsby hospitals The main focus for health records this year has been The operations centres at both Grimsby and to improve the tracking and quality of health records. Scunthorpe continue to develop and adapt to ensure We have worked hard to communicate to all users of a service that supports the day-to-day operability health records the importance of timely, accurate and of the Trust’s sites. Links with partner organisations appropriate tracking of health records. This campaign have been forged and strengthened to ensure any has been led by the health records manager but has operational barriers are managed in a multi-agency had the full support of the chief executive, director approach. and assistant director of operations. The operations centres are established as the ‘central The motto we are using to promote this is ‘You take it – hub’, monitoring operational activity and facilitating You track it’. On the back of this we have also developed timely management and escalation as appropriate to key performance indicators (KPI) to ensure tracking is ensure there is an appropriate response, providing a happening through the Trust and these findings are ‘step-up’ platform for the operational groups. presented to the Medical Records Committee. The operations centres’ functions have been tested With regards to the quality of health records we have and challenged on several occasions throughout the reviewed processes to ensure the records are prepared last year, including the management of resources correctly for attendances and are currently working with throughout periods of adverse weather. the clinicians to review how we split large health records The importance of maintaining operational into multi volumes and what should be in the most preparedness links with assurance requirements has current volume. led to a new role of resilience manager/operations centre manager which leads on resilience, emergency preparedness and business continuity within the Trust.

20 Planned care services Cancer services – endoscopy and outpatients Performance on cancer waiting times for 2012/13 has been maintained and as a Trust we have continued Endoscopy has shown a sustained increase in activity to achieve the national cancer targets on the whole. over and above 10 per cent predicted nationally and Cancer performance continues to be a challenge, and is predicted to maintain the same level of increase the Trust’s robust processes within cancer services, throughout 2013/14. the groups and Hull and East Yorkshire Hospitals are This is being managed by using endoscopist and reinforced on a frequent basis. nursing resources flexibly and embarking on a Over the last financial year there continues to be programme to develop the role and the number significant improvement in the quality and quantity of nurse endoscopists. Goole will play a significant of data we record within our electronic system called part in the expansion of Trust-wide endoscopy Somerset Cancer Register. services and an investment in equipment and staffing resources will enable the required flexing of capacity Over the last year, cancer services has carried out over the coming year. extensive work within the groups and with clinical multi-disciplinary team (MDT) leads to ensure data The Trust has also established joint working with that is required for the National Clinical Audit Support Louth to use any spare capacity. There has been Programmes (NCASP) within lung, bowel, head and significant capital investment in endoscopy as a neck and upper GI, has been collected and submitted whole and the Trust is mid-way through the upgrade to meet national deadlines. of decontamination units on the Scunthorpe and Grimsby hospital sites which will allow increased For the National Lung Cancer Audit the clinical MDT throughput in facilities that meet the standards leads for lung at Scunthorpe and Grimsby hospitals for decontamination. JAG (Joint Advisory Group) received a letter of recognition for submitting 100 per accreditation has continued to be a key driver for cent of the data required. developments. There are notable pressures within outpatients associated with space utilisation and short notice changes to clinics which results in additional hours. A project to understand the main issues has been undertaken with recommendations to be communicated with key stakeholders once completed. The Trust has also agreed to invest in an outpatients’ utilisation system which will allow more timely and robust recording and reporting of changes and effects on room utilisation and additional staffing.

Performance on cancer waiting times for 2012/13 has been maintained and as a Trust we have continued to achieve the national cancer targets on the whole.

21 Chief nurse directorate

The chief nurse directorate provides direction in admitted as an emergency are now screened for the Trust’s key priority areas of quality and patient dementia and an appropriate referral made to mental experience. The chief nurse leads on discussions health services as required. relating to the national nursing agenda and considers with the heads of nursing/midwifery and senior nurses in the organisation how they Learning disabilities will impact on nursing and midwifery generally and within the organisation across acute and The quality matrons continue to work closely with community settings. the learning disability specialist nurses across the health community to improve the care of patients A chief nurse strategy has been developed which aims with a learning disability. Patients are also asked to develop a nursing and midwifery culture that places for their feedback in order to influence further quality at the heart of everything we do, where we service developments. Training days and workshops deliver a positive patient experience and improved involving service users are in place to raise awareness outcomes. of living with a learning disability. The principles of the strategy include:

• Improve patient safety Falls • Ensure a positive patient experience The comprehensive falls pathway is now in use • Enhance professionalism throughout the Trust including a one hourly slips, • Improve clinical leadership close to the patient. trips and falls prevention plan. Falls incidents are monitored by the lead quality matron and a full

investigation takes place for any repeat fall or a fall Nursing contribution to quality that leads to moderate or severe injury. care Individual wards receive their falls information (taken from the falls incident report) and these are displayed Pressure ulcers in ward areas along with falls prevention posters. The quality matrons work hard to ensure there is sufficient The pressure ulcer group reviews all incidents provision of appropriate equipment available within of pressure damage, identifying the themes and the ward areas to reduce the risk of falls. ensuring lessons learned are disseminated across all areas. A new care bundle for pressure ulcer prevention has been rolled out with supportive Infection control education to ensure there is an increased focus on prevention of pressure damage. The matrons link with the existing infection prevention team and support the actions contained The quality matrons work closely with the team of within the Trust MRSA and clostridium difficile action tissue viability nurses to ensure there is a reduction plans as well as overall assistance in reducing all in the incidents of hospital acquired pressure ulcers. hospital acquired infection. The tissue viability nurses have been working hard to ensure the appropriate and sufficient replacement of specialised mattresses across the Trust. End of life care

The deputy chief nurse chairs the acute trust end of Dementia life care implementation group that works to ensure delivery of the national End of Life Care Strategy Work is ongoing to deliver innovative training to (2008). The themes of work relate to providing ensure all staff in the Trust have the appropriate skills a positive experience for patients and carers, and knowledge to deliver high quality care to patients ensuring standards of care and effective workforce with dementia. Dementia champions have been development. identified to support this work in each area and have begun to meet regularly to share good ideas and best Innovative training sessions are in place and a practice. particular focus this year has been on end of life care for patients with a non-cancer diagnosis. The One of the dementia champions has created a specialist palliative care team has worked closely 'dementia-friendly' bay on her ward and has pursued with the matrons and ward managers to improve the funding to roll out the simple ideas throughout number of patients on the Liverpool Care Pathway (LCP) the rest of the ward. All patients over the age of 75 who die in their preferred place of care.

22 It has been a challenging year in relation to the negative Quality matrons images presented in the media regarding the use of the LCP. It continues to be used as the gold standard care There are four quality matrons within the chief pathway for patients at the end of life. nurse directorate who work collaboratively with operational matrons, the infection prevention and control team and heads of nursing and midwifery to support the delivery of the Trust’s Nutrition and hydration overall objectives and service priorities. They The quality matron with lead for nutrition has have a particular focus on nursing and midwifery led a Department of Health funded pilot across practice, patient experience and safeguarding. three wards with the aim of improving the hydration They also work with departments and wards to of patients. The hydrant project is based around ensure a focus on the quality of patient care. The promoting the use of a hands-free sports bottle style quality matrons continue to monitor and drive system that makes it easier for certain patients to forward quality standards and promote a positive access drinks. patient experience.

In addition to promoting independence and Patient experience enhancing the patient experience, it aims to reduce The patient experience group continues to review urinary infections and subsequently reduce length results from local and national surveys and from of stay. Initial feedback from patients has been very other patient feedback mechanisms, monitoring positive in terms of how easy the system is to use and required actions on an over-arching action plan. how it has helped them to increase their fluid intake. The quality matron with lead for patient

Safety Thermometer experience has been instrumental in The directorate has implemented the use of the NHS preparing the Trust to implement the national Safety Thermometer, a monthly point prevalence survey 'Family and Friends Test' question which has to monitor the number of pressure ulcers, patients with been piloted and formally launched in April 2013. falls, catheter-associated urinary infection and a venous The group is reviewing how as an organisation we thromboembolism (VTE). can make better use of patient stories to improve quality of care and the patient experience. The results present the wards with their overall harm- free care rate. These are used to then celebrate success and to drive improvements where needed in the quality of patient care.

23 Chief nurse directorate

15 steps challenge Productive Ward The 15 steps challenge is a national toolkit, Principles of the ‘productive wards’ approach have underpinned by the Care Quality Commission (CQC) been used within a number of key projects. The lead Essential Standards, to assist Trusts to understand and nurse has been leading the development of a nursing identify the key components of high quality care that handover tool which will be transferred into an are important to patients and carers from their first electronic system in the future. contact with a ward. Work is also underway to promote more effective/ The productive series lead has been working efficient ward rounds as part of the seven day with patient representatives to undertake 'ward working project. The productive approach is being walkarounds' and provide structured feedback about used to inform and influence the development how patients and visitors view the ward based on of a new ward team, created from the merger of their first impressions after walking 15 steps into the two former ward teams. clinical environment. Patient representatives have

been engaged within annual ward reviews and within the pilot of the '15 steps challenge' process. Chaplaincy

It has been another challenging year for the Ward reviews chaplaincy within the Trust in terms of delivering support to patients and relatives on the wards, The annual ward review process has been reviewed particularly at times of loss and fulfilling other by the deputy chief nurse in conjunction with the obligatory duties including the provision of an on-call heads of nursing. The unannounced visits have been system. mapped to the CQC Essential Standards and an The Revd Charles Thody and the Revd Anne electronic tool has been developed. McCormick have continued to build good This provides reports and dashboards that enable relationships with ward and departmental staff. wards and departments to clearly view progress and They have also been working closely with chaplaincy use it to plan improvements in their service and care volunteers and with the voluntary services manager provided. to explore how the use of volunteers can be developed further.

The Revd Thody has also been forging links with From PEAT to PLACE local churches and ministers and reviewing the most effective way to deliver a robust on-call service to The deputy chief nurse has been preparing for the the sites. He is very keen to engage with the local transition from PEAT (Patient Environment Action church community and for them to be involved with Team) to PLACE (Patient-led Assessment of the Care providing spiritual and pastoral support. Environment). This has involved recruiting additional patient assessors and training and equipping both He is also keen to deliver training and work with patient and staff assessors to undertake the annual a wide variety of staff groups throughout the self-assessment. organisation in order to raise awareness of the service but also so staff feel better equipped to support The assessment will review the cleanliness and patients and carers. A training package in spiritual condition of the hospitals, the quality of the food awareness has been developed and has evaluated and how well privacy and dignity are maintained. well. The directorate team continues to work with other directorates to improve the environment of care The chaplaincy is also keen to review existing within these domains, as evidenced on the Trust-wide bereavement services and is continuing to look at action plan. how it can improve the services it provides where ever possible.

24 Voluntary services Safeguarding The Trust is extremely fortunate to have almost 700 The safeguarding team covers a variety of specialist volunteers, of all ages, covering our three hospital areas including child protection, adult protection, sites in a diverse range of ways that supports patients looked-after children and Prevent. Despite increasing and staff. This amounts to volunteers offering in throughput, the team has continued to provide training total more than 120,000 hours every year. Volunteers at appropriate levels in relation to child protection/ work alongside staff to enhance the quality of care adult protection and Prevent. In line with national provided to inpatients and outpatients. standards, it has provided expert advice and support and supervision to staff groups within the Trust and Having volunteers in our hospitals enhances has developed and updated policies in relation to the patient/visitor journey and also supports safeguarding children, safeguarding adults and Prevent. staff in helping them to deliver quality services. A new service at Grimsby hospital has been The ‘looked after children health’ teams are implemented working with 'Macmillan Vision' committed to ensuring all children in care of their to provide a Macmillan information and support respective local authorities have access to accurate centre. Plans are in place to open a similar centre assessments of their health needs within appropriate at Scunthorpe hospital in 2013. A similar service in timescales and all looked after children have a Goole hospital is being piloted within the outpatients health care plan in place that will inform the child’s department. overall care plan. During 2012/2013 there has been a significant increase in the number of children brought The Trust is also keen to provide trained volunteers into care. The health teams continue to develop and to assist patients at mealtimes. A small pilot has been additional funding has been received to ensure the undertaken, which was reviewed in April 2013, to services are staffed to appropriate levels to meet need. evaluate the benefits and consider expansion of the programme. Our guides service at our hospitals has The paediatric liaison team has links with been expanded with patients/visitors being escorted departments across the Trust to facilitate effective to the correct department. A number of volunteers information sharing between hospital and have been involved in a time-limited survey linked to community and also identifies child protection the review of visiting times. and significant health issues in families who access these services. Specifically during the past year, the The volunteers supply immeasurable value and we service has focused on children who fail to attend are truly grateful that these remarkable people give appointments. Liaison at Goole hospital is provided their time freely to support us. by a specialist nurse within the team.

25 Chief nurse directorate

The sudden unexpected death in children (SUDIC) The PLFs continue to provide twice-monthly mentor service is responsible for providing an appropriate updates and individual team updates to ensure response when a child dies unexpectedly within improvement with compliance. Monthly reports are the community and is part of an overall child shared with members of the Nursing and Midwifery death review process co-ordinated by the local Advisory Forum. safeguarding children boards. Following the death of The PLFs have also been working hard on engaging any child between 0-16 years, the family is contacted with all allied healthcare professionals (AHPs). Again by one of the SUDIC nurses and support is offered as this has proved challenging but improvements have required. Work is continuing ongoing to develop this been made. The PLFs have also been working hard further with links to the chaplaincy department of to source new placements both within the Trust and the Trust. externally, this being of increasing importance as A new area of work for the team in 2012/2013 services move away from traditional NHS provision. has been to co-ordinate and deliver the new As the training for nurses becomes degree level only, Prevent agenda. Prevent aims to identify vulnerable the PLFs are reviewing ways to ensure the students individuals (adult and child) who are susceptible are able to achieve the new NMC requirements for to exploitation and radicalisation with a view to more inter-professional working and ensuring they preventing further harm. have basic skills to care for all patients and those with more complex needs.

Practice learning facilitators This includes looking at different models of placements and mentorship. With the new Local During 2012/13 the practice learning facilitators (PLFs) Education and Training Boards (LTEBs) due to take have continued to work closely with clinical placement over from the SHA in April 2013, the PLFs are aware areas to ensure the Trust has sufficient capacity to of the need to ensure the LETB objectives are being accommodate its commissioned pre-registration met within the Trust with regard to quality placement student nurse numbers and to ensure it maintains the education. quality of the learning environment. The PLFs continue to ensure compliance and improve The PLFs have continued to work on improving the the quality of our placements. Work is also on- RAG (red/amber/green) rating against the Strategic going around how we can effectively utilise student Health Authority's (SHA) PPQA (Practice Placement feedback not only on placements but in relation to the Quality Assurance) standards. Although there patient experience. has been significant improvement in most areas, compliance with the Nursing and Midwifery Council (NMC) standards for mentors still remains a challenge.

26 The newly qualified preceptorship programme Delivering single sex accommodation - continues to develop through feedback. A quality matron has two regular teaching sessions to raise the privacy and dignity profile of the role and to emphasise the important role The Trust, in accordance with guidance issued since each nurse can play in ensuring the provision of high 2007, has been working to improve privacy and quality care. dignity within clinical facilities, particularly focusing on ensuring that: men and women have separate sleeping areas (eg single sex bays) and separate toilets Professional development team and bathrooms that they can reach without having to pass through (or close to) opposite sex areas. The Trust has made a smooth transition from what was previously the National Vocational Qualifications Additionally a privacy and dignity policy is in place, (NVQ) to the Qualifications Credit Framework (QCF), with a relevant action plan being in place to ensure offering qualifications in health care and assessing as all appropriate actions are taken forward. Patient part of the training assessing and quality assurance information has been developed and made available qualification. on the Trust intranet and internet sites. The Trust continues to receive outstanding Recent LINKs Enter and View visits have been reports from City and Guilds Awarding Body at its undertaken which have provided positive feedback annual inspections. The work of the professional in relation to maintenance of dignity and respect development team evolves to respond to the needs with some minor recommendations being made of staff and in response to service need. for improvement. These recommendations will be implemented and monitored by the patient The team delivers mandatory modules in dementia experience group via the privacy and dignity action awareness to health care assistants new to the Trust plan. and offers the module as a QCF diploma for other members of staff. There has also been a focus on development of clinical skills. Research and development

During 2012 the management of the research Central bank and development team transferred to the chief nurse directorate. The department offers a central The central bank has been working hard all year to corporate function within the Trust and takes an respond to requests for shift cover within the wards organisational-level lead in ensuring research is and departments, eg nursing, healthcare assistant conducted and managed to high scientific, ethical and support staff. The bank has been developing a and financial standards. hub concept that will be instrumental in improving recruitment processes across the Trust. Help and support is offered in a range of activities associated with research, which will assist researchers Due to reconfiguration, management of the central through their project pathway. These include bank has recently been transferred to the directorate protocol development, methodology, study and of organisational development and workforce. questionnaire design, randomisation, Trust approval, ethical approval and information/guidance. Programmes of research are welcomed and Electronic rostering encouraged from all areas of practice. In addition, It has been another busy year for the e-rostering team research undertaken within the Trust supports supporting roll-outs across a number of disciplines. the research portfolio of HYMS (Hull York Medical The matrons have been involved in approving rosters School). and the system has been used to provide data to inform the review of nursing establishments. Due to reconfiguration, management of the e-rostering team has recently been transferred to the directorate of finance, performance and planning.

27 Facilities

Facilities is responsible for estates maintenance, complete allocated work electronically without capital building projects, property, catering, returning to the workshop areas, saving downtime portering, cleaning, transport, car parking, and increasing efficiency. security, waste management and carbon As part of the estates rationalisation scheme, a reduction/sustainability, site utilisation and space demolition programme has taken place at Grimsby management. hospital aimed at reducing surplus temporary buildings that are no longer fit for purpose.

Estates The effective use of space has become more focused over this last year with further embedding Over this last financial year the estates team of site utilisation to provide a closer link between has supported major capital projects and delivered the reconfiguration of clinical services and estate backlog maintenance projects worth £1.8 million utilisation. Plans to rationalise the estate are in place including: and have begun at Grimsby hospital and will continue on the Scunthorpe hospital site. • Completion of Scunthorpe hospital’s Blue Sky Imaging Suite, which includes CT/MRI services The Marks and Spencer coffee shop extension at Grimsby hospital was completed in May 2012. An • Completion of the refurbishment of ward A1 to internal courtyard has been landscaped to provide produce a decant facility at Grimsby hospital outdoor space which is open to members of the • Completion of a major window replacement public and staff. scheme at Grimsby hospital • Commencement of the refurbishment of seven passenger lifts at Scunthorpe and Grimsby Transport and travel hospitals The Trust’s second travel plan was launched in • Upgrade of theatre ventilation at Grimsby January 2013 following Trust Board approval in hospital December 2012. A travel plan is a specific travel strategy to promote sustainable and active travel by • Re-surfacing of roads Trust-wide. increasing choice and reducing the need to travel. It The estates maintenance teams now use portable is a continuous, dynamic process for encouraging a digital devices that enable staff to retrieve and change in travel behaviour towards more sustainable

28 and active travel modes, as well as promoting good • Raise awareness to those who use the car parking employment practice. facility that the owner/operator has considered and, where appropriate, taken action to reduce The Trust has had its travel plan in place for the last crime within the parking facility that they have five years and a number of measures to facilitate the chosen to use. use of sustainable and low carbon travel practices (for both commute and business travel) have already Catering been implemented. The main kitchen at Scunthorpe and Grimsby The Trust was awarded a Motorvate Gold level hospitals both received their annual unannounced accreditation for the second year running for inspections from Environmental Health Officers continuing to drive down its transport carbon (EHO). Both areas received the highest award and footprint. The Trust’s footprint has reduced from therefore retained the five star status for maintaining 1,510,806kg in 2005/06 to 1,054,416kg in 2010/11 – a such high standards of food safety, hygiene and reduction of 456,390kg or 30.2%. cleanliness. This has been achieved by staff using the shuttle Trust-wide catering services entered into a bus between Grimsby and Scunthorpe hospitals, collaborative arrangement with a neighbouring the Park and Ride bus at Scunthorpe, using video NHS hospital trust in the spring of 2012. The United conferencing technology instead of travelling across Lincolnshire Hospital NHS Trust (ULHT) produces food sites and even pedal power, supported by a ‘cycle to using NHS chefs within its own central production work’ scheme. The award includes the Trust’s lease units (CPUs) based at its Lincoln and Boston hospitals. cars, pool cars and vans, and grey fleet. The meals have proved popular and both Trusts At the awards a representative of Motorvate said: “The continue to work together to ensure the best quality Trust has demonstrated a significant commitment from of food is served to patients. senior management with respect to reducing CO2 emissions throughout the organisation. This is backed up by the Carbon Management Programme and the Cleaning allocation of resources for carbon reduction and Trust- Quality standards achieved in previous years have wide sustainability projects including transport related also been maintained in other support areas such projects.” as cleaning and portering. Results of PEAT (Patient As part of the Safer Parking Scheme, the Trust has been Environment Action Team) inspections for 2012/13 for awarded the Park Mark Safer Parking Award for all of cleaning were ‘excellent’ at all sites demonstrating its car parks for the third consecutive year. The scheme is high standards and levels of patient satisfaction. The owned by the Association of Chief Police Officers and is new Patient Led Assessment of the Care Environment managed by the British Parking Association. Its purpose (PLACE) will replace PEAT in April so the Trust looks is to: forward to its patients undertaking this assessment. • Reduce crime and the fear of crime within parking facilities • Provide guidance to owners, operators and developers of parking facilities, both new and existing, on how to establish and maintain a safe and secure environment through the introduction of proven management processes, physical measures and site security systems

29 Facilities

Sustainability report The NHS aims to reduce its carbon footprint by 10 per cent between 2009 and 2015. Reducing the amount of energy used in our organisation contributes to this goal. There is also a financial benefit which comes from reducing our energy bill. Our energy costs have increased by 16 per cent in the 2012/2013, the equivalent of 89 hip operations. We have put plans in place to reduce carbon emissions and improve our environmental sustainability. Over the next 10 years we expect to save £23,530 as a result of these measures. The Trust’s director of facilities is the board level lead for sustainability, whose role is to ensure that sustainability issues have visibility and ownership at the highest level of the organisation. We recover or recycle 158.271 tonnes of waste, which is 10 per cent of the total waste we produce. Our total energy consumption has risen during the year, from 63,751 to 67,882 MWh. Our relative energy Other Rail Air Road Gas Electricity consumption has2008-2009 changed during the year,4014.52 from 0.48 to 0.52 MWh/square metre. Renewable energy6177.2 represents 10845.14 0.0 per cent of our2009-2010 total energy use. We 3800.30do not generate any energy. We have not made67.03 arrangements6151.96 to 10884.64 purchase electricity2010-2011 generated from renewable3834.32 sources. 0.99 0.12 190.24 6812 10859.77 2011-2012 3892 7.87 387.84 5975.19 10662.18 2012-2013 4101.71 6.23 4.37 785.90 6577 10816.12 Energy consumption

2008-2009

2009-2010

2010-2011

2011-2012

2012-2013

0 MWh Other Rail 7500 Air Road Gas 15000 Electricity 22500 30000 2008-2009 4014.52 6177.2 10845.14 2009-2010Other Rail 3800.30Air Road Gas Electricity67.03 6151.96 10884.64 2010-2011 3834.32 0.99 0.12 190.24 6812 10859.77 2011-2012 3892 7.87 387.84 5975.19 10662.18 2012-2013 4101.71 6.23 4.37 785.90 6577 10816.12 Our measured greenhouse gas emissions have increased by 1,362 tonnes this year.

Carbon emissions

2008-2009

2009-2010

2010-2011

2011-2012

2012-2013

0 Tonnes C2e 7500 15000 22500 30000 Other Rail Air Road Gas Electricity

30 Our water consumption has reduced by 22,909 cubic meters in the recent financial year. In 2012/13 we spent £333,284 on water.

Water consumption

2008-2009

2009-2010

2010-2011

2011-2012

2012-2013

Cubic metres 50k 100k 150k 200k 250K

During 2012/13 our gross expenditure on the CRC energy efficiency scheme was £246,696. The scheme is a mandatory scheme aimed at improving energy efficiency and cutting emissions in large public and private sector organisations. During the financial year our expenditure on business travel was £708,474. Our expenditure on waste in the last two years was incurred as follows:

£450k Expenditure on waste £400k Total waste arising £350k Waste sent to landfill £300k Waste recycled/reused £250k Waste incinerated/energy from waste £200k

£150k

£100k

£50k

£0 2011-2012 2012-2013

The Trust has an up-to-date sustainable development management plan, this is a good way to ensure that an NHS organisation fulfils its commitment to conducting all aspects of its activities with due consideration to sustainability, whilst providing high quality patient care. The NHS Carbon Reduction Strategy asks for the boards of all NHS organisations to approve such a plan. As part of this work we plan to start work on calculating the carbon emissions associated goods and services we procure. The Trust also has a sustainable transport plan because the NHS places a substantial burden on the transport infrastructure, whether through patient, clinician or other business activity. This generates an impact on air quality and greenhouse gas emissions. It is therefore important that we consider what steps are appropriate to reduce or change travel patterns.

31 Organisational development and workforce directorate

During 2012/2013 the directorate has seen many Apprentices changes happen in the way in which it provides services to the organisation. The Trust has been actively recruiting apprentices within the past year and at the end of January 2013 A dedicated team has been developed to ensure the was successful in recruiting 34 new apprentices to the organisational development and workforce strategy is organisation, bringing the total number to 48. taken forward and work commenced on engagement with our staff in the development and implementation These are undertaking a variety of training programmes of the Trust’s vision and values. In addition a staff portal under the national apprenticeship scheme from health is being developed to engage staff and provide two way care assistant to electrician. The Trust continues to communications. commit to investing in the workforce of the future and offering opportunities to local people. In order to address a range of issues involving the recruitment and deployment of staff, a Recruitment Hub has been established. This will bring together the range of functions currently involved in Equality and diversity recruitment activity. The Hub will ultimately provide The Trust secured the equality delivery system which a fully centralised recruitment service and lead enables us to provide details and evidence to ensure workforce planning for the Trust. compliance with the Equality Act. Work continues in relation to developing leadership The Trust has taken the equality objectives forward and development which builds on the work that was has a nominated non-executive director lead now with undertaken during 2011 following a Trust-wide the executive team having equality objectives set within management restructure. the annual objective setting process. The Trust is working with NHS Yorkshire and Humber as a pilot site for the Innov8 project which is about developing individuals particularly around leadership programmes and training opportunities accessed by staff which support equality, diversity and inclusion. Sickness absence The Trust, in partnership with staff side colleagues, reviewed and updated its sickness absence policy and procedure during 2012 and this is now being consistently applied to manage sickness absence across the Trust.

12 months 9 months Staff sickness absence 2011/12 2010/11 2012/13 2012/13

Days lost (long term) 55,536 38,336 44,042 44,425

Days lost (short term) 26,986 22,046 27,828 30,256

Total days lost 82,522 60,382 71,870 74,681

Total staff years 226 221 197 205

Average working days lost 19 18 17 19

Total staff employed in period 6,839 6,833 6,770 6,571

Total staff with absence in period 4,379 3,354 4,120 3,904

Total staff without absence in period 2,460 3,479 2,650 2,667

Percentage staff with no sick leave 35.97% 50.91% 39.14% 40.59%

32 Staff survey All Trusts are required to undertake a national staff survey in order to determine their employees’ perceptions of the Trust as an employer and healthcare provider. Historically the Trust has undertaken a full census survey of all staff but this year moved to a sample survey. The results of the 2012 staff survey have recently become available from which a summary is provided below.

Trust Improvement/ 2011/12 2012/13 Deterioration Response rate National National Trust Trust Average Average

% of staff having well structured appraisals 34% 54 % 30 % 51 % 4% decrease in last 12 months

Trust Improvement/ 2011/12 2012/13 Deterioration Top 4 ranking scores National National Trust Trust Average Average

% of staff experiencing physical violence from patients, 4 % 8 % 9 % 15 % 5% increase relatives or the public in last 12 months

% of staff experiencing harassment, bullying or abuse 10 % 15 % 23 % 30 % 13% increase from patients, relatives or the public in last 12 months

% of staff experiencing physical violence from staff in 0 % 1 % 2 % 3 % 2% increase last 12 months

% of staff experiencing harassment, bullying or abuse 15 % 16 % 22 % 24 % 7% increase from staff in last 12 months

Trust Improvement/ 2011/12 2012/13 Deterioration Bottom 4 ranking scores National National Trust Trust Average Average

% of staff having well structured appraisals 21% 34 % 21 % 36 % No change in last 12 months

% of staff agreeing that their role makes a difference to 89 % 90 % 84 % 89 % 5% decrease patients

% of staff appraised in last 12 months 61 % 81 % 64 % 84 % 3% increase

% of staff receiving health and safety training 76 % 81 % 62 % 74 % 14% decrease in last 12 months

33 Organisational development and workforce directorate

Work toward addressing the above concerns has Occupational health begun. This work includes developments within the internal marketing of the staff survey to staff During the year changes were made to the response rates for future years and a significant occupational health department which saw a investment to review the appraisal process. collaboration with Doncaster and Bassetlaw Hospitals NHS Foundation Trust. This has seen the occupational Reviewing the total findings of the staff survey has health service move to a nurse-led service. This determined that there is significant synergy between model has allowed the Trust to provide a service the outcomes of the staff survey and requirements which is flexible in its approach but maintains to address any concerns in the survey and the Trust’s available access to expert staff with the occupational established culture change action plan. health service. It also allows us to respond to The culture action plan, endorsed and committed to Trust incidents and manage complex cases more by the Trust Board focuses on three dominant work effectively and efficiently. streams, these being: • Social movement and workforce resilience Training and development • Leadership style and workforce development There has been a considerable change to the training • Reward and recognition. and development department over the past year. Combined these three work streams are designed to Postgraduate and undergraduate medical education establish a common purpose through our vision and and library services have moved from the medical values which is being launched in 2013, to stimulate director to the organisational development and and improve morale and to review and enhance how workforce directorate. The departments are led by we enact change management process. the head of education, training and development. The work streams proactively stimulate staff engagement through initiatives such as ‘An Audience with Karen’, ‘Meet the Chief’ and the ‘Dragons NVQ training Den’. To complement this we are investing in A number of staff have undertaken NVQ training internal communications and marketing to increase including: two people from maintenance who have staff awareness of Trust developments and the completed their Level 3 engineering; 27 learners opportunities available to them, such as those from facilities have completed Level 2 QCF in Health mentioned above. Support Services and 54 learners in care have Turning towards leadership and management achieved Level 3 (17 people) and Level 2 (37 people). style we are reviewing our internal leadership development programmes in order to achieve a greater team orientated, motivational, engaging and Management development inspirational management style. The Trust continues to provide a valued range of Complementing this investment in management multi-disciplinary management training including and leadership style and skills the work streams also an Institute of Leadership and Management (ILM) inject investment in the internal career progression endorsed first line manager programme. There have for all staff through the establishment of an also been two cohorts of coaching and mentoring internal coaching and mentoring network and the which enables participants to become a qualified establishment of value led recruitment and value led coach which will support the newly established appraisals, the later interventions coming later this coaching network. calendar year. Finally the Trust has placed an increased focus on workforce total reward and recognition. The revised reward and recognition strategy is designed to not only acknowledge staffing achievements, drive quality and stimulate NHS family inclusivity The students are well supported by but to also provide rewards which stimulate the the undergraduate medical education desired behaviours that feature in the organisations team and the wider organisation. New identified high performing culture. students have featured in local press and media expressing the positive experience they have had at our hospitals.

34 Mandatory training Postgraduate medical education Key work has been undertaken on mandatory The postgraduate medical education department training in conjunction with the mandatory trainers. continues to provide a comprehensive service of A new training needs analysis has been agreed and education and support for doctors in training, to refined reporting systems have been developed. enable them to meet their learning outcomes to The oracle learning management (OLM) function has progress. The department continues to ensure been upgraded and can now provide all staff with the standard of delivery of training meets the their own compliance record. A mandatory training requirements of various governing bodies. information system has also been developed which The Trust has made significant progress to ensure all enables staff to identify their training needs and link educational supervisors have completed the relevant them to the options available to complete the training. training to ensure the trainees are receiving high standards of supervision within their rotations. Support staff The Trust continues to deliver the requirements of the Clinical Skills and Simulation Strategy in which Support staff have been able to access a wide range doctors are given the opportunity to develop, and of courses both internally and externally which has improve their clinical practical skills in clinical skills enabled them to gain a qualification pertinent to the labs and simulated patient environments prior to role they are currently undertaking. This has been undertaking the procedure on patients. The Trust has facilitated using funding which was bid for through also held a number of successful training days which the Strategic Health Authority have been highly rated by participants Undergraduate medical The medical education team provide a number of courses which include updates in acute medicine education and intensive care seminar, transvaginal ultrasound course, advanced trauma life support course, The Trust continues to provide placements for newborn life support course, Mock PACES course medical students from both Sheffield, and Hull and many more. It also hosts the MRCP PACES and York medical schools. The students are well Examinations on behalf of the Royal College of supported by the undergraduate medical education Physicians and Surgeon Glasgow. These activities not team and the wider organisation. New students have only raise the profile of the Trust but also generate featured in local press and media expressing the income. positive experience they have had at our hospitals. There were monitoring visits from both medical schools over the year which indicated the students were having a positive learning experience in the clinical environment.

35 Organisational development and workforce directorate

Trust library services Communications and marketing The Trust libraries made further quality The communications and marketing team was improvements this year and achieved a 95 per cent restructured in 2012, including the appointment of a compliance rating against the Libraries Quality head of communications and marketing, to enable it Assurance Framework that NHS libraries are assessed to deliver a Trust-wide service encompassing media against in . This was achieved by maintaining relations, internal communications, and PR and a culture of constantly assessing, reviewing and marketing activity. surveying the services provided and adjusting them The team of four are based in Scunthorpe hospital in order to best meet user’s needs. and work with staff across all Trust sites and services. The team has been working on a new model of Internal links with the Trust’s operational groups providing e-book access to users in order to provide have been strengthened, resulting in a better flow easy access to e-books for Trust staff that are too busy of information and higher number of ‘good news’ to access the physical library environment. stories to share internally and externally. For those staff who participated in an e-book trial, we A focus on proactive media relations has seen a are happy to report that 100 per cent of them would significant increase in the number of news stories recommend the particular e-book platform we used issued and a corresponding increase in positive to a colleague. Consequently we can now work on coverage in local media. The number of media the feasibility of making the e-book access available enquiries received has also seen a large increase, and to Trust staff in general. as well as collating responses to these enquiries, the team have organised interviews and media briefings The great advantage of the particular e-book with executives, frontline staff and patients. platform we used is that the user selects the e-book titles we purchase rather than the library staff, thus New internal communications methods, such as the making the service much more responsive to the ‘weekly bulletin’, have been developed and existing users of our services. channels improved, while marketing activity has been created and implemented to promote specific messages and services to the public and to GPs, for example the Trust’s new CT and MRI scanning service at Goole hospital, and the new ‘GP News’ newsletter tailored for GPs in each locality.

A focus on proactive media relations has seen a significant increase in the number of news stories issued and a corresponding increase in positive coverage in local media.

36 Spring/Summer 2013 digital edition News Main News New MRI and CT scanning services for Goole N L G Lesley regains sight after 35 years Your N Local A&E gets thumbs up from CQC

Trust mortality rates under scrutiny April 2013 Are you up to date Hospitals New system to keep patients hydrated In this issue: with your mandatory 15 steps challenge accepted ❖ Woman regains sight Also in the issue after 35 years Trust to feature in BBC 2 Embrace programme Services combine to communicate with young ❖ Staff SuperDraw training? winners New mums to get extra support from peers New paediatricians join the Trust ❖ Safe and Sound sessions Hospital to provide support for carers Linked

80 new students join for HYMS placements ❖ Changes to IT features Trust transport gets the gold again Main Story - Mortality taking the helpdesk necessay steps Interactive help for travellers to Goole hospital ❖ Call for first Family Pages - Communicating with the young responders Spotlight - Lloyds awarded pharmacy contract Staff news - Warm welcome to Spotlight - New Macmillan support centre - Grimsby new staff and new job roles ❖ New 15 steps Find out what to do Spotlight - Improved bowel services at Scunthorpe Transport - Out & About challenge on page 2... around the Trust and community Cover story: Spotlight - New PTNS treatment & Hand surgery Spotlight on hospital and Blue sky imaging community service developments Spotlight - New technique aids quicker recovery gets Royle opening Click to read Contact me with Governor and membership Whats on. Events for govenors, members & everyone news views and events your news If you have a news story you Foundation Trust members newsletter previous 1 next would like to share then home please contact marketing and communications officerlisa. [email protected] or call her on SGH 2529. The deadline for May’s newsletter is Monday April 18 2013. Lottery draw Who did Dr. Dosh pay a visit to? (see page 5) Cover picture by Guy Hageman

37 Clinical quality and assurance directorate

Clinical audit Quality assurance The Trust continues to manage a comprehensive Quality assurance is a key priority for the programme of clinical audit, which incorporates all the organisation. During 2012/13 a lot of work has been major priorities such as national audit requirements, invested in this area to ensure the Trust is able to have NHS Litigation Authority requirements, etc. ‘board to ward’ assurance that any quality of care concerns are identified and addressed proactively. The work described above in relation to the NICE dashboards supports this work. In order to monitor the key priorities of the National Institute for Health and Clinical Excellence organisation, a monthly quality report is published (NICE) guidance continues to be published regularly. which outlines the quality priorities the Trust has The Trust has invested resource during the year agreed and the progress towards meeting them. This to monitor compliance with such guidance. The is presented to the quality and patient experience development and increased publication of NICE committee and also the Trust Board and the overall Quality Standards is the next key challenge for the findings are published in the Annual Quality Account. organisation to ensure this guidance is absorbed within the organisation and used appropriately. The quality assurance work around the mortality agenda has already begun to use these quality standards Mortality to evaluate care delivery in specific ‘pathway’ or As a result of the Trust’s own monitoring of mortality ‘specialty’ specific areas, but much more work is key outcome measures, a number of quality planned for this area during 2013/14. assurance processes have been developed. This is to ensure that appropriate quality surveillance data is made available and reported to the operational Health Assure from Allocate teams. This is so they can constantly improve the Software quality of care provided to our patients. Such work includes the development of a ‘trigger tool’ review of Health Assure is an online governance solution used all cases of mortality to escalate any cases meeting by more than 120 NHS Trusts in England and was a pre-defined list of ‘triggers’ for review by a senior introduced in the Trust in January 2011. The system medical colleague and/or a senior nursing colleague, is designed to allow contributors (‘owners’ and dependant on the trigger. During 2013/14, this ‘sponsors’) of standards to whom the responsibility process will become imbedded as a routine quality for demonstrating compliance has been delegated, assurance process assessing all such cases on an to record their own self-assessment of compliance ongoing basis thus providing timely and relevant with these standards and allows for evidence to be information on which clinical teams can act on. Plans added to support such assessments. During 2013/14, are in place to expand this review work still further to this is a key priority for the organisation to ensure encapsulate the care given to patients managed after continued use of the system. discharge in the North Lincolnshire area by the Trust’s community and therapy services teams. During this financial year, the Trust commissioned Health Assure to develop a number of interactive The results of this quality surveillance tool are dashboards within the current system allowing supported by a suite of comprehensive data reports greater pro-active management of quality available from the Trust’s information team which go performance and risk within the organisation. The together to make up the monthly mortality report vision for this project was the compilation of a which is another useful tool for the Trust Board to number of different quality indicators in one place seek assurance from. allowing ‘drill-down’ to ward level performance for Further detail in relation to the work undertaken each of these indicators. This provides more ‘board with regards to mortality can be found in the Annual to ward’ oversight of quality performance and Quality Account. allows appropriate resources to be targeted on areas requiring additional support. This project, while still underway, has resulted in a lot of interest from other NHS organisations who acknowledge its benefits. This too will remain a key priority for 2013/14.

38 Document control e-learning programmes to support the flexible training arrangements needed for our health care The Trust recognises the importance of professionals. effective management of procedural and other documentation (document control) as an element Further work has continued on developing and of governance arrangements and an aid to assuring maintaining the Trust’s risk register, with continued patient safety, and is committed to a comprehensive, review and monitoring of the Trust’s risk register systematic approach. The dedicated Trust document confirm or challenge group, to ensure that risks controller has continued to make refinements are appropriately graded. This enables appropriate to the document control system process such as prioritisation/ranking of risks on the risk register, and spreadsheet tools linking evidence of approval and in turn ensures that investment decisions target the equality assessments. Work on managing information most significant risk issues. In addition, the quarterly for patients has also been continued during this time. non-executive director review and challenge process provides on-going assurance to the Trust Board that risks of all kinds are being appropriately identified, Risk management assessed and managed. A number of risk prevention work programmes have The Trust’s risk management and governance been developed and continue to be developed. arrangements have been further strengthened by the introduction of a new directorate of clinical and quality assurance. Information governance The new directorate sees the formation of a new central team of risk and governance facilitators, each The risk and governance service is responsible for working to a group, with key responsibilities for ensuring the Trust operates within the legislative supporting the organisation in its risk management framework for information governance, together and governance arrangements. The team is with appropriate confidentiality standards as supported by a risk and governance co-ordinator, defined within the Caldicott guidelines. The Trust’s who leads and supports the team in a co-ordinated information governance steering group, which approach to risk management. reports to the Trust governance committee, is responsible for monitoring and reporting on the The Trust has in place a range of mechanisms for organisation’s compliance with the legislative reporting incidents and raising concerns with both requirements in respect of information governance. a long standing well-embedded paper-based The risk and governance team supports various work incident form, which is widely used throughout the programmes which support the organisation in organisation, and an online incident reporting system ensuring the required standards are met. which is also now well-embedded. These enable staff easy access to report incidents with quicker review and actions by the organisation. Claims There is significant emphasis on learning lessons and ‘closing the loop’ following incidents, complaints In 2012/13, there has been an increase in both the and claims. A number of mechanisms have been number of clinical and non-clinical claims received developed and strengthened with renewed focus compared with 2011/12. There continues to be an on feedback directly to individuals. Mechanisms also increased emphasis on the importance of learning include regular analysis reports, newsletters, use of lessons from claims, following the risk management the intranet and via local directorate governance initiative introduced by the NHS Litigation Authority groups and team meetings. in February 2010. Consequently there is a renewed focus on the Trust’s systems to identify and learn Work is continuing on developing a range of training lessons arising from claims, in particular looking to programmes to further strengthen the organisation’s address the same type claims and reduce the number risk management arrangements. This is focusing of these claims. on investigations and learning from incidents, complaints and claims. Key to this is ensuring staff Work at both group level and centrally within the have access to appropriate training, advice and risk and governance team continues to ensure support to enable pro-active management of risk. appropriate actions are taken in response to identified learning points. The Trust has continued to embed training and support for Consent to Examination or Treatment and the Mental Capacity Act and Deprivation of Liberty Safeguards with the launch of a series of

39 Clinical quality and assurance directorate

Health and safety Infection control The electronic health and safety system was The Trust continues to maintain progress with the transferred onto the supplier’s secure network during reduction of healthcare associated infections. This this year allowing increased development of its use year we had three cases of MRSA bacteraemias which and enhanced auto-notifications. An added benefit is is one lower than the previous year. that upgrades are instant and new version upgrades Despite a reduction in the absolute cases of hospital are included in the maintenance schedule. All this acquired C. difficile (37 plus one for Goole Neuro was done at no additional cost to the Trust. Rehabilitation Unit, versus 45 for last year) the In addition the opportunity was taken to review all organisation was unable to hit the limit of 34 set for the existing assessment recorded on the system the Trust. A multi modal approach has been taken to and now a consolidation programme is being reduce and maintain these low numbers. implemented which will reduce the number of As reflected in the community at large and on a assessments by combining where appropriate or national scale, the Trust has experienced a high having single assessment for a number of areas. number of cases of norovirus which has necessitated The vocera/solotraxx lone worker system continues a number of bay and full ward closures. to be expanded into areas where lone working is The team continues to monitor a wide range of now undertaken and work has been ongoing to infections and other indicators which are scrutinised improve the system. More work is planned to use by the infection control committee and Trust Board. the capabilities of the wireless infrastructure to take into notifications of location of equipment, fire There has been further strengthening of cross alarm activations etc and this work will continue into boundary working in the North Lincolnshire 2013/14. community with the transfer of community and therapy services to the Trust. The Trust’s safety management system has been audited over the year to develop an action plan for 2013/14 to enable the Trust to achieve a higher award level than that determined after an external audit. Fire safety management is now embedded into the directorate and a review of all high risk and moderate risks has now been completed and the assessments updated on the system. A review of the practical training highlighted options for bringing this in- house to offer greater capacity and flexibility for delivery to staff and this was completed in the latter half of 2012/13. Training sessions have commenced and an extensive programme will be implemented in 2013/14 to increase the numbers trained. Fire safety management in new/refurbishment programmes continues to be integrated within working procedures and overall action plans have been developed for each site. This work includes on- going development of emergency and contingency plans to give guidance in such events.

40 How the Trust is run

41 How the Trust is run

Operation of the Board of Responsibilities of the Council of Governors include: Directors and the Council of • Provide a response when consulted by the Board of Directors Governors • Appointment and dismissal of the chairman and The operation of the Board of Directors is described other non-executive directors in detail in the Trust Constitution. In general terms, however, it has responsibility for the business functions • Setting the salary and conditions of employment of the Trust. The board exercises its powers directly of the chairman and non-executive directors through sub-committees, and through delegation to • Appointment of, and if appropriate, removal of members of staff. the Trust’s external financial auditors The sub-committees of the Board of Directors • Acceptance of the Trust’s Annual Accounts and include; audit, finance, remuneration and terms the Auditor’s Report on them and the Annual of service, charitable funds, local awards, facilities Report and information committee, trust governance and assurance, quality and patient experience, infection • To approve the appointment of the chief control and mortality performance. The Board of executive. However, the Council will not appoint Directors meets monthly. The decisions typically the chief executive. made by the board would include:

• Approval, or otherwise, of Trust policies The appointments process for the chairman, chief • Approval, annually, of Trust business and financial executive and the other directors of the Trust plans Executive directors are appointed by a committee consisting of the non-executive directors, the • High level direct operational decisions (as defined chairman and the chief executive (except when a in the Scheme of Delegation) chief executive is being appointed). • Establishment of and appointment to, sub- The non-executive directors themselves, including committees and working groups as required. the chairman, are appointed by the Council of Governors. In making those appointments, however, the Council has to apply certain criteria for eligibility Council of Governors and also to take account of the views of the Trust Board as to the particular skills required. Northern One of the key differences in the management Lincolnshire and Goole Hospitals NHS Foundation arrangements of a Foundation Trust is that the Trust has adopted the following process to make sure Board of Directors is no longer accountable to the that all of these requirements are met. Department of Health, but to the local community which it serves. In practice, it is the Council of Governors which acts as proxy for the community and it is an important part of the role of the Nominations Committee Governors to ensure that the Board of Directors does This is a sub-committee of the Trust Board, not breach the organisation’s terms of authorisation which oversees the process for identification and as a Foundation Trust. nomination of candidates for all directors’ posts, There are at least four full meetings of the Council of including that of chairman and the chief executive. Governors annually and all of these are held in public. The committee regularly reviews the structure, size In addition to these there are several working groups and composition of the Board of Directors and makes including steering, membership, training and local recommendations for changes where appropriate. It involvement network groups. also gives full consideration to succession planning, taking into account the challenges and opportunities facing the NHS Foundation Trust and the skills and expertise required on the board. The Nomination Committee evaluates the balance of skills, knowledge and experience on the board and, in the light of this evaluation, prepares a description of the role and capabilities required for a particular appointment of an executive director.

42 Appointment of executive Appointment of chairman directors The process for the appointment of a chairman is essentially the same as for other non-executive The Nominations Committee identifies suitable directors. There are, however, two further eligibility candidates to fill executive director vacancies as they criteria to be taken into account: arise. It evaluates their skills against the description of capabilities required, and makes recommendations No individual who is simultaneously a chairman of to the chairman, the other non-executives directors another NHS Foundation Trust can be appointed as and (except in the case of the appointment of a chief chairman executive) the chief executive, who are responsible On appointment, the chairman must meet the for making the appointment. In accordance with the criteria for independence as specified in the Trust constitution, the appointment of a chief executive Constitution. requires the approval of the Council of Governors.

Appointment of non-executive directors The Nominations Committee identifies suitable candidates to fill non-executive director vacancies as they arise (this is carried out by advertisement and open competition) and supplies a shortlist to the Appointments and Remuneration Committee, which is a sub-committee of the Council of Governors. The Appointments and Remuneration Committee evaluates the skills of candidates against the description of capabilities required and makes a recommendation on the appointment to the Council of Governors. Candidates for non-executive director positions are required to provide the Council of Governors with details of their other significant commitments, with a broad indication of the time involved, and also to provide an undertaking that they will have sufficient time to fulfil their role. Additionally, the Trust constitution specifies that non-executive directors must be members of the Trust and so candidates must live within one of the specified public constituencies. It is only the Council of Governors that has the authority to appoint non-executive directors. In making such appointments, however, the council must have regard to the recommendations of the Appointments and Remuneration Committee, the other commitments of candidates, and the views of the Board of Directors on the qualifications, skills and experience required for the position.

43 Executive directors and non-executive directors who served during 2012/2013

Trust Board of Directors There is close co-operation between the directors of the Trust and the governors to allow directors to appreciate the views of governors and members. In particular, directors routinely attend the meetings of the Council of Governors. In addition, all sub groups of the Council of Governors have at least one non-executive director member whose remit includes informing the Trust Board of the discussions which have taken place and the decisions made.

Dr Jim Whittingham Chairman Jim was born and brought up in Scunthorpe. He studied at the University of Sheffield and was awarded a PhD in 1979. He subsequently worked in IT in vehicle leasing before joining the University of Humberside in Hull. Jim undertook a wide range of management roles with the university including in finance, HR, registry, student services, MIS and IT before being appointed as a pro vice chancellor in 1996. As pro vice chancellor, Jim took a leading role in the establishment of the University of Lincoln and the development of the university’s new Brayford Pool campus in Lincoln. Jim left the university in March 2008 in order to move into interim management. He was appointed chairman of the trust in July 2010 and his current term of office ends in July 2016.

Karen Jackson Chief executive Karen has worked in the NHS since 1993, and took up a position as director of finance, information and performance at the Trust in August 2008. She started her career in the NHS at Leeds Teaching Hospital as chief financial accountant then assistant director. Her previous post was as deputy director of finance at Sheffield Teaching Hospitals NHS Foundation Trust. Karen is a qualified chartered accountant and did her initial training at KPMG. In her spare time she is involved with a number of NHS charities as the national treasurer on a voluntary basis. She was appointed chief executive in September 2010.

Executive directors Wendy Booth Director of clinical and quality assurance and Trust secretary Wendy was appointed director of clinical and quality assurance and Trust secretary in August 2012, having previously held the posts of head of governance and Trust secretary (from 2008 to 2012), assistant director - risk management (from 2001 to 2008) and trust risk manager (from 1997 to 2001). Prior to that she worked in a variety of administration/general management roles prior to moving in to, and specialising in, governance/risk management.

44 Dr Karen Dunderdale Chief nurse Karen was born and brought up in Scunthorpe. She qualified as a nurse in 1991 and worked as a staff nurse at Scunthorpe hospital on a general medical ward before moving to coronary care. In 1996 she became a cardiac nurse specialist developing cardiac rehabilitation and heart failure services. She has contributed substantially to the development of cardiac nursing within the region and raised expectation nationally. Karen has held the position of secretary to the British Association for Cardiac Rehabilitation and vice-chair of the South Humber Research Ethics Committee. Karen attained her PhD in Quality of Life in Chronic Heart Failure in 2007 from York University. She has gone on to present her work to a variety of audiences both orally and in print. More recently Karen has held the position of assistant director of nursing focusing on the Grimsby site before becoming the chief nurse in 2011.

Nigel Myhill Director of facilities and information Nigel Myhill, who is a chartered engineer (CEng), was appointed director of facilities management in January 2009. His previous post was director of estates and facilities at Barnsley Primary Care Trust (PCT), having previously worked for the National Blood Service and Norfolk Mental Health Care NHS Trust. Nigel has also spent time in the private sector, with Center Parcs and Anglian Water PLC. He is vice-chair of the Health Estates and Facilities Management Association (HefmA), which is a national organisation representing estates and facilities professionals in the NHS.

Dr Neil Pease Director of organisational development and workforce Neil has worked in the NHS for nearly 20 years and has worked as a porter and healthcare assistant in this time. His first degree was in sports medicine. He moved in to medical education where he pioneered the use of clinical simulation in palliative care education. Previous senior management posts have included head of education and organisational development at Doncaster and Bassetlaw Hospitals. He also worked at NHS Hull on the health inequalities agenda, linking public health based projects into wider reaching initiatives. The work Neil undertook in Hull was to consolidate the link between good health, employment and educational status. His work focused on raising aspirations in health, education and employment and working in partnership with other agencies he designed an ‘Earning and Learning’ strategy for the city. Neil has also worked at Hull Kingston Rovers Rugby League Club as director of strategic development. He has published work on several themes including sports medicine, medical education and organisational development. Neil holds a Professional Doctorate from Sheffield Hallam University on the subject of organisational development. He took up his post with the trust in October 2011.

45 Executive directors and non-executive directors who served during 2012/2013

Mike Rocke Director of finance, planning and performance Mike was appointed director of finance, planning and performance in November 2010 having previously held the post of deputy director of finance within the Trust. Mike qualified as a management accountant at Harrogate Healthcare Trust and joined North East Lincolnshire NHS in 1992 having previously held posts in the NHS in Preston and Hull.

Dr Liz Scott Medical director Liz, who qualified from St Bartholomew’s Hospital Medical School in 1982, joined the Trust in March 2006 as medical director. Prior to joining the Trust, Liz was the head of the no delays team in the NHS Institute for Innovation and Improvement. Upon qualifying, she pursued a career in public health, with consultant and director posts in Hertfordshire, Northern and Yorkshire Region (during which time she led the Leeds review of acute hospital services) and Leeds. She then became the implementation director for the 2003 Consultant Contract in England.

Angie Smithson Director of operations Angie was appointed to the post of director of service and business development in January 2009 having previously held the post of divisional manager, family services. Angie qualified from Cambridge and Huntingdon School of Nursing in 1989 and held a variety of nursing posts in hospitals before moving into general management roles, including a brief spell in the private sector. She was general manager for the RNTNE Division at the Royal Free Hampstead NHS Trust before moving home to Lincolnshire in 2004.

Pete Wisher Director of diagnostics and therapeutics Pete was appointed as director in May 2011 having previously undertaken the role of Path Links divisional general manager since 2001. Pete is a qualified biomedical scientist having started in the NHS in 1979 and specialising in haematology and transfusion science. He moved to Grimsby hospital from Hull in 1985 and became the pathology manager in 1993. He has since undertaken a variety of roles including the development of the Path Links Pathology Service which has brought together all the pathology services across greater Lincolnshire and acted as project director for the Foundation Trust application between 2005 and 2007.

46 Non-executive directors

All of the non-executive directors fulfil the criteria for independence as specified in the Code of Governance.

Philip Jackson Deputy chairman Philip has lived and worked in the area since childhood. He is a chartered chemist and chartered health and safety practitioner. After a varied career in the local chemical industry in technical and managerial roles, he established his own health and safety consultancy in 1999. Involved in local politics since his late teens, Philip was a member of Grimsby Borough Council and currently represents the Waltham Ward on North East Lincolnshire Council. He is a lay member of DEFRA’s Advisory Committee on Pesticides and, in 2012, was appointed Chair of Humberside Probation Trust. In his free time, Philip plays squash and is a member of The Institute of Advanced Motorists. Philip joined the Board in 2004 and his term of office ends in April 2014.

Alan W Bell BSc Alan is a graduate of Durham University with electrical engineering qualifications which he acquired while working for BICC Plc (now Balfour Beatty) after university. He also attended the Oxford University Business Summer School in 1973. After BICC he joined Hepworth Ceramic Holdings Plc initially as marketing director and then managing director of Hepworth Industrial Plastics where he pioneered the development of uPvc windows in the UK and was also responsible for the introduction of external gas and electricity meter boxes, in British houses, made out of GRP. Following Hepworths he joined the Bowater Corporation Plc as European marketing director, a role which included him becoming chairman of numerous subsidiaries in England and Germany and completing a number of company acquisitions and disposals. He then took a significant personal shareholding in a Scottish chipboard and MDF business whose fortunes he transformed in three years to the extent that it is now a world leader in particleboard and fibreboard technology. Alan then joined the Spring Ram Corporation Plc initially as the managing director of the new 500,000 sq ft factory in Scunthorpe later as a main board director. Moving on from there he became a major shareholder, chairman and chief executive of Full Circle Industries Plc before retiring to develop a handful of smaller private businesses, one of which he still owns. He is 62 years old and his personal interests include: rugby union where he is an ex-president of Scunthorpe RUFC; restoring classic Aston Martin cars and the rebuilding of his 18th century farmhouse in the Snowdonia National park. He was appointed to the Board in August 2010 and his term of office ends in July 2013.

Ian Davey Ian is a chartered accountant with extensive commercial experience at senior management level. He is company secretary of a privately owned group of companies based at Scunthorpe. He was a founder Trustee of St Andrew's Hospice in Grimsby and is now vice-president. Ian is a deputy lieutenant for the County of Lincolnshire, and until retirement served as a lay canon of Lincoln Cathedral. He originally came from London but moved to with his family in 1966. His term of office began in July 2007 and he left the Trust in July 2012.

47 Executive directors and non-executive directors who served during 2012/2013

Neil Gammon During a 37-year career in the engineer branch of the Royal Air Force, Neil served in a dozen UK locations and in Germany and Saudi Arabia. His final post saw him commanding Royal Air Force Cosford and the Defence College of Aeronautical Engineering, where he was responsible for training aeronautical engineers for the three Services. He left the Royal Air Force in 2009 and settled with his wife in their home in Ashby cum Fenby. Neil has an Honorary Doctorate of Business Administration from the University of Lincoln, for whom he works part-time on their distance learning programme and he was appointed an Independent Member of Humberside Police Authority in May 2010. Neil retains Royal Air Force links through his presidency of both the Grimsby and Cleethorpes Branch of the Royal Air Forces Association and Number 866 () Squadron of the Air Training Corps. He is a Fellow of the Royal Aeronautical Society and the Chartered Management Institute, a Liveryman of the Worshipful Company of Scientific Instrument Makers and enjoys travel, skiing and current affairs. He joined the Board in August 2010 and his term of office ends in July 2013.

Michelle Wilson Michelle lives near Goole. Currently retired, she was employed in the NHS for 27 years, her early career was at Leeds General Infirmary and St James’s University Hospital, progressing to hold Board level posts in Hull and York. She was an active member of the Institute of Health Services Management throughout her career including elected member to the National Council of the Institute representing Yorkshire. She was also a member of the British Association of Day Surgery, the Institute of Facilities Management and an associate member of the Chartered Institute of Purchasing and Supply. Since leaving the health service, Michelle has been involved in voluntary work locally as treasurer and trustee for Home-Start Goole and District and as a volunteer advisor with Boothferry Citizen Advice Bureau (CAB). She has recently become a lay representative for the Yorkshire and Humber Deanery. Married, her hobbies include walking and scuba diving. She has no declared political activity and holds no other ministerial appointment. Michelle joined the Board in June 2008 and her term of office ends in June 2013.

Stan Shreeve FCCA Stan is a semi-retired businessman and qualified accountant with experience at board level as chief executive, chief financial officer and non-executive director in both the public and private sectors. He is used to working in change environments, with experience of evaluating, funding, integrating and reorganising businesses. He has worked extensively with venture capitalists and financial institutions. With VC backed Anker, he gained experience of pan-European management and reorganisation within a culturally diverse business. He also has experience of integrated acquisitions and reorganisation of businesses in most EU member states. He has sector experience in fast moving consumer goods (FMCG) in food - including the management and development of brands, manufacturing environments including light engineering, service based IT and software businesses. He has also worked in large multinational, small and medium enterprises (SME) and start up environments. Stan joined the Board in 2012 and his term of office ends June 2014.

48 Appointment and termination of Statement of Compliance with non-executive directors the NHS Foundation Trust Code The normal term of office of a non-executive director of Governance is three years. Removal of a non-executive director, The Trust Board and directors agree and support the other than at the end of a term of office, requires the principles set out in the NHS Foundation Trust Code approval of three-quarters of the members of the of Governance, published by Monitor on September Council of Governors. 29 2006 and updated and re-issued in March 2010. The Trust first reviewed its compliance with the Code of Governance on becoming a Foundation Trust in Appropriate board roles 2007. An action plan designed to bring the Trust into compliance with the code was first prepared, Changes to executive directors of the Trust Board monitored by the Trust Board, and signed off as being occurred during 2012/13. Whilst the Trust Board of substantially complete during 2008. A review of the Directors in its current configuration is relatively Trust’s compliance against the 2010 revisions did new, it encompasses the experience, skills and not identify any areas of non-compliance. The Trust expertise needed to ensure compliance with the is able to confirm its on-going compliance with the Code of Governance and to provide the direction and provisions within the code for the period 2012/13. leadership required to face the challenges of 2013/14.

Director’s interests The Trust Register of Directors’ Interests, which gives full details of all the relevant commercial and other interests of directors, can be viewed on the Trust website at: http://www.nlg.nhs.uk/about/Directors_interests.pdf

Director’s attendance at Trust Board meetings 31.7.12 29.1.13 25.9.12 29.5.12 26.3.13 24.4.12 26.6.12 26.2.13 28.8.12 27.11.12 18.12.12 Title Name Att. 30.10.12 Chief executive Karen Jackson 91% PPAPPPPPPPPP Chief nurse Dr Karen Dunderdale 91% APPPPPPPPPPP Medical director Dr Liz Scott 91% PPPPPPPPPAPA Director of finance, planning and performance Mike Rocke 100% PPPPPPPPPPPA Director of diagnostics and therapeutics Pete Wisher 100% PPPPPPPPPPPP Director of operations Angie Smithson 100% PPPPPPPPPPPP Chairman Jim Whittingham 91% PPAPPPPPPPPP Non-executive director Alan Bell 100% PPPPPPPPPPPP Non-executive director Neil Gammon 91% PPPPPPAPPPPP Non-executive director Stan Shreeve* 100% PPPPPPPPPPPA Non-executive director Philip Jackson** 73% PPPAPAPPAPPA Non-executive director Michelle Wilson 91% PAPPPPPPPPPP Director of clinical assurance & quality/Trust secretary Wendy Booth 100% PPPPPPPPPPPP Director of OD and workforce Dr Neil Pease 91% PPPPAPPPPPPP Director of facilities and information Nigel Myhill 82% PPPPPPPAPPAP *Ian Davey left in May 2012 **Chaired June Board Attendance 14 14 13 14 14 14 14 14 14 14 14 11 Key: P = Present A = Absent No of meetings 12 YYYYYYYYYYYY

49 Trust Board sub-committees (NB. ‘Core’ executive director members are highlighted in bold and italics.)

Frequency Reports to the Board which the Relationships and Communication with other Sub Committee Purpose Chair Executive Director/NED Membership of Meetings Committee Oversees Board Sub-Committees and the Board The chair of the Audit Committee is also the chair of the Finance Committee. Minutes of each meeting are submitted to the Finance Committee, Trust Stan Shreeve; Michelle Wilson;Neil Gammon Annual Governance Statement (previously SIC)/ Head of Governance Committee, Quality and Patient Experience Committee and the In attendance: Internal Audit Opinion Statement; Annual audit plan; Annual Oversees the establishment and maintenance of an effective system of internal control that supports the achievement of the Trust Board. Audit Committee Five times per annum Stan Shreeve Director of finance, planning and performance; external audit assurance letter organisation’s objectives. One of the NED members of the Trust Governance Committee must also be Director of clinical and quality assurance a member of the Audit Committee. One of the NED members of the new As required: Chief executive and other executive directors Quality and Patient Experience Committee must also be a member of the Audit Committee. All NEDs Chief executive; Director of finance, planning The chair of the Finance Committee is also the chair of the Audit Committee. On behalf of the Trust Board, to give detailed consideration to the Trust’s financial (and associated performance) issues in and performance; Director of operations; Director of Monthly Performance Compliance Report; Monthly Trading Minutes of each meeting are submitted to the Audit Committee and the Finance Committee order to provide the Trust Board with assurance, information on key issues and clear decision points. To have oversight of the Monthly Stan Shreeve diagnostics and therapeutics Report; Quarterly Monitor Declaration Trust Board. Minutes and relevant reports from this committee are also delivery of the capital programme. (Other executive directors to attend as the agenda dictates) submitted to the Estates Committee. All NEDs Chief executive*; Director of OD and workforce* A ‘decision record’ from each meeting is provided to the Trust Board for Remuneration and As required but no less As required: Director of finance, planning and information. Terms of Service To determine the levels of remuneration, allowances and other terms and conditions of service for the employees of the Trust. than three times per Jim Whittingham performance*; Trust secretary* Remuneration Strategy; Complex HR Issues report Confidential issues relating to the chief executive and/or executive directors Committee annum *Unless own salaries or performance assessments are are circulated to non-executive directors only. being discussed All NEDs (three named members: Jim Whittingham, Stan Shreeve and Neil Gammon) Charitable Funds Quarterly (more To oversee the management of charitable funds within defined policies and procedures. Jim Whittingham Director of finance, planning and performance (or Any specific issues requiring the attention of the Board Minutes of each meeting are submitted to the Trust Board. Committee frequently if required) deputy); Director of operations (or deputy); Chief nurse (or deputy) As required: Chief executive Neil Gammon; Jim Whittingham Local Awards To assess consultant nominations against the strict criteria set out in the guide to the Consultants’ Clinical Excellence Awards As required Angie Smithson Medical director (or deputy); Director of OD and Annual Report Minutes/outcomes from each meeting are submitted to the Trust Board Committee Scheme workforce (or deputy); Director of operations To ensure the estate and its development contribute to the business operations of the Trust. To assure the Trust Board that the Alan Bell; Jim Whittingham ; Stan Shreeve Facilities and estate is being utilised and managed effectively and efficiently. Within the context of NHS Service Planning and management Estates Strategy; Options for space utilisation; Estates Director of facilities and information; Director of Information arrangements, to consider means which will ensure the Trust identifies under-used and surplus land and property, and KPIs and benchmarking; Oversees the management and Minutes of each meeting are submitted to the Trust Board. Minutes of each Quarterly Alan Bell finance, planning and performance; As required or Committee (previously where appropriate either: uses the under-utilised asset to generate additional revenue, or, disposes of it in ways which will disposal of the estate; Oversight of the backlog investment meeting are also submitted to the Finance Committee. deputy: Director of operations; Chief nurse; Director of Estates Committee) create maximum benefit for the Trust. The latter will require approval of the Board and for protected assets approval of the programme diagnostics and therapeutics regulator also. Quarterly Trust Assurance Framework Reports; Quarterly Neil Gammon ; Michelle Wilson Risk Register Reports; Annual Statement of Internal Control The current chair of the Trust Governance Committee is a member of the Medical director; Chief nurse (or deputy); Director (SIC); Quarterly and six-monthly Risk Management; Analysis Audit Committee. of facilities and information (or deputy); Director Reports (e.g. incidents, complaints/ PALS and claims); SUIs Minutes of each meeting are submitted to the Audit Committee and Trust To oversee the development of the Trust’s governance strategy and arrangements. To assure the Trust Board that the Trust has Trust Governance and of finance, planning and performance (or deputy); (as required); Annual Review of Risk Management Strategy Board. in place the necessary controls to manage its risk exposure, meet statutory and other governance requirements and achieve Bi-monthly Neil Gammon Assurance Committee Director of OD and workforce (or deputy); Director of and Health and Safety Policy Statement; Annual Governance ‘Highlight’ or exception reports are submitted by the Trust Governance its principal objectives clinical and quality assurance Report; Annual Fire Certificate and Report; Annual IG Toolkit Committee to the Trust Board as required. Appropriate representatives from the directorates of Return; High Level Inquiry Reports and Action Plans, as The Trust Board also receives the outcome of the annual review of operations and diagnostics and therapeutics required (e.g. Mid Staffordshire etc.). External Inspection and performance of the committee. Audit Reports; Annual Equality Report Minutes of each meeting are submitted to the Trust Governance Committee, Audit Committee and the Trust Board. The quality of the patient experience has been identified as a key corporate priority within Northern Lincolnshire & Goole Quality Strategy; Annual Quality Account & Report of Philip Jackson; Neil Gammon; Alan Bell One of the NED members of the Quality & Patient Experience Committee is Hospitals NHS Foundation Trust. In accordance with established good practice and in order to ensure that the Trust has in External Assurance; Monthly Quality Report; Annual Medical Director; Chief Nurse; Director of clinical and a member of the Trust Governance Committee and one is a member of the Quality and Patient place a co-ordinated and effective approach to understanding the experience of patients who use our services and ensuring Clinical Audit Strategy and Programme; Annual Clinical Monthly Philip Jackson quality assurance; Director of operations Audit Committee. Experience Committee that the appropriate actions are taken where gaps are identified, a Board level Quality & Patient Experience Committee is in Audit Report; Patient Survey Reports and Action Plans; As required: Chief Executive and other executive directors ‘Highlight’ or exception reports are submitted by the Quality and Patient place. The Quality & Patient Experience Committee will also be responsible for overseeing the development of the Trust’s Gap Analysis and Action Plan: Monitor Quality Governance or deputies Experience Committee to the Trust Board as required. overarching Quality Strategy ensuring that the quality of care provided meets national and best practice guidance. Framework The Trust Board also receives the outcome of the annual review of performance of the committee. Neil Gammon; Jim Whittingham Minutes of each meeting are submitted to the Trust Board. To provide strategic direction for the prevention and control of healthcare acquired infections in Northern Lincolnshire and Medical director; Chief executive; Chief nurse; Director Monthly HCAI report Infection Control One of the NED members of the committee chairs the Trust Governance Goole Hospitals NHS Foundation Trust. To oversee and drive the organisation’s performance against the Trust’s infection Monthly Neil Gammon of facilities and information; Director of clinical and Monthly MRSA and C.Difficile RCA Action Plans Committee and Assurance Committee and both NED members are members also of the Prevention and Control Strategy ensuring that there is a strategic response to new legislation and national guidelines. quality assurance. Appropriate representatives from the Annual Infection Control Report Quality and Patient Experience Committee. directorates of operations and diagnostics and therapeutics Reducing mortality has been identified as a key corporate priority within Northern Lincolnshire and Goole Hospitals Jim Whittingham; Stan Shreeve Minutes of the Mortality Performance Committee will be submitted to the Mortality Performance NHS Foundation Trust. In accordance with established good practice, and in order to ensure that the Trust has in place a Medical director; Chief executive; Chief nurse; Monthly Mortality Report Quality and Patient Experience Sub-Committee and the Trust Board. Monthly Jim Whittingham Committee coordinated and effective approach to reducing mortality, a Board level Mortality Performance Committee will oversee all Director of operations; Director of clinical and quality Mortality Action Plan One of the NED members of the committee is also a member of the Quality work streams identified in the Mortality Action Plan. assurance and Patient Experience Committee.

50 Trust Board sub-committees (NB. ‘Core’ executive director members are highlighted in bold and italics.)

Frequency Reports to the Board which the Relationships and Communication with other Sub Committee Purpose Chair Executive Director/NED Membership of Meetings Committee Oversees Board Sub-Committees and the Board The chair of the Audit Committee is also the chair of the Finance Committee. Minutes of each meeting are submitted to the Finance Committee, Trust Stan Shreeve; Michelle Wilson;Neil Gammon Annual Governance Statement (previously SIC)/ Head of Governance Committee, Quality and Patient Experience Committee and the In attendance: Internal Audit Opinion Statement; Annual audit plan; Annual Oversees the establishment and maintenance of an effective system of internal control that supports the achievement of the Trust Board. Audit Committee Five times per annum Stan Shreeve Director of finance, planning and performance; external audit assurance letter organisation’s objectives. One of the NED members of the Trust Governance Committee must also be Director of clinical and quality assurance a member of the Audit Committee. One of the NED members of the new As required: Chief executive and other executive directors Quality and Patient Experience Committee must also be a member of the Audit Committee. All NEDs Chief executive; Director of finance, planning The chair of the Finance Committee is also the chair of the Audit Committee. On behalf of the Trust Board, to give detailed consideration to the Trust’s financial (and associated performance) issues in and performance; Director of operations; Director of Monthly Performance Compliance Report; Monthly Trading Minutes of each meeting are submitted to the Audit Committee and the Finance Committee order to provide the Trust Board with assurance, information on key issues and clear decision points. To have oversight of the Monthly Stan Shreeve diagnostics and therapeutics Report; Quarterly Monitor Declaration Trust Board. Minutes and relevant reports from this committee are also delivery of the capital programme. (Other executive directors to attend as the agenda dictates) submitted to the Estates Committee. All NEDs Chief executive*; Director of OD and workforce* A ‘decision record’ from each meeting is provided to the Trust Board for Remuneration and As required but no less As required: Director of finance, planning and information. Terms of Service To determine the levels of remuneration, allowances and other terms and conditions of service for the employees of the Trust. than three times per Jim Whittingham performance*; Trust secretary* Remuneration Strategy; Complex HR Issues report Confidential issues relating to the chief executive and/or executive directors Committee annum *Unless own salaries or performance assessments are are circulated to non-executive directors only. being discussed All NEDs (three named members: Jim Whittingham, Stan Shreeve and Neil Gammon) Charitable Funds Quarterly (more To oversee the management of charitable funds within defined policies and procedures. Jim Whittingham Director of finance, planning and performance (or Any specific issues requiring the attention of the Board Minutes of each meeting are submitted to the Trust Board. Committee frequently if required) deputy); Director of operations (or deputy); Chief nurse (or deputy) As required: Chief executive Neil Gammon; Jim Whittingham Local Awards To assess consultant nominations against the strict criteria set out in the guide to the Consultants’ Clinical Excellence Awards As required Angie Smithson Medical director (or deputy); Director of OD and Annual Report Minutes/outcomes from each meeting are submitted to the Trust Board Committee Scheme workforce (or deputy); Director of operations To ensure the estate and its development contribute to the business operations of the Trust. To assure the Trust Board that the Alan Bell; Jim Whittingham ; Stan Shreeve Facilities and estate is being utilised and managed effectively and efficiently. Within the context of NHS Service Planning and management Estates Strategy; Options for space utilisation; Estates Director of facilities and information; Director of Information arrangements, to consider means which will ensure the Trust identifies under-used and surplus land and property, and KPIs and benchmarking; Oversees the management and Minutes of each meeting are submitted to the Trust Board. Minutes of each Quarterly Alan Bell finance, planning and performance; As required or Committee (previously where appropriate either: uses the under-utilised asset to generate additional revenue, or, disposes of it in ways which will disposal of the estate; Oversight of the backlog investment meeting are also submitted to the Finance Committee. deputy: Director of operations; Chief nurse; Director of Estates Committee) create maximum benefit for the Trust. The latter will require approval of the Board and for protected assets approval of the programme diagnostics and therapeutics regulator also. Quarterly Trust Assurance Framework Reports; Quarterly Neil Gammon ; Michelle Wilson Risk Register Reports; Annual Statement of Internal Control The current chair of the Trust Governance Committee is a member of the Medical director; Chief nurse (or deputy); Director (SIC); Quarterly and six-monthly Risk Management; Analysis Audit Committee. of facilities and information (or deputy); Director Reports (e.g. incidents, complaints/ PALS and claims); SUIs Minutes of each meeting are submitted to the Audit Committee and Trust To oversee the development of the Trust’s governance strategy and arrangements. To assure the Trust Board that the Trust has Trust Governance and of finance, planning and performance (or deputy); (as required); Annual Review of Risk Management Strategy Board. in place the necessary controls to manage its risk exposure, meet statutory and other governance requirements and achieve Bi-monthly Neil Gammon Assurance Committee Director of OD and workforce (or deputy); Director of and Health and Safety Policy Statement; Annual Governance ‘Highlight’ or exception reports are submitted by the Trust Governance its principal objectives clinical and quality assurance Report; Annual Fire Certificate and Report; Annual IG Toolkit Committee to the Trust Board as required. Appropriate representatives from the directorates of Return; High Level Inquiry Reports and Action Plans, as The Trust Board also receives the outcome of the annual review of operations and diagnostics and therapeutics required (e.g. Mid Staffordshire etc.). External Inspection and performance of the committee. Audit Reports; Annual Equality Report Minutes of each meeting are submitted to the Trust Governance Committee, Audit Committee and the Trust Board. The quality of the patient experience has been identified as a key corporate priority within Northern Lincolnshire & Goole Quality Strategy; Annual Quality Account & Report of Philip Jackson; Neil Gammon; Alan Bell One of the NED members of the Quality & Patient Experience Committee is Hospitals NHS Foundation Trust. In accordance with established good practice and in order to ensure that the Trust has in External Assurance; Monthly Quality Report; Annual Medical Director; Chief Nurse; Director of clinical and a member of the Trust Governance Committee and one is a member of the Quality and Patient place a co-ordinated and effective approach to understanding the experience of patients who use our services and ensuring Clinical Audit Strategy and Programme; Annual Clinical Monthly Philip Jackson quality assurance; Director of operations Audit Committee. Experience Committee that the appropriate actions are taken where gaps are identified, a Board level Quality & Patient Experience Committee is in Audit Report; Patient Survey Reports and Action Plans; As required: Chief Executive and other executive directors ‘Highlight’ or exception reports are submitted by the Quality and Patient place. The Quality & Patient Experience Committee will also be responsible for overseeing the development of the Trust’s Gap Analysis and Action Plan: Monitor Quality Governance or deputies Experience Committee to the Trust Board as required. overarching Quality Strategy ensuring that the quality of care provided meets national and best practice guidance. Framework The Trust Board also receives the outcome of the annual review of performance of the committee. Neil Gammon; Jim Whittingham Minutes of each meeting are submitted to the Trust Board. To provide strategic direction for the prevention and control of healthcare acquired infections in Northern Lincolnshire and Medical director; Chief executive; Chief nurse; Director Monthly HCAI report Infection Control One of the NED members of the committee chairs the Trust Governance Goole Hospitals NHS Foundation Trust. To oversee and drive the organisation’s performance against the Trust’s infection Monthly Neil Gammon of facilities and information; Director of clinical and Monthly MRSA and C.Difficile RCA Action Plans Committee and Assurance Committee and both NED members are members also of the Prevention and Control Strategy ensuring that there is a strategic response to new legislation and national guidelines. quality assurance. Appropriate representatives from the Annual Infection Control Report Quality and Patient Experience Committee. directorates of operations and diagnostics and therapeutics Reducing mortality has been identified as a key corporate priority within Northern Lincolnshire and Goole Hospitals Jim Whittingham; Stan Shreeve Minutes of the Mortality Performance Committee will be submitted to the Mortality Performance NHS Foundation Trust. In accordance with established good practice, and in order to ensure that the Trust has in place a Medical director; Chief executive; Chief nurse; Monthly Mortality Report Quality and Patient Experience Sub-Committee and the Trust Board. Monthly Jim Whittingham Committee coordinated and effective approach to reducing mortality, a Board level Mortality Performance Committee will oversee all Director of operations; Director of clinical and quality Mortality Action Plan One of the NED members of the committee is also a member of the Quality work streams identified in the Mortality Action Plan. assurance and Patient Experience Committee.

Note: The relationship between the Trust Governance Committee and Quality and Patient Experience Committee continues to evolve. Where the core membership of a particular Board level sub-committee has been agreed, that time commitment must be honoured and the relevant director must ensure their attendance, or (in respect of executive directors) that of a suitable deputy when they are unable to attend. 51 Council of Governors

Governors 2012/2013 Composition of the Trust’s A governor forms part of the Council of Governors Council of Governors (COG) and represents the interests of Foundation The Trust’s Constitution dictates the composition of Trust members and partner organisations in the the Council of Governors. To ensure compliance with local community in the development of the Trust. the Health and Social Care Act 2012 and Monitors’ Governors hold the Trust Board to account for model core Constitution, changes to the Trust’s the performance of the Trust and also exercise Constitution were initially discussed and approved at statutory duties. The composition of the COG is set the Council of Governors’ Annual Members’ Meeting out in the Trust Constitution, and governors are held on Thursday September 27 2012, and final encouraged to act in the best interests of the Trust approval given at the Council of Governors Meeting and are bound to adhere to its values and code of on January 30 2013. The table opposite outlines the conduct. previous and new composition. Governors are the link between our members The majority of the key changes detailed above are (determining their needs/views on the delivery currently being implemented. A by-election for the of services) and the directors who make decisions Goole and Howdenshire constituency governor about the services (hold responsibility for delivery). vacancy has been held with the newly elected Governors are responsible for conveying information governor being declared on April 26 2013. It has now from the Board of Directors to members about been declared. The new composition reflects the affordability, service plans and health improvement abolition of Primary Care Trusts (PCTs) and transition initiatives. In this way the population served by the to Clinical Commissioning Groups (CCGs) as of April Foundation Trust will be directly involved in its’ 1 2013, and both GP and CCG governors will be governance. included in the group. The two local authority seats Our Council of Governors has both elected and will be made available, but neither will be allocated nominated governors with: to a specific local authority, and will instead be shared by all four qualifying local authorities. • Public governors being elected by our public members • Staff governors being elected by staff members Governors throughout 2012/2013 • Nominated governors being nominated from There were four new elections to the Council of partner organisations. Governors during the year for public governors Governors serve a term of office for up to three and two new elections for staff governors, four re- years at the end of which time they are able to offer elections of existing public governors, and two newly themselves for re-election/re-nomination (serving nominated governors from partner organisations. for a maximum of nine years in total). However, The scheduled annual elections for all constituencies governors cease to hold office if they no longer: is November, and a detailed report of the election is available on the Trust website. • Live in the area of their constituency (public governors) All governors who have served during the 2012/13 year are listed below with the dates of their terms of • Work for our Trust (staff governors); office. Where a governor’s term has ended during the • Are supported in office by the organisation that year the reason is given in parentheses. they represent (nominated governors).

52 Current and future composition of the Trust’s Council of Governors

Proposed Revised Constitution: Current Constitution: Number of Number of Electing/Appointing Body and Rationale Electing/ Appointing Body Governors Governors (where appropriate)

1 Public Constituency Governors: Constituencies Public Constituency Governors: Constituencies

North East Lincolnshire 5 North East Lincolnshire 5 North Lincolnshire 5 North Lincolnshire 5 East and 2 East and West Lindsey 2 Goole and Howdenshire 2 Goole and Howdenshire 3*

Sub-total 14 Sub-total 15*

2 Staff governors 6 Staff governors 4*

3 Primary Care Trust governors: Commissioners (PCTs replaced by CCGs)*

North East Lincolnshire Care Trust Plus 1 North East Lincolnshire 1 North Lincolnshire Primary Care Trust 1 North Lincolnshire 1 GP providers*: North East Lincolnshire 1 North Lincolnshire 1 East Riding of Yorkshire 1 Lincolnshire 1 4 Qualifying local authority governors: North East Lincolnshire Council 1 Qualifying local authority governors*: 2 North Lincolnshire Council 1

5 Qualifying medical schools: Qualifying medical schools: Hull York Medical School 1 Hull York Medical School 1

Sub-total 11 Sub-total 13

Public governor majority 3 Public governor majority 2

Total number of governors 25 Total number of governors 28

* highlights the changes

53 Council of Governors

Governor attendance at meetings • Steering Group Information about each governor’s attendance at • Steering Group and Local Involvement Network formal meetings of the Council of Governors and Groups other meetings during the 2012/13 year are detailed • Training Group. below. There have been seven formal meetings It should be noted that the information given of the Council of Governors (including the Annual below with regard to attendance at meetings is Members’ Meeting) during 2012/13, and other relevant only to the meetings that have taken place meetings attended include the Appointments and during each of the governors’ term of office. This Remuneration Committee, Quality and Patient is in respect of Kath Allen, Jeremy Baskett, Eileen Experience Committee and the following Council of Blanchard, Helen Blow, Ian Davey, Neville Dawson, Governors sub-groups: Ron Kitching, Judith Onyett, Joanna Preston and Jim • Membership Working Group Rhodes.

East and West Lindsey Council of Governors Other Meetings Mr Jeremy Baskett from 8/2/2011 to 22/9/2012 (resigned) 3 of 4 0 Mrs Sheila Fisher from 23/11/2006 to 3/12/2015 – re-elected 3/12/2012 5 of 7 2 of 5 Mrs Judith Onyett from 3/12/2012 to 27/11/2013 – newly elected 3/12/2012 1 of 2 N/A Goole and Howdenshire Council of Governors Other Meetings Mrs Susan Diack from 8/2/2011 to 27/11/2013 5 of 7 10 of 12 Mr Roy Taylor from 23//11/2011 to 3/12/2015 – re-elected 3/12/2012 6 of 7 7 of 7 North East Lincolnshire Council of Governors Other Meetings Mrs Eileen Blanchard from 4/12/2009 to 3/12/2012 (did not stand for re-election) 4 of 5 7 of 7 Miss Helen Blow from 3/12/2012 to 27/11/2013 – newly elected 3/12/2012 2 of 2 N/A Mr Philip Bond (lead governor) from 23/11/2006 to 3/12/2015 – re-elected 3/12/2012 6 of 7 12 of 12 Mr Ian Davey from 3/12/2012 to 3/12/2015 – newly elected 3/12/2012 2 of 2 N/A Mr Ron Kitching from 23/11/2006 to 5/4/2012 (resigned) None N/A Mr Jeff Shaw from 23/11/2008 to 27/11/2013 4 of 7 6 of 6 Ms Liz Stones from 23/11/2011 to 22/11/2014 6 of 7 13 of 15 North Lincolnshire Council of Governors Other Meetings Mrs Kath Allen from 3/12/2012 to 22/11/2014 – newly elected 3/12/2012 2 of 2 N/A Mr Neville Dawson from 23/11/2011 to 3/7/2012 (resigned) 1 of 3 2 of 3 Mrs Maureen Dobson from 28/11/2007 to 27/11/2013 6 of 7 15 of 15 Mr Harold Edwards from 23/11/2011 to 3/12/2015 – re-elected 3/12/2012 6 of 7 11 of 11 Mr Paul Grinell from 4/12/2009 to 3/12/2015 – re-elected 3/12/2012 6 of 7 10 of 11 Mr Hugh Rogers from 23/11/2008 to 22/11/2014 4 of 7 2 of 3 Staff Council of Governors Other Meetings Mrs Lesley Barsley from 15/3/2011 to 27/11/2013 5 of 7 5 of 10 Dr Protap Gupta from 4/12/2009 to 22/11/2014 1 of 7 1 of 4 Miss Joanna Preston from 15/3/2011 to 3/12/2012 (did not stand for re-election) 2 of 5 0 of 6 Mr Jim Rhodes from 28/11/2010 to 1/5/2012 (resigned) 0 of 1 N/A Ms Jen Smith from 3/12/2012 to 27/11/2013 – automatic election 1 of 2 N/A Dr Curtis Sonny from 3/12/2012 to 3/12/2015 – automatic election 2 of 2 N/A Nominated Governors Council of Governors Other Meetings Hull York Medical School - No representative since 6/5/2010 N/A N/A NHS North Lincolnshire Council of Governors Other Meetings Mr Ian Reekie from 5/9/2011 to 4/9/2014 4 of 7 N/A North East Lincolnshire Care Trust Plus Council of Governors Other Meetings Ms Lisa Hilder from 7/9/2012 to 19/7/2014 – newly appointed 2012 2 of 3 N/A Mrs Zena Robertson from 20/7/2011 to 7/09/2012 – (replaced) 2 of 2 N/A North East Lincolnshire Council Council of Governors Other Meetings Cllr Matthew Brown from 18/6/2012 to 18/6/2015 – newly appointed 2012, resigned February 2013 2 of 4 N/A Cllr Karl Wilson from 8/6/2011 to 18/6/2012 – (replaced) 0 of 2 North Lincolnshire Council Council of Governors Other Meetings Cllr Rob Waltham from 19/3/2012 to 19/3/2015 2 of 7 N/A

54 Declaration of interests Trust membership All governors are required to declare any material Our Trust membership consists of both public and commercial or other interests and the Trust staff constituencies with the public constituency maintains a register of these. This can be viewed by being made up of public members (who have the appointment at the Membership Office, Modular ability to vote for and elect public governors), and the Building, Scunthorpe General Hospital. Alternatively, staff constituency being made up of staff members the electronic version of the register is available on (who have the ability to elect staff governors). the Trust’s website at: http://www.nlg.nhs.uk/about/Governors_interests. pdf Public constituency It should be noted that governors’ participation in Becoming a public member of the Trust is voluntary Trust business consists of much more than purely and free of charge and is open to anyone of 16 years attendance at formal meetings. Throughout 2012/13 of age or above, who lives in an area specified below Governors have taken part in a range of activities as an area for a public constituency (subject to the including: serving on committees and working additional grounds for eligibility or disqualification groups, hosting members’ events, undertaking of members described in Annex 8 of the Trust ward review visits, and participating in membership Constitution). recruitment activities. The public constituencies are divided into four main areas as detailed in the table below:

Number of Name of Minimum governors the public Area of the public constituency by electoral wards number of to be constituency members elected The wards of: Ashby, Axholme Central, Axholme North, Axholme South, Barton, Bottesford, Brigg and North Lincolnshire Wolds, Broughton and Appleby, Brumby, and Gunness, Burton upon Stather 500 5 and Winterton, Crosby and Park, Ferry, Frodingham, Kingsway/Lincoln Gardens, Ridge and Town. The wards of: North East Croft Baker, East Marsh, Freshney, Haverstoe, Heneage, Humberston and New Waltham, 500 5 Lincolnshire Immingham, Park, Scartho, Sidney, South, Sussex, Waltham, West Marsh, Wolds and Yarborough. The wards of: Goole and Howdenshire Goole North, Goole South, Howden, Howdenshire, Snaith, Airmyn and Rawcliffe and 200 3 Marshlands. The wards of: Alford, Binbrook, , , Coningsby/Tattershall, Croft, Frithville, Grimoldby, Halton Holegate, Holton Le Clay, , Hundleby, , Legbourne, Louth North Holme, Louth Priory, Louth St James, Louth St Margarets, Louth St Marys, Louth St Michaels, Louth Trinity, Ludford, Central, Mablethorpe East, Mablethorpe North, Mareham Le Fen, Marsh Chapel, North Somercotes, North Thoresby, Roughton, Sibsey, Scarborough, Skegness East and West Seacroft, Skegness St Clements, Skegness Winthorpe, Skidbrook with Saltfleet Lindsey 200 2 Haven, , Stickney, Sutton on Sea North, Sutton on Sea South, Tetford, Tetney, Trusthorpe/Mablethorpe South, Wainfleet/Friskney, Willoughby/Sloothby, Withern with Stain, Woodhall Spa and . Bardney; ; Cherry Willingham; Dunholme; Fiskerton; Gainsborough East; Gainsborough North; Gainsborough South West; Hemswell; Kelsey; Lea; ; Middle Rasen; Nettleham; Saxilby; Scampton; Scotter; Stow; Sudbrooke; Thonock; Torksey; Waddingham & Spital; Welton; Wold View; Yarborough.

55 Council of Governors

Staff constituency Current membership Staff membership is open to individuals who The Trust has a current membership of 11,737 as at are employed by the Trust under a contract of March 12 2013, who have elected or appointed an employment provided that: active Council of Governors. The tables below and right provides a detailed breakdown: • He or she is employed by the Trust under a contract of employment which has no fixed term The membership has a similar demographic or has a fixed term of at least 12 months, or proportion to the population served by the Trust, and membership recruitment will be somewhat targeted • He or she has been continuously employed by the in 2013/14 to endeavour to ensure a representative Trust under a contract of employment for at least membership is engaged by the Trust. 12 months • All qualifying members of staff are automatically invited to become members of the Trust, but are able to opt out if they wish to do so. Individuals who exercise functions for the purposes of the Trust, otherwise than under a contract of employment, may become members of the staff constituency provided such individuals have exercised those functions continuously for a period of at least 12 months.

Figures as at 12th March 2013

Total Membership Age Group - No. % Pop * Overview Public Members Public Members 5,345 0 to 16 0 0.00% 1.58% Staff Members 6,392 17 to 21 799 14.95% 6.98% Total Members 11,737 22 + 4,546 85.05% 91.45% (Not Stated) 10 n/a n/a Total 5,345 100% 100% * Persons under the age of 16 have been excluded from the calculation of population percentages as they are not eligible for trust membership.

Not Breakdown by Constituency Male Female Total Stated Goole & Howdenshire 188 254 2 444 North East Lincolnshire 697 1460 0 2,157 North Lincolnshire 785 1,296 0 2,081 East & West Lindsey 256 407 0 663 Staff 1,089 4,993 310 6,392 Total 3,015 8,410 312 11,737

56 Socio-economic groupings (derived from IMD scores above) Class Number % Pop A,B,C1 2,870 53.70% 46.05% C2 835 15.62% 18.68% D 822 15.38% 17.72% E 818 15.30% 17.55%

Ethnicity - Public Members No. % Pop

White British 4941 93.65% 97.02% White Irish 31 0.59% 0.51% White Other 51 0.97% 0.94% Black Caribbean 2 0.04% 0.06% Black African 9 0.17% 0.09% Black Other 1 0.02% 0.02% Asian Indian 27 0.51% 0.31% Asian Pakistani 7 0.13% 0.11% Asian Bangladeshi 22 0.42% 0.14% Asian Other 9 0.17% 0.07% Other Chinese 3 0.06% 0.17% Other Other 6 0.11% 0.10% Other Not Stated 5 0.9% 0.00% Mixed White and Asian 4 0.08% 0.16% Mixed White and Black Caribbean 2 0.04% 0.13% Mixed White and Black African 1 0.02% 0.06% Mixed Other 1 0.02% 0.11% Not Stated 154 2.92% 0.00% Total 5276 100% 100%

Deprivation - Public Members (Indices of multiple deprivation - derived from postcodes)

England Quintile Number % NLAG reference comparison 1 (most deprived) 936 17.5% 36.21 - 77.43 34.23 - 86.36 2 920 17.2% 22.52 - 35.86 21.17 - 34.22 3 937 17.5% 16.08 - 22.48 13.73 - 21.16 4 1,202 22.5% 11.19 - 15.99 8.36 - 13.72 5 (least deprived) 1,350 25.3% 3.49 - 11.14 0.59 - 8.35

57 Membership strategy

Introduction Engagement with members The current membership strategy outlines the • The membership working group will help the Trust’s approach to the recruitment of, and Trust and governors to engage with members, communications with, its members, although this and will provide an annual membership plan of strategy is being re-written and updated in 2013. actions to be taken to develop engagement with members.

General principles Contact with governors The Trust is committed to achieving a membership large enough to represent the views of local people. Members who wish to discuss issues with individual Nevertheless, it recognises that size alone is not governors should make contact in the first instance necessarily a sufficient measure of success and will with the membership office. This can be done: aim for a membership that participates in Trust • by telephoning 01724 387946, activities. • by e-mailing to nlg-tr.FoundationTrustOffice@ The Trust is also committed to ensuring that all nhs.net sections of the population it serves are appropriately represented within its membership. • by writing to: The Trust recognises that it has a responsibility to Foundation Trust Membership Office consult with its membership on service change and FREEPOST: RRYL – SZKA – SYAU developments, and also to facilitate the engagement Scunthorpe General Hospital of members with the Council of Governors. Cliff Gardens Scunthorpe DN15 7BH Operation of the membership working group Membership recruitment 2012/13 In accordance with its terms of reference, the membership working group has the lead role in implementing this strategy on behalf of the Council Action Date Total of Governors. Its main areas of activity will be as Cardiology members’ event April 12 2012 2 follows:

Monitoring Governor Roy Taylor April 30 2012 5 Joint event with Accord, Navigo • In accordance with its terms of reference, May 18 2012 5 and North East Lincolnshire LINks the working group will monitor the size and composition of the membership to ensure it Normanby Hall Mini day June 17 2012 4 continues to be representative of the population Membership stand at the Pods, served by the Trust June 19 2012 0 Scunthorpe Recruitment of members Goole family fun day July 28 2012 2 • The working group will maintain and expand the membership in order to satisfy the Monitor Goole precinct Oct 12 2012 65 Compliance Framework and any other regulatory requirements. The working group will fix and Foundation Trust mailbox On-going 0 review an annual target for the growth of public membership. This target will be set out in the Members’ events On-going 0 annual membership plan Press releases for members’ events On-going 0

58 Annual governance statement 2012/2013

59 Annual Governance statement 2012/2013

1. Scope of responsibility and assurance remain on an equal footing with other organisational priorities As Accounting Officer, I have responsibility for maintaining a sound system of internal control • To ensure that governance, quality and safety that supports the achievement of the Northern are seen as the responsibility of all staff who, in Lincolnshire and Goole Hospitals NHS Foundation discharging those responsibilities, have access to, Trust’s policies, aims and objectives, whilst and support from, an appropriately skilled and safeguarding the public funds and departmental responsive governance support team assets for which I am personally responsible, in • To ensure that the Trust’s governance, quality accordance with the responsibilities assigned to me. and infection control resource is targeted in the I am also responsible for ensuring that the Northern right place at the right time with an emphasis Lincolnshire and Goole Hospitals NHS Foundation on outcomes rather than process and improved Trust is administered prudently and economically and quality and safety that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out • To ensure that during a period of inevitable in the NHS Foundation Trust Accounting Officer increased emphasis on cost effectiveness in Memorandum. healthcare, that this is not at the expense of reduced quality or poor governance in our organisation. A devolved management structure describes lines of accountability at appropriate 2. The purpose of the system levels with clear clinical and managerial leadership of internal control roles being defined. The system of internal control is designed to manage In line with the principles of devolution within the risk to a reasonable level rather than to eliminate all Northern Lincolnshire and Goole Hospitals NHS risk of failure to achieve policies, aims and objectives; Foundation Trust, and in accordance with the Scheme it can therefore only provide reasonable and not of Delegation, responsibility for the management/ absolute assurance of effectiveness. control and funding of a particular risk rests with the directorate/group concerned. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to However, where action to control a particular risk falls the achievement of the policies, aims and objectives outside the control/responsibility of that domain, of the Northern Lincolnshire and Goole Hospitals NHS where local control measures are considered to be Foundation Trust, to evaluate the likelihood of those potentially inadequate or require significant financial risks being realised and the impact should they be investment or the risk is ‘significant’ and simply realised, and to manage them efficiently, effectively cannot be dealt with at that level, such issues are and economically. escalated to the Trust governance and assurance committee, executive team or Trust Board for a The system of internal control has been in place decision to be made. in Northern Lincolnshire and Goole Hospitals NHS Foundation Trust for the year ended March 31 2013 Supporting this devolved structure are central non- and up to the date of approval of the annual report clinical directorates – including as above the new and accounts. directorate of clinical and quality assurance. These directorates have a nucleus of experienced and appropriately qualified staff to lead, support and advise staff at all levels across the organisation with 3. Capacity to handle risk the identification and management of risk. Leadership and accountability The existing organisational management structure Training illustrates the Trust’s commitment to effective governance including risk management processes. A Through the provision of a comprehensive new directorate of clinical and quality assurance was governance and risk management awareness and created on Monday September 17 2012 following an training programme – with training sessions being extensive consultation exercise. delivered both centrally and within individual directorates/groups and engaging internal and The key aims of the proposal to introduce the new external trainers, and through individual personal directorate were as follows: development, staff are trained and equipped to • To continue to raise the profile of governance by identify and manage risk in a manner appropriate to ensuring governance (and quality governance) their authority and duties.

60 The governance and risk management training experience committee. The Trust governance and programme is reviewed annually by the directorate assurance committee, on behalf of the Trust Board, of clinical and quality assurance to ensure that it routinely receives information on serious untoward remains responsive to the needs of Trust staff and a incidents (SUIs) including lessons identified and specific budget is provided to support its ongoing learned. development. The Trust actively encourages networking and There is regular reinforcement of the requirements has strong links with relevant central bodies, eg of the Trust’s mandatory training policy and National Health Service Litigation Authority (NHSLA), training needs analysis (which includes elements of Health and Safety Executive (HSE), and acts on governance and risk management training) and the recommendations/alerts from these bodies as duty of staff to complete training deemed mandatory appropriate. for their role. In order to ensure that the ‘mandatory’ The Trust continues to develop its relationship with training sessions are appropriately classified as such the Care Quality Commission (CQC) - escalating risks/ and are targeted at the correct staff groups, a review concerns in respect of patient safety/quality as they of the Trust’s mandatory training policy and training occur, together with the actions taken or proposed, needs analysis was completed during 2012/13. and in order to provide assurance that the Trust Board A revised training needs analysis has been agreed, has appropriate oversight of its quality governance/ supported by an electronic mandatory training patient safety risks. information system. The aim of the revised training The Trust also routinely considers and acts upon the needs analysis and system is to demystify mandatory recommendations of relevant national high level training and enable individual members of staff to enquiries (eg Mid Staffordshire/Francis, Colin Norris quickly and easily identify the mandatory training etc) through the use and monitoring of robust action requirements of their role, whilst also over time plans. offering a more robust monitoring and reporting system. A key focus for 2013/14 will be on ensuring an 4. The risk and control increase in compliance with mandatory training requirements. Compliance will be monitored by the framework executive team and regular reports provided to the Trust Board. The management of risk The Trust has in place a risk management strategy which is reviewed by the Trust Board annually. Control mechanisms including The Northern Lincolnshire and Goole Hospitals NHS ‘Learning Lessons’ Foundation Trust is committed to the management of risk (both clinical and non-clinical) in order A single IT risk management system (Datix) is in place to improve the quality of care; provide a safe which links all key risk elements (including incident environment for the benefit of patients, staff and reporting, complaints/PALS and claims management) visitors by reducing and, where possible, eliminating and which, in turn, informs the Trust’s risk register the risk of loss, harm or damage; and protecting its (which is also held on Datix). assets and reputation. This is achieved through a Lessons learned when things go wrong are process of identification, analysis, evaluation, control, shared throughout the organisation via a range elimination and transfer of risk. of mechanisms including safety alerts, ‘learning The Trust’s risk management strategy is an integral lessons’ newsletters, governance forums and via the part of the Trust’s approach to continuous quality dedicated ‘learning lessons’ review group, which improvement and is intended to support the Trust was implemented to ensure that lessons learned in delivering the key objectives within the quality following incidents/complaints and PALS and claims strategy as well as ensuring compliance with external are effective and are widely disseminated. Further standards, duties and legislative requirements. mechanisms for ensuring the sharing of transferrable lessons – as well as good practice – are being Risks are identified routinely from a range of reactive explored. and pro-active and internal and external sources including workplace risk assessments, analysis of The Trust Board routinely considers specific risk issues incidents, complaints/PALS, claims, external safety and receives minutes from Board sub-committees alerts and other standards, targets and indicators etc, including the audit committee, Trust governance and are appropriately graded and ranked and included on assurance committee and the quality and patient the Trust’s risk register.

61 Annual Governance statement 2012/2013

A risk register – ‘Confirm or challenge’ group is in The Trust currently holds Level 2 accreditation in place to review and monitor risks added to the risk respect the NHSLA Risk Management Standards for register and quarterly reports from the risk register Acute Trusts and Level 1 accreditation in respect of are submitted to the Trust governance and assurance the CNST Maternity Standards. committee and Trust Board. The Trust also has in place a range of mechanisms for The Trust has also identified a non-executive director managing and monitoring risks in respect of quality to lead the challenge in respect of the risk register including: and to report to the Board as part of the submission • The Trust has in place a quality strategy which has of the quarterly risk register reports. The Trust been endorsed by the Trust Board recognises that, as risks can change and new risks can emerge over time, the review and updating of risks • The Trust has in place a quality and patient on the risk register is an ongoing, dynamic process. experience committee (a sub-committee of the Board) which meets monthly and is chaired Risk management is embedded in the activity of the by a non-executive director. The quality and organisation by virtue of robust organisational and patient experience committee is responsible committee structures. Of fundamental importance is for monitoring performance against key quality the Trust’s commitment to the ongoing development objectives. The minutes of the quality and of a ‘fair blame’ culture, where incident reporting patient experience committee are submitted to is openly and actively encouraged and the focus the Trust Board when things go wrong is on ‘what went wrong, not who went wrong’, and a progressively ‘risk aware’ • The Trust has published annual quality accounts workforce. in 2008/09, 2009/10, 2010/11 and 2011/12 and has prepared its 2012/13 quality account The Trust agrees annual governance/risk management objectives, which are shared • A quality report, which reports progress against through the business planning and performance key quality objectives in year is prepared and management frameworks. Business planning and submitted monthly to the quality and patient service development proposals do not proceed experience committee and the Trust Board. This without an appropriate assessment of and therefore monthly report in turn informs the annual quality recognition/acceptance of the risks involved. account. The submission of this monthly report ensures that the Trust Board focuses on quality in The Trust also has in place an assurance framework, the same way that it has historically considered which is designed to assist the Trust in the control finance and performance of risk. The framework incorporates and provides a comprehensive evidence base of compliance • The Trust has in place arrangements and against a raft of internal and external standards, monitoring processes to ensure ongoing targets and requirements including CQC registration compliance with other service accreditation requirements, NHS Litigation Authority Risk standards eg bowel screening, colposcopy, cancer, Management Standards for Acute Trusts, CNST CPA, MHRA (for blood products) and HTA licences Maternity Standards, Information Governance Toolkit for mortuary and post mortems etc Standards. • The Trust governance and assurance committee Assurance to the Trust Board on compliance with monitors performance with NICE guidance these requirements is provided via quarterly Trust implementation and minutes of that committee assurance framework reports and is supported by a are submitted to the Trust Board. Compliance robust internal audit programme. The quarterly Trust with NICE guidance is also monitored, internally assurance framework report routinely captures, and via the performance review process and the Trust Board considers, the information held by externally via the PCT quality contract group the CQC about the Trust which is contained within • The medical director monitors mortality and the CQC Quality and Risk Profile (QRP). morbidity statistics – via a mortality task group – The Trust also continues to roll-out Health Assure and provides regular updates on progress against (previously Performance Accelerator), an automated the Trust’s mortality action plan to the quality and governance and assurance system which will support patient experience committee and Trust Board. the ongoing development and management of Whilst historically, mortality information was the Trust assurance framework. Developments included on a quarterly basis within the monthly during 2012/13 have included the development of quality report, during 2012 a separate monthly a ward/department quality and patient experience mortality report was introduced and is submitted dashboard which will be fully operational early to the quality and patient experience committee 2013/14. and the Trust Board. Further development of

62 these arrangements occurred during March 2013, CQC: Registration and essential when the decision was taken by the Trust Board that the mortality task group should become a standards of quality and safety formal sub-committee of the Trust Board and The Northern Lincolnshire and Goole Hospitals should be renamed the mortality performance NHS Foundation is not fully compliant with the committee, although the quality and patient registration requirements of the Care Quality experience committee will retain an assurance role Commission (CQC). In February 2013, the Trust • Ward standards have been introduced and are received its planned but unannounced inspection monitored via a programme of unannounced visit by the CQC. Whilst no major concerns were ward reviews highlighted during the visit, it was identified that some action is required in respect of the following • A programme of announced director visits is also outcomes: in place to all wards and departments – clinical and non-clinical – in order to ensure that there • Outcome 4: Care and welfare of people who use is ‘Board to Ward’ oversight and ownership of our services (moderate impact) quality and safety issues • Outcome 14: Supporting workers (moderate impact) • The Trust has identified non-executive directors • Outcome 21: Records (minor impact) to lead the challenge in respect of specific aspects of governance including HCAI, risk management Actions are underway to address the non- and the risk register, mortality, falls, pressure compliances identified. ulcers and quality and patient experience Data security • Within the revised management structure The Trust continues to strengthen its arrangements introduced in July 2011, the directorate of the for information governance and has the following chief nurse has responsibility for focusing on the arrangements in place: quality of the patient experience and is the Board lead for quality and the patient experience • An information governance steering group, a sub- committee of the Trust governance and assurance • A nursing dashboard is in place to monitor the committee nursing contribution to safety and quality. This information will in future be captured as part • An information security policy of the wider quality and patient experience • Compliance at Level 2 or above across all 45 dashboard managed within Health Assure and requirements within the information governance reported to the quality and patient experience toolkit which has been independently verified by committee and the Trust Board. internal audit. • The Trust routinely considers and acts upon In respect of data security the following the recommendations of national quality arrangements are in place: benchmarking exercises, eg national patient surveys • A security feature at login to the Trust network, • The Trust acts upon patient feedback from giving guidance to users and requiring complaints and concerns and from feedback acceptance of ‘rules of use’ from patient and public involvement (PPI) representatives (eg Links). • IT policies which take account of updated national requirements • A ‘best practice’ IT security awareness leaflet • The encryption of all removable/portable devices including laptops, USB pens and CDs, specifically • Laptop encryption has been completed on all laptops/clinical tablets • Encrypted USB pens have been allocated to staff • Support for the use of staff who own PDA devices has been removed, floppy drives have been blocked from use, no machines are purchased with floppy drives as standard and port blocking software has been implemented

63 Annual Governance statement 2012/2013

• CD/DVD writers are not issued as a standard Equality, diversity and human rights piece of equipment. Where the use of these Control measures are in place to ensure that all the writers is required, the creation of data on organisation’s obligations under equality, diversity these devices is covered by Trust policies and human rights legislation are complied with. • The creation of data on PACs CDs is governed by Trust policy and encryption ability is Carbon reduction available. Tracking procedures are in place for The Trust has undertaken a review of its carbon CDs sent off site. emissions in line with the NHS Carbon Reduction Strategy and Climate Change Act. The Trust has a Carbon Trust approved carbon management plan Patient and public involvement (PPI) in place which sets out reduction delivery plans. The Trust ensures that public stakeholders are The Trust’s facilities and information committee (a involved in understanding the risks which impact sub-committee of the Trust Board) oversees work upon them by a variety of means: the principal to reduce emissions, ensures compliance with the amongst these being the operation of the Council Climate Change Act and how these impact on of Governors and during 2012/13 the introduction emergency preparedness. The group also ensures of Board meetings held in public. The Council meets the Trust is compliant with the Carbon Reduction at least four times per year in public and receives a Commitment and Energy Performance Directive. comprehensive report on performance (and risks of non-delivery) on each occasion. These reports are published along with the rest of the council papers 5. Review of economy, efficiency on the Trust internet site. and effectiveness of the use of A PPI policy and procedure is also in place and reflects the requirements of the Department of resources Health (DOH) guidance ‘Real Involvement’ and the The Trust’s clinical activities are managed under comments from PPI representatives such as the three a devolved management structure with clinical Local Involvement Networks (LINks) and Overview leadership provided by clinical directors with the and Scrutiny Committees (OSCs). structure supported by senior managers within Additionally, the Trust engages actively with three the directorate of operations and the directorate OSCs and continues to collaborate closely with of diagnostics and therapies. The overall clinical the three LINks. A protocol for joint working with infrastructure is led by executive directors, both of the LINks is in place and is reviewed annually whom are members of the Trust Board. The finance and opportunities for joint working have been function has been organised in a manner to provide agreed. The Trust will continue to develop these dedicated support the clinical and non-clinical arrangements as part of the transition of the three structure of the organisation along with business LINks to Health Watch. planning, performance and information technology support which come under the overarching The Trust’s comprehensive internet website provides responsibility of the directorate of finance, planning the public with ready access to information across all and performance. areas of Trust activity and the organisation also uses its newsletter for members to inform the public of Throughout the year, the Trust placed a significant new developments and items of interest. focus on the requirement to drive efficiencies through improvements to productivity and cost. NHS Pension Scheme The Trust remains focussed on ensuring that it can continue to deliver in a competitive environment As an employer with staff entitled to membership which is financially challenging and which is of the NHS Pension Scheme, control measures are in expected to continue in the foreseeable future. place to ensure all employer obligations contained within the scheme regulations are complied with. In order to support the management structure the This includes ensuring that deductions from salary, Trust refreshed both the Scheme of Delegation and employer’s contributions and payments in to the the Powers Reserved to the Board in April 2012 which scheme are in accordance with the scheme rules, and ensures that the decision making powers within the that member pension scheme records are accurately Trust are delegated to the appropriate level whilst updated in accordance with the timescales detailed maintaining a consistent and coherent control in the regulations. framework. The refreshment to the Trust Board Scheme of Delegation has also been underpinned by changes to the delegated powers within each of

64 the Trust’s directorates in order to ensure that this is is proactive and continuously reviews and realigns consistent with the delegated powers set out in the its structure where necessary, to allow it to adapt Trust’s new financial system which was implemented and respond to the rapidly changing business in December 2012 which enhances and strengthen its environment brought about by the changes in the reporting environment. economy, the NHS environment, competitive markets and patient pathway redesign. The Trust has also The Trust maintains a strong focus on performance established a workforce review group specifically management, all directorates and groups are to firm up plans for future workforce numbers and explicitly made responsible for the delivery of to oversee implementation with due regard to financial and other performance targets through future commissioners’ intentions. In support of this a system of performance agreements which are work the Trust has developed an organisational agreed as part of the annual business planning cycle development and workforce strategy which has been and monitored through a series of regular meetings endorsed by the Trust Board. chaired by the chief executive. The Trust is satisfied that it has robust internal control The business and financial framework adopted mechanisms in place and these are monitored annually by the Trust Board contains an overarching on a quarterly basis by Monitor, the Independent assessment of the strategic planning climate within Regulator. which the framework has been constructed and sets out the mechanisms by which the key risks emanating from the strategic context are to be managed. This assessment both reflects the national 6. Annual quality report planning context and the emerging local context; The directors of Northern Lincolnshire and Goole it therefore is cognisant of the financial planning Hospitals NHS Foundation Trust are required under context for the public sector as a whole; especially the Health Act 2009 and the National Health Service the expectation for significant efficiencies over the (Quality Accounts) Regulations 2010 (as amended) course of the medium term. to prepare Quality Accounts for each financial year. The Trust conducts a comprehensive review of the in- Monitor has issued guidance to NHS Foundation year progress of the business and financial framework Trust Boards on the form and content of annual in the form of a mid-year review report – any issues quality reports which incorporate the above legal or emerging risks not previously identified within requirements in the NHS Foundation Trust Annual the original framework are identified and mitigating Reporting Manual. actions recommended and actioned during this The following arrangements are in place within process. Northern Lincolnshire and Goole Hospitals NHS The finance committee, of which all non-executive Foundation Trust to assure the Board that the Quality directors are members, provides assurance to the Account presents a balanced view and that there are Trust Board as to the achievement of the Trust’s appropriate controls in place to ensure the accuracy financial plan and priorities and, in addition, acts as of data: the key forum for the scrutiny of the robustness and effectiveness of all cost efficiency opportunities. It interfaces with the other Trust Board committees Governance and leadership: and the Trust executive team and also has particular regard to the work of the planning and delivery • The Trust has appointed a member of the Board, group (PDG) which set the agenda, and co-ordinates the chief nurse, to lead on quality. The chief nurse, the activities of, the investment planning group (IPG). supported by the director of clinical and quality assurance, will advise the Trust Board on all matters The overall planning function also supports and co- relating to the preparation of the Trust’s annual ordinates a rigorous process of internal performance Quality Account management through a regular schedule of performance review meetings chaired by the chief • The Trust has an assistant head of quality assurance executive. Further compliance is assured through post to support the development of the quality quarterly monitoring and annual planning process agenda with auditors. • The Trust’s director of finance, planning and The Trust understands that the environment in performance is responsible for ensuring the which it operates is changing significantly and that quality of the performance data which informs the business development of services must be the Annual Quality Account. A deputy director of linked to the operational support which ultimately information and information technology, to whom delivers the quality outcomes for patients. The Trust this responsibility is delegated, is also in post.

65 Annual Governance statement 2012/2013

Policies: • The report arising from the audit review, including any gaps in assurance and remedial • Policies and procedures are in place in relation to actions required, will be agreed through the the capture and recording of patient data Trust’s audit committee and submitted internally • Clinical coding follows national guidelines to the Trust Board and Council of Governors in addition to a local policy, as per the Audit and externally to Monitor. As with the 2011/12 Commission’s guidelines. remedial actions, the action plan will be monitored via the quality and patient experience committee. Systems and processes: The Trust Board also now receives quarterly data quality reports via the monthly quality report. • Systems and processes are in place for the audit and validation of performance data. 7. Review and effectiveness As Accounting Officer, I have responsibility for People and skills: reviewing the effectiveness of the system of internal • All staff involved in collecting and reporting control. on quality metrics are suitably trained and My review of the effectiveness of the system of experienced internal control is informed by the work of the • All PAS users have to receive training before internal auditors, clinical audit and the executive being issued a password, and individual user managers and clinical leads within the Northern activity is auditable Lincolnshire and Goole Hospitals NHS Foundation Trust who have responsibility for the development • Clinical coding is regularly audited both internally and maintenance of the internal control framework. and externally by the Audit Commission and audits also take place with individual clinicians. I have drawn on the content of the Annual Quality Report attached to this Annual Report and other performance information available to me. My review is also informed by comments made by the external Data use and reporting: auditors in their management letter and other reports. • As above, monthly quality reports, which outline the Trust’s performance against key quality objectives I have been advised on the implications of the result including benchmarking and comparative data, and of my review of the effectiveness of the system are the subject of discussion and challenge at every of internal control by the Trust Board, the audit monthly quality and patient experience committee committee, the Trust governance and assurance and Trust Board meeting, inform the annual Quality committee and the quality and patient experience Account committee and a plan to address weaknesses and ensure continuous improvement of the system is in • The Trust also considers and acts upon place. information received via the Dr Foster alerts and the CQC quality and risk profile and the The head of internal audit provides me with an information also informs the relevant Trust action opinion on the overall arrangements for gaining plans eg mortality. assurance through the assurance framework and on the controls reviewed as part of the internal audit • In preparation for the requirement for a published work (Appendix A refers). The assurance framework audit opinion in the 2012/13 Quality Account, the and the monthly performance reports provide me purpose of which is to provide assurance on the with evidence that the effectiveness of the controls arrangements in place to ensure Quality Accounts in place to manage the risks to the organisation are fairly stated and in respect of the accuracy achieving its principal objectives have been of the information and indicators within the reviewed. report, audit review will be undertaken. This will involve sample testing in respect of a number of mandated quality indicators.

66 Gaps in controls CQC planned review The following control issues arose during 2012/13: As above, in February 2013, the Trust received its planned but unannounced inspection visit by the Mortality CQC. Whilst no major concerns were highlighted during the visit, it was identified that some action is The Trust is shown as an outlier in respect of its required in respect of the following outcomes: mortality ratios in comparison to the national average of 100. The Trust is one of the 14 Trusts involved in the • Outcome 4: Care and welfare of people who use Keogh Review which will review: our services (moderate impact) • Whether existing action by these Trusts to • Outcome 14: Supporting workers (moderate impact) improve quality is adequate and whether any • Outcome 21: Records (minor impact) additional steps should be taken Actions are underway to address the non- • Any additional external support that should be compliances identified. made available to the Trust to help improve, and Maintenance and review of the effectiveness of the • Any areas that may require regulatory action in system of internal control has been provided by order to protect patients. comprehensive mechanisms already referred to in Mortality rate improvement remains the Trust’s this statement. Further measures include: foremost priority. The medical director is the Board • Regular reports to the Trust Board from the Trust’s level lead for mortality. risk register including NED review/challenge A mortality strategy and action plan is in place and is • Regular risk management activity reports to regularly updated. Progress against the action plan the Trust Board covering incidents, complaints/ and the priority clinical work streams is monitored PALS and claims analysis and including details of by the mortality performance committee (a sub- lessons learned/changes in practice committee of the Trust Board). • Receipt by the Trust Board of minutes/reports Progress against the action plan is also monitored from key forums including the audit committee, and challenged monthly by the Trust Board. A specific Trust governance and assurance committee and NED challenge role has also been identified. The Trust the quality and patient experience committee has also commissioned a number of external reviews to both validate the work completed to date and to • The ongoing development of the Trust assurance identify any further required actions. framework, which is managed via the Health Assure automated governance system, to support Clostridium difficile the collation of evidence of compliance with the standards and targets captured within the At the end of quarter four, the Trust had incurred 37 Trust assurance framework and the reporting of clostridium difficile infections against a trajectory of performance 34 and against a backdrop of considerable activity pressures during the latter part of 2012/13. Of those • Further independent external review in April cases, 26 of the 37 cases were deemed to be not 2012 by KPMG of the Trust’s board assurance and preventable. self certification processes. Whilst no significant control issues were identified arising from that The Trust’s limit for 2013/14 is 30. The Trust’s clostridium review, some actions were identified for further difficile action plan continues to be scrutinised and strengthening the Trust’s arrangements and monitored by the infection control committee, a these have been progressed during 2012/13. [The sub-committee of the Trust Board. The Trust Board 2013 review by KPMG is also now underway] also continues to monitor performance and progress against the Trust’s clostridium difficile action plan on a • Actions arising from the above review included monthly basis to ensure that the limit for 2013/14 is met. the further refinement of the approach to self-certification at annual plan to include Accident and emergency performance consideration of assurances from the clinical audit process and the attendance of the head of quality The Trust breached its overall accident and at the annual Trust Board event to consider self emergency target at the end of quarter four. This certification. The Trust’s annual planning and reflects a departure from performance during self certification protocol was also updated to previous quarters and again reflects the considerable reinforce the requirement to ensure that there is activity pressures during the latter part of 2012/13. sufficient focus on the prospective nature of the Across the year as a whole performance was compliant self-certification process for service performance with the 95% threshold. Plans are in place to ensure targets that the Trust returns to compliance in May 2013. 67 Annual Governance statement 2012/2013

• Consideration of a monthly quality report, Francis Inquiry and the updating of that analysis allowing the Trust Board to monitor and manage and the development of an action plan in March quality in the way it has historically around finance 2013. Monitoring of actions agreed arising from and other obligations. The information contained that process will occur via the Trust governance within this monthly report, in turn, informs the and assurance committee and so this will remain Trust’s Annual Quality Account a live/working document • The provision of monthly compliance report to • All of the above measures serve to provide the Trust Board, which covers a combination of ongoing assurance to me, the executive team and specific Licence and key contractual obligations the Trust Board of the effectiveness of the system and including the identification of key risks to of internal control. future performance and mitigating actions • The provision of the monthly trading report to the Trust Board. As with the compliance report this 8. Conclusion report includes the identification of key risks to In conclusion, where issues have been identified future performance and mitigating actions during 2012/13, action has been taken or action plans • Ongoing monitoring of compliance against the are in place to address the gaps in control identified. requirements of Monitor’s quality governance The Trust Board is satisfied that plans are adequate framework to ensure delivery of these targets or improvements during 2013/14. Where appropriate these action • The completion and submission to the Trust Board plans will be tested via relevant external scrutiny and in February 2013 of an initial gap analysis against review processes. the recommendations within the report of the

Karen Jackson Chief executive (29 May 2013)

68 Head of internal audit opinion on the effectiveness of the system of internal control at Northern Lincolnshire and Goole Hospitals NHS Foundation Trust for the year ended 31 March 2013

Roles and responsibilities The head of internal audit opinion The whole Board is collectively accountable for The purpose of my annual HoIA Opinion is to maintaining a sound system of internal control and contribute to the assurances available to the is responsible for putting in place arrangements for Accountable Officer and the Board which underpin gaining assurance about the effectiveness of that the Board’s own assessment of the effectiveness of overall system. the organisation’s system of internal control. The Governance Statement is an annual statement This Opinion will in turn assist the Board in the by the Accountable Officer, on behalf of the Board, completion of its AGS. which records the stewardship of the organisation My opinion is set out as follows: to supplement the accounts. It gives a sense of how successfully the organisation has coped with 1. Overall opinion the challenges it faces and of how vulnerable the 2. Basis for the opinion organisation’s performance is or might be. The statement draws together position statements and 3. Commentary. evidence on governance, risk management and control, to provide a more coherent and consistent reporting mechanism. Overall opinion The organisation’s Assurance Framework should Significant assurance can be given that there is a bring together all of the evidence required to support generally sound system of internal control, designed the Annual Governance Statement (AGS). to meet the organisation’s objectives, and that In accordance with NHS Internal Audit Standards, controls are generally being applied consistently. the Head of Internal Audit (HoIA) is required to However, some weaknesses in the design and/ provide an annual opinion, based upon and limited or inconsistent application of controls put the to the work performed, on the overall adequacy achievement of particular objectives at risk, most and effectiveness of the organisation’s risk notably in relation to the management of mobile management, control and governance processes devices, catering services and mandatory training (i.e. the organisation’s system of internal control). arrangements. This is achieved through a risk-based plan of work, agreed with management and approved by the Audit Committee (or equivalent), which should provide a Basis for the opinion reasonable level of assurance, subject to the inherent limitations described below. The basis for forming my opinion is as follows: The opinion does not imply that Internal Audit has 1. An assessment of the design and operation of the reviewed all risks and assurances relating to the underpinning Assurance Framework and supporting organisation. The opinion is substantially derived processes; and from the conduct of risk-based plans generated from 2. An assessment of the range of individual opinions a robust and organisation-led Assurance Framework. arising from risk-based audit assignments contained As such, it is one component that the Board takes into within internal audit risk-based plans that have been account in making its Governance Statement. reported throughout the year. This assessment has taken account of the relative materiality of these areas and management’s progress in respect of addressing control weaknesses.

69 Commentary of Sterile Services, Professional Registration, Management of Mobile Devices, Catering The commentary below provides the context for my Services, Theatre Utilisation, Complaints opinion and together with the opinion should be Management and Mandatory Training read in its entirety. Arrangements. Of the 34 reviews completed • Our assessment of the design and operation of to date, 22 provided significant assurance, 6 the Trust’s Assurance Framework was intended to provided limited assurance (CRB Checking ascertain compliance with current Department Procedures, Management of Lease Cars, of Health advice and guidance. Our review has Management of Mobile Devices, Post Tender confirmed that the Framework is compliant and Arrangements, Catering Services and Mandatory fit for purpose Training Arrangements) and 6 did not require an assurance level. Internal Audit activity provides • Our audit work for 2012/13 was drawn from the reasonable and not absolute assurance around Operational Internal Audit plan approved by the the organisation’s control environment based Audit Committee in February 2012. This was a upon work undertaken risk based plan which set aside sufficient days to undertake the required levels of financial systems • We have a rigorous follow up process and the work as well as a range of operational audits. overall results of post audit review demonstrate Regular reports have been presented to the Audit that 84% of recommendations followed up have Committee concerning achievement of the plans been implemented fully and on time. We are and any in-year changes confident that where recommendations have been implemented, this has improved the overall control • During the year, a range of audit assignments environment operating within the organisation. have been performed to complete the plan including areas of mandated coverage (e.g. Board Assurance Framework, Information Governance Toolkit and core financial systems work i.e. Accounts Receivable, Budgetary Control, Payment by Results and Travel & Benita Jones Expense Claims). In addition, we have covered areas the Trust considered to be of significant Director of Audit Services risk including Medication Errors, Management 12 April 2013

70 Financial reports and accounts 2012/13

71 Financial reports and accounts 2012/13

Financial review The overall level of demand referred to the Trust continues to increase. In line with the stated At the end of the financial year 2012/13 the Trust intentions of the Trust’s commissioners the Trust generated a bottom line surplus of approximately has been asked to see fewer patients in outpatient £2.1 million after taking into account all follow-up sessions although there has been a exceptional items. The Trust has therefore noticeable increase in patients seen via accident and maintained a strong financial position during emergency (A&E); a trend also experienced in many a period of significant financial restraint whilst other parts of the country. treating more patients than previously experienced Despite the continued increase in the patients since gaining foundation trust status. referred, the Trust continues to deliver on the annual The strategic planning climate faced by all acute targets for waiting times against the eighteen week, providers continue to require providers to deliver cancer and A&E pathways although the extraordinary on a challenging programme of productivity and referral pressures over the winter period caused the efficiency improvements – the scale of which Trust to fall below the A&E waiting time standard for will result in the need for a continuing process of the last quarter of the year. restructuring across the whole of the Trust asset The Trust reported more cases of clostridium difficile base; including its workforce. As a consequence, a infections than the mandated threshold of 34 during provision has been made for the anticipated cost 2012/13; although the actual number of 37 cases of this programme and the surplus quoted above is lower, on average, per bed day than the norm it is therefore after a charge of £2.6 million has been is still anticipated to result with the Trust receiving incorporated into overall statement in order to reflect an amber-red governance rating from Monitor, the the cost of funding this programme. Foundation Trust regulator, when the A&E waiting The surplus of £2.1 million also incorporates a time breach for the final quarter of the year is taken reversal of a £2.6 million charge previously made to into account. reflect changes in asset values. During 2012/13 the The Trust continues to place utmost priority on Trust commissioned an external agency to conduct enhancing the quality of the clinical services it a thorough review of asset values; this therefore provides through investing in the estate and clinical provides a firm accounting foundation from which infrastructure whilst, at the same time, maintaining the efficiency programme referred to above can be financial stability. embarked from. The aim of improving both the quality of services The review of the Trust’s land and buildings involved delivered to patients and the overall environment a series of valuation adjustments across the whole of from which they are provided was a key influencing the Trust estate which, when fully netted off, resulted factor in the programme of a capital investment in an accounting impairment charge of approximately programme which amounted to £10.5 million during £11.3 million. These adjustments do not impact on the course of the year. the overall underlying financial assessment of the Trust’s financial performance and, as a consequence, The cost of funding this programme, combined the Trust is anticipated to be assessed with a financial with other non-recurrent costs associated with the risk rating of three by Monitor, the Foundation Trust workforce restructuring programme resulted in the regulator, which is in accordance with the original Trust reducing its internal cash balances by £2.6 plan (risk rating of one = high risk; risk rating of five = million during the year; the Trust ended 2012/13 low risk). with cash balances of £32.7 million; this strong underlying liquidity provides the Trust with a firm The maintenance of a financial risk rating of at least foundation for a programme of further investments three remains a key strategic goal for the Trust and in order to continue the programme of quality and underpins the construction of the Trust’s future environmental improvements. medium term financial plans. Following the finalisation of the Estate Strategy the The totality of all the above measures will result in in-year investment programme was also adjusted the Trust reporting an accounting deficit of £9.2 in order to make further progress in addressing million for the financial year ending March 31 2013. backlog maintenance. It is anticipated that the capital It is anticipated that, by making these charges to programme for 2013/14 and beyond will continue this the accounts, the Trust will be able to construct a process. programme which will realise significant recurrent savings designed to support the Trust’s on-going The Trust did not have to rely on the working capital efficiency and cost reduction programme and facility of £24.0 million available to it during 2012/13. therefore will be an integral contribution to the Trust’s longer term financial security.

72 Looking ahead In order to meet the challenges which lay ahead the Trust is has reviewed its strategic plans and has The outlook looking into 2013/14 and beyond constructed an expenditure plan which therefore remains significantly challenging with continued balances the competing need for continued expectations of limited growth in overall health investments in service quality and for further savings funding. This means that, along with most other and efficiencies. acute provider organisations, the future investments in clinical quality improvements which remain Since gaining foundation trust status the Trust fundamental to the Trust’s medium term plan must has significantly reduced its internal unit costs as be generated from an internally driven programme of measured by the national, Reference Cost index; the efficiencies and productivity improvements. challenge for the Trust and the local community is to ensure that the overall future configuration of acute The financial strategy which formed the basis for the services is sustainable for the longer term future. 2012/13 accounting position set out above therefore also provides the foundation for the development The Trust has to submit an integrated business plan of the medium term plans designed to address the to its regulator, Monitor at the end of May 2013. The challenge for the future. Trust’s plan for 2013/14 is based around maintaining both financial stability and performance against the Therefore, the Trust’s corporate plans are set in such waiting time and other standards set out for all acute a way that it will rely only upon income growth trusts whilst working with local commissioners to within the financial allocations available to the lay the foundation for potential reconfiguration of Trust’s local commissioners, and Trust contracting services in 2014 and beyond. strategy has been based upon close cooperation with commissioners to agree joint plans, and to ensure joint ownership of financial plans across all organisations. At present, the Trust still expects to agree contract terms which will maintain income levels which support realistic expenditure plans which provide Mike Rocke the Trust with sufficient scope to continue to invest Director of finance, planning and performance in the safety and quality of the services the Trust is management contracted to provide.

73 Financial reports and accounts 2012/13

Income and expenditure Where we get our income from? As an NHS Foundation Trust, we receive most of our income from Service Level Agreements with our commissioners for services provided, based on the national / locally agreed tariff. For the year 2012/13, the income details are given below:

£ million Primary Care Trusts Income 283.1 Private patients/others 2.3 Education and training 8.5 Other income 26.2 Total 320.1 This assessment includes, income from healthcare and non-healthcare activities (£317.5 million) and revenue generated via the reversal of charges previously made to the account (£2.6 million). This therefore results in the following split of overall revenue for the Trust:

Income

88% Primary Care Trusts Other income Education and training 8% Private patients/others

3% 1%

74 What we spend our income on Operating expenses totalled around £315.2 million for the year to March 2013. This expenditure includes £2.6 million related to restructuring costs, predominantly for redundancies and early retirements. An analysis of operating expenses by type is shown below:

£ million Services received from other NHS Trusts/bodies 3.4 Medical pay 60.9 Income Services received from otherNursing pay 1 61.9 NHS Trusts/Bodies Scientific/therapeutic/prof. tech. 35.8 Medical pay 19 Healthcare assistants-support staff 23.7 Scientific/Theraputic/Prof. 11 Tech. Other pay 31.9 Nursing pay Supplies and services20 56.0 Health car assistants - support 8 staff Establishment and premises 20.4 Other pay Depreciation and impairments10 7.8 Supplies and services Other non pay 18 13.4 Establishment and premises 6 Total 315.2 Depreciation and impairments 3 Other non pay 4 Public dividend capital 3.7

Chart 2 Expenditure 1% 4% 3% Services received from other NHS Trusts/Bodies Medical pay 6% Scientific/Theraputic/Prof. Tech. 19% Nursing pay Health car assistants - support staff Other pay Supplies and services 18% Establishment and premises Depreciation and impairments 11% Other non pay

10%

8% 20%

75 Financial reports and accounts 2012/13

Our investments (capital items) In constructing the overall package of savings measures for 2013/14, all the directorates and The Trust has continued its ongoing programme of divisions have reviewed their workforce numbers investment in improving patient accommodation and the programme of efficiency gains via cost and facilities, medical equipment and information reduction is expected to continue through to the technology. The Trust invested a total of £10.5 million. next financial year. It is anticipated that the above Investments were made in a range of medical and plan could contribute substantially to the Trust’s diagnostic equipment, cancer treatment facilities, required savings target for 2013/14 if successfully continuing programme of ward improvements and implemented. refurbishments and control of infection. The financial plan to be submitted to Monitor at the end of May 2013 will include an overall efficiency target of £15.9 million which is anticipated to be Our management costs delivered through a combination of budgetary The Trust is committed in ensuring that the maximum savings, review of terms and conditions and increases amount of resource is devoted to treating patients in commercial income. The individual plans which on the clinical frontline and therefore embarked on comprise this package have been subject to a a programme of reducing the cost of management detailed quality impact assessment review in order within the Trust. to assure the Trust Board that none of the proposed measures have any detrimental effect on clinical Management costs, as a percentage of income quality. continues therefore to reduce as workforce resources are focused on frontline patient care.

Management costs % of Trust income Finance committee 2012/13 3.6% The Trust’s finance committee oversees the 2011/12 3.7% performance of the finance function. The committee 2010/11 4.4% provides both an independent review and assurance 2009/10 4.1% to the Trust Board as to the achievement of the Trust’s financial plan and priorities and, in addition, acts as the key forum for the scrutiny of the robustness and effectiveness of cost efficiency opportunities. Efficiency and value for money The finance committee is a formal committee The Trust’s financial plan for 2012/13 contained a established by the Trust Board. It interfaces with the challenging cost improvement programme target. other Trust Board committees and the Trust Executive Throughout the year, the Trust’s planning and Team and will also have particular regard to the work delivery group was established to drive a programme of the contracting and business planning team, the of initiatives designed to support the efficiency planning and delivery group and the performance programme. review meetings. The operational pressures brought about by the The committee is chaired by a non-executive director, continued increase in referrals and the focus on who also chairs the audit committee. The members improving clinical quality meant that savings through include the chairman, all non-executive directors and reductions in clinical infrastructure not neither all executive directors. realistic nor appropriate during the course of the year. The committee has the right to investigate any The predominant focus this financial year was on the activity within its terms of reference and has the delivery of savings through efficiencies in staffing powers to seek any information it requires from any rotas, both clinical and support services, through the employee and all employees are directed to co- continued roll-out in the E-rostering programme, operate with any request made by the committee. the continuation of a strategic non pay review and through a programme of estates review and In addition, the committee is authorised by the Trust rationalisation. The Trust made reasonable progress Board to obtain outside legal or other independent in achieving these savings although it the balance professional advice and to secure the attendance of between efficiencies brought about by cost reduction outsiders with relevant experience or expertise if it and those via productivity gains via treating more considers this necessary patients through a lower unit cost was altered during the latter stages of the financial year as activity pressures increased.

76 Going concern Liquidity and borrowings The financial statements for the period ended March At March 31 2013, the Trust had a cash balance of 31 2013 have been prepared on a going concern £32.7 million and a working capital facility of £24.0 basis, as stated in the Chief Executive’s Accounting million. The Trust did not make use of its working Officer Statement on page 89 of the Accounts. capital facility during the period and ended the period with a healthy cash balance. The cash position The Trust is in the process of formulating a three year was partly influenced by slippage in the delivery of financial plan and investment programme in advance certain aspects of the capital programme, internally of the annual plan submission at the end of May. generated resources and interest receivables. The Trust recognises that to meet the future financial At this point in time, the Trust does not envisage the challenges, it needs to invest in infrastructure, new need to utilise the working capital facility available to equipment and technology. it in the delivery of these plans on the basis that the The three year capital plan is currently under Trust will receive income for the service it provides construction although the Business and Financial from the commissioners in accordance with the Framework – 2013/14 highlights the potential that the contract agreement. Trust to seek alternative funding in addition to that achieved from operating income in order to support the programme of transformational change. Our external auditors From a national planning context, contractually, The Trust appointed Price Waterhouse Coopers as all acute trusts will face significant financial and external auditors during 2012/13 and all the activities operational challenges in the coming years. In undertaken this financial year have been those response, the Trust’s corporate plans are set in such prescribed under the Code of Practice. The fees paid a way that it will rely only upon income growth for external auditors for the year totalled £55,000. significantly within the allocations available to commissioners. At present, the Trust still expects to agree contract terms which will maintain income levels sufficient to support realistic expenditure plans. Political and charitable donations The Trust has constructed an expenditure plan which The Trust has not made any political or charitable maintains a realistic approach to investment and has donations. set a savings plan of £15.9 million for 2013/14, based The Trust continues to benefit from charitable upon the projected savings deliverable in the year. donations and legacies. The Trust is grateful for all Our ability to remain a going concern will very much the donors, individual fund raisers and fundraising depend upon the delivery of the local operational organisations including League of Friends, RVS, and financial plans both revenue and capital. Any Hospital Welfare society and many other local deviation could put the Trust’s finances at risk and its organisations for their continued support. status as a going concern. The Trust is Corporate Trustee of the charity, Northern Whilst the 2013/14 financial risks are significant, the Lincolnshire and Goole Hospitals NHS Foundation Trust has processes to manage or mitigate them and Trust Charitable Funds. This charity provides some has a provision for risk built into the financial plan. equipment to the Trust, and also funding to improve Other contingencies, including the potential to slip patient experience and funding to enhance the staff capital plans and improve the working capital position skills and hospital environment. by other means, will also be identified during the year. The Trust contracting strategy has been based upon close cooperation with major commissioners to agree joint plans, and to ensure joint ownership of financial plans across all organisations. The Trust will also work closely with the commissioners and endeavour to mitigate risks of activity demand beyond the contract and which ensures that the financial risks are managed across the NHS community. Therefore, these financial statements have been prepared on the basis that the Trust is a going concern and reflected the implications of statutory policy changes, changes in commissioner intentions, financial control and performance, and key financial indicators. 77 Financial reports and accounts 2012/13

Property, plant and equipment Other income During this financial year, professional valuations The statutory limitation on private patient income were carried out by DTZ Debenham Tie Leung in Section 44 of the 2006 Act was repealed with Limited. effect from October 1 2012 by the Health and Social Care Act 2012. Therefore, the financial statements The valuations are carried out in accordance with disclosures that were provided previously are no the current Valuation Standards and UK Valuation longer required. For 2012/13 Foundation Trusts may Standards contained within the Royal Institute of wish to disclose a note explaining this but this is not Chartered Surveyors (RICS) Valuation Standards – mandatory. The Red Book, which are consistent with the agreed requirements of the Department of Health and HM However, for this financial year, the Trust will disclose Treasury. the private patient income cap to be consistent with 2011/12 accounts as shown in note 4.2 to the In accordance with the requirements of the accounts. Department of Health, the Modern Equivalent Asset (MEA) based valuations were undertaken in July 2012 The Trust’s significant non healthcare income within as at the retrospective valuation date of April 1 2012. note 5 includes £9.6 million relating to the provision of pathology services offered by Path Links division Following this, the Trust has conducted a full review of the trust. of its estates and has developed an estates strategy which has been approved by the estates committee Details of non healthcare income and other income and the Trust Board. As per the strategy, certain are set out in note 5 to the accounts. buildings have been declared non-operational and these have been earmarked for subsequent demolition. The results of the valuations have been Activity and performance incorporated into the financial statements. The number of patients seen during the course of this The Trust also has reviewed all its equipment financial year as compared to the previous year is as assets and their lives based on experience, market follows: intelligence and expertise and the details are included in note 15 to the accounts. 2011/12 2012/13 +/- %

Non elective spells 46,956 47,424 468 1.0% Senior managers’ remuneration Elective spells 54,110 55,802 1,692 3.1% and pension Outpatient 386,496 382,496 (4,000) (1.0)% As required by the Companies Act 2006 the NHS attendances Foundation Trust has prepared a Remuneration Report containing information about director's Critical care days 17,677 18,291 614 3.5% remuneration. Within this Trust, this report will be in respect of the senior managers of the Trust. A&E attendances 134,152 136,460 2,308 1.7%

The definition of "senior managers" is: 'those persons TOTAL 639,391 640,473 1,082 0.2% in senior positions having authority or responsibility for directing or controlling the major activities of the NHS body. This means those who influence the decisions of the entity as a whole rather than the decisions of individual directorates or departments.' Target Actual Target Actual

For the purposes of this report, this covers the Trust's 2011/12 2011/12 2012/13 2012/13 non-executive directors, executive directors and 18 week referral to 23 18.3 head of governance. 90% 96% treatment admitted weeks weeks Details of senior employees remuneration is set 18 week referral out in note 9.5 and further details included in the 18.3 17 to treatment non 95% 98% Remuneration report which can be found on pages weeks weeks admitted 79 - 81 of this Annual Report and the contents in pages 94 -133 are duly audited. The Trust 4 hour A&E waiting 95% 95.7% 95% 92% participates in the NHS Pension scheme and details time limit of the Accounting Policy for pension schemes are set out in note 1.6 to the accounts.

78 Remuneration report For any other local pay arrangements, not determined by Agenda for Change, pay increases 1. Remuneration and terms of service were consistent with Agenda for Change increases. A system of appraisal and personal development committee planning has been adopted for all staff. The Trust’s remuneration and terms of service committee, which is a sub committee of the Trust Board, sets the principles of the pay and rewards 2. Appointments and remuneration strategy for the Trust to ensure that it is both committee for non-executive directors equitable and fair. (including deputy chairman and The committee approves the overall approach and chairman) methodology for determining pay and conditions of staff subject to local terms. It also ensures that The appointments and remuneration committee the Trust’s most senior directors and managers reports directly to the Council of Governors. The are appropriately and fairly rewarded for their terms of reference of this committee includes the contributions, conforming to the Trusts’ probity recruitment and review of the remuneration of the and financial integrity as part of the corporate chair and non-executive directors. The membership governance arrangements. of the committee is five governors elected by the council, of whom no more than one shall be a All non-executive directors are members of the staff governor. The meeting is chaired by the lead remuneration and terms of service committee. governor of the Council of Governors. The director of organisational development and workforce provides secretarial support to the committee as required, and Remuneration of executive directors advises on matters such as remuneration, appraisal and recruitment. The trust secretary provides The remuneration package and conditions of service advice to the committee on issues relating to the for executive directors is determined by the Trust Constitution. remuneration and terms of service committee Each year, the remuneration and terms of service committee considers the contribution of each Remuneration of chair and non- director against the functions and responsibilities of the post as defined in the current job description and executive directors as foreseen for the future. This is carried out, at least The remuneration and terms of office of non- on a bi annual basis, in the context of an independent executive directors is determined by the Council assessment of equivalent pay rates for similar roles of Governors at a general meeting in accordance within the NHS. All executive directors of the trust with the Trust’s Constitution. The appointments board have permanent contracts of employment. and remuneration committee, which is a sub The notice period for executive directors is three committee of the Council of Governors consider the months and the arrangements for compensation responsibilities and time commitments of the role payments for early termination of contract will and recommend the level of remuneration for the comply with NHS regulations. The remuneration chairman and non-executive members of the Trust for executive directors does not include any Board. The committee may also consult external performance related bonuses and none of the advisors as required to determine the level of executives receives personal pension contributions remuneration. other than their entitlement under the NHS Pension The terms of office of the non-executive directors and Scheme. the chairman are shown further on in this report The notes to the 2012/13 accounts contained in pages Remuneration of all other staff 87 to 133 of this report includes the remuneration details including those of the senior managers. Agenda for Change, the nationally introduced new pay reform for the NHS effective from October 1 2004, covered all directly employed staff, except very senior managers (directors) and those covered by Doctors and Dentists Pay Review body. Karen Jackson - Chief executive 29 May 2013

79 Audited senior managers’ 2012/13 2011/12 remuneration 2012/13 Salaries and allowances Salary Salary (bands of (bands of Name and Title £5,000) £5,000)

£000’s Compensation for Loss of office(bands£5,000) of £000’s Benefits in kind - Lease Cars (Rounded to the nearest £Hundred) £00 £000’s Compensation for Loss of office(bands£5,000) of £000’s Benefits in kind - Lease Cars (Rounded to the nearest £Hundred) £00 Dr J Whittingham Chairman £35 - £40 £35 - £40

Mrs K Jackson Chief executive * £165 - £170 14 £140 - £145 13

Director of finance, information & performance Mr M Rocke £100- £105 1 £100- £105 management *

Dr E Scott Medical director * £140 - £145 £140 - £145

Director of human resources & organizational Ms L Ludgrove - £5 - £10 £145- £150 3 development *** Acting director of human resources & MS Jane Heaton - £15 - £20 organizational development (11/12 part year) Director of human resources & organizational Dr Neil Pease £90 - £95 11 £40 - £45 12 development (11/12 part year) *

Mr N Myhill Director of facilities management * £85 - £90 2 £80 - £85

Ms J Partridge Director of nursing & patient services *** - £175- £180

Ms K Chief nurse (11/12 part year) £85 - £90 £45 -£50 Dunderdale

Ms A Smithson Director of operations * £100 - £105 22 £100 - £105 21

Director of diagnostics and therapeutics (11/12 Mr P Wisher £115 - £120 14 £90 - £95 9 part year) * Director of clinical quality assurance and Ms W Booth trust secretary (head of governance and trust £75 - £80 8 £60 - £65 14 secretary 2011/12) *

Ms M Wilson Non executive director £10 - £15 £10 - £15

Cllr P Jackson Non executive director £10 - £15 £10 - £15

Mr I Davey Non executive director (retired 31/7/12) £0 - £5 £10 - £15

Mr A Bell Non executive director £10 - £15 £10 - £15

Mr N Gammon Non executive director £10 - £15 £10 - £15

Mr S Shreeve Non executive director (appointed 7/6/12) £10 - £15 -

£000 £000* £000 £000*

Gross remuneration including national 1,361 7 1,200 8 insurance and pension contributions Band of Highest Paid Director’s Total £165 -£170 ** £140 - £145 ** Remuneration (£000) Median Remuneration (£000) £23 ** £24 **

Ratio 7.5 ** 6.0 **

* All the benefit in kind relates to lease cars. in the chief executive’s pay and the recruitment of 40 ** The median is the middle item salary when the annualised wte apprentices and 35 wte hotel services staff. This salaries of all members of staff including agency and also reduced the median remuneration in 2012/13. The seconded staff, (excluding bank staff and the highest ratio is obtained by dividing the highest paid directors paid director) are arranged in descending order. salary by the median salary. The increase in the median ratio from 2011/12 to *** These Directors left the Trust and were paid 2012/13 is due to the combined effects of the increase compensation for loss of office.

80 Audited pension benefits 2012-13 Real increase/(Decrease) in pension Real increase/(Decrease) age 60 (bands of £2,500) at aged sum at Real Increase in Lump in pension increase real to 60 related (bands of £2,500) age 60 at pension at accrued Total 2013 (bands of £5,000) 31 March to age 60 related sum at Lump pension at accrued 2013 (bands of £5,000) 31 March at Value Transfer Equivalent Cash 2013 31st March at Value Transfer Equivalent Cash 2012 31 March in Cash Real increase/(Decrease) Value Transfer Equivalent

Name and title £’000 £’000 £’000 £’000 £’000 £’000 £’000

Mrs K Jackson Chief executive 2.5 - 5.0 7.5 - 10.0 35 - 40 105 - 110 588 510 51

Director of finance, planing & Mr M Rocke (0 - 2.5) (2.5 - 5.0) 40 - 45 130 - 135 847 801 4 Performance management

Dr E Scott Medical director (0 - 2.5) (0.0 - 2.5) 55 - 60 170 - 175 1,109 1032 22

Mr P Wisher Director of diagnostics and therapeutics 0.0 - 2.5 0.0 - 2.5 45 - 50 135 - 140 833 760 33

Director of hr and organisational Dr Neil Pease 0.0 - 2.5 5.0 - 7.5 10 - 15 30 - 35 157 118 32 development

Mr N Myhill Director of facilities management 0.0 - 2.5 5.0 - 7.5 25 - 30 85 -90 517 440 55

Karen Dunderdale Chief nurse 2.5 - 5.0 10.0 - 12.5 25 - 30 80 - 85 400 321 63

Ms A Smithson Director of service & business development (0.0 - 2.5) (0.0 - 2.5) 30 - 35 95 - 100 512 477 10

Ms W Booth Head of governance and trust secretary (0 - 2.5) (0.0 - 2.5) 25 - 30 85 - 90 453 426 5

The chairman and non-executive members do not receive arrangement which the individual has transferred to the NHS pensionable remuneration, therefore there will not be any pension scheme. They also include any additional pension entries in respect of pensions for the chairman and non- benefit accrued to the member as a result of their purchasing executive members. additional years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines and framework Cash Equivalent Transfer Values prescribed by the Institute and Faculty of Actuaries. A Cash Equivalent Transfer Value (CETV) is the actuarially The basis of CETV calculations are based in the Department of assessed capital value of the pension scheme benefits accrued Work and Pensions regulations which came into force on 13th by a member at a particular point in time. The benefits valued October 2008. are the member’s accrued benefits and any contingent spouse’s pension payable from the scheme. Real increase in CETV A CETV is a payment made by a pension scheme or This reflects the increase in CETV effectively funded by the arrangement to secure pension benefits in another pension employer. It takes account of the increase in accrued pension scheme or arrangement when the member leaves a scheme due to inflation, contributions paid by the employee (including and chooses to transfer the benefits accrued in their former the value of any benefits transferred from another scheme or scheme. The pension figures shown relate to the benefits arrangement) and uses common market valuation factors for that the individual has accrued as a consequence of their total the start and end of the period. An inflation factor of 5.2 per membership of the pension scheme, not just their service in a cent has been applied this financial year as per the guidance senior capacity to which disclosure applies. from NHS Pensions Agency. The CETV figures and the other pension details include the value of any pension benefits in another scheme or

81 Financial reports and accounts 2012/13

Regulatory ratings report Governance risk rating: The governance risk rating uses a RAG (red amber green) rating system, based upon a system of penalty The risk rating system: points for failing to remain compliant with a set of core performance indicators. Grading runs through Monitor governs Trust ratings based upon systems the following range – red, amber-red, amber-green, set out in their compliance framework. They use a green. A red rating would normally trigger Monitor combination of a financial risk rating, based upon key intervention. financial performance indicators, and a governance risk rating, based on compliance with a set list of Monitor will also in certain circumstances apply an performance indicators and targets, to assess Trust “override rating”, where they judge that the point compliance with core duties set out in their Terms system alone does not adequately reflect the extent of Authorisation. Plan submissions and in-year of risk. Any override rating remains in place until performance are evaluated against these measures removed by Monitor. to grade Trusts on compliance and risk of non- The table opposite sets out the governance risk compliance. position of the Trust. Where Trusts do not remain compliant with the target The Trust entered 2012/13 with an existing override levels set for either rating, they will be taken through rating of amber-red relating to clostridium difficile an escalation process by Monitor, who will make their performance through 2011/12. The Trust had planned own assessment as to the appropriate actions to take. to deliver compliant performance on all indicators, Monitor may judge the Trust to be in breach of its and hence the plan declared a green rating. Terms of Authorisation, and sanction intervention which may include removal of the Trust Board. The Trust remained compliant against all indicators in the first two quarters. The override condition applied Financial risk rating: by Monitor meant that this green rated performance was adjusted to amber-red for quarter one, but the The Financial Risk Rating (FRR) uses a rating system override was lifted in August 2012, and so quarter two of one to five, where one represents the highest risk was rated as green. and five the lowest risk. Risk ratings of two or less are judged by Monitor as the trigger for escalation. The Trust retained its green rating in quarter three. Ratings are based on a weighted average of banded One compliance issue related to two-week waiting performance against a key financial performance and time limits for patients with potential breast cancer liquidity targets. symptoms – the Trust saw 92.5 per cent of these patients within the time limit, whereas the national target threshold was 93 per cent. This was the only The Trust rating history is as follows: cancer waiting time issue experienced through the year, and triggered 0.5 penalty points, insufficient to alter the green rating. In the final quarter, the Trust faced performance issues from two other service areas:

Outturn 2011/12 Plan 2012/13 Q1 2012/13 Q2 2012/13 Q3 2012/13 Q4 2012/13 1. An increase in clostridium difficile infections in the final quarter pushed the Trust beyond FRR 3 3 3 3 3 3 its threshold of 34 – with a total of 37 infections for the year (of which 26 were classed as “clinically unavoidable”) The Trust set out a plan for the year to maintain a risk 2. In common with many providers, pressures rating of three throughout the year, and delivered across urgent care services affected A&E this performance. This reflects the fact that despite performance – the Trust saw 92.3 per cent of expenditure and savings plan delivery issues, attenders within four hours, compared to the additional income receipts were sufficient to support a target rate of 95 per cent. compliant financial position overall. The Trust therefore was rated as amber-red in the The Trust is also projecting ongoing compliance with final quarter. a financial risk rating of three or better for at least the next 12 months within the plan submitted for 2013/14. The Trust expects to return to full compliance with all indicators from the first quarter of 2013/14, and to maintain compliance throughout the year. The plan submitted for 2013/14 therefore sets an anticipated green rating.

82 Governance risk position of the Trust:

Outturn Plan Q1 Q2 Q3 Q4 2011/12 2012/13 2012/13 2012/13 2012/13 2012/13

Underlying Amber Amber Green Green Green Green rating Green Red

Override Amber Amber rating Red* Red*

83 Financial reports and accounts 2012/13

Independent Auditors’ Report to the Council of Governors of Northern Lincolnshire and Goole Hospitals NHS Foundation Trust

We have audited the financial statements of addition, we read all the financial and non-financial Northern Lincolnshire and Goole NHS Foundation information in the Annual Report and Accounts to Trust for the year ended 31 March 2013 which identify material inconsistencies with the audited comprise the Statement of Comprehensive financial statements. If we become aware of any Income, the Statement of Financial Position, the apparent material misstatements or inconsistencies Statement of Cash Flows, the Statement of Changes we consider the implications for our report. in Taxpayers’ Equity and the related notes. The financial reporting framework that has been Opinion on financial statements applied in their preparation is the NHS Foundation In our opinion the financial statements: Trust Annual Reporting Manual 2012/13 issued by the Independent Regulator of NHS Foundation • Give a true and fair view, of the state of the NHS Trusts (“Monitor”). Foundation Trust’s affairs as at 31 March 2013 and of its income and expenditure and cash flows for Respective responsibilities of directors the year then ended to 31 March 2013 and auditors • Have been prepared in accordance with the NHS As explained more fully in the Directors’ Responsibilities Foundation Trusts Annual Reporting Manual Statement the directors are responsible for the 2012/13. preparation of the financial statements and for being satisfied that they give a true and fair view in Opinion on other matters prescribed accordance with the NHS Foundation Trust Annual by the Audit Code for NHS Foundation Reporting Manual 2012/13. Our responsibility is to audit and express an opinion on the financial Trusts statements in accordance with the National Health • In our opinion the part of the Directors’ Remu- Service Act 2006, the Audit Code for NHS Foundation neration Report to be audited has been properly Trusts issued by Monitor and International Standards prepared in accordance with the NHS Foundation on Auditing (ISAs) (UK and Ireland). Those standards Trusts Annual Reporting Manual 2012/13 require us to comply with the Auditing Practices Board’s Ethical Standards for Auditors. • The information given in the Directors’ Report for the financial year for which the financial state- This report, including the opinions, has been ments are prepared is consistent with the financial prepared for and only for the Council of Governors statements. of Northern Lincolnshire and Goole NHS Foundation Trust in accordance with paragraph 24 of Schedule Matters on which we are required to 7 of the National Health Service Act 2006 and for no report by exception other purpose. We do not, in giving these opinions, accept or assume responsibility for any other purpose We have nothing to report in respect of the following or to any other person to whom this report is matters where the Audit Code for NHS Foundation shown or into whose hands it may come save where Trusts requires us to report to you if: expressly agreed by our prior consent in writing. • In our opinion the Annual Governance Statement Scope of the audit of the financial does not meet the disclosure requirements set out in the NHS Foundation Trust Annual Reporting statements Manual 2012/13 or is misleading or inconsistent An audit involves obtaining evidence about the with information of which we are aware from our amounts and disclosures in the financial statements audit. We are not required to consider, nor have sufficient to give reasonable assurance that we considered, whether the Annual Governance the financial statements are free from material Statement addresses all risks and controls or that misstatement, whether caused by fraud or error. risks are satisfactorily addressed by internal controls This includes an assessment of: whether the • We have not been able to satisfy ourselves that accounting policies are appropriate to the NHS the NHS Foundation Trust has made proper ar- Foundation Trust’s circumstances and have been rangements for securing economy, efficiency and consistently applied and adequately disclosed; the effectiveness in its use of resources reasonableness of significant accounting estimates made by the NHS Foundation Trust; and the • We have qualified, on any aspect, our opinion on overall presentation of the financial statements. In the Quality Report.

84 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.

Ian Looker (Senior Statutory Auditor) For and on behalf of PricewaterhouseCoopers LLP Chartered Accountants and Statutory Auditors Leeds 29 May 2013

Notes: The maintenance and integrity of the Northern Lincolnshire and Goole website is the responsibility of the directors; the work carried out by the auditors does not involve consideration of these matters and, accordingly, the auditors accept no responsibility for any changes that may have occurred to the financial statements since they were initially presented on the website. Legislation in the governing the preparation and dissemination of financial statements may differ from legislation in other jurisdictions.

85 86 The Trust annual accounts 2012/13

Foreword to the Accounts Northern Lincolnshire and Goole Hospitals NHS Foundation Trust

The Trust achieved Foundation Status in May 2007. These accounts for the year ended 31 March 2013 have been prepared by Northern Lincolnshire and Goole Hospitals NHS Foundation Trust in accordance with the paragraphs 24 and 25 of schedule 7 to the National Health Service Act 2006 in the form which the Independent Regulator of NHS Foundation Trusts (Monitor) has, with the approval of the Treasury directed. Northern Lincolnshire and Goole Hospitals NHS Foundation Trust’s Annual Report and Accounts are presented to Parliament pursuant to Schedule 7, paragraph 25(4) of the National Health Service Act 2006.

Signed: Date: 29 May 2013

Karen Jackson - Chief executive

87 Accounts 2012/13

88 Statement of the chief executive’s responsibilities as the accounting officer of Northern Lincolnshire and Goole Hospitals NHS Foundation Trust

The NHS Act 2006 states that the chief executive is the accounting officer of the NHS Foundation Trust. The relevant responsibilities of the accounting officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of 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 NHS Act 2006, Monitor has directed the Northern Lincolnshire and Goole Hospitals 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 Northern Lincolnshire and Goole Hospitals NHS Foundation Trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year. In preparing the accounts, the Accounting 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 • Prepare the financial statements on a going concern basis. The accounting officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS Foundation Trust and to enable him/her to ensure that the accounts comply with requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the NHS Foundation Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities. To the best of my knowledge and belief, I have properly discharged the responsibilities set out in Monitor’s NHS Foundation Trust Accounting Officer Memorandum.

Signed: Date: 29 May 2013

Chief executive

89 Accounts 2012/13

Statement of comprehensive income for the year ended 31 March 2013

2012/13 2011/12 Note £000 £000 Revenue Revenue from patient care activities 4 285,466 280,879 Other operating revenue 5 32,051 32,746 Operating Expenses 6 (312,019) (306,189) Operating Surplus/(Deficit) before Restructuring/ Impairments 5,498 7,436 relating to Market Value changes Restructuring costs (2,625) (3,804) Impairments of Property, Plant and Equipment 13 (507) (1,487) Reversal of previous Impairments of Property, Plant and Equipment 13 2,656 2,271 Operating surplus for the financial year 5,022 4,416

Finance costs: Finance Income 11 686 554 Finance costs 12 (142) (170) Surplus/(deficit) for the financial year 5,566 4,800

Public dividend capital dividends payable (3,702) (3,669) Share of (Loss) Profit of Joint Ventures accounted for using equity (24) 50 method of accounting Gain/Loss from Transfer by Absorption 234 0 Retained Surplus for the year 2,074 1,181

Other comprehensive income

Gains on revaluations on Property, Plant and Equipment 13 11,926 28,499 Losses on revaluations on Property, Plant and Equipment 13 (23,192) (27,071)

Total comprehensive (expense) / income for the year (9,192) 2,609

Allocation of Profits/(Losses) for the period: 2012/13 2011/12 £000 £000 (a) Surplus for the period attributable to: (i) owners of the parent. 2,074 1,181

TOTAL 2,074 1,181 (b) total comprehensive income/ (expense) for the period attributable to: (i) owners of the parent. (9,192) 2,609

TOTAL (9,192) 2,609

The notes on pages 94 to133 form part of these accounts

90 Statement of financial position as at 31 March 2013

31 March 31 March 2013 2012 Note £000 £000 Non-current assets Intangible assets 14 814 999 Property, plant and equipment 15 136,088 142,232 Trade and other receivables 18 14 23 Total non-current assets 136,916 143,254 Current assets Inventories 17 2,561 2,994 Trade and other receivables 18 11,640 11,406 Cash and cash equivalents 20 32,732 35,340 Total current assets 46,933 49,740 Total assets 183,849 192,994 Current liabilities Trade and other payables 22 (31,841) (32,072) Borrowings 23 (199) (187) Provisions 31 (5,564) (5,846) Other liabilities 24 (1,817) (1,484) Total current liabilities (39,421) (39,589) Net current assets/(liabilities) 7,512 10,151 Total assets less current liabilities 144,428 153,405

Non-current liabilities Trade and other payables 22 (34) (43) Borrowings 23 (330) (529) Provisions 31 (5,909) (5,551) Total non-current liabilities (6,273) (6,123) Total assets employed 138,155 147,282

Financed by taxpayers’ equity: Public dividend capital 123,843 123,778 Income and expenditure reserve 2,141 67 Revaluation reserve 12,171 23,437 Total Taxpayers’ Equity 138,155 147,282

The financial statements on pages 94 to 133 were approved by the Audit Committee on behalf of the Trust Board and signed on its behalf by:

Signed: Date: 29 May 2013

(Chief executive)

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Statement of changes in taxpayers’ equity

Public Income and Revaluation Dividend Expenditure Total Reserve Capital (PDC) Reserve

£000 £000 £000 £000

Balance at 31 March 2012 123,778 23,437 67 147,282

Changes in taxpayers’ equity for 2012/13 Total Comprehensive Income for the year: Retained surplus/(deficit) for the year 0 0 2,074 2,074 Revaluation gains on Property plant and Equipment 0 11,926 0 11,926 Impairment losses on Property, plant and Equipment 0 (23,192) 0 (23,192) Public Dividend Capital Received 65 0 0 65

Balance at 31 March 2013 123,843 12,171 2,141 138,155

Public Income and Revaluation Dividend Expenditure Total Reserve Capital (PDC) Reserve £000 £000 £000 £000

Balance at 31 March 2011 123,778 22,009 (1,114) 144,673

Changes in taxpayers’ equity for 2011/12 Total Comprehensive Income for the year: Retained surplus/(deficit) for the year 0 0 1,181 1,181 Revaluation gains/(losses) and impairment losses on 0 28,499 0 28,499 property, Plant and Equipment Impairment losses on Property, Plant and Equipment 0 (27,071) 0 (27,071)

Balance at 31 March 2012 123,778 23,437 67 147,282

92 Statement of cash flows for the year ended 31 March 2013 Note 31 March 31 March 2013 2012 Cash flows from operating activities Operating surplus/(deficit) from continuing operations * 5,022 4,416 Non- cash income and expense: Depreciation and amortisation 6 7,330 11,278 Impairments 6 507 1,487 Reversal of Impairments 5 (2,656) (2,271) Decrease in inventories 17 433 1,294 Decrease in trade and other receivables (225) (1,638) (Decrease)/ increase in trade and other payables (513) 327 Increase/(decrease) in other liabilities 333 (4,225) Increase/(decrease) in provisions 31 76 (3,657) Other Movements in operating cash flows 395 292 Net cash generated from/(used in) operations 10,702 7,303

Cash flows from investing activities Interest received 11 686 554 Payments for property, plant and equipment (10,129) (7,957) Proceeds from disposal of plant, property and equipment 360 626 Payments for intangible assets (222) (181) Net cash generated from (used in) from investing activities (9,305) (6,958)

Net cash generated from (used in) before financing 1,397 345

Cash flows from financing activities PDC dividend received 65 0 PDC dividend paid (3,842) (3,348) Capital element of finance lease (187) (174) Interest element of finance lease (41) (54) Net cash generated from (used in) financing activities (4,005) (3,576)

Net (decrease) in cash and cash equivalents (2,608) (3,231) Cash and cash equivalents at the beginning of the financial year 35,340 38,571 Cash and cash equivalents as at 31st March 2013 20 32,732 35,340

31 March 31 March * Operating surplus/(deficit) from continuing operations 2013 2012 Operating Surplus/(Deficit) before Restructuring/ Impairments 5,498 7,436 relating to market value changes Restructuring costs (2,625) (3,804) Reversal of Impairments included within income 2,656 2,271 Impairments charged to expenses re Revaluation of (507) (1,487) Property, Plant and Equipment 5,022 4,416

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Notes to the accounts 1. Accounting policies Monitor has directed that the financial statements of NHS Foundation Trusts shall meet the accounting requirements of the FT ARM which shall be agreed with HM Treasury. Consequently, the following financial statements have been prepared in accordance with the FT ARM 2012/13 issued by Monitor. The accounting policies contained in that manual follow International Financial Reporting Standards (IFRS) and HM Treasury’s FREM to the extent that they are meaningful and appropriate to NHS foundation trusts. The accounting policies have been applied consistently in dealing with items considered material in relation to the accounts.

1.1 Accounting convention These accounts have been prepared on a going concern basis, under the historical cost convention modified to account for the revaluation of land and buildings. Plant and equipment, Intangible assets, inventories and certain financial assets and financial liabilities have been reviewed to represent fair value as at 31st March 2013.

1.2 Consolidation 1.2.1 Subsidiaries The NHS Foundation Trust had no subsidiaries or associates in this accounting period which required consolidation. Until 31 March 2013, NHS charitable funds considered to be subsidiaries are excluded from consolidation in accordance with the accounting direction issued by Monitor.

1.3 Joint ventures The Foundation Trust has entered into a co-operation agreement with the Brain Injuries Rehabilitation Trust (BIRT) to form a separate entity Goole Neuro Rehabilitation Centre (GNRC) which operates from Ward 4 at Goole District Hospital. The Joint Venture provides both NHS care and care independent to the NHS but within an NHS location. The Commissioners, Social Services and other agencies commission services from the Joint venture and the Joint Venture is managed on a day to day basis by BIRT. The Joint Venture accesses support services and has access to NHS facilities from Northern Lincolnshire and Goole Hospitals NHS Foundation Trust which are governed by appropriate Service Level Agreements. The Trust includes within its financial statements its share of the activities, assets and liabilities.

1.4 Critical accounting judgements and key sources of estimation and accuracy 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. Revisions to accounting estimates are recognised in the period in which the estimate is revised if the revision affects only that period or in the period of the revision and future periods if the revision affects both current and future periods. The Trust has continued to develop plans to restructure both front line services and support functions in order to meet the changing service requirements set out by Commissioners and also to meet the ongoing requirement to deliver efficiency savings as mandated through the Operating Framework and tariff. The Trust has set out an ongoing restructuring plan in order to respond to the market pressures facing the organisation through the current period of restricted income growth and increased competitive threat, and this has been updated through the second half of 2012/13, following the Mid Year review process, in order to prepare the organisation for 2013/14 and beyond.

94 The Trust has signed off planning assumptions going forward which will see further projected reductions in pay spend. It is inevitable that this process will incorporate some measures which will result in non recurrent costs – redundancy and early retirement costs, and to a lesser extent payments in line with Trust pay protection policies. For 2012/13, the Trust has refreshed its calculations in respect of the required provision to cover these restructuring costs. This includes both the remaining aspects of the programme set out at the end of 2011/12 which have not been completed in year, and also the additional changes which have been agreed through the second half of 2012/13. Calculations have been primarily based upon estimates of the anticipated proportion of cost saving to be delivered through contracted staff reductions (both voluntary and compulsory – that is, excluding the contribution forecast through reductions in non contracted pay costs and through natural wastage. In addition, the planning work underlying the projected savings plans include identified individuals with significant exit costs. These costs have been provided in addition to the general cost assessments. The projected total requirement to support committed plans made by 31st March 2013 derived on this basis is £4.985m. The existing provision as at 31st March 2013, retained from the amount set aside at the end of 2011/12, was £2.360m. Therefore, an additional charge has been included for 2012/13 of £2.625m. Annual leave accruals The Trust had written to all members of staff requesting details of their outstanding annual leave at the end of March 2013. The response from this survey was 14%. The value of the outstanding amount has been calculated based on the returns received back from staff and their average salary, extrapolated to cover the whole workforce, allowing for other errors and omissions. This value was stress tested against known information including the response, the normal terms of allowed to carry forward leave and due regard to the timing of Easter holidays. The Trust is carrying £3.055 mil (2011/12 £2.642 mil)

1.5 Income Income is accounted for applying the accruals convention. The income is shown gross except where administrative arrangements exists, whereby the associated income is netted off with the corresponding expenditure in accordance with the NHS foundation Trust Financial Reporting Manual (FT ARM). In recognising income in the current financial year, the Trust has considered and followed IAS18 Income in respect of services provided is recognised when, and to the extent that, performance occurs and is measured at fair value of the consideration receivable. The main source of income for the trust is contracts with commissioners in respect of healthcare services. Where income has not been received prior to the year end, but the provision of a healthcare service has commenced, i.e. partially completed patient spells, then the income relating to the patient activity is accrued. The closing accrued income is estimated based on the number of days of incomplete spells at an average daily tariff adjusted to reflect the case mix. 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. The Trust receives income under the NHS Injury Cost Recovery Scheme, designed to reclaim the cost of treating injured individuals to whom personal injury compensation has subsequently been paid e.g. by an insurer. The Trust recognises the income when it receives notification from the Department of Work and Pension’s Compensation Recovery Unit that the individual has lodged a compensation claim. The income is measured at the agreed tariff for the treatments provided to the injured individual, less a provision for unsuccessful compensation claims and doubtful debts which is 12.4 % above the national recommended rate. This rate is based on local trends and experiences of recovery. 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. Therefore, the financial statements disclosures that were provided previously are no longer required. However, only for this financial year, the Trust will be showing this detail within the financial statements for comparative purposes.

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1.6 Expenditure 1.6.1 Expenditure on employee benefits Short-term employee benefits Salaries, wages and employment-related payments are recognised in the period in which the service is received from employees. The cost of annual leave entitlement earned but not taken by employees at the end of the period is recognised in the financial statements to the extent that employees are permitted to carry-forward leave into the following period.

1.6.2 Pension costs NHS Pensions Scheme Past and present employees are covered by the provisions of the NHS Pensions Scheme. Details of the benefits payable under these provisions can be found on the NHS Pensions website at www.nhsbsa.nhs. uk/pensions. 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 NHS Foundation Trust to identify its share of the underlying scheme liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS Body of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period. Employer’s 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.

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

1.7 Property, plant and equipment Recognition Property, plant and equipment is capitalised if: • 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 will be supplied 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 • The item has cost of at least £5,000 or • Collectively, a number of items have a cost of at least £5,000 and individually have a cost of more than £250, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or • Items form part of the initial equipping and setting-up cost of a new building, ward or unit, irrespective of their individual or collective cost. Where a large asset, for example a building, includes a number of components with significantly different asset lives, the components are treated as separate assets and depreciated over their own useful economic lives. Borrowing costs associated with the construction of new assets are not capitalised.

96 Valuation All property, plant and equipment are measured initially at cost, representing the cost 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. Land and buildings used for the trust’s services or for administrative purposes are stated in the statement of financial position at their revalued amounts, being the fair value at the date of revaluation less any subsequent accumulated depreciation and impairment losses. Revaluations are performed by professional valuers every five years and in the intervening years by the use of appropriate indices or by interim valuation as necessary to ensure that carrying amounts are not materially different from those that would be determined at the end of the reporting period. Fair values are determined as follows: • Freehold Properties - Existing Use Value (EUV) • Specialised buildings - Depreciated Replacement Cost (DRC) ~ Modern Equivalent Asset (MEA) • Others - DRC ~ EUV • Land - Modern Equivalent (MEA) Useful economic lives For any new acquisition of property, plant and equipment, the following table details the useful economic lives for the main classes of assets and where applicable, sub categories within each.

Main assets Sub category Life in years

Buildings Structural Engineering Up to 100 years Fixtures Plant, Machinery and Equipment 5 to 15 years Furniture and Fittings 5 to 10 years Vehicles / Transport Equipment Up to 7 years IT Equipment Up to 5 years Intangible Up to 10 years

During this financial year, professional valuations were carried out by DTZ Debenham Tie Leung Limited. The valuations are carried out in accordance with the current Valuation Standards and UK Valuation Standards contained within the Royal Institute of Chartered Surveyors (RICS) Valuation Standards – The Red Book, which are consistent with the agreed requirements of the Department of Health and HM Treasury. In accordance with the requirements of the Department of Health, the Modern Equivalent Asset (MEA) based valuations were undertaken in July 2012 as at the retrospective valuation date of 1 April 2012. Property assets have been valued primarily by using the Depreciated Replacement Cost (DRC) approach. In accordance with VS6.6, the DRC will be subject to the prospect and viability of the continued occupation and use by the Trust. The Market Value for readily identifiable alternative uses would not be higher than the Existing Use. Properties in the course of construction for service or administration purposes are carried at cost, less any impairment loss. Cost includes professional fees but not borrowing costs, which are recognised as expenses immediately, as allowed by IAS 23 for assets held at fair value. Assets are revalued and depreciation commences when they are brought into use. The ultimate objective of the valuation is to place a value upon the asset. In this the value of the land in providing a modern equivalent facility was also considered.

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The modern equivalent may be located on a new site out of town, or be on a smaller site due to changes in the way services are provided. The site is valued based on the size of the modern equivalent, and not the actual site area occupied at present, which has given rise to reduction in the land values. The results of these valuations have been incorporated into these financial statements. Equipment assets are valued using appropriate indices (for 2012/13 no change) and predominantly the Depreciated Replacement Cost is assumed to be the fair value. Annually, an equipment review is also conducted by the department/directorate/equipment specialist and the life of the Equipment assets is reviewed in conjunction with the experts in the field (Medical Electronics/Suppliers/market intelligence). Assets in the course of construction are valued at current cost and they are revalued by professional valuers when they are brought into use or as part of the five or intervening years valuation which ever occurs first. These assets include any existing land or buildings under the control of a contractor. Subsequent expenditure Subsequent expenditure relating to an item of property, plant and equipment is recognised as an increase in the carrying amount of the asset when it is probable that additional future economic benefits or service potential deriving from the cost incurred to replace a component of such item will flow to the enterprise and the cost of the item can be determined reliably. Where a component of an asset is replaced, the cost of the replacement is capitalised if it meets the criteria for recognition above. The carrying amount of the part replaced is de-recognised. Other expenditure that does not generate additional future economic benefits or service potential, such as repairs and maintenance, is charged to the Statement of Comprehensive Income in the period in which it is incurred. Depreciation Freehold land, properties under construction, and assets held for sale are not depreciated. Otherwise, depreciation and amortisation are charged to write off the costs or valuation of property, plant and equipment and intangible non-current assets, less any residual value, over their estimated useful lives, in a manner that reflects the consumption of economic benefits or service potential of the assets. The estimated useful life of an asset is the period over which the Trust expects to obtain economic benefits or service potential from the asset. This is specific to the Trust and may be shorter than the physical life of the asset itself. Estimated useful lives and residual values are reviewed each year end, with the effect of any changes recognised on a prospective basis. Assets held under finance leases are depreciated over their estimated useful lives Revaluation and impairments At each reporting period end, the Trust checks whether there is any indication that any of its tangible or intangible non-current assets have suffered an impairment loss. If there is indication of an impairment loss, the recoverable amount of the asset is estimated to determine whether there has been a loss and, if so, its amount. Intangible assets not yet available for use are tested for impairment annually. In accordance with the FT ARM, impairments 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 equal to the lower of (i) the impairment charged to operating expenses; and (ii) the balance in the revaluation reserve attributable to that asset before the impairment An impairment arising from a loss of economic benefit or service potential is reversed when, and to the extent that, the circumstances that gave rise to the loss is reversed. Reversals are recognised in operating income to the extent that the asset is restored to the carrying amount it would have had if the impairment had never been recognised. Any remaining reversal is recognised in the revaluation reserve. Where, at the time of the original impairment, a transfer was made from the revaluation reserve to the income and expenditure reserve, an amount is transferred back to the revaluation reserve when the impairment reversal is recognised. Other impairments are treated as revaluation losses. Reversals of ‘other impairments’ are treated as revaluation gains. Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income as an item under “Other Comprehensive Income”.

98 De-recognition Assets intended for disposal, are reclassified as ‘Held for Sale’ once all of the following criteria are met: • The asset is available for immediate sale in its present condition subject only to terms • Which are usual and customary for such sales • The sale must be highly probable i.e. • Management are committed to a plan to sell the asset • An active programme has begun to find a buyer and complete the sale • The asset is being actively marketed at a reasonable price • The sale is expected to be completed within 12 months of the date of classification as “Held for Sale” and • The actions needed to complete the plan indicate it is unlikely that the plan will be dropped or significantly changed. Following reclassification, the assets are measured at the lower of their existing carrying amount and their ‘fair value less costs to sell’. Depreciation ceases to be charged and the assets are not revalued, except where the ‘fair value less costs to sell’ falls below the carrying amount. Assets are de-recognised when all material sale contract conditions have been met. Property, plant and equipment which is to be scrapped or demolished does not qualify for recognition as ‘Held for Sale’ and instead is retained as an operational asset and the asset’s economic life is adjusted. The asset is de-recognised when scrapping or demolition occurs.

1.8 Donated assets Donated and grant funded property, plant and equipment assets are capitalised at their fair value on receipt. The donation/grant is credited to income at the same time, unless the donor imposes a condition that the future economic benefits embodied in the grant are to be consumed in a manner specified by the donor, in which case, the donation/grant is deferred within liabilities and is carried forward to future financial years to the extent that the condition has not yet been met. The donated and grant funded assets are subsequently accounted for in the same manner as other items of property, plant and equipment. Within these financial statements, the Trust does not have any donations with conditions attached at this present moment in time

1.9 Intangible assets Recognition Intangible assets are non-monetary assets without physical substance, which are capable of sale separately from the rest of the Trust’s business or which arise from contractual or other legal rights. They are recognised only when it is probable that future economic benefits will flow to, or service potential be provided to, the Trust; where the cost of the asset can be measured reliably, and where the cost is at least £5,000. Internally generated intangible assets Internally generated goodwill, brands, mastheads, publishing titles, customer lists and similar items are not capitalised as intangible assets Expenditure on research is not capitalised. Expenditure on development is capitalised only where all of the following can be demonstrated: • The project is technically feasible to the point of completion and will result in an intangible asset for sale or use • The Trust intends to complete the asset and sell or use it • The ability to sell or use the intangible asset

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• How the intangible asset will generate probable future economic benefits or service potential • The availability of adequate technical, financial and other resources to complete the intangible asset and sell or use it and • The ability to measure reliably the expenditure attributable to the intangible asset during its development. Software Intangible assets acquired separately are initially recognised at fair value. Software that is integral to the operating of hardware, for example 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, for example application software, is capitalised as an intangible asset. 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. Increases in asset values arising from revaluations 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 and impairments are charged to the revaluation reserve to the extent that there is an available balance for the asset concerned, and thereafter are charged to operating expenses. Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income as an item of ‘other comprehensive income’ Intangible assets held for sale are measured at the lower of their carrying amount or ‘fair value less costs to sell’. Amortisation Intangible assets are amortised over their expected useful economic lives in a manner consistent with the consumption of economic or service delivery benefits. Economic lives of intangible assets

Intangible assets - internally generated Min. Life - Years Max. Life - Years

Information technology 5 10 Intangible assets - purchased Software 5 10 Licences & Trademarks 5 10

1.10 Government grants Government grants are grants from Government bodies other than income from primary care trusts or NHS trusts for the provision of services. Where a Government grant is used to fund revenue expenditure it is taken to the Statement of Comprehensive Income to match that expenditure

1.11 Inventories Inventories are valued at the lower of cost and net realisable value. The Trust continues its policy on reducing stock and as far as possible follows Just in Time principles. The reduction in Drugs relates to the of dispensing to Lloyds Pharmacy within the DPoW Trust premises towards the end of the financial year.

1.12 Private Finance Initiative (PFI) transactions At the 31 March 2013, the Trust did not have any PFI transactions

100 1.13 Leases

The Trust as lessee Finance leases Where substantially all risks and rewards of ownership of a leased asset are borne by the NHS Foundation Trust, the asset is recorded as property, plant and equipment and a corresponding liability is recorded. The value at which both are recognised is the lower of the fair value of the asset or the present value of the minimum lease payments, discounted using the interest rate implicit in the lease The asset and liability are recognised at the commencement of the lease. Thereafter the asset is accounted for as an item of property plant and equipment The annual rental is split between the repayment of the liability and a finance cost so as to achieve a constant rate of finance over the life of the lease. The annual finance cost is charged to Finance Costs in the Statement of Comprehensive Income. The lease liability, is de-recognised when the liability is discharged, cancelled or expires. Operating leases Other leases are regarded as operating leases and the rentals are charged to operating expenses on a straight-line basis over the term of the lease. Operating lease incentives received are added to the lease rentals and charged to operating expenses over the life of the lease. Leases of land and buildings Where a lease is for land and buildings, the land component is separated from the building component and the classification for each is assessed separately. The Trust as lessor The Trust has made spaces available within the three sites to the local PCT/CTP, Disability Trust etc. renewable on an annual basis. These are operating leases and the rental from these leases are recognised on a straight line basis within these financial statements.

1.14 Cash and cash equivalents Cash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value.

1.15 Clinical negligence costs The NHS Litigation Authority (NHSLA) operates a risk pooling scheme under which the NHS FoundationTrust pays an annual contribution to the NHSLA, which, in return, settles all clinical negligence claims. Although the NHSLA is administratively responsible for all clinical negligence cases, the legal liability remains with the NHS Foundation Trust. The total value of clinical negligence provisions carried by the NHSLA on behalf of the NHS Foundation Trust is disclosed at note 31, but is not recognised in the Trust’s accounts.

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

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1.17 Provisions The NHS Foundation 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. Where the effect of the time value of money is significant, the estimated risk-adjusted cash flows are discounted using HM Treasury’s discount rate of 2.35% in real terms, except for early retirement provisions and Injury Benefit provisions which both use Treasury’s pension discount rate of 2.35% in real terms When some or all of the economic benefits required to settle a provision are expected to be recovered from a third party, the receivable is recognised as an asset if it is virtually certain that reimbursements will be received and the amount of the receivable can be measured reliably. Present obligations arising under onerous contracts are recognised and measured as a provision. An onerous contract is considered to exist where the Trust has a contract under which the unavoidable costs of meeting the obligations under the contract exceed the economic benefits expected to be received under it. A restructuring provision is recognised when the Trust has developed a detailed formal plan for the restructuring and has raised a valid expectation in those affected that it will carry out the restructuring by starting to implement the plan or announcing its main features to those affected by it. The measurement of a restructuring provision includes only the direct expenditures arising from the restructuring, which are those amounts that are both necessarily entailed by the restructuring and not associated with on-going activities of the entity.

1.18 Sustainability and Carbon Reduction Commitment The CRC scheme is a mandatory cap and trade scheme for non-transport CO2 emissions. The Trust has registered with the CRC scheme, and therefore, is required to surrender to the government an allowance for every tonne of CO2 emitted during the financial year. Accordingly, the Trust has recognised a liability (and related expense) in respect of this obligation for CO2 emissions. The carrying amount of the liability at 31 March 2013 reflects the CO2 emissions that have been made during this financial year, less the allowances (if any) surrendered voluntarily during the financial year in respect of that financial year The liability will be measured at the amount expected to be paid out at the rate of £12 per tonne allowance.

1.19 Contingencies Contingent assets (that is, assets arising from past events whose existence will only be confirmed by one or more future events not wholly within the entity’s control) are not recognised as assets, but are disclosed in note 32 where an inflow of economic benefits is probable. Contingent liabilities are not recognised, but are disclosed in note 32, unless the probability of a transfer of economic benefits is remote. Contingent liabilities are defined as: • possible obligations arising from past events whose existence will be confirmed only by the occurrence of one or more uncertain future events not wholly within the entity’s control; or • present obligations arising from past events but for which it is not probable that a transfer of economic benefits will arise or for which the amount of the obligation cannot be measured with sufficient reliability.

1.20 Public dividend capital Public dividend capital (PDC) is a type of public sector equity finance based on the excess of assets over liabilities at the time of establishment of the predecessor NHS trust. HM Treasury has determined that PDC is not a financial instrument within the meaning of IAS 32. A charge, reflecting the cost of capital utilised by the NHS Foundation Trust, is payable as public dividend capital dividend. The charge is calculated at the rate set by HM Treasury (currently 3.5%) on the average relevant net assets of the NHS Foundation Trust during the financial year. Relevant net assets are calculated as the value of all assets less the value of all liabilities, except for (i) donated assets, (ii) net cash balances held with the Government Banking Services (GBS), excluding cash balances held in GBS accounts that relate to a short-term working capital facility, and (iii) any PDC dividend balance receivable or payable. In accordance with the requirements laid down by the Department of Health (as the issuer

102 of PDC), the dividend for the year is calculated on the actual average relevant net assets as set out in the “pre-audit” version of the annual accounts. The dividend thus calculated is not revised should any adjustment to net assets occur as a result of the audit of the annual accounts.

1.21 Value Added Most of the activities of the NHS Foundation Trust are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.

1.22 Corporation Tax The NHS Foundation Trust has carried out a review of corporation tax liability of its non healthcare activities. At present, all activities are either ancillary to the Trust’s patient care activity or are below the de minimus level at which corporation tax is due. Therefore, the Trust has determined that it has no liability for corporation tax. Further guidance is awaited from Monitor, HM Treasury and the Inland Revenue

1.23 Foreign exchange The functional and presentation currencies of the Trust are sterling. A transaction which is denominated in a foreign currency is translated into the functional currency at the spot exchange rate on the date of the transaction. The Trust does not have any assets or liabilities denominated in a foreign currency at the Statement of Financial Position date.

1.24 Third party assets Assets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since the NHS Foundation Trust has no beneficial interest in them. However, they are disclosed in a separate note (note 36) to the accounts in accordance with the requirements of HM Treasury’s Financial Reporting Manual.

1.25 Losses and special payments Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way that individual cases are handled. Losses and special payments are charged to the relevant functional headings in the Statement of Comprehensive Income 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). However, note 38 is compiled directly from the losses and compensations register which is prepared on an accrual basis with the exception of provisions for any future losses.

1.26 Financial instruments - Financial assets and financial liabilities Recognition Financial assets and financial liabilities which arise from contracts for the purchase or sale of non-financial items (such as goods or services), which are entered into in accordance with the Trust’s normal purchase, sale or usage requirements, are recognised when, and to the extent which, performance occurs i.e. when receipt or delivery of the goods or services is made Financial assets or financial liabilities in respect of assets acquired or disposed of through finance leases are recognised and measured in accordance with the accounting policy for leases described below. Financial assets are recognised when the Trust becomes party to the financial instrument contract or, in the case of trade receivables, when the goods or services have been delivered. Financial assets are derecognised when the contractual rights have expired or the asset has been transferred. All other financial assets and financial liabilities are recognised when the Trust becomes a party to the contractual provisions of the instrument.

103 Accounts 2012/13

De-recognition All financial assets are de-recognised when the rights to receive cash flows from the assets have expired or the Trust has transferred substantially all of the risks and rewards of ownership. Financial liabilities are de-recognised when the obligation is discharged, cancelled or expires. Classification and measurement Financial assets are classified into the following categories: • Financial assets at fair value through income and expenditure • Loans and receivables • Available for sale financial assets. Financial liabilities are classified as: • Fair value through income and expenditure or as • Other financial liabilities. Financial assets and financial liabilities at fair value through income and expenditure Financial assets and financial liabilities at “fair value through income and expenditure” are financial assets or financial liabilities held for trading. A financial asset or financial liability is classified in this category if acquired principally for the purpose of selling in the short-term. Derivatives are also categorised as held for trading unless they are designated as hedges. [Derivatives which are embedded in other contracts but which are not “closely-related” to those contracts are separated-out from those contracts and measured in this category]. Assets and liabilities in this category are classified as current assets and current liabilities. These financial assets and financial liabilities are recognised initially at fair value, with transaction costs expensed in the Statement of Comprehensive Income . Subsequent movements in the fair value are recognised as gains and losses in the Statement of Comprehensive Income Loans and receivables Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. They are included in current assets. The Trust’s loans and receivables comprise of, cash and cash equivalents, NHS debtors, 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 payments/ 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 charged/credited to the Statement of Comprehensive Income. Available for sale financial assets Available-for-sale financial assets are non-derivative financial assets which are either designated in this category or not classified in any of the other categories. They are included in long-term assets unless the trust intends to dispose of them within 12 months of the Statement of Financial Position date. Available-for-sale financial assets are recognised initially at fair value, including transaction costs, and measured subsequently at fair value, with gains or losses recognised in reserves and reported in the Statement of Comprehensive Income as an item of “other comprehensive income”. When items classified as “available-for-sale” are sold or impaired, the accumulated fair value adjustments recognised are transferred from reserves and recognised in “Finance Costs” in the Statement of Comprehensive Income. Other financial liabilities All other financial liabilities are recognised initially at fair value, net of transaction costs incurred and measured subsequently at amortised cost using the effective interest method, except for loans from Department of Health, which are carried at historic cost. The effective interest rate is the rate that exactly discounts estimated future cash payments through the life of the asset, to the net carrying amount of the financial liability.

104 They are included in current liabilities except for amounts payable more than 12 months after the Statement of Financial Position date, which are classified as long-term liabilities. Interest on financial liabilities carried at amortised cost is calculated using the effective interest method and charged to 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. The Trust has reviewed all its main contracts and any derivatives the contracts many have with other contracts are “closely-related” and therefore, does not warrant separate accounting or disclosure Determination of fair value For financial assets and financial liabilities carried at fair value, the carrying amounts are determined from using a number of appropriate techniques including quoted market prices, independent professional appraisals, discounted cash flow analysis, and previous trends and experiences. Impairment of financial assets At the end of the reporting period, the Trust assesses whether any financial assets, other than those held at ‘fair value through profit and loss’ are impaired. Financial assets are impaired and impairment losses recognised 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 expenditure and the carrying amount of the asset is reduced directly/through a provision for impairment of receivables. If, in a subsequent period, the amount of the impairment loss decreases and the decrease can be related objectively to an event occurring after the impairment was recognised, the previously recognised impairment loss is reversed through expenditure to the extent that the carrying amount of the receivable at the date of the impairment is reversed does not exceed what the amortised cost would have been had the impairment not been recognised. The Trust has reviewed its income receivable from the Injury Recovery unit on an annual basis taking into account local trends of recovery and appropriate top up provision has been made for irrecoverable debtors, over and above the proposed bad debts provision of 12.6% recommended by the Department of Health. In line with the policy, the Trust has undertaken a review of all outstanding debts and suitable provisions are recognised within these statements for bad and doubtful debts.

1.27 Transfers of functions from other NHS bodies For functions that have been transferred to the trust from another NHS body, the assets and liabilities transferred are recognised in the accounts as at the date of transfer. The assets and liabilities are not adjusted to fair value prior to recognition. The net gain corresponding to the net assets transferred is recognised within income, but not within operating activities For property plant and equipment assets, the Cost and Accumulated Depreciation balances from the transferring entity’s accounts are preserved on recognition in the Trust’s accounts. The Trust absorbed the Community Services from NHS North Lincolnshire on 1st April 2011. Part of that transfer, some additional equipment assets have been absorbed as at 1st April 2012. These changes are actioned as per Monitor ARM. The transaction included as at 31st March 2013 are as follows:- £000’s GCRC Value of Property, Plant and Equipment - All Equipment at 1st April 2012 351 Depreciation for the year 2012/13 (117) Net book value additions are included within the Statement of Comprehensive Income as shown below: Gains through Absorption 234

105 Accounts 2012/13

1.28 Accounting standards that have been issued but have not yet been adopted The Treasury FReM/FT ARM does not require the following standards and interpretations to be applied in 2012-13. The application of the standards as revised would not have a material impact on the accounts for 2012-13, were they applied in that year:

IFRS 7 Financial Instruments - Disclosure Effective 2013/14 IFRS 9 Financial Instruments Assets & Liabilities Under Consultation IFRS 10 Consolidated Financial Statements Effective 2013/14 IFRS 11 Joint Arrangements Effective 2013/14 IFRS 12 Disclosure of Interests in Other Entities Effective 2013/14 IFRS 13 Fair Value Measurement Effective 2013/14 IFRS 12 Income Amendment Effective 2013/14

IAS 1 Presentation of Financial Statements Effective 2013/14 (Other Comprehensive Income) OCI Effective 2013/14 IAS 27 Separate Financial Statements Effective 2013/14 IAS 28 Associate and Joint Ventures Effective 2013/14 IAS 19 Employee Benefits Effective 2013/14 IAS 32 Financial Instruments Presentation Effective 2013/14

2 Operating segments The Trust’s major activity is health care and therefore is treated as a single segment.

Healthcare Total 2012/13 2011/12 2012/13 2011/12 £000 £000 £000 £000

Income 317,517 313,625 317,517 313,625 Surplus before impairments and 2,550 4,201 2,550 4,201 Restructuring Restructuring costs (2,625) (3,804) (2,625) (3,804) Impairment reversals relating to market 2,656 2,271 2,656 2,271 value changes included in income Impairments relating to market value changes charged to expenses (507) (1,487) (507) (1,487) Retained Surplus 2,074 1,181 2,074 1,181 Segment net assets 138,155 147,282 138,155 147,282

106 3. Income generation activities The trust undertakes certain activities with an aim of break even or achieving a small profit, which is then used to support patient care. Some of these activities are essential for providing the right level of service to the patients and visitors and the profit element, if any, is incidental to the service provision. The following table provides details of activities whose gross income exceeded £1 million

i) Car parking and security services 2012/13 2011/12 £000 £000

Income 1,528 1,302 Direct costs (846) (792) Surplus before indirect costs 682 510

Car parking is a managed service operated by ISS Mediclean. The income is collected by the Trust and is accounted for gross within the financial statements. The costs set out above relate solely to charges associated with the managed service contract.

ii) Catering services across three sites

Catering income amounted to £0.9 mil (£0.9 mil 2011/12) during the year. However, the costs associated with the income generation forms part of the costs of the total catering provision for patients, staff and visitors and could not be separately identified.

4. Revenue from patient care activities 2012/13 2011/12 £000 £000

Strategic health authorities 50 0 NHS trusts 0 260 Primary care trusts 283,116 278,456 Non-NHS: Private patients 814 711 Overseas patients (non-reciprocal) 137 60 Injury costs recovery* 1,117 1,319 Other 232 73 285,466 280,879

* Injury cost recovery income is subject to a provision for impairment of receivables of 25%, which is 12.4% more than the recommended Department of Health rate, to reflect expected rates of collection based on historical trend.

107 Accounts 2012/13

4.1. Income from Activities by Activity 2012/13 2011/12 £000 £000 Acute Trusts Elective income 46,985 50,125 Non elective income 76,836 73,690 Outpatients income 48,726 49,050 A&E income 12,062 11,070 Other NHS Clinical income * 93,695 90,639 278,304 274,574

Private Patient Income 814 711 Other non protected Clinical income 6,348 5,594

285,466 280,879

* Other NHS Clinical income includes income from non tariff services relating to activity such as Pathology, Radiology, Imaging, Therapy, Community etc. Under the Terms of Authorisation, the Trust is required to provide mandatory services. The allocation of operating income between mandatory services and other services is given below

2012/13 2011/12 £000 £000

Mandatory services 276,011 271,634 Non mandatory services 9,455 9,245 285,466 280,879

The Trust experienced increased demand on services during the course of the year and the number of patients treated was higher than in 2011/12. Elective spells were 3% higher compared to the same period last year with critical care days 4% up and A&E attendances 2% up.

108 4.2. Private patient income 2012/13 2011/12 2002/03 £000 £000 Base year* £000

Private Patient income including overseas visitors 951 771 3,003 Total Patient related income 285,466 280,879 154,013

Proportion as % 0.33% 0.27% 1.95%

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. Therefore, this note is no longer required. However for consistency purposes, the Trust has included this information in these financial statements.

5. Other operating revenue 2012/13 2011/12 £000 £000 Education, training and research 8,548 8,727 Charitable and other contributions to expenditure 978 526 Non-Patient Care services to other bodies ** 17,691 18,619 Profit on disposal of Property plant and equipment 0 372 Other revenue *** 4,834 4,502 32,051 32,746 Impairment Reversals 2,656 2,271

Total Other Income 34,707 35,017

** Non Patient Care Services to other bodies includes £9.587mil (£9.4 mil 2011/12) income from United Lincolnshire Hospitals NHS Trust for Pathology services, £2.865 mil from other providers for Pathology Services, and £4.992 mil relates to other provider to provider agreements. *** Other revenue includes £1.528 mil (£1.302 mil 2011/12) for car parking, £0.895 mil (£0.866 mil 2011/12) for catering and £0.759 mil (£0.621 mil 2011/12) for accommodation

109 Accounts 2012/13

6. Operating expenses 2012/13 2011/12 £000 £000

Services from other NHS Trusts (2,314) (1,240) Services from PCTs (7) (153) Services from other NHS bodies 0 (32) Services from Foundation Trusts (536) (451) Purchase of healthcare from non NHS bodies (604) (643) Non Executive Directors’ costs (111) (112) Executive Directors’ costs (1,250) (1,086) Staff costs (212,839) (206,457) Supplies and services - clinical (52,185) (52,319) Supplies and services - general (3,918) (3,880) Establishment (3,520) (3,657) Transport (1,568) (1,354) Premises (15,271) (14,194) Provision for impairment of receivables ( Bad Debts) 50 (139) Depreciation, amortisation and impairments (7,330) (11,278) Consultancy fees (509) (279) Audit fees * (55) (66) Clinical negligence (6,483) (6,182) Loss on disposal of property plant and equipment (146) (33) Other ** (3,423) (2,634) Operating expenses before impairments/Restructuring (312,019) (306,189)

Impairments of property, plant and equipment *** (507) (1,487) Restructuring costs **** (2,625) (3,804)

Total operating expenses including technical items (315,151) (311,480)

* The change in audit fees includes charges relating to the quality audit work ** Other costs include £0.541 mil ( £0.510 mil 2011/12) of insurance costs, £0.780 mil (£0.644 mil 2011/12) training costs, £0.485 mil (£0.406 mil 2011/12) legal costs, £0.510 mil early retirements benefit (£ nil 2011/12). *** Impairment expenditure £0.507mil (£1.487 mil for 2011/12) relates to the reduction in the Trust’s property assets that have been charged to the Statement of Comprehensive Income. **** Restructuring relates to the redundancy costs expected to be paid out following the mid year review and work force planning arrangements.

7. Limitation on external auditors liability 2012/13 2011/12 £000 £000

Limit as per the auditors’ engagement letter 1,000 Unlimited

The auditors’ fee for this financial year is £55 k (2011/12 £66k) which relates to the statutory audit including Quality Accounts.

110 8. Operating leases 8.1 As lessee The Trust ‘s operating leases below consists of predominantly lease cars Payments recognised as an expense 2012/13 2011/12 £000 £000

Minimum lease payments 837 774

837 774

8.2 Annual commitments under non cancellable operating leases are:

Total future minimum lease payments 2012/13 2011/12 £000 £000 Payable: Not later than one year 900 633 Between one and five years 914 639 Total 1,814 1,272

Most of the increase in lease payments is due to lease cars relating to the salary sacrifice lease car scheme.

8.3 As lessor

The Trust has made spaces available within the three sites to the local PCT/CTP, Disability Trust etc. renewable on an annual basis. These are operating leases and the rental from these leases are recognised on a straight line basis within these financial statements.

9. Employee costs and numbers

9.1 Employee costs 2012/13 2011/12

Permanently Permanently Total Other Total Other Employed Employed £000 £000 £000 £000 £000 £000

Salaries and wages 172,867 170,572 2,295 168,011 165,505 2,506 Social Security Costs 12,952 12,952 0 12,901 12,901 0 Employer contributions 19,443 19,443 0 19,305 19,305 0 to NHS Pension scheme * Agency/Contract Staff 8,827 0 8,827 7,335 0 7,335 Termination benefits 2,625 2,625 0 3,920 3,920 0 Employee benefits 216,714 205,592 11,122 211,472 201,631 9,841 expense

* For more details on pension costs, please refer to the note 9.7 on page 114.

111 Accounts 2012/13

9.2 Monthly average number of people employed 2012/13 2011/12 Permanently Permanently Total Other Total Other Employed Employed WTE WTE WTE WTE WTE WTE

Medical and dental 663 561 102 636 550 86 Administration and 1,136 1,130 6 1,116 1,115 1 estates Healthcare assistants and 1,029 994 35 1,070 1,011 59 other support staff Nursing, midwifery and 1,497 1,479 18 1,478 1,471 7 health visiting staff Scientific, therapeutic 947 942 5 970 960 10 and technical staff Total 5,272 5,106 166 5,270 5,107 163

At the end of March, the Trust has released 85 WTE predominantly from a range of support functions (101 headcount) including voluntary and compulsory redundancies. During this financial year the Trust has recruited 40 WTE apprentices. 35 WTE hotel services staff who were working through agency were also absorbed into the Trust.

9.3 Retirements due to ill-health During 2012/13 there were 10 (2011/12 ,9) early retirements from the Trust agreed on the grounds of ill-health. The estimated additional pension liabilities of these ill-health retirements will be £0.610 mil (2011/12 £0.786 mil). The cost of these ill-health retirements will be borne by the NHS Business Services Authority - Pensions Division.

9.4 Management costs 2012/13 2011/12 £000 £000

Management costs 11,321 11,677 Income 317,517 315,896

Management costs as a % of income 3.6% 3.7%

112 9.5 Directors’ remuneration analysis 2012/13 2011/12 £000 £000

Executive and Non Executive Directors’ 1,096 964 Salaries National Insurance - Employers 126 113 Pension contributions - Employers 139 122

Total 1,361 1,199

The Director’s remuneration has increased this financial year by 13%. 7.7 % of the increase is due to full year effect of three Directors who joined the Trust part way during 2011/12 and 4.8 % of the increase relates to pay increases for certain individuals for taking on additional responsibilities. The Trust also seconded one Director to the United Lincolnshire Hospitals NHS Trust from October 2012 to March 2013, whose salary is included in full within the 2012/13 values.

9.6 Staff termination and other exit packages (a) (b) (c) (d) (e) Number Total number Number of Total number of other of Exit compulsory of Exit Exit Package cost and - Excluding directors departures Packages by redundancies Packages agreed cost band 2012/13 2011/12 2012/13 2012/13 < £10,000 5 13 18 19 £10,001 - £25,000 3 22 25 53 £25,001 - £50,000 2 27 29 52 £50,001 - £100,000 6 19 25 35 £100,001 - £150,000 2 2 4 13 £200,001 - £250,000 0 0 0 1 £300,001 - £350,000 0 0 0 1

Total number of Exit Packages by type 18 83 101 174

Total resource cost £000 767 2,984 3,751 7,380

All the above payments have been made as per the NHS terms and conditions on termination of employees.

113 Accounts 2012/13

9.7 Pension costs Past and present employees are covered by the provisions of the NHS Pensions Scheme. Details of the benefits payable under these provisions can be found on the NHS Pensions website at www.nhsbsa. nhs.uk/pensions. The scheme is an unfunded, defined benefit scheme that covers NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS Body of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period. The scheme is subject to a full actuarial valuation every four years (until 2004, every five years) and an accounting valuation every year. An outline of these follows: a) Full actuarial (funding) valuation The purpose of this valuation is to assess the level of liability in respect of the benefits due under the scheme (taking into account its recent demographic experience), and to recommend the contribution rates to be paid by employers and scheme members. The last such valuation, which determined current contribution rates was undertaken as at 31 March 2004 and covered the period from 1 April 1999 to that date. The conclusion from the 2004 valuation was that the scheme had accumulated a notional deficit of £3.3 billion against the notional assets as at 31 March 2004. In order to defray the costs of benefits, employers pay contributions at 14% of pensionable pay and most employees had up to April 2008 paid 6%, with manual staff paying 5%. Following the full actuarial review by the Government Actuary undertaken as at 31 March 2004, and after consideration of changes to the NHS Pension Scheme taking effect from 1 April 2008, his Valuation report recommended that employer contributions could continue at the existing rate of 14% of pensionable pay, from 1 April 2008, following the introduction of employee contributions on a tiered scale from 5% up to 8.5% of their pensionable pay depending on total earnings. On advice from the scheme actuary, scheme contributions may be varied from time to time to reflect changes in the scheme’s liabilities. b) Accounting valuation A valuation of the scheme liability is carried out annually by the scheme actuary as at the end of the reporting period by updating the results of the full actuarial valuation. Between the full actuarial valuations at a two-year midpoint, a full and detailed member data-set is provided to the scheme actuary. At this point the assumptions regarding the composition of the scheme membership are updated to allow the scheme liability to be valued. The valuation of the scheme liability as at 31 March 2011, is based on detailed membership data as at 31 March 2008 (the latest midpoint) updated to 31 March 2011 with summary global member and accounting data. The latest assessment of the liabilities of the scheme is contained in the scheme actuary report, which forms part of the annual NHS Pension Scheme (England and Wales) Resource Account, published annually. These accounts can be viewed on the NHS Pensions website. Copies can also be obtained from The Stationery Office. c) Scheme provisions The NHS Pension Scheme provided defined benefits, which are summarised below. This list is an illustrative guide only, and is not intended to detail all the benefits provided by the Scheme or the specific conditions that must be met before these benefits can be obtained: The Scheme is a “final salary” scheme. Annual pensions are normally based on 1/80th for the 1995 section and of the best of the last three years pensionable pay for each year of service, and 1/60th for the 2008 section of reckonable pay per year of membership. Members who are practitioners as defined by the Scheme Regulations have their annual pensions based upon total pensionable earnings over the relevant pensionable service.

114 With effect from 1 April 2008 members can choose to give up some of their annual pension for an additional tax free lump sum, up to a maximum amount permitted under HMRC rules. This new provision is known as “pension commutation”. Annual increases are applied to pension payments at rates defined by the Pensions (Increase) Act 1971, and are based on changes in retail prices in the twelve months ending 30 September in the previous calendar year. Early payment of a pension, with enhancement, is available to members of the scheme who are permanently incapable of fulfilling their duties effectively through illness or infirmity. A death gratuity of twice final year’s pensionable pay for death in service, and five times their annual pension for death after retirement is payable. For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to the statement of comprehensive income at the time the Trust commits itself to the retirement, regardless of the method of payment. Members can purchase additional service in the NHS Scheme and contribute to money purchase AVC’s run by the Scheme’s approved providers or by other Free Standing Additional Voluntary Contributions (FSAVC) providers.

10. Better Payment Practice Code 10.1 Better Payment Practice Code - measure of compliance 2012/13 2011/12 Number £000 Number £000

Total Non-NHS trade invoices paid in the year 68,241 88,856 67,150 79,773 Total Non NHS trade invoices paid within target 55,294 69,602 60,072 69,171 Percentage of Non-NHS trade invoices paid within 81% 78% 89% 87% target

Total NHS trade invoices paid in the year 3,594 24,370 3,385 25,302 Total NHS trade invoices paid within target 2,417 19,613 2,606 22,513 Percentage of NHS trade invoices paid within target 67% 80% 77% 89%

The Better Payment Practice Code requires the Trust to aim to pay all undisputed invoices by the due date or within 30 days of receipt of goods or a valid invoice, whichever is later. The Trust pays all its suppliers within the normal terms. The BPPC performance this financial year has dropped due to the implementation issues relating to Integra - the new financial ledger system from 1st December 2012.

10.2 The Late Payment of Commercial Debts (Interest) Act 1998

2012/13 2011/12 £000 £000 Compensation paid to cover debt recovery costs under this £0 £0 legislation

115 Accounts 2012/13

11. Finance income 2012/13 2011/12 £000 £000

Interest on loans and receivables 686 554

Total 686 554

12. Finance costs 2012/13 2011/12 £000 £000

Finance leases (41) (53) Other finance costs - unwinding of discount on (101) (117) provisions Total (142) (170)

13. Revaluation of assets (property, plant and equipment) - DV valuations summary

Impairments 2012/13 2011/12 £000 £000

Impairments charged to Revaluation Reserve (23,192) (27,071) Impairments charged to Statement of (507) (1,487) Comprehensive income Total Impairments due to Market Changes (23,699) (28,558)

Revaluation gains 2012/13 2011/12 £000 £000

Revaluation gains credited to Revaluation Reserve 11,926 28,499 Revaluation gains relating to previous impairments 2,656 2,271 credited to income Total Revaluation gains due to Market Changes 14,582 30,770

116 14. Intangible assets Software, Software, Licences and Licences and Trademarks Trademarks £000 £000 31 March 2013 31 March 2012

Gross cost at 1 April 4,553 4,352 TCS Adjustments 0 20 Gross cost at 1 April restated 4,553 4,372 Additions purchased 222 181 Disposals other than by sale* (90) 0 Gross cost at 31 March 4,685 4,553

Accumulated amortisation at 1 April 3,554 3,046 Disposals other than by sale* (90) 0 Charged during the year 407 508 Amortisation at 31 March 3,871 3,554

Net book value Purchased 814 999 Total at 31 March 814 999

Intangible assets are depreciated over 5 to 10 year period on a straight line basis. All intangible assets are purchased and they are not subject to indexation or revaluations.

* Relates to the disposal of Tele Radiology Licences

117 Accounts 2012/13

15. Property, plant and equipment The Trust received Charitable Contributions of £0.679 mil during this financial year to support capital purchases. The assets purchased are predominantly medical equipment funded from donations and legacies received by the Trust. The Trust’s Property have been revalued on a Modern Equivalent Asset basis as at 31st March 2010 by the District Valuers in accordance with the Treasury’s guidelines. At the 1st April 2012, the Trust’s Valuers (DTZ) completed a revaluation of the Estate which resulted in a net downward valuation. The results of this valuation have been included in these financial statements. The property asset lives are as stated in the revaluation by the Trust Valuers. In line with the Trust’s Estates strategy and rationalisation program, and some of the non specialised building assets have been declared non operational and these assets have been valued by the Trust Valuers to the land value. These are predominantly on the North side of Diana, Princess of Wales Hospital site and have been earmarked for demolition as per the Estates Strategy. The impairments relating to these assets are charged to the Statement of Comprehensive Income. Basis of valuation The valuations have been carried out primarily on the basis of Market Value Existing Use using the depreciated replacement cost (DRC) methodology on a modern substitute basis. Non-operational property, including surplus land, has been valued to Market Value Alternate Use. Unless otherwise stated, the assumption has been made that the properties valued will continue to be in the occupation of the Hospital Trust for the foreseeable future having regard to the prospect and viability of the continuance of that occupation. Method of valuation Depreciated Replacement Cost (DRC) is the method of valuation adopted for arriving at the value of specialised operational property for financial accounting purposes as recommended by UK GAPP, the Royal Institution of Chartered Surveyors and HM Treasury. “DRC is based on an estimate of the Market Value for the existing use of the land, plus the current gross replacement (reproduction) costs of the improvements, less allowances for physical deterioration and all relevant forms of obsolescence and optimisation.” Where the actual use of the property is so special that it proves impossible to categorise it in general market terms, land has been valued assuming the benefit of planning permission for development for a use, or a range of uses, prevailing in the vicinity of the actual site. In these circumstances, the Market Value for the Existing Use (MVEU) of the land has been arrived at having regard to the cost of purchasing a notional replacement site in the same locality that would be equally suitable for the existing use and of the same size, with normally the same physical and locational characteristics as the actual site, other than characteristics of the actual site that are irrelevant, or of no value, to the existing use.

118 15. Property, plant and equipment

Plant, Buildings machinery excluding Assets under & Transport Furniture & Land dwellings Dwellings construction equipment equipment I.T. fittings Total £000 £000 £000 £000 £000 £000 £000 £000 £000

Cost or valuation at 31 21,922 101,981 3,893 593 34,602 215 5,045 583 168,834 March 2012 Additions purchased 0 4,085 0 1,183 3,293 30 767 131 9,489 Additions donated 0 540 0 0 139 0 0 0 679 Transfers by absorption 0 0 0 0 351 0 0 0 351 Revaluations 263 10,952 711 0 0 0 0 0 11,926 Impairments (12,321) (10,060) (811) 0 0 0 0 0 (23,192) Reclassifications 0 551 0 (554) 3 0 0 0 0 Disposals (114) (1) (266) 0 (1,419) (130) (173) (36) (2,139) At 31 March 2013 9,750 108,048 3,527 1,222 36,969 115 5,639 678 165,948

Accumulated Depreciation 0 36 0 0 22,887 207 3,111 361 26,602 at 1 April 2012 Disposals 0 (1) (4) 0 (1,342) (130) (121) (35) (1,633) Transfers by absorption 0 0 0 0 117 0 0 0 117 Impairments 21 406 80 0 0 0 0 0 507 Reversal of Impairments 0 (2,656) 0 0 0 0 0 0 (2,656) Reclassifications 0 0 0 0 (133) 0 135 (2) 0 Charged during the year 0 2,418 74 0 3,539 3 815 74 6,923 At 31 March 2013 21 203 150 0 25,068 80 3,940 398 29,860

Net book value Purchased 9,729 104,852 3,377 1,222 11,116 35 1,692 258 132,281 Donated 0 2,993 0 0 785 0 7 22 3,807 Total at 31 March 2013 9,729 107,845 3,377 1,222 11,901 35 1,699 280 136,088

Owned 9,729 107,845 3,377 1,222 11,377 35 1,699 280 135,564 Finance Leased 0 0 0 0 524 0 0 0 524 Total at 31 March 2013 9,729 107,845 3,377 1,222 11,901 35 1,699 280 136,088

Protected 9,729 107,845 0 0 0 0 0 0 117,574 Un protected 0 0 3,377 1,222 11,901 35 1,699 280 18,514 Total at 31 March 2013 9,729 107,845 3,377 1,222 11,901 35 1,699 280 136,088

119 Accounts 2012/13

15. Property, plant and equipment Plant, Buildings machinery excluding Assets under & Transport Furniture & Land dwellings Dwellings construction equipment equipment I.T. fittings Total £000 £000 £000 £000 £000 £000 £000 £000 £000

Cost or valuation at 31 21,885 106,537 4,314 392 35,111 268 8,961 1,751 179,219 March 2011 TCS adjustments # 0 0 0 0 700 593 0 1,293

Valuation - Gross costs 21,885 106,537 4,314 392 35,811 268 9,554 1,751 180,512 1 April 2011 Restated Additions purchased 0 4,454 0 568 2,290 0 258 7,570 Additions donated 0 10 0 0 280 0 0 0 290 Revaluations 340 16,985 254 0 (224) 0 (28) 0 17,327 Impairments (118) (26,371) (582) 0 0 0 0 0 (27,071) Reclassifications 0 366 0 (367) 0 0 1 0 0 Disposals (185) 0 (93) 0 (3,555) (53) (4,740) (1,168) (9,794) At 31 March 2012 21,922 101,981 3,893 593 34,602 215 5,045 583 168,834

Accumulated Depreciation 0 5,887 324 0 22,847 258 6,750 726 36,792 at 31 March 2011 TCS adjustments # 0 0 0 0 239 0 250 0 489 Accumulated Depreciation 0 5,887 324 0 23,086 258 7,000 726 37,281 at 1 April 2011 Restated Disposals 0 0 (9) 0 (3,522) (53) (4,740) (1,169) (9,493) Revaluations 0 (10,403) (516) 0 (225) 0 (29) 1 (11,172) Impairments 0 1,487 0 0 0 0 0 0 1,487 Reversal of Impairments 0 (2,271) 0 0 0 0 0 0 (2,271) Charged during the year 0 5,336 201 0 3,548 2 880 803 10,770 At 31 March 2012 0 36 0 0 22,887 207 3,111 361 26,602

Net book value Purchased 21,922 99,905 3,893 593 10,780 8 1,920 195 139,216 Donated 0 2,040 0 0 935 0 14 27 3,016 Total at 31 March 2012 21,922 101,945 3,893 593 11,715 8 1,934 222 142,232

Owned 21,922 101,945 3,893 593 10,999 8 1,934 222 141,516 Finance Leased 0 0 0 0 716 0 0 0 716 Total at 31 March 2012 21,922 101,945 3,893 593 11,715 8 1,934 222 142,232

Protected 21,922 101,945 0 0 0 0 0 0 123,867 Un protected 0 0 3,893 593 11,715 8 1,934 222 18,365 Total at 31 March 2012 21,922 101,945 3,893 593 11,715 8 1,934 222 142,232

# Adjusted for Transforming Community Services Assets

120 15. Property, plant and equipment Donated assets 31 March 2013 31 March 2012 Buildings Buildings Ex Plant and Ex Plant and Dwellings machinery I.T. Furniture Total Dwellings machinery I.T. Furniture Total £000 £000 £000 £000 £000 £000 £000 £000 £000 £000

Cost or valuation at 1 April 2,043 2,899 109 84 5,135 2,022 2,925 109 84 5,140 Additions purchased 540 139 0 0 679 10 280 0 0 290 Disposals 0 (111) 0 (36) (147) 0 (306) 0 0 (306) Impairments (58) 0 0 0 (58) (362) 0 0 0 (362) Revaluation gains 525 0 0 0 525 373 0 0 0 373 At 31st March 3,050 2,927 109 48 6,134 2,043 2,899 109 84 5,135

Accumulated depreciation 3 1,964 95 57 2,119 100 1,979 86 50 2,215 at 1st April Disposals 0 (107) 0 (36) (143) 0 (300) 0 0 (300) Impairments 0 0 0 0 0 (72) 0 0 0 (72) Revaluation 0 0 0 0 0 (124) 0 0 0 (124) Charged during the year 54 285 7 5 351 99 285 9 7 400 At 31st March 57 2,142 102 26 2,327 3 1,964 95 57 2,119

Net Book Value 2,993 785 7 22 3,807 2,040 935 14 27 3,016 at 31st March

Assets held under finance lease 31 March 2013 31 March 2012 Plant and Plant and machinery I.T. Total machinery I.T. Total £000 £000 £000 £000 £000 £000

Cost or valuation at 1 April 1,315 36 1,351 1,258 36 1,294 Additions purchased 0 0 0 57 0 57 At 31st March 1,315 36 1,351 1,315 36 1,351

Accumulated depreciation at 1st 599 36 635 411 36 447 April Disposals 0 0 0 (2) 0 (2) Charged during the year 192 0 192 190 0 190 At 31st March 791 36 827 599 36 635

Net Book Value at 31st March 524 0 524 716 0 716

121 Accounts 2012/13

2012/13 - Property Valuations Summary by the DTZ

The Trust Valuers (DTZ) completed a valuation of the Property Assets at 1st April 2012 and concluded that there were changes to the Value of Property Assets. The Trust identified that these changes are material and therefore, the results have been incorporated into these financial statements. The outcome from the valuation was that, on all three sites, some of the assets suffered impairments whilst other assets had revaluation gains. The Trust has finalised its Estates Strategy and Rationalisation programme. The approximate net impact of the Trust’s valuations are given below.

Net Change Impairment in Valuation Reversals Changes to Site increase Charged to Included as Revaluation (Decrease) Expenses Income Reserves Description £ 000 £ 000 £ 000 £ 000

Diana, Princess of Wales Hospitals, Land and (4,331) (158) 1,459 2,872 Grimsby Buildings Land and Scunthorpe General Hospital (8,986) (196) 1,197 7,789 Buildings Land and Goole District Hospital (605) 0 0 605 Buildings Land and Other 0 (153) 0 0 Buildings Total (13,922) (507) 2,656 11,266

All the above changes relate to properties in the Trust’s main Healthcare segment.

16. Capital commitments Contracted capital commitments at 31 March 2013 not otherwise included in these financial statements:

2012/13 2011/12 £000 £000

Property, plant and equipment 723 3,042 Intangible assets 102 102 Total 825 3,144

17. Inventories 17.1 Inventories 2012/13 2011/12 £000 £000 Materials:- Drugs 793 1,058 Consumables 1,281 1,391 Energy 109 145 Other 378 400 Total 2,561 2,994 Of which held at net realisable value: 2,561 2,994

The Trust continues its policy on reducing stock and as far as possible follows Just in Time principles. The reduction in Drugs relates to the outsourcing of dispensing to Lloyds Pharmacy within the DPOW Trust premises towards the end of the financial year.

122 17.2 Inventories recognised in expenses 2012/13 2011/12 £000 £000

Inventories recognised as an expense in the period * 35,232 36,223

Total 35,232 36,223

* Inventories recognised in expenses is calculated using transactions from the purchase ledger on the appropriate expenditure areas.

18. Trade and other receivables

18.1 Trade and other receivables Current Non-current 31 March 2013 31 March 2012 31 March 2013 31 March 2012 £000 £000 £000 £000

NHS receivables * 4,689 4,927 0 0 Other trade receivables ** 4,848 4,598 14 23 VAT net receivables 403 385 0 0 Provision for the impairment of (997) (1,082) 0 0 receivables Prepayments other 2,697 2,578 0 0 Total 11,640 11,406 14 23

* NHS receivables include £178k (£38k 2011/12) of PDC dividend. ** Other trade receivables include £2.2 mil of Injury Cost Recovery (Previously RTA) receivables, £2.4 mil of other receivables.

18.2 Ageing of impaired receivables 2012/13 2011/12 £000 £000 0 - 30 days 105 111 30-60 Days 315 219 60-90 days 339 215 90- 180 days 541 497 Over 180 days 1,361 1,914 Total 2,661 2,956

123 Accounts 2012/13

18.3 Receivables past their due date but not impaired 31 March 2013 31 March 2012 £000 £000

0 - 30 days 9,890 9,240 # 30-60 Days 100 211 60-90 days 0 48 90- 180 days 0 56 Over 180 days* 0 0 Total 9,990 9,555

* The majority of this relates to RTA receivables (£0.84 mil) and also there are a number of outstanding invoices relating to other NHS and Non NHS suppliers which are over due and under query and the Trust is in the process of resolving these queries and appropriate bad debt provision has been included for any non payment. # Restated to include total receivables

18.4 Provision for impairment of receivables 31 March 2013 31 March 2012 £000 £000

Balance at 1 April (1,082) (964) (Increase) in provision in the year (285) (563) Amounts utilised 35 21 Unused amounts reversed 335 424 Balance at 31 March (997) (1,082)

The provision for bad debt has been calculated following a detailed review of all outstanding invoices as at 31st March 2013. The departmental heads were involved in determining the potential bad debt values in view of the nature of the services provided and the possibility of potential receipts. The RTA provision for bad debt has been increased to 25% based on the recovery trend in the past years and the level of potential cancellations.

19. Other current assets 31 March 2013 31 March 2012 £000 £000

EU Emissions trading scheme allowances 0 0 Other assets 0 0 Total 0 0

124 20. Cash and cash equivalents 31 March 2013 31 March 2012 £000 £000

Balance at 1 April 35,340 38,571 Net change in year (2,608) (3,231) Balance at 31 March 32,732 35,340

Made up of Cash with Government Banking Services 32,302 34,534 Commercial banks and cash in hand 430 806

Cash and cash equivalents as in statement of financial position 32,732 35,340 Cash and cash equivalents as in statement of cash flows 32,732 35,340

21. Non-current assets held for sale

At the Statement of Financial Position date, the Trust does not have any assets held for sale.

22. Trade and other payables Current Non-current 31 March 2013 31 March 2012 31 March 2013 31 March 2012 £000 £000 £000 £000

NHS payables * (4,935) (5,008) 0 0 Other trade payables - revenue 0 0 (34) (43) Other trade payables - capital (2,968) (2,695) 0 0 Tax and social security costs (4,187) (4,521) 0 0 Accruals (5,631) (4,105) 0 0 Other ** (14,120) (15,743) 0 0 Total (31,841) (32,072) (34) (43)

* NHS payables includes £2.6 mil for NHS Pension agency payments ** Other includes £0.7 mil for Agenda for Change residual issues, £3.1 mil for accrued annual leave, £1.0 mil for SAS (Staff Grade and Associate Specialist) contracts, £5.1 mil of trade payables.

23. Borrowings Current Non-current 31 March 2013 31 March 2012 31 March 2013 31 March 2012 £000 £000 £000 £000

Finance lease liabilities (199) (187) (330) (529) Total (199) (187) (330) (529)

The above relates to payments due to suppliers in relation to the lease of medical and other equip- ment over the term of the lease.

125 Accounts 2012/13

24. Other liabilities Current Non-current 31 March 2013 31 March 2012 31 March 2013 31 March 2012 £000 £000 £000 £000

Other (Deferred Income) (1,817) (1,484) 0 0 Total (1,817) (1,484) 0 0

The £1.817 mil of deferred income in 2012/13 includes £0.6mil clinical trials income, £0.3mil training income and £0.24mil relating to transforming pathology services.

25 Finance lease obligations

The Trust has some medical equipment under leasing arrangements. The table below shows the amounts payable under the terms of the lease for these equipment.

Amounts payable under finance leases: Minimum lease payments 31 March 2013 31 March 2012 £000 £000

Within one year 227 228 Between one and five years 350 577 Less future finance charges (48) (89) Present value of minimum lease payments 529 716 Included in: Current borrowings 199 187 Non-current borrowings 330 529 529 716 There are no sub leases or contingent rents

26. Finance lease receivables (i.e. as lessor)

The Trust has arrangements with other NHS and non NHS bodies whereby the Trust receives income for the premises rented to these bodies. These arrangements are covered by annual service level agreements and are normally for a term of one year, renewable at the end of each year by mutual agreement. This income is included within this year’s operating income shown in these financial statements. These arrangements are not classed as leases.

27. Finance lease commitments

As at the 31 March 2013, the Trust does not have any Finance Lease commitments.

28. Private Finance Initiative contracts

The Trust does not have any PFI schemes at the 31 March 2013

29. Other financial liabilities

The Trust does not have any other Financial Liabilities

126 30 Prudential Borrowing Limit (PBL) 31 March 2013 31 March 2012 £000 £000

Long Term Borrowing Limit set by Monitor 62,500 60,600 Maximum Working Capital Facility set by Monitor 24,000 18,000

Total prudential borrowing limit 86,500 78,600

Long Term Borrowing at 31 March 2013 529 716

Working Capital Borrowing at 31st March 2013 529 716

The Foundation Trust is required to comply and remain within a Prudential Borrowing Limit. This is made up of 2 elements: • the maximum cumulative amount of long-term borrowing. This is set by reference to the 4 ratio tests set out in Monitor’s Prudential Borrowing Code. The financial risk rating set under Monitor’s Compli- ance Framework determines one of the ratios and therefore can impact on the long term borrowing limit. • the amount of any working capital facility approved by Monitor. Further information on the NHS Foundation Trust Prudential Borrowing Code and Compliance Framework can be found on the website of Monitor, the Independent Regulator for NHS Foundation Trusts £529k of borrowing relates to long term commitments against Finance Leases. During the period to 31 March 2013, the Trust remained within the Prudential Borrowing Limit.

At 31 March 2013, the Trust had a working capital facility of £24 mil.

Actual Ratios Approved PBL Actual Ratios Approved PBL Financial Ratios March 2013 Ratios 2012/13 March 2012 Ratios 2011/12

Minimum Dividend Cover 3.6 3.9 6.4 6.7 Minimum Interest Cover 327.0 306.0 317.4 364.5 Minimum Debt Service Cover 37.0 31.0 31.8 24.1 Minimum Debt Service to Revenue 0.0% 0.0% 0.0% 0.0%

127 Accounts 2012/13

31. Provisions Current Non-current 31 March 2013 31 March 2012 31 March 2013 31 March 2012 £000 £000 £000 £000

Pensions relating to other staff - retirement (292) (278) (2,544) (2,281) Legal claims (227) (158) 0 0 Restructurings & Redundancies (4,190) (4,888) (795) (1,223) Other (Demolition, Injury Benefit & Carbon Reduction (855) (522) (2,570) (2,047) Commitment) Total (5,564) (5,846) (5,909) (5,551)

Pensions Redundancies relating to and Total other staff Legal claims Restructurings Other £000 £000 £000 £000 £000

At 1 April 2012 (11,397) (2,559) (158) (6,111) (2,569) Arising during the year (4,863) (510) (200) (2,625) (1,528) Used during the year 4,541 298 84 3,751 408 Reversed unused 347 0 47 0 300 Unwinding of discount (101) (65) 0 0 (36) At 31 March 2013 (11,473) (2,836) (227) (4,985) (3,425)

Expected timing of cash flows: In the remainder of the spending review (5,564) (292) (227) (4,190) (855) period to 31 March 2013 Between 1 April 2013 and 31 March 2018 (3,343) (1,097) 0 (795) (1,451) From 1 April 2018 onwards (2,566) (1,447) 0 0 (1,119) Thereafter 0 (11,473) (2,836) (227) (4,985) (3,425)

£46,320,000 is included in the provisions of the NHS Litigation Authority at 31/3/2013 (31/03/12 £32,631,000), as detailed below;

31 March 2013 31 March 2012 £000 £000 Clinical Negligence Claims 41,495 27,959 Employee Liabilities Scheme 4,825 4,672 46,320 32,631

Provision for retirement relates to pre 1995 premature pensions and the amount provided is based on the actual number of members of staff and their demographic and gender factor. Provision for redundancies of £5.0 mil will be discharged as part of the workforce review process. The Trust has a well established staff reduction programme linking to the efficiency gains the Trust is compelled to make. The above provision has been made based on the Cost Improvement Plans agreeed by the Trust Board. The majority of these reductions is expected to be discharged in the coming financial year.

Other provisions include demolition provision of £1.6 mil, £0.2mil of Carbon Reduction commitment provision and the balance relates to injury benefit relating to named individuals’ payments.

128 32. Contingencies 32.1 Contingent liabilities 2012/13 2011/12 £000 £000 £000 £000

NHSLA notified EL/PL claims (99) (88) Total (99) (88)

The North East Patches have informed the Trust that they will pursue a claim of £0.68 mil for potential compensation for breach of contract. The Trust is in the process of obtaining appropriate advice and at this stage, no provision has been made within the finanical statements.

32.2 Contingent assets

There are no contingent assets in the current financial year.

33. Financial instruments 33.1 Financial assets Loans and Total receivables £000 £000

Receivables 6,559 6,559 Cash and cash equivalent 32,732 32,732

Total at 31 March 2013 39,291 39,291

Receivables 6,399 6,399 Cash and cash equivalent 35,340 35,340

Total at 31 March 2012 41,739 41,739

33.2 Financial liabilities Other financial Total liabilities £000 £000

Payables * (38,143) (38,143) Other borrowings (529) (529)

Total at 31 March 2013 (38,672) (38,672)

Payables * (37,916) (37,916) Other borrowings * * (716) (716)

Total at 31 March 2012 (38,632) (38,632)

* The payables includes £4.985 mil (£6.111 mil in 2011/12) of redundancy and restructuring provisions. ** Other borrowings relates to Obligations under Finance Leases.

129 Accounts 2012/13

33.3 Financial risk management Financial reporting standard IFRS 7 requires disclosure of the role that financial instruments have had during the period in creating or changing the risks a body faces in undertaking its activities. Because of the continuing service provider relationship that the NHS trust has with primary care trusts and the way those primary care trusts are financed, the NHS trust is not exposed to the degree of financial risk faced by business entities. Also financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The NHS trust has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the NHS trust in undertaking its activities. The Trust’s treasury management operations are carried out by the finance department, within parameters defined formally within the trust’s standing financial instructions and policies agreed by the board of directors. Trust treasury activity is subject to regular review by the trust’s Finance Committee and the Trust’s internal auditors. Currency risk The Trust is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. The trust has no overseas operations. The trust therefore has low exposure to currency rate fluctuations. Interest rate risk The Trust currently has no borrowings and therefore, no interest rate risk in relation to borrowings. Credit risk Because the majority of the Trust’s income comes from contracts with other public sector bodies, the trust has low exposure to credit risk. The maximum exposures as at 31 March 2013 are in receivables from customers, as disclosed in the Trade and other receivables note 18.1. Liquidity risk The Trust’s operating costs are incurred under contracts with primary care Trusts, which are financed from resources voted annually by Parliament . The Trust funds its capital expenditure from internally generated funds and funds obtained within its prudential borrowing limit. The Trust is not, therefore, exposed to significant liquidity risks.

34. Events after the reporting period There are no post balance sheet events in the reporting period.

35. Related party transactions During the year none of the Department of Health Ministers, Trust Board Members or members of the key management staff, or parties related to any of them, has undertaken any material transactions with Northern Lincolnshire and Goole Hospitals NHS Foundation Trust. The Department of Health is regarded as a related party. During the year, this Trust has had a significant number of material transactions with other entities for which the Department of Health is regarded as the parent Department. These entities are: Strategic Health Authorities, Primary Care Trusts, NHS Trusts, NHS Foundation Trusts, NHS Litigation Authority, NHS Purchasing and Supply Agency In addition, the trust has had a number of material transactions with other government departments and other central and local government bodies. The Trust has also received revenue and capital payments from a number of charitable funds, certain of the trustees for which are also members of the NHS trust board.

130 31 March 31 March 2012/13 2012/13 Organisation 2013 2013 Income Expenditure Receivables Payables £000 £000 £000 £000 Barnsley PCT 779 0 0 42 Department of Health 0 0 208 40 Doncaster PCT 1,098 0 0 71 Doncaster and Bassetlaw NHS Foundation Trust 0 211 3 81 East Riding Of Yorkshire PCT 20,639 39 57 0 0 299 0 70 Hull And East Yorkshire Hospitals NHS Trust 842 1,413 78 342 Hull Teaching PCT 418 0 0 0 Humber NHS Foundation Trust 331 125 0 53 Leeds PCT 173 0 0 0 Leeds Teaching Hospital NHS Trust 6 350 0 201 Lincolnshire Community Health Services NHS Trust 1,004 6 174 0 Lincolnshire Partnership NHS Foundation Trust 267 0 0 0 Lincolnshire Teaching PCT 40,271 0 1,323 0 NHS Blood & Transplant 0 1,624 0 0 National Heath Service Pension Scheme 0 19,443 0 2,603 NHS Litigation Authority 0 6,541 0 0 NHS Business Services Authority 1,459 0 67 0 North East Lincolnshire CTP 107,716 28 1,075 0 North East Lincolnshire Council 207 594 59 0 North Lincolnshire PCT 109,582 191 689 406 North Lincolnshire Council 598 620 121 0 North Yorkshire & York PCT 702 0 0 0 University Hospitals NHS Foundation Trust 65 90 62 31 Rotherham Doncaster And South Humber Mental 65 64 15 0 Health NHS Foundation Trust Sheffield Children’s NHS Foundation Trust 57 650 0 156 Sheffield Teaching Hospitals NHS Foundation Trust 9 717 0 187 United Lincolnshire Hospitals NHS Trust 9,682 1,536 150 351 University Hospitals of Leicester 159 15 134 0 Wakefield District PCT 364 0 0 0 York Hospitals NHS Foundation Trust 492 0 121 22 Yorkshire and The Humber Strategic Health Authority 9,036 0 38 25 Other (Total) 2,017 1,336 513 255

Total Related Parties 308,038 35,892 4,887 4,936

HM Revenue and Customs ( Taxes and Duties) 0 12,952 403 4,187 Other Government Departments 0 12,952 403 4,187 Comparatives 2011/12 Total Related Parties 304,176 45,084 4,834 5,008 Other Government Departments 12,901 385 4,521

131 Accounts 2012/13

35. Related party transactions continued Key management Personnel In 2012/13, apart from what is shown within the Remuneration report, no other payment was made to key management personnel.

2012/13 2011/12 Expenditure Expenditure £000 £000

1. Short term employee benefits 0 0 2. Post employment benefits 0 0 3. Other long term benefits 0 0

Charitable Funds The Northern Lincolnshire and Goole Hospitals NHS Foundation Trust Board is the Corporate Trustee of the NHS Charitable Funds and therefore, the Charitable Funds represents a subsidiary of the Foundation Trust on the basis that:- • has control over the NHS charitable fund (as determined by IAS 27 (revised); and • benefits from the NHS charitable fund. HM Treasury has granted dispensation to the application of IAS 27 (revised) by NHS foundation trusts solely in relation to the consolidation of NHS charitable funds for 2011/12 and 2012/13. From 2013/14, NHS foundation trusts will need to consolidate the NHS charitable funds.

For 2012/13, the financial position of the NHS Charitable Funds is as follows:-

2012/13 2011/12 £000 £000 Statement of Financial Activities Total Incoming Resources 560 570 Total Resources Expended* (1,115) (618) Net (outgoing) resources before transfers (555) (48) Gains on revaluation and disposal 226 19 Other fund movements 0 (2) Net movement in funds (329) (31)

* Expenditure includes £38k (£43k 2011/12) administration costs and £299k (£236k 2011/12) expenditure on medical equipment, staff training and development

Statement of Financial position Investments 1,932 2,339 Cash 529 309 Other Current Assets 28 45 Current Liabilities (211) (86) Total Charitable Funds 2,278 2,607

(The Charitable Fund Accounts are subject to Audit approval)

132 36. Third party assets The Trust held £17,000 (2011/12 £16,000) casn and acsh equivalents which relates to monies held by the NHS Trust on behalf of patients. This has been excluded from the cash and cash equivalents figures reported in the accounts.

37. Intra-Government and other balances Current Non-current Current Non-current receivables receivables payables payables £000 £000 £000 £000

Balances with other Central Government Bodies 599 0 (6,790) 0 Balances with NHS Bodies 4,511 0 (2,322) 0 Balances with Local Authorities 180 0 (11) 0 Intra Government balances 5,290 0 (9,123) 0 Balances with bodies external to Government 6,350 14 (22,718) (34) At 31 March 2013 11,640 14 (31,841) (34)

Balances with other Central Government Bodies 80 0 (7,075) 0 Balances with NHS Bodies 4,927 0 (2,443) 0 Balances with Local Authorities 212 0 (11) 0 Intra Government balances 5,219 0 (9,529) 0 Balances with bodies external to Government 6,187 23 (22,543) (43) At 31 March 2012 11,406 23 (32,072) (43)

38. Losses and special payments There were 136 (77 cases in 2011/12) cases of losses and special payments totalling £192k (£195k in 2011/12) paid during the year.

There were no cases exceeding £250,000 in this year and prior year.

133 134 Annual Quality Account 2012/13

135 Annual Quality Account 2012/13

136 Quality Account Summary

Contents

1.0 Part 1: Statement on quality from the chief executive of the Trust 139

2.0 Part 2: Priorities for improvement and statements of assurance from the board 142 Overview of the quality of care against 2012/13 quality priorities

2.1 Priorities for improvement: Overview of the quality of care against 2012/13 142 quality priorities

2.1a Clinical effectiveness quality indicators 142

2.1b •• Patient safety quality indicators 158

2.1c •• Patient experience quality indicators 169

2.2 •• Quality priorities for 2013/14 176

2.3 Statements of assurance from the board 178

2.3a •• Information on the review of services 178

2.3b •• Information on participation in clinical audits and national confidential 178 enquiries

2.3c •• Information on participation in clinical research 187

2.3d •• Information on the Trust’s use of the CQUIN framework 188

2.3e •• Information on never events 188

2.3f •• Information relating to the Trust’s registration with the Care Quality 189 Commission

2.3g •• Information on quality of data 189

2.3h •• Information on information governance 189

2.3i •• Information payment by results clinical coding audit 189

2.3j •• Trust performance against a core set of indicators 189

2.3k •• Summary Hospital-Level Mortality Indicator (SHMI) 190

2.3l •• Patient Reported Outcome Measures (PROMS) 192

137 Annual Quality Account 2012/13

2.3m •• Readmissions to hospital 193

2.3n •• Personal needs of patients 194

2.3o •• Staff recommending Trust as a provider to friends and family 196

2.3p •• Risk assessed for venous thromboembolism 197

2.3q •• Clostridium difficile infection reported within the Trust 198

2.3r •• Patient safety incidents 199

3.0 Part 3: An overview of the quality of care based on performance in 2012/13 202 against indicators

3.1 •• Performance against 2012/13 indicators 202

3.2 Performance against relevant indicators and performance thresholds 204

3.3 Information on staff survey report 205

3.5 Information on patient survey report 207

ANNEX 209

1 Annex 1: Statements from commissioners 210

2 Annex 2: Statement from Healthwatch organisations 211

3 Annex 3: Statement from the Overview and Scrutiny Committees 212

4 Annex 4: Statement from the Trust Governors’ service quality monitoring group 214

5 Annex 5: Statement of directors’ responsibilities in respect of the Quality Report 215

6 Annex 6: Independent auditor’s report to the Board of Governors on the 216 Annual Quality Report

7 Annex 7: Glossary 219

8 Annex 8: Mandatory performance indicator definitions 223

138 PART 1: Statement on quality from the chief executive of the Northern Lincolnshire and Goole Hospitals NHS Foundation Trust

I am delighted to be able to take this opportunity to During the year, the Trust has been under a lot of introduce the annual quality account for the Northern scrutiny regarding its performance against various Lincolnshire and Goole Hospitals NHS Foundation mortality measures. This has generated a lot of Trust (also referred to as ‘the Trust’ throughout interest locally. I and the Trust Board therefore this report). Whilst publication of this document is have welcomed the news of the impending visit now mandatory, I feel strongly that this provides from a team lead by Sir Bruce Keogh, NHS Medical an excellent opportunity for us as an organisation Director, to provide an additional degree of external to outline just some of the focussed pieces of work scrutiny and support in accelerating our already undertaken during the last financial year covering comprehensive action plans. We have supported April 2012 to March 2013. I hope from your reading the planning stages of this review fully, providing through this you can understand some of the key the team with lots of evidence to inform their review challenges faced by the organisation throughout the and make it as useful as possible. At the same time year and also feel assured that the organisation’s staff we as a Trust have commissioned external reviews of at all levels are dedicated to constantly strive to focus our information and clinical systems and assurance on and improve the quality of care we provide to our mechanisms from such external organisations as patients, service users and carers. KPMG auditors, local peer NHS organisations and experts from other NHS institutions to help guide As a Foundation Trust, the format of our quality the comprehensive internal programme of work that account has to meet certain requirements provided is underway. As a result of this hard work, I am very to us by the Department of Health and Monitor and pleased with the continuing improvements in the as a result in some areas this is quite prescriptive. Trust’s performance against the various mortality Despite this we have done our utmost to provide indicators such as the Risk Adjusted Mortality the following information in a way that enables all Indicator (RAMI) and the most recent iterations of audiences, but particularly our local population, to be the Summary Hospital Mortality Indicator (SHMI). able to receive and understand the key points. We are confident of ensuring that patient safety Whilst we publish this particular account on an remains a key priority and therefore the positive annual basis, I want to assure you that quality and results following the implementation in November of the indicators chosen to help us focus on and the National Early Warning Score (NEWS) within the improve key areas are taken very seriously within organisation provides me with confidence that any the organisation throughout the year. A monthly signs of deterioration in our patients can be identified account and performance against key indicators and acted on. To ensure that we continue to improve outlined within this report is provided to the quality these are the areas that the Trust have identified as and patient experience committee, chaired by a needing to remain as key quality indicators for the non-executive director, who receives and challenges 2013/14 financial year. the report to ensure the organisation is always You will note that our quality priorities for the coming striving to improve quality of care and service. This financial year which started in April 2013 remain report is then presented on a monthly basis to myself focussed on improving key areas, some of which and the Trust Board and as a result of this, and our are those areas where progress has been made but commitment to transparency, this monthly report is where further work is still necessary. To complement then available to the public, allowing our Foundation the Trust Board’s focus on improved quality of patient Trust members within all local communities the care, you will notice that a key quality target also opportunity to be both informed and assured of relates to the morale of the organisations’ workforce our commitment to quality. As a result of these – its dedicated staff from all backgrounds, specialisms processes and assurance mechanisms, to the best and departments – which ensures that the of my knowledge the information contained in this organisation is able to provide the services it does. document is accurate.

139 Annual Quality Account 2012/13

The Trust recognises that to provide high quality this we have implemented a quality strategy which services, our staff need to feel engaged, respected, further demonstrates this. The overall statement of listened to and appreciated. It is our determination intent and vision for this is: therefore that this will be a focal point of the Trust’s •• ‘To provide a range of high quality clinical services work going forward and will feature as high on our that are financially viable and which allow the quality improvement plans as clinical improvement provision of a comprehensive range of emergency work. services to our local population’ The organisation has performed well during the year •• This vision is underpinned by a number of despite a backdrop of immense change within the strategic goals, the first of which states: National Health Service. I am particularly proud of the consistently positive feedback we receive from our •• ‘To provide excellent care to patients in a safe and patients and service users of their experiences within modern environment’. our organisation. I am pleased with our continued The Trust Board and I therefore look forward to improvement with reduction of MRSA within the working closely and providing quality leadership organisation and we are focussed on using this good throughout the rest of this coming financial year example of quality improvement to help us improve to allow our dedicated teams of staff to fulfil the our performance with clostridium difficile incidence above strategic goal of providing excellence in a throughout this coming year. The Trust actively safe environment. I look forward to outlining our promotes the policy of reporting all incidents or near continuing achievements both throughout the year misses no matter how seemingly insignificant they in the monthly quality report as well as next year in may appear to be the staff involved, by doing this we our annual quality account publication. strive to identify lessons to be learnt which allows us to then focus on improving patient safety, I am therefore pleased with the level of Trust reported incidents as this shows we taking this area very seriously. I hope from what I have said and from the following quality account that you can see that the Trust board Karen Jackson, Chief executive and I are keenly focussed on quality. To support

140 About Northern Lincolnshire and Goole Hospitals NHS Foundation Trust

Northern Lincolnshire and Goole Hospitals Our core business can be defined as: NHS Foundation Trust (referred to as ‘The Trust’ •• Delivering a full range of emergency secondary throughout this report) consists of three hospitals, health care services, including intensive and high these are: dependency care •• Diana, Princess of Wales Hospital in Grimsby (also •• Maintaining a comprehensive range of planned referred to as DPoW) services, in an environment of patient choice and •• Scunthorpe General Hospital located in contestability Scunthorpe (also referred to as SGH) •• Ensuring a full range of secondary care diagnostic •• Goole and District Hospital (also referred to as services are available locally. GDH). The Trust has developed, through extensive The Trust was established as a combined hospital consultation with the local health community, a five- and community Trust on April 1 2001, and achieved year strategic direction. This describes the Trust’s key Foundation Status on May 1 2007. It was formed strategic priorities for the next five years and beyond, by the merger of North East Lincolnshire NHS Trust to support the healthcare requirements of the local and Scunthorpe and Goole Hospitals NHS Trust and population. operates all NHS hospitals in Scunthorpe, Grimsby Our primary strategy is “Local Services for Local and Goole. Its name reflects the wider geographical People” – to be the provider of choice for the local area in which the Trust is a major provider of health health community. This is in line with the strategic care. vision of local commissioners: Running three hospitals, separated by considerable •• Broadly comprehensive district general hospitals distances, poses a significant service delivery in Grimsby and Scunthorpe, supported from challenge, but also allows the Trust to serve a wider Goole population. NLaG also provides a range of services delivered outside of hospital settings. Due to these •• Rationalisation, reconfiguration and consolidation geographical distances a key way the Trust uses managed in a collaborative way to help measure and monitor quality of care is •• Joint development of modernisation initiatives through site by site breakdowns of performance across the health community. against various measures. You will see this illustrated throughout the following sections of the report.

For latest news from Northern Lincolnshire and Goole Hospitals NHS Foundation Trust visit our website at: www.nlg.nhs.uk Follow the Trust on Twitter: @NHSNLaG

141 Annual Quality Account 2012/13

PART 2: Priorities for improvement and statements of assurance from the board 2.1 Priorities for improvement: Overview of the quality of care against 2012/13 quality priorities Information reported within Part 2 Due to the timings necessary to compile the annual quality account, the most recent information available presented is not always to the end of the financial year. Despite this at least 12 months trending information is available. Priorities for improvement This section of the report highlights the achievement during 2012/13 towards achieving the priorities which we set out in our Annual Quality Account for 2011/12 for this financial year. The quality priorities are divided into three sections: clinical effectiveness, patient safety and patient experience. During 2012/13 the following quality priorities were monitored by the monthly quality report which was presented and reviewed on a monthly basis by the Trust’s quality and patient experience (QPEC) committee and the Trust Board. Section 2.2 of this report (page 176) details the quality priorities for the 2013/14 financial year. In some cases these quality priorities have changed from those reported on below. Where this is the case, beneath each indicator, the rationale for the change is explained. A note on interpretation of the following information Wherever possible throughout this report, unfamiliar terms or acronyms have been explained in the body of the report. Where this has not been possible due to compliance with the national template set for the Trust’s annual quality account submission, every effort has been made to ensure the glossary (page 219) provides the necessary definition to aid the reader’s interpretation of this information.

2.1a Clinical effectiveness

CE1 – Reduction in mortality ratios Introduction to data on mortality: One of the Trust’s most important quality measures is that of mortality. The Trust has invested a lot of work into this area to ensure that the organisation’s performance with mortality measures is understood, monitored and acted upon to ensure the quality of care afforded to the Trust’s local population is being consistently improved. In order to report the Trust’s position on mortality, it is worth explaining some of the different mortality measures and how the Trust uses these internally. There are two primary ways to measure mortality, both of which are used by the Trust: 1. Crude mortality – expressed as a percentage, calculated by dividing the number of deaths within the organisation by the number of patients treated 2. Standardised Mortality Ratios (SMR). These are statistically calculated mortality ratios that are heavily dependent on the quality of recording and coding data. These are calculated by dividing the number of deaths within the Trust by the expected number of deaths.

142 This expected level of mortality is based on individual, patient specific risk factors that a person will present with on their admission ie their diagnosis or the reason for their attending the hospital, their age and their existing medical conditions and illnesses. These, as well as in hospital data such as the type of admission i.e. an elective admission for a planned procedure or an unplanned emergency admission with an acute medical/surgical condition, all inform the statistical model’s calculation of expected mortality within the organisation. As these Standardised Mortality Ratios (SMRs) are statistical calculations, they are expressed in a specific format. Based on the average expected mortality within the UK, an organisation’s expected level of mortality would be expressed at a level of 100. Therefore an SMRs of more than 100 would be considered to be a higher than would be expected mortality ratio. Conversely, an SMR of less than 100 would be a mortality ratio less than would be expected. The Trust’s performance against these indicators is monitored on an ongoing basis by the Trust’s mortality performance committee (MPC) which is chaired by the Trust’s chairman. This committee oversees the Trust’s numerous work streams being undertaken to improve the Trust’s actual and reported performance in this area. One way the committee is empowered to do this is through the monthly mortality report which reports the Trust’s latest performance with these indicators. Whilst explaining the different ways in which the Trust monitors performance with mortality measures, it is worth noting that there are a number of different Standardised Mortality Ratios (SMR) in use throughout the United Kingdom. The most frequently used SMR indicators are:

1. Summary-Hospital Level Mortality Indicator (SHMI). The SHMI is the ‘official’ NHS Standardised Mortality Ratio (SMR). The way it is calculated is the same for all NHS organisations and so allows individual Trusts to be ranked in terms of their performance. The Summary-Hospital Level Mortality Indicator (SHMI) however does not just calculate the levels of in- hospital expected mortality. The Summary-Hospital Mortality Indicator (SHMI) includes deaths within the community within 30 days following hospital discharge. This is the only SMR indicator to include community mortalities, all others focus solely on deaths within the hospital. As a result of this SHMI is based not only on in-hospital collected data, but also requires data from the Office for National Statistics. Due to this methodology, when the SHMI is published each quarter, the time frame being reported on by the SHMI ranges from 6 months – 18 months behind current performance. To illustrate this, in April 2013 when the most recent SHMI was published, the reporting period was October 2011 – September 2012. Whilst the indicator provides a comparable picture of performance, the Trust has struggled to use the Summary-Hospital Mortality Indicator (SHMI) effectively in order to monitor Trust performance due to the significant time lag in reporting. 2. Risk Adjusted Mortality Index (RAMI). The Risk Adjusted Mortality Index (RAMI) is another example of a Standardised Mortality Ratio (SMR). It is provided to NHS Trusts to use by a private company called CHKS. The product enables the Trust to use this software to analyse its own internally collected data. The RAMI is just another example of an information tool for which NHS organisations can use to track and monitor performance with their mortality ratios. The Risk Adjusted Mortality Indicator (RAMI) whilst an SMR is calculated differently to the methodology used by the SHMI. This means that direct comparison of performance against the two indicators is not possible. One example of a key difference is in connection with patients receiving palliative care. Such patients are included in the Summary Hospital Level Mortality Indicator (SHMI), however in the RAMI indicator, these patients would be excluded. The RAMI assess in-hospital mortality only. If a patient were to die following their discharge from hospital, this would not be reflected in the Trust’s RAMI data. As a result of this, the RAMI indicator is based on in-hospital collected data only meaning that performance can be monitored in a much more timely manner usually meaning that data is available four or five weeks after the event. Alongside SHMI, the Trust has used the Risk Adjusted Mortality Index (RAMI) heavily in its monitoring and taking action based on mortality ratios. You will see in the following sections the Trust’s current use of this mortality ratio.

143 Annual Quality Account 2012/13

3. Hospital Standardised Mortality Ratio (HSMR). This indicator is another example of a Standardised The RAMI or risk adjusted mortality indicator is a statistical expression of the Trust’s expected mortality. As Mortality Ratio (SMR) provided for NHS organisations to track their performance against mortality indices. referred to in the introduction to this section, there are other versions of this statistical model, referred to as a The HSMR is also provided by a commercial company called Dr Foster, who use this indicator to rate NHS Standardised Mortality Ratio (SMR), RAMI is the main indicator that the Trust uses to monitor this area. Trust performance on an annual basis in their Good Hospital Guide Publication. In the same way as CHKS The ‘expected’ aspect of the calculation is heavily dependent on data quality and recording. A RAMI of 100 is the provide their RAMI indicator, NHS Trusts have to pay a subscription to make use of these indicators, and accepted national average and therefore equates to the Trust’s expected level of mortality. as the Trust is already using the CHKS product, no subscription is paid for the HSMR indicator and so the Trust does not have ready access to the results from this indicator. Anything above 100 demonstrates an above expected mortality rate and anything lower than 100 demonstrates a lower than expected mortality ratio, according to the statistical model employed. In exactly the same way as the RAMI calculation methodology differs to that of the SHMI, the HSMR is calculated using different rules and methodologies for instance HSMR does not include all hospital This chart shows that since August 2012 there has been a reduction of RAMI which brings us far nearer to the mortality, rather it groups deaths within certain chapters and uses these to assess mortality performance. performance of our peers. In January 2013, the monthly RAMI for the Trust was 89. The peer value was 86. A note of caution when interpreting Standardised Mortality Ratios: This chart reflects much of the Trust’s focus on these mortality indicators and the action plan currently in place The use of a Standardised Mortality Ratio (SMR) in assessing and ranking performance must always be interpreted to ensure the Trust continually improves performance in this area. An example of some of the action already with caution. As these are ratios of actual deaths against expected levels of mortality they are heavily dependent having been taken is improvements in the accurate recording and coding of appropriate diagnosis groups and on data and the accuracy of recording. co-morbidities. Some cases identified from specific project work, were found to have had gaps As a result of this, there interpretation is likened to that of a smoke alarm, in the same way as the smoke alarm sounding does not mean there is definitely a fire, an SMR indicator ofabove 100 does not definitely indicate a problem. in the documented and coded history recorded within the Trust’s information systems. As already alluded to in the introduction, the Standardised Mortality AsHowever, a result just as of it would the Trust’s be unwise continued to ignore a smoke focus alarms on mortality warning and measures, not investigate, the the first Trust section takes the of the same view, SMRs above 100 are not ignored they are proactively investigated by a number of methods involving Ratios (SMR) base the calculation of expected mortality on such recorded and quality report deals with the Trust’s performance with the Risk Adjusted Mortality Indicator coded details. (RAMI)the Trust’s Standardised information team Mortality and the quality Ratio and audit (SMR). team. More information is included on pages 60 regardingThese departments the Trust’s efforts are performance guided by and withoverseen the by the Summary-Hospital mortality performance Level committee Mortality (MPC) who Indicator Therefore by not capturing the full patient ‘story’ the risk factors that are used (SHMI)ensure appropriate and more clinical information leaders are on also just involved some and of takingthe actions appropriate taken action already where regardingneeded. mortality. to calculate the expected mortality aspect of the calculation will produce a risk As a result of the Trust’s continued focus on mortality measures, the first section of the quality report deals with that under reports the expected mortality resulting in a higher than expected the Trust’s Target: performance (CE1a) with Thethe Risk Trust Adjusted aspires Mortality to achieve Indicator (RAMI)a Risk Standardised Adjusted MortalityMortality Ratio Index (SMR). (RAMI) SMR ratio. As a result of this work to improve these systems the RAMI is More informationbelow 100. is included This onmay page take 190 regardingmore than the Trust’sone year performance to achieve. with the However, Summary-Hospital during Level 2012/13 noticeably reducing at a faster rate than the peer comparators. Mortalitywe Indicator aim to (SHMI) achieve and more a 10 information point reduction on just some and of an the overall actions takendownward already regardingtrend. mortality. As mentioned in the introduction, a high RAMI score should be taken as an •T• arget: (CE1a) The Trust aspires to achieve a Risk Adjusted Mortality Index (RAMI) below 100. This may take alert and should be investigated more thoroughly. The mortality performance more Achievement than one year to achieve. (April However,2012 – duringJanuary 2012/13 2013): we aim From to achieve May a 102012, point the reduction Trust’s and RAMIan has committee (MPC) receives the monthly mortality report and based on this overallbeen downward consistently trend. below 100 appropriate and clinically lead projects are initiated and overseen. •A•  chievement The trend (April line 2012 on – Januarythe chart 2013): below From Mayillustrates 2012, the a Trust’s downward RAMI has trend been consistently reducing belowat a 100quicker These projects have taken the form of investigative audits and as a result of this •• The trendpace line to onthat the of chart the below Trust’s illustrates peer acomparators downward trend and reducing national at a quicker performance pace to that of the Trust’s work and the Trust’s greater understanding of key themes, this approach will peer Incomparators April 2012 and national the Trust’s performance RAMI was 102, in January 2013 the Trust’s RAMI had not feature much more action focussed project work. The following indicators reduced to 89, a reduction of 13 points. relating to condition specific mortality areas, specifically CE1b deals with •• In April 2012 the Trust’s RAMI was 102, in January 2013 the Trust’s RAMI had reduced to 89, a reduction of 13 points. stroke care, CE1c outlines cardiac conditions and CE1d focusses on respiratory 210 conditions. Trust (NLAG) Monthly Risk Adjusted Mortality Indicator (RAMI) vs Peer Group 190 These are individual examples of condition specific areas identified as seeming outliers in terms of the Standardised Mortality Ratio (SMR) where specific 170 investigative projects have been undertaken and will still feature as part of the action plan moving forward. 150 130

Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality 110 Account?

RAMI 90 Yes, in the 2011/12 quality account, the Trust set out the following as a quality priority for 2012/13:

70 “The Trust aspires to achieve a RAMI below 100. This may take more than one year to achieve. However 12 13 12 12 12 12 12 12 12 12 12 11 11 11 11 11 11 11 11 11 11 10 10 12 10 10 10 10 10 10 10 10 11 10 during 2012/13 we aim to achieve a 10 point reduction for the 10 highest RAMIs by site and Health Resource ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Jul Jul Jul Group (HRG) chapter, and an overall downward trend.” Jan Jan Jan Jan Jun Jun Jun Oct Oct Oct Apr Apr Apr Sep Feb Sep Feb Sep Feb Dec Dec Dec Aug Aug Aug Nov Nov Nov Mar Mar Mar May ‐ 12 May ‐ 11 May ‐ 10 Throughout the financial year a lot of work has been invested in monitoring, understanding and acting on a number of mortality indices. As a result of this and the importance ascribed to this area, the Trust board NLAG Peer Average National Average Linear (NLAG) requested a monthly report to be commissioned dedicated to this area.

Source:Source: Information services, producedproduced using using CHKS CHKS Live Live Software Software This monthly mortality report compliments the existing monthly quality report and provides the Trust board and other sub committees with a detailed view of the Trust’s performance against the various mortality indicators. Comment:Comment: The The above above chart illustrates chart illustrates the Trust’s monthly the Trust’s RAMI versus monthly a peer RAMIgroup of versus comparable a peer Trusts group and of This level of detail therefore allowed for more in depth reporting and analysis of mortality across the organisation. comparablethe national average. Trusts and the national average. The RAMI or risk adjusted mortality indicator is a statistical expression of the Trust’s expected mortality. As referred to in the introduction to this section, there are other versions of this statistical model, referred to as a Standardised Mortality144 Ratio (SMR), RAMI is the main indicator that the Trust uses to monitor this area. The ‘expected’ aspect of the calculation is heavily dependent on data quality and recording. A RAMI of 100 is the accepted national average and therefore equates to the Trust’s expected level of mortality. Anything above 100 demonstrates an above expected mortality rate and anything lower than 100 demonstrates a lower than expected mortality ratio, according to the statistical model employed.

Directorate of Clinical and Quality Assurance, April 2013 Page 10 of 97 The RAMI or risk adjusted mortality indicator is a statistical expression of the Trust’s expected mortality. As referred to in the introduction to this section, there are other versions of this statistical model, referred to as a Standardised Mortality Ratio (SMR), RAMI is the main indicator that the Trust uses to monitor this area. The ‘expected’ aspect of the calculation is heavily dependent on data quality and recording. A RAMI of 100 is the accepted national average and therefore equates to the Trust’s expected level of mortality. Anything above 100 demonstrates an above expected mortality rate and anything lower than 100 demonstrates a lower than expected mortality ratio, according to the statistical model employed. This chart shows that since August 2012 there has been a reduction of RAMI which brings us far nearer to the performance of our peers. In January 2013, the monthly RAMI for the Trust was 89. The peer value was 86. This chart reflects much of the Trust’s focus on these mortality indicators and the action plan currently in place to ensure the Trust continually improves performance in this area. An example of some of the action already having been taken is improvements in the accurate recording and coding of appropriate diagnosis groups and co-morbidities. Some cases identified from specific project work, were found to have had gaps in the documented and coded history recorded within the Trust’s information Focus on: CHKS systems. As already alluded to in the introduction, the Standardised Mortality CHKS is a leading provider of healthcare and Ratios (SMR) base the calculation of expected mortality on such recorded and healthcare improvement services, developing coded details. solutions for healthcare organisations in over 20 countries. Therefore by not capturing the full patient ‘story’ the risk factors that are used to calculate the expected mortality aspect of the calculation will produce a risk The Trust uses CHKS Live software to analyse that under reports the expected mortality resulting in a higher than expected and report routine Trust performance from SMR ratio. As a result of this work to improve these systems the RAMI is internally collected and coded information noticeably reducing at a faster rate than the peer comparators. that takes place on a monthly basis. The Trust is therefore enabled to monitor and act on the As mentioned in the introduction, a high RAMI score should be taken as an information provided using this software. alert and should be investigated more thoroughly. The mortality performance committee (MPC) receives the monthly mortality report and based on this RAMI which stands for Risk Adjusted appropriate and clinically lead projects are initiated and overseen. Mortality Indicator is an example of one key use of CHKS. By monitoring this mortality These projects have taken the form of investigative audits and as a result of this measure and using it to ‘drill down’ key work and the Trust’s greater understanding of key themes, this approach will areas of Trust performance can be identified not feature much more action focussed project work. The following indicators and prioritised for improvement work, if relating to condition specific mortality areas, specifically CE1b deals with necessary. Alternatively, sometimes this stroke care, CE1c outlines cardiac conditions and CE1d focusses on respiratory highlights improvements that could be made conditions. in connection with the Trust’s data collection or quality of data being used to form the basis These are individual examples of condition specific areas identified as seeming outliers in terms of the Standardised Mortality Ratio (SMR) where specific of such data analysis. investigative projects have been undertaken and will still feature as part of the action plan moving forward.

Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality Account? Yes, in the 2011/12 quality account, the Trust set out the following as a quality priority for 2012/13: “The Trust aspires to achieve a RAMI below 100. This may take more than one year to achieve. However during 2012/13 we aim to achieve a 10 point reduction for the 10 highest RAMIs by site and Health Resource Group (HRG) chapter, and an overall downward trend.” Throughout the financial year a lot of work has been invested in monitoring, understanding and acting on a number of mortality indices. As a result of this and the importance ascribed to this area, the Trust board requested a monthly report to be commissioned dedicated to this area. This monthly mortality report compliments the existing monthly quality report and provides the Trust board and other sub committees with a detailed view of the Trust’s performance against the various mortality indicators. This level of detail therefore allowed for more in depth reporting and analysis of mortality across the organisation.

145

provides the Trust board and other sub committees with a detailed view of the Trust’s performance against the various mortality indicators. This level of detail therefore allowed for more in depth reporting and analysis of mortality across the organisation. As a result of this, the second element of the 2011/12 quality account indicator set for the 2012/13 financial year to aim for “a 10 point reduction for the 10 highest RAMIs by site and Health Resource Group (HRG)Annual chapter, andQuality an overall downwardAccount trend” was2012/13 felt to have been superseded by these developments. To remain focussed the Trust has prioritised an overall downward trajectory for the organisation’s mortality indicators as a whole and specific pathway areas relating to As a result of this, the second element of the 2011/12 quality account indicator set for the 2012/13 financial year to stroke,aim for cardiac “a 10 point conditions reduction for and the 10respiratory, highest RAMIs which by site are and outlinedHealth Resource following Group this (HRG) is chapter, sections and CE1b,an CE1coverall and downward CE1d. trend” was felt to have been superseded by these developments.

To remain focussed the Trust has prioritised an overall downward trajectory for the organisation’s mortality Rationale for changing this quality priority for 2013/14: The Risk Adjusted Mortality indicators as a whole and specific pathway areas relating to stroke, cardiac conditions and respiratory, which are Indicator (RAMI) is a Standardised Mortality Ratio (SMR). For the indicator to stay relevant outlined following this is sections CE1b, CE1c and CE1d. and a useful quality marker an annual rebasing occurs where the average mortality marker of 100Rationale is reset. for changingThis annual this quality event priority makes for it 2013/14:very difficult The Risk to Adjusted set an Mortality improvement Indicator (RAMI) trajectory is a that reliesStandardised solely Mortality on a figureRatio (SMR). of For 100. the Theindicator ‘official’ to stay relevant NHS wideand a useful mortality quality indicatormarker an annual is now the Summaryrebasing occurs Hospital where the Mortality average mortality Indicator marker (SHMI). of 100 is Whilst reset. This monitoring annual event thismakes official it very difficult indicator to set is problematican improvement due trajectory to the lackthat relies of monthly solely on areporting figure of 100. available from the NHS Information Centre andThe the ‘official’ time lagNHS widein the mortality availability indicator ofis nowthe the most Summary recent Hospital data Mortality(as a Indicatorresult of(SHMI). the inclusionWhilst of communitymonitoring mortalitythis official within indicator 30 is days problematic of hospital due to thedischarge). lack of monthly To addressreporting availablethese problems,from the NHS a new targetInformation is going Centre to beand used, the time at lag present in the availability this is in of discussion the most recent at datathe (asTrust’s a result Mortality of the inclusion Performance of Committeecommunity (MPC).mortality within 30 days of hospital discharge). To address these problems, a new target is going to be used, at present this is in discussion at the Trust’s Mortality TargetPerformance (CE1b): Committee To achieve (MPC). a 10 point reduction in the Risk Adjusted Mortality Index (RAMI) duringTarget 2012/13 (CE1b): To from achieve stroke a 10 point and reduction an overall in the downward Risk Adjusted trajectory. Mortality Index (RAMI) during 2012/13 from

stroke and an overall downward trajectory.  Achievement (April 2012 – January 2013): During the period of April 2012 and •A• chievementJanuary 2013 (April 2012an upward – January trend 2013): was During noticed, the period the of average April 2012 RAMIand January was 2013 116. an In upward April 2012 trendthe was Trust’s noticed, RAMIthe average was RAMI 107, was in116. January In April 2012 2013 the Trust’s this RAMI had was reduced 107, in January to 106, 2013 a this 1 had point reducedreduction. to 106, a Since 1 point reduction April 2010, however, the Trust’s performance in this is area has •• Sincimprovede April 2010, as however, seen inthe the Trust’s following performance chart in thiswhich is area illustrates has improved a downward as seen in the trend following chart  which The illustrates previous a downward 12 months, trend specifically April 2011 to March 2012, the average RAMI was 150 versus a RAMI of 116 between April 2012 and January 2013, representing a •• The previous 12 months, specifically April 2011 to March 2012, the average RAMI was 150 versus a RAMI of 116 34 point reduction in RAMI. between April 2012 and January 2013, representing a 34 point reduction in RAMI.

Trust (NLAG) Monthly Stroke (ICD‐10) Risk Adjusted Mortality Indicator (RAMI) vs Peer Group (Health Resource Group) 400 350 300 250

200 RAMI 150 100 50 0 13 12 12 12 12 12 12 11 11 11 11 11 11 10 12 10 12 12 10 10 12 12 12 11 11 11 11 11 11 10 10 10 10 10 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Jul Jul Jul Jan Jan Jan Jun Jun Jun Oct Oct Oct Apr Apr Apr Sep Feb Sep Feb Sep Dec Dec Dec Aug Aug Aug Nov Nov Nov Mar Mar May ‐ May ‐ May ‐

NLAG (ICD‐10) Peer (HRG) Linear (NLAG (ICD‐10))

Source: Information services, produced using CHKS Live Software Source: Information services, produced using CHKS Live Software DirectorateComment: of Clinical The above and Quality chart Assurance,illustrates Trust April performance2013 in terms of RAMI for this condition specificPage 12 ofarea. 97 The Trust performance is based on nationally agreed ICD-10 codes used to represent stroke. No peer comparison is available to the Trust using the same methodology, so for comparisons sake the peer average stroke HRG (Health Resource Group) performance is illustrated. The linear trend line demonstrates a downward trend over time since April 2010.

146 This clinical condition group of stroke has been one of the areas that the Trust has assessed in more detail. As a result of this project work, the teams within this service based at Diana, Princess of Wales Hospital (DPoW) and Scunthorpe General Hospital (SGH) have developed a comprehensive action plan to take necessary action to constantly strive to improve the quality of care provided to patients requiring stroke care. As a result of this focussed effort, the above chart illustrates the downward trajectory of the Trust’s performance with the Risk Adjusted Mortality Indicator (RAMI) for this condition specific area since April 2010. Regular meetings are held with key clinical staff within this service to ensure that any areas requiring additional review are picked up, incorporated within the action plan and implemented.

Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality Account? No, there has been no change to this quality priority during the 2012/13 reporting period.

Rationale for changing this quality priority for 2013/14: A new target is to developed for 2013/14 to take into account Target the difficulties (CE1c): of settingTo achieve an improvement a 10 trajectory point reduction based on a innumerical the Risk RAMI Adjustedfigure and the Mortality delay in obtainingIndicator timely SHMI (RAMI) data. This during is currently 2012/13 being discussed for cardiac at the conditions Trust’s Mortality and Performance an overall Committee downward (MPC). trajectory. •T• arget (CE1c): To achieve a 10 point reduction in the Risk Adjusted Mortality Indicator (RAMI) during 2012/13  for Achievementcardiac conditions and (April an overall 2012 downward – January trajectory. 2013): During the period of April 2012 and •A• chievementJanuary 2013(April 2012an upward – January trend 2013): was During noticed the period with of Aprilaverage 2012 and RAMI January of 201384. anIn upwardApril 2012 trendthe was Trust’s noticed RAMI with average was 101RAMI inof 84.January In April 20122013 the this Trust’s had RAMI reduced was 101 to in January91, a reduction 2013 this had of 10 reducedpoints to 91, a reduction of 10 points  For the period since April 2010, however Trust performance has improved as •• For the period since April 2010, however Trust performance has improved as indicated in the following chart whichindicated illustrates in a thedownward following trend chart since April which 2010 illustrates a downward trend since April 2010  The previous 12 month period average, specifically April 2011 to March 2012, was •• The105 previous versus 12 month a RAMI period of average, 84 in thespecifically period Aprilof April2011 to2012 March to 2012, January was 105 2013, versus representinga RAMI of 84 in a the21 period point of Aprilreduction 2012 to inJanuary RAMI. 2013, representing a 21 point reduction in RAMI.

Trust (NLAG) Monthly Cardiac Conditions (HRG) Risk Adjusted Mortality Indicator (RAMI) vs Peer Group (HRG) 250

200

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RAMI 100

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0 12 12 12 12 12 11 11 12 11 11 11 10 10 11 10 12 12 13 10 12 12 12 11 12 11 11 11 11 10 11 10 10 10 10 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Jul Jul Jul Jan Jan Jan Jun Jun Jun Oct Oct Oct Apr Apr Apr Sep Feb Sep Feb Sep Dec Dec Dec Aug Aug Aug Nov Nov Nov Mar Mar May ‐ May ‐ May ‐

NLAG (HRG) Peer (HRG) Linear (NLAG (HRG))

Source: Information services, produced using CHKS Live Software Source: Information services, produced using CHKS Live Software Comment:Comment: The The above above chart chart illustrates illustrates Trust performance Trust performance in terms of RAMI in termsfor this ofcondition RAMI specific for this area. condition The specificTrust performance area. The and Trust that of performancethe peer group is and based that on the of cardiac the peer conditions group HRG is (Health based Resource on the Group), cardiac conditionsa pre-defined HRG grouping (Health of hospital Resource codes that Group), represent a conditions pre-defined and surgery grouping within of the hospital cardiac HRG codes chapter. that representThe linear trend conditions line demonstrates and surgery a downward within trend the over cardiac time since HRG April 2010. chapter. The linear trend line demonstratesThis is another ofa thedownward key condition trend specific over areastime havingsince beenApril identified 2010. by the Trust as being an outlier. A project Thisspecific is another working group of the was key established condition and a specific number of areas case reviews having were been initiated. identified As a result by of thethis specific Trust as beingaction an has outlier.been made A possible project and specific due to this, working improvements group in was service established delivery have and been a made. number of case reviews were initiated. As a result of this specific action has been made possible and due to this, improvements in service delivery have been made. This is illustrated in the above chart which illustrates a downward trajectory in terms of the Trust’s performance with147 the Risk Adjusted Mortality Index (RAMI) for this condition specific area. Performance with mortality indicators in this group is monitored on a monthly basis with the monthly mortality report.

Has the quality indicator been changed during the year from that set in last years (2011/12) Quality Account? No, there has been no change to this quality priority during the 2012/13 reporting period.

Rationale for changing the quality priority for 2013/14: A new target is to developed for 2013/14 to take into account the difficulties of setting an improvement trajectory based on a numerical RAMI figure and the delay in obtaining timely Summary Hospital Mortality Indicator (SHMI) data. This is currently being discussed at the Trust’s Mortality Performance Committee (MPC). Directorate of Clinical and Quality Assurance, April 2013 Page 14 of 97 Annual Quality Account 2012/13

This is illustrated in the above chart which illustrates a downward trajectory in terms of the Trust’s performance with the Risk Adjusted Mortality Index (RAMI) for this condition specific area. Performance with mortality indicators in this group is monitored on a monthly basis with the monthly mortality report.

Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality Account? No, there has been no change to this quality priority during the 2012/13 reporting period. Rationale for changing the quality priority for 2013/14: A new target is to developed for 2013/14 to take into account Target the difficulties (CE1d): of settingTo achievean improvement a 10 trajectory point reduction based on a numerical in the RiskRAMI figure Adjusted and the Mortality delay in obtainingIndicator timely Summary (RAMI) Hospital during Mortality 2012/13 Indicator for respiratory (SHMI) data. Thisconditions is currently and being an discussed overall at downward the Trust’s Mortalitytrajectory. Performance Committee (MPC).

•T• arget (CE1d): To achieve a 10 point reduction in the Risk Adjusted Mortality Indicator (RAMI) during 2012/13  During the period of April 2012 and for respiratoryAchievement conditions (April and an 2012 overall – downward January trajectory. 2013): January 2013 a downward trend was noticed with an average RAMI of 88. In April •A• chievement2012 the (April Trust’s 2012 RAMI – January was 2013): 89, in During January the period 2013 of this April had 2012 reduced and January to 201384, a downward reduction of trendfive was points noticed with an average RAMI of 88. In April 2012 the Trust’s RAMI was 89, in January 2013 this had reduced For theto 84, entire a reduction period of five since points April 2010, a downward trend is also observed •• F or Thethe entire previous period since12 monthApril 2010, period a downward average, trend isspecifically also observed April 2011 to March 2012 was 111 versus RAMI of 88 in this most recent period of April 2012 to January 2013, •• The previous 12 month period average, specifically April 2011 to March 2012 was 111 versus RAMI of 88 in this mostrepresenting recent period ofa April23 point 2012 to reduction January 2013, in RAMI.representing a 23 point reduction in RAMI.

Trust (NLAG) Monthly Respiratory Conditions (HRG) Risk Adjusted Mortality Indicator (RAMI) vs Peer Group (HRG) 250

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RAMI 100

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0 12 12 12 12 12 11 11 11 11 11 12 12 10 12 13 10 12 12 12 10 11 12 11 11 11 11 11 10 11 10 10 10 10 10 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Jul Jul Jul Jan Jan Jan Jun Jun Jun Oct Oct Oct Apr Apr Apr Sep Feb Sep Feb Sep Dec Dec Dec Aug Aug Aug Nov Nov Nov Mar Mar May ‐ May ‐ May ‐

NLAG (HRG) Peer (HRG) Linear (NLAG (HRG))

Source:Source: Information Information services, services, producedproduced using CHKSCHKS Live Live Software Software Comment: The above chart illustrates Trust performance in terms of RAMI for this condition specific area. The Comment:Trust performance The andabove that ofchart the peer illustrates group is basedTrust onperformance the respiratory in conditions terms of HRG RAMI (Health for Resource this condition specificGroup), aarea. pre-defined The Trust grouping performance of hospital codes and that that represent of the conditionspeer group and isprocedures based onwithin the the respiratory respiratory conditionsHRG chapter. HRG The linear (Health trend line Resource demonstrates Group), a downward a pre-defined trend over time grouping since April of 2010. hospital codes that represent conditions and procedures within the respiratory HRG chapter. The linear trend lineThis demonstrates is another condition a downward specific area trendthat the over Trust timehas reviewed since inApril detail. 2010. The Trust’s current mortality action plan contains further plans for this area to receive additional focussed improvement work to ensure that patients Thisrequiring is another admission condition for respiratory specific related problems area that receive the the Trust most appropriate has reviewed evidenced in based detail. care The for their Trust’s currentcondition. mortality As a result action of the workplan undertaken contains so further far in this plans area, thefor abovethis area chart illustratesto receive a downward additional trajectory focussed improvementsince April 2010, the work additional to ensure plans for clinically that patients lead improvements requiring in this admission area will help for bolster respiratory this improvement. related problems receive the most appropriate evidenced based care for their condition. As a result of the work undertaken so far in this area, the above chart illustrates a downward trajectory since April 2010, the additional plans for clinically lead improvements in this area will help bolster this improvement.

Has the quality indicator been changed during the year from that set in last years (2011/12) Quality Account? No, there has been no change to this quality priority during the 2012/13148 reporting period.

Rationale for changing quality priority for 2013/14: A new target for mortality is needed as a result of the work undertaken in this area, the details of this indicator are still being agreed with the Trust’s mortality performance committee (MPC) at the point of writing this report.

Directorate of Clinical and Quality Assurance, April 2013 Page 15 of 97 Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality Account? No, there has been no change to this quality priority during the 2012/13 reporting period. Rationale for changing quality priority for 2013/14: A new target for mortality is needed as a result of the work undertaken in this area, the details of this indicator are still being agreed with the Trust’s mortality performance CE2committee – ‘Check (MPC) Your at the Charts’point of writing this report.

Target – To fully implement the ‘Check Your Charts’ element of the Patient Safety First Campaign CE2 – ‘Check Your Charts’ AchievementTarget – To fully (October implement the2012 ‘Check – March Your Charts’ 2013): element Since of October the Patient 2012, Safety when First Campaign routine monitoring ofAchievement this indicator, (October in 2012 line – with March National 2013): Since Institute October 2012, for when Health routine and monitoring Care of Excellence this indicator, in (NICE) line Technologywith National AppraisalInstitute for HealthGuidelines and Care (TAG) Excellence 50 (NICE)began, Technology 99% ofAppraisal observations, Guidelines (TAG) assessed 50 began, using 99% of a randomobservations, sample assessed audit using methodology a random sample haveaudit methodology been compliant have been with compliant these with recommendations these recommendations laid outlaid by out NICE. by NICE.

Trust % complaince with the check your charts element and sample details 99.7 100 100 320 98.9 100 310 99 (%) 311 97.1 98 300

(n=) 97 95.6 290 297 96 290 280 95 compliance sample 281 283 270 94 93 267 Patient 260 92

250 91 Percentage 240 90 Oct Nov Dec Jan Feb Mar

Patient sample audited % compliance with NICE TAG 50

Source: Information services, Nursing Dashboard v4.0 Source: Information services, Nursing Dashboard v4.0 The above chart illustrates the Trust percentage compliance with the check your Comment:Comment: The above chart illustrates the Trust percentage compliance with the check your charts element. On chartsthe primary element. vertical On axis the the primarynumber of vertical patients sampledaxis the each number month toof ascertainpatients compliance sampled is eachshown monthand on to ascertainthe secondary compliance vertical axis, the is percentage shown and compliance on the in each secondary month with verticalthis indicator axis, based the on NICE percentage TAG 50 compliance in each monthguidelines. with this indicator based on NICE TAG 50 guidelines. As already referred to in the preceding sections As already referred to in the preceding sections dealing with specific mortality dealing with specific mortality quality indicators, Focus on: Nursing Dashboard quality indicators, focussed mortality improvement plans are in place as are focussed mortality improvementcondition specific plans working are in groups, place all of which are overseen by the Trust’s Mortality The nursing dashboard is a tool that as are condition specificPerformance working groups, Committee all (MPC). of which At the same time,Focus other on: quality Nursing improvement Dashboard work provides a mechanismare for overseen feedback by the Trust’s Mortality Performance streams have been underway within nursing. TheOne nursingof these dashboard projects and is listeda tool asthat on performance basedCommittee on important (MPC). At the same time, other quality measures of nursing. a quality indicator for 2012/13 related to this checkprovides your a chartsmechanism indicator. for feedbackThis was on improvement work streamsa National have Patient been Safety underwayAgency (NPSA) auditperformance tool to help organisationsbased on important monitor It is designed to improvewithin nursing nursing. care One of theseand improve projects the frequency and listed of key as nursing a observationsmeasures ofto nursing.improve detection of the quality by providing frontline staff quality indicator for 2012/13deteriorating related patient to and this ensure check appropriate Itaction is designed was taken to improve in such cases.nursing Prior care to with information on trends, emerging your charts indicator. ThisNovember was 2012, a Nationalthe Trust used Patient a deteriorating quality patient by score providing called frontline the Patient staff At with Risk problems and successes. Safety Agency (NPSA)(PAR) score, audit this allowed tool for to the helpresults of specificinformation observations on trends, to yield emerging a score and Such metrics and indicatorsorganisations can monitor andbased improve on the score the defined frequency actions of necessary problems to guide andnursing successes. staff in their care of empower the publickey to choose nursing between observations such to deteriorating improve detection patients. In of November the 2012,Such the metricsPAR score and was indicators replaced can with the care options which deterioratingmatter to them as patient andNational ensure Early appropriateWarning Score action(NEWS). This nationallyempower developed the public deteriorating to choose between patient much as it matters to the nursing and was taken in such cases.score Prior provided to aNovember better warning 2012, system with careits own options predefined which matterand clearly to them marked as midwifery profession. much as it matters to the nursing and documentation to support staff identify and act quicker. the Trust used a deteriorating patient score called midwifery profession. the Patient At Risk (PAR) score, this allowed for the results of specific observations to yield a score and based on the score defined actions necessary to 149 guide nursing staff in their care of such deteriorating patients. In November 2012, the PAR score was replaced with the National Early Warning Score (NEWS). This nationally developed deteriorating patient score provided a better Directorate of Clinical and Quality Assurance, April 2013 Page 16 of 97 Annual Quality Account 2012/13

The above chart highlights some months were performance dipped noticeably in the months following the adoption of this new deteriorating patient score. As a result of this monthly monitoring in the quality report, this was highlighted and additional education, retraining and focus was placed on the National Early Warning Score (NEWS) by members of the Chief Nurse Directorate. As observed in more recent months, performance has returned to 100 per cent compliance. Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality Account? No, there has been no change to this quality priority during the 2012/13 reporting period. Rationale for changing the quality priority for 2013/14: The Trust recognises the importance of timely patient observations and as a result of this, on the November 26 2012 the National Early Warning Scoring (NEWS) system was adopted by the Trust. NEWS scoring allows patient deterioration to be clearly observed and appropriate action to be taken. NEWS replaced the Trust’s previous deteriorating patient identifier the Patient at Risk (PARs) scoring system. During March and April 2013 the Trust’s compliance with NEWS scoring will be audited. The on-going monitoring of NEWS compliance within the Trust has also been added to the Trust’s Quality Priorities for 2013/14 (see page 176 of this report).

News release: Training to help tackle mortality rates Training designed to help clinical staff spot deteriorating patients is being made mandatory at Northern Lincolnshire and Goole Hospitals NHS Foundation Trust (NLAG). The ALERT course, which stands for ‘acute and life threatening events: recognition and treatment’ was developed by staff at Portsmouth Hospitals NHS Trust. It teaches doctors and nurses to anticipate, recognise and prevent patients from becoming critically ill. The one day course, which is both theoretical and practical, includes patient scenarios covering many different conditions that staff may come across. Although the course is offered at other Trusts, NLAG is one of the first in the country to make it mandatory for all clinical staff. Those working in acute areas will be prioritised as the training is rolled out and staff will be required to complete the course once every four years. Feedback from those who have taken the course previously has been very positive, with comments including: “Brilliant day – can’t fault it. Fantastic learning, course should become mandatory training”, “It is one of the best courses I have ever been on” and “Excellent course – good for improving knowledge and recognising and treating ill patients – should be mandatory!”. A similar half day course for healthcare assistants (HCA) is also being introduced as mandatory. Created by the same people, the BEACH (bedside emergency care for health care workers) course was developed to train HCAs in basic techniques and give them the skills needed to recognise deteriorating patients. Once staff have completed the training they are added to a national database, so if they move jobs they have evidence they have completed the course. Karen Dunderdale, chief nurse at the Trust, said: “It is vital that all of our clinical staff know what signs to look out for so that we can intervene as early as possible with these patients and prevent them from becoming critically ill.” Liz Scott, medical director at the Trust, said: “We are working very hard to do everything we can to improve our mortality position at the Trust and making this course mandatory is just one small part of this significant work.”

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CE3 – Patient Observations

Target: For patient observations to have been recorded at in accordance with planned frequency in 95% of cases.

AchievementCE3 (April – Patient 2012 Observations– February 2013): Since April 2012, the Trust achieved this target in 97% of patientTarget: For observations patient observations assessed. to have been In recorded months at inwere accordance performance with planned fellfrequency below in 95%the of 95% cases. threshold, Quality Matrons have been involved in these areas with a view to identifying and Achievement (April 2012 – February 2013): Since April 2012, the Trust achieved this target in 97% of patient targeting anyobservations problem assessed. areas. In months were performance fell below the 95% threshold, Quality Matrons have been involved in these areas with a view to identifying and targeting any problem areas.

Patient observations recorded in accordance with planned frequency 105% 100%

95% 90% (%) 85% 80% 75% 70% Percentage 65% 60% 11 12 11 11 11 11 11 12 12 12 12 12 12 12 12 13 13 11 11 12 12 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Jul Jul Jan Jan Jun Jun Oct ‐ 11 Oct ‐ 12 Apr Apr Sep Feb Sep Feb Dec Dec Aug Aug Nov Nov Mar May May

Apr‐ May‐ Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐ Mar‐ Apr‐ May‐ Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐ 11 11 11 11 11 11 11 11 11 12 12 12 12 12 12 12 12 12 12 12 12 13 13 DPoW 100%100%100%100%100% 99% 99% 100% 99% 100% 99% 100% 92% 97% 100%100%100%100% 94% 100% 99% 95% 95% SGH 100%100%100%100%100%100%100%100% 83% 92% 99% 98% 98% 98% 90% 100% 99% 100%100%100% 99% 99% 93% GDH 97% 94% 83% 73% 88% 80% 90% 100% 85% 100% 100%100% 77% 76% 100%100%100%100%100%100%100%100% Threshold 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

KEY to abbreviations: Source: InformationSource: Information services, Nursingservices, NursingDashboard Dashboard v4.0 v4.0 DPoW: Diana, Princess of Wales Hospital, Grimsby KEY to abbreviations:Comment: The DPoW: above chart Diana, illustrates Princess the percentageof Wales Hospital, of patient Grimsby SGH: Scunthorpe General Hospital, observations recorded SGH: Scunthorpe within the planned General frequency Hospital, or twice daily. The GDH: Goole and District Hospital vertical axis demonstrates GDH: Goole the andpercentage District compliance Hospital with this indicator whilst the horizontal axis outlines the months in which this indicator has Comment:been The measured, above going chart back illustratesto April 2011. the percentage of patient observations recorded within the plannedAs referred tofrequency at the beginning or twice of this report,daily. the The Trust vertical is made of axisup of threedemonstrates hospital sites and the for percentage some complianceindicators, with this the ability indicator to benchmark whilst individual the horizontal site performance axis isoutlines extremely valuable the months especially in in view which of the this indicator hasgeographical been measured, distances between going the back sites. to April 2011.

In this particular example, the chart demonstrates the Trust’s monitoring of another key nursing measure of As referredquality to at that the has beginning a large impact of on this mortality. report, the Trust is made of up of three hospital sites and for some indicators, the ability to benchmark individual site performance is extremely valuable especiallyLinked to the in previous view ofindicator the geographical (CE2) this quality priority distances relates tobetween the recording the of sites. key patient In this observations particular that are the foundation for the deteriorating patient scores which are so useful in identifying and acting when a example, thepatient chart is highlighted demonstrates as having deteriorated.the Trust’s monitoring of another key nursing measure of quality that has a large impact on mortality. Linked to the previous indicator (CE2) this quality priority relatesIt is worth to thenoting recording that the above of chartkey prior patient to November observations 2012 reflects that performance are the with foundation the observations for the recorded in line with the Patient At Risk (PAR) score and after November 2012, the indicator mirrors the deterioratingobservations patient takenscores that informwhich the are newly so implemented useful in National identifying Early Warning and actingScoring systemwhen (NEWS). a patient is highlighted as having deteriorated. It is worth noting that the above chart prior to November 2012 reflectsHas the performance quality indicator with been the changed observations during the year recorded from that in set line in last with year’s the (2011/12) Patient Quality At Risk (PAR) scoreAccount? and after November 2012, the indicator mirrors the observations taken that inform the newlyYes, the wordingimplemented for this indicator National has been Early changed Warning from that Scoring documented system in the (NEWS). Trust’s 2011/12 quality account, which read:

“To ensure patient observations have been recorded at least twice daily.”

Directorate of Clinical and Quality Assurance, April 2013 Page 18 of 97151 Annual Quality Account 2012/13

As illustrated by the target statement at the start of section CE3, the wording has changed slightly, however the substance of the indicator itself is unchanged and demonstrates the Trust’s performance with patient observations being recorded in line with planned frequencies or in other words, twice daily. Rationale for changing the quality priority for 2013/14: During November 2012 the National Early Warning Scoring (NEWS) system was adopted by the Trust. NEWS scoring allows patient deterioration to be clearly observed and appropriate action to be taken. NEWS replaced the Trust’s previous deteriorating patient identifier the Patient at Risk (PARs) scoring system. Due to the high priority of this early warning scoring system, a specific quality priority will be dedicated to compliance with this indicator (see the Trust’s quality priorities for 2013/14 page 176 of this report).

News release: New-look bedside documents to improve safety A new type of bedside documentation, called the National Early Warning Score or NEWS, has been introduced at hospitals in Grimsby, Scunthorpe and Goole, to help improve patient safety. Chief nurse Karen Dunderdale said: “The NEWS scheme was launched last year and we decided to implement it as early as possible because it can have a crucial impact on patient safety. “NEWS is a coherent document that provides a more consistent way of monitoring patients than the Patient At Risk Score method we used previously. The introduction of the system has gone very smoothly and effectively. “The success of the launch across all our wards at Scunthorpe, Grimsby and Goole hospitals is down to our dedicated doctors and nurses, who have adapted to the new system very quickly. “The staff have really taken to it and I’m very proud of them.” Every hospital bed has a chart that is used to record measurements such as the patient’s pulse rate, blood pressure and temperature. These measurements help the nursing and medical teams decide the severity of illness of the patient and if the patient needs more urgent care. “It has been so successful we are now looking at using the scheme in the community.”

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CE4 – National Early Warning Score (NEWS) Target: A Completed NEWS Score to have been recorded with each set of observations in 95% of cases.CE4 – National Early Warning Score (NEWS) Target: A Completed NEWS Score to have been recorded with each set of observations in 95% of cases. AchievementAchievement (April 2012(April 2012 – February – February 2013): 2013): The Trust The achieved Trust this achieved indicator in 93%this of indicator patient observations in 93% of patient observationsaudited. As mentioned audited. already As mentioned in this report, NEWSalready is listed in as this a quality report, priority NEWS for 2013/14 is listedand so will as be a quality priority for 2013/14monitored onand a monthly so will basis be within monitored the quality on report a monthly and a final basisposition withinwill again the be reported quality in reportthe 2013/14 and a final positionquality will account. again be reported in the 2013/14 quality account.

A completed National Early Warning Score (NEWS) has been recorded with each set of observations 105% 100% 95% 90% (%) 85% 80% 75% 70%

Percentage 65% 60% 11 11 11 12 12 12 12 13 11 11 11 11 11 11 12 12 12 12 12 12 12 12 13 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Jul Jul Jan Jan Jun Jun Oct ‐ Oct ‐ Apr Apr Sep Feb Sep Feb Dec Dec Aug Aug Nov Nov Mar May May

Apr‐ May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐ Mar Apr‐ May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐ 11 ‐11 11 11 11 11 11 11 11 12 12 ‐12 12 ‐12 12 12 12 12 12 12 12 13 13 DPoW 82% 84% 85% 98% 93% 90% 87% 93% 99%100%95% 99% 98% 98% 93% 84% 96% 92% 94% 99% 99% 99% 94% SGH 76% 79% 99% 89% 95% 98%100%96%100%96%100%99%100%85% 82% 99% 89% 92% 94% 91% 97% 87% 93% GDH 100%97% 73% 90% 67% 68% 86% 80% 67% 96% 100%100%87% 84% 83%100%90% 86% 90%100%90%100% Threshold 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Source: Information services, Nursing Dashboard v4.0 KEY to abbreviations: Source: Information services, Nursing Dashboard v4.0 DPoW: Diana, Princess of Wales Comment: The above chart illustrates the percentage of observations Hospital, Grimsby DPoW: Diana, Princess of Wales Hospital, Grimsby KEY to abbreviations:which contained a completed National Early Warning Score (NEWS). The SGH: Scunthorpe General Hospital, SGH: Scunthorpe General Hospital, vertical axis illustrates the percentage compliance with this indicator and GDH: Goole and District Hospital GDH: Goole and District Hospital the horizontal axis outlines the months in which this indicator has been measured, going back to April 2011. Comment: The above chart illustrates the percentage of observations which contained a completed NationalThe chart also Early demonstrates Warning a hospital Score site (NEWS). break down Theof the verticaldata. In line axis with theillustrates comments themade percentage in indicator CE2 and CE3, this indicator and the questions used to capture this information were changed slightly in November compliance to with reflect this the Trust’s indicator moving andaway from the Patient horizontal At Risk (PAR) axis scoring outlines to National the Early months Warning Scoring in which (NEWS). this indicator has been measured, going back to April 2011. The chart also demonstrates a hospital siteThis break again outlinesdown theof proactivethe data. steps In being line taken with by nursingthe comments staff throughout made the organisationin indicator to improve CE2 theand identification and action taken for those patients identified as having deteriorated. CE3, this indicator and the questions used to capture this information were changed slightly in November to reflect the Trust’s moving away from Patient At Risk (PAR) scoring to National Early Warning Scoring (NEWS). This again outlines the proactive steps being taken by nursing staff throughout the organisation to improve the identification and action taken for those patients identified as having deteriorated.

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Directorate of Clinical and Quality Assurance, April 2013 Page 20 of 97 Annual Quality Account 2012/13

Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality Account? Yes, in the 2011/12 quality account, the Trust set the following quality priority: “A Completed PARS Score to have been recorded with each set of observations in 95 per cent of cases.” The Trust amended this quality indicator during 2012/13 as a result of the Trust’s adoption of the National Early Warning Score (NEWS) in November 2012. The NEWS scoring system aims to recognise patients that are at risk of deteriorating in order to proactively change treatment as necessary. Therefore previous data from April 2011 – October 2012 is reporting performance with Patient at Risk Scores (PARs), the previous deteriorating patient trigger used by the Trust. Post-November 2012, performance with regard to NEWS was monitored. Rationale for changing the quality priority for 2013/14: A very similar indicator will be used in the monitoring of quality performance in 2013/14. This will be a more specific assessment of compliance with NEWS both in terms of documented observations and appropriate action taken as a result.

News release: Having one National Early Warning Score (NEWS) with the same charts in every hospital will:

•• Provide the basis for a unified and systematic approach to both the first assessment of the patient and continuous tracking of their clinical condition throughout their stay, with a simple trigger for escalating their care •• Standardise the training of all staff engaged in the care of patients in hospitals in the National Early Warning Score system, so that staff should only need to be trained once instead of each time they move to a hospital that has a different system •• Provide standardised data on regional variations in illness severity and resource requirements, as well as objective measurements of illness severity and clinical outcomes – an invaluable research resource.

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CE5 – Emergency Re-admissions (Dementia) Target: To realise a downward trajectory for emergency re-admission rates for patients with dementia. CE5 – Emergency Re-admissions (Dementia) AchievementTarget: (April To realise 2012 a downward – December trajectory 2012): for emergency The chartre-admission below rates demonstrates for patients with a dementia. downward trajectory forAchievement emergency (April re-admission 2012 – December rates 2012): Thefor chartpatients below admitteddemonstrates to a thedownward Trust trajectory with dementia. for emergency re-admission rates for patients admitted to the Trust with dementia.

Emergency readmission rates for dementia patients discharged 25.00% (%)

20.00% Rates 15.00%

10.00% admission Re ‐ 5.00%

0.00% 11 11 11 12 12 12 12 11 11 11 11 11 11 12 12 12 12 12 12 12 12 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Emergency Jul Jul Jan Jun Jun Oct ‐ Oct ‐ Apr Apr Sep Feb Sep Dec Dec Aug Aug Nov Nov Mar May May Trust Linear (Trust)

Source: Information services team, coded data Source: Information services team, coded data Comment: The above chart illustrates the percentage of patients with dementia who were readmitted to the Trust as an emergency following their hospital discharge. The vertical axis demonstrates the percentage of such Comment:patients The whilstabove on thechart horizontal illustrates line the monthsthe percentage where data is availableof patients to outline with Trust dementia performance who against were readmittedthis to indicator the Trust are shown. as an The emergency bold line represents following the Trust their performance hospital since discharge. April 2011 and The the linear vertical trend lineaxis demonstratesclearly the illustrates percentage a downward of trajectory such patients for this indicator. whilst on the horizontal line the months where data is availableHas the qualityto outline indicator Trust been performance changed during againstthe year from this that indicator set in last are year’s shown. (2011/12) The Quality bold line representsAccount? the Trust performance since April 2011 and the linear trend line clearly illustrates a downwardNo, trajectorythere has been for no this change indicator. to this quality priority during the 2012/13 reporting period. Has the qualityRationale indicatorfor changing the been quality changed priority for during 2013/14: Due the to yearthe limited from nature that of benchmarking set in last data years with (2011/12) whichQuality to compare Account? the Trust No, performance there haswith peers,been the no value change of this indicator to this was quality limited. priority during the 2012/13 reportingAlso in response period. to the national priority of dementia and the national Commissioning for Quality and Innovation (CQUIN) indicator, it was felt that inclusion of monthly performance with this CQUIN indicator regarding dementia Rationale would for be changing a more useful the indicator quality going forward. priority for 2013/14: Due to the limited nature of benchmarkingFor a fulldata explanation with which of the Commissioningto compare for the Quality Trust and performance Innovation framework, with pleasepeers, see the the glossaryvalue onof this indicator waspages limited. 219. For more Also information in response on the CQUIN to the scheme national see section priority 2.3d on of page dementia 188. and the national Commissioning for Quality and Innovation (CQUIN) indicator, it was felt that inclusion of monthly performance with this CQUIN indicator regarding dementia would be a more useful indicator going forward. For a full explanation of the Commissioning for Quality and Innovation framework, please see the glossary on pages 89. For more information on the CQUIN scheme see section 2.3d on page 57.

Directorate of Clinical and Quality Assurance, April 2013 Page 22 of 97155 Annual Quality Account 2012/13

News release: Improvements in care for dementia patients Improvements are being made to the care that patients with dementia receive at the Northern Lincolnshire and Goole Hospitals NHS Foundation Trust. A new initiative called ‘my life’, which aims to ensure people with dementia get patient centred- care, is being introduced, awareness training is being rolled out to all clinical staff, a new screening tool has been introduced, dementia champions are being allocated to wards and physical improvements have been made to ward areas. Tara Filby, deputy chief nurse at the Trust, said: “It is so important that we constantly strive to improve the care we provide to patients with dementia. We know that in the future hospitals will see many more older patients admitted and we want to make sure we are at the forefront of the very best care for our older population.” This week, May 19 to May 25, is dementia awareness week - the Alzheimer’s Society’s annual flagship campaign. ‘Worrying changes nothing - talking changes everything’ is the focus of the campaign for this year. Stroke Unit at Grimsby hospital enhanced Being admitted to a hospital ward can be disorientating and frightening for someone with dementia and it may make them more confused and anxious than usual. They sometimes find the environment loud and unfamiliar, and they might not understand why they are there. In an attempt to ease this, staff on the stroke unit at Grimsby’s Diana, Princess of Wales Hospital have looked at how they can help make the ward environment less confusing for dementia patients. Thanks to a generous donation from the Grimsby Hospital League of Friends they’ve been able to make simple changes that will provide enhanced care for patients with dementia.

156

CE6 – Length of stay (dementia)

Target: To realise a downward trajectory for the length of stay for patients with dementia during 2012/13. CE6 – Length of stay (dementia) Achievement (April 2012 – December 2012): The following chart highlights the length of Target: To realise a downward trajectory for the length of stay for patients with dementia during 2012/13. stay for patients with dementia and demonstrates that performance throughout the year has broadlyAchievement remained (April the 2012 same. – December No downward, 2012): The followingor conversely chart highlights upward the trends length ofare stay discernible for patients from the data.with dementia and demonstrates that performance throughout the year has broadly remained the same. No downward, or conversely upward trends are discernible from the data. Average length of stay (LOS) for patients with dementia 20

18 16 days 14 ‐ 12 10 (LOS) 8 6 stay 4 of 2 0 12 12 12 12 12 12 12 12 12 11 11 11 11 11 11 12 12 11 11 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Length ‐ Jul Jul Jan Jun Jun Oct Oct Apr Apr Sep Feb Sep Dec Dec Aug Aug Nov Nov Mar May ‐ 12 May ‐ 11

Apr‐ May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐ Mar Apr‐ May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ 11 ‐11 11 11 11 11 11 11 11 12 12 ‐12 12 ‐12 12 12 12 12 12 12 12 DPoW 12.4 7.7 9.5 7.7 8.2 8.8 9.1 9.2 9.5 10.3 8.5 8.2 9.1 9.0 10.3 9.8 11.1 9.4 8 9.5 11.8 SGH 9.4 5.6 7.1 8.4 7.4 7.1 5.9 8.1 7.4 7.5 6.9 5.2 6.4 9.8 8.8 8.4 8.6 8.1 9.1 8.7 11.2 GDH 10.2 10.4 6.3 10.8 4.2 13.6 10.1 7.9 12.1 10.3 8.4 9.3 5.8 6.2 5.7 6.0 17.5 10.6 0 0 10

Source: Information services team, coded data KEY to abbreviations: Source: Information services team, coded data DPoW: Diana, Princess of Wales KEY Comments:to abbreviations: The above DPoW:chart demonstrates Diana, Princess the average of Wales length Hospital, of stay Grimsby for Hospital, Grimsby patients with dementia. SGH: The vertical Scunthorpe axis demonstrates General Hospital, the average length SGH: Scunthorpe General Hospital, of hospital stay (LOS) in days GDH: for Goole patients and admitted District with Hospital dementia whilst the GDH: Goole and District Hospital horizontal axis illustrates the months where this has been measured, starting Comments:in April 2011. TheA breakdown above of performance chart demonstrates at site level is also the helpful average for more length detailed of internal stay monitoring for patients of this area. with dementia. The vertical axis demonstrates the average length of hospital stay (LOS) in days for patientsThe Trust-wide admitted dementia with delivery dementia plan that whilst was generatedthe horizontal following axis the resultsillustrates of the thenational months dementia where audit, this has includedbeen measured, a number of actionsstarting to assistin April with 2011.the improvement A breakdown in Length of of performance Stay (LOS) for patients at site with level dementia. is also helpfulThese for included more implementationdetailed internal of the monitoring dementia screening of this toolarea. for patients over the age of 75 years that are admitted as an emergency (linked to the national Commissioning for Quality and Innovation (CQUIN) framework), to identify patients with early signs of dementia and to enable speedier referral to mental health liaison teams The for Trust-wide advice and support dementia that would delivery help to planfacilitate that a more was effective generated and timely following discharge, theas well results as ensuring of the nationalthat correct dementia follow-up audit, care was included received awith number signposting of and actions improved to access assist to withrelevant the support improvement services in Lengthafter discharge. of Stay Another (LOS) action for patients was to implement with dementia. dementia awareness These training included for relevant implementation front-line staff ofto the dementiaraise awareness screening of how tool a person for with patients dementia over may thebe affected age of in a 75 hospital years environment that are with admitted advice on ashow an emergencyto improve (linkedcare and treatment. to the nationalThis was also Commissioning aimed to have a positive for effect Quality on patient and length Innovation of stays (CQUIN)and the framework),overall patient to identifyand carer experience.patients with Training early is available signs viaof e-learningdementia packages and to and enable on the Diana,speedier Princess referral of to mentalWales, Grimsby health (DPoW) liaison site, teams the local for mental advice health and provider support has been that delivering would somehelp classroom to facilitate based sessions.a more Work is continuing to facilitate similar sessions on the other sites and in the community as well as other actions effective and timely discharge, as well as ensuring that correct follow-up care was received focused on improving the care of patients with dementia, e.g. person-centred planning. with signposting and improved access to relevant support services after discharge. Another actionHas wasthe quality to implement indicator been dementia changed awarenessduring the year training from that for set relevant in last year’s front-line (2011/12) staff Quality to raise awarenessAccount? of how a person with dementia may be affected in a hospital environment with adviceNo, thereon how has been to improve no change care to this and quality treatment. priority during This the was 2012/13 also reporting aimed period. to have a positive effect on patient length of stays and the overall patient and carer experience. Training is available via Rationale e-learning for packageschanging the and quality on priority the Diana, for 2013/14: Princess Due to ofthe Wales,limited nature Grimsby of benchmarking (DPoW) data site, with the localwhich mental to compare health the provider Trust performance has been with deliveringpeers, the value some of this classroom indicator was based limited. sessions. Also in response Work to is the national priority of dementia and the national Commissioning for Quality and Innovation (CQUIN) indicator, Directorateit was offelt Clinical that inclusion and Quality of monthlyAssurance, performance April 2013 with this CQUIN indicator regarding dementiaPage would 24 of 97 be a more useful indicator going forward.

157

continuing to facilitate similar sessions on the other sites and in the community as well as other actions focused on improving the care of patients with dementia, e.g. person-centred planning.

Has the quality indicator been changed during the year from that set in last years (2011/12) Quality Account? No, there has been no change to this quality priority during the 2012/13 reporting period.

Rationale for changing the quality priority for 2013/14: Due to the limited nature of benchmarking data with which to compare the Trust performance with peers, the value of this indicator was limited. Also in response to the national priority of dementia and the national Commissioning for Quality and Innovation (CQUIN) indicator, it was felt that inclusion of monthly performance with this CQUIN indicator regarding dementia would be a more useful indicator going forward. Annual Quality Account 2012/13 2.1b PATIENT SAFETY 2.1b Patient safety PS1 – MRSA bacteraemia incidence

PS1 – MRSAAchieve bacteraemia a level of no incidence more than three MRSA Bacteraemias developing after 48 Target: y hoursTarget: intoAchieve the a levelinpatient of no more stay than (hospital three MRSA acquired). Bacteraemias developing after 48 hours into the inpatient t

stay (hospital acquired). e f

Performance (April (April 2012 –2012 March – 2013): March two 2013): cases two cases a

Previous performance:performance: S t 2011/2012: four cases of hospital acquired MRSA bacteraemia (post 48 hours)  2011/2012: four cases of hospital acquired MRSA bacteraemia (post 48 hours) n

2010/2011: 2010/2011: eight cases of eight hospital cases acquired of MRSA hospital bacteraemia acquired (post MRSA 48 hours) bacteraemia (post 48 hours) e i t

Hospital acquired MRSA bacteraemias (post 48 Hours) a 5 P (n=) 4

3 2 2 2 2

Bacteraemias 1 1 1 1 1 1 1 1

1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 MRSA 0 of

10 11 10 12 10 10 10 10 10 10 11 11 11 11 11 11 11 11 11 11 12 12 12 12 12 12 12 12 12 12 13 13 13 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Jul Jul Jul Jan Jan Jan Jun Jun Jun Oct ‐ 10 Oct ‐ 11 Oct ‐ 12 Apr Apr Apr Sep Feb Sep Feb Sep Feb Dec Dec Dec Aug Aug Aug Nov Nov Nov Mar Mar Mar May May May Number

Source: Trust infection control database, information services team Source: Trust infection control database, information services team Comment: The above chart demonstrates the number of hospital acquired MRSA bacteraemias since April 2010. The vertical axis demonstrates the number of hospital acquired MRSA bacteraemia identified within the Trust Comment:whilst the horizontal The axis above illustrates chart the months demonstrates this information the has been number identified of from, hospital beginning acquired in April 2010. MRSA bacteraemiasDuring eight consecutive since months April in 2010. 2012/13 Theno hospital vertical acquired axis MRSA demonstrates bacteraemia were the recorded. number of hospital acquiredHas the quality MRSA indicator bacteraemia been changed identified during the within year fromthe thatTrust set whilstin last year’s the horizontal(2011/12) Quality axis illustrates theAccount? months this information has been identified from, beginning in April 2010. During eight consecutive months in 2012/13 no hospital acquired MRSA bacteraemia were recorded. No, there has been no change to this quality priority during the 2012/13 reporting period.

DirectorateRationale forof Clinical changing and Qualitythe quality Assurance, priority April for 2013 2013/14: This indicator has not been replaced forPage 2012/13, 25 of 97 however the threshold for MRSA bacteraemia has been reduced from three to 0.

158

Has the quality indicator been changed during the year from that set in last years (2011/12) Quality Account? No, there has been no change to this quality priority during the 2012/13 reporting period.

Rationale for changing the quality priority for 2013/14: This indicator has not been replaced for 2012/13, however the threshold for MRSA bacteraemia has been reduced from three to 0.

PS2 – Clostridium difficile Target: Achieve a level of no more than 34 hospital acquired C. Difficile cases over the financial year 2011/12. PS2 – Clostridium difficile

Target: Achieve a level of no more than 34 hospital acquired clostridium difficile cases over the financial year 2011/12. Performance (April 2012 – March 2013): 37 cases Performance (April 2012 – March 2013): 37 cases Previous performance: Previous performance:  2011/2012: 2011/2012: 41 cases 41 of caseshospital ofacquired hospital clostridium acquired difficile Clostridium Infections. Difficile Infections.  2010/2011: 43 cases of hospital acquired Clostridium Difficile Infections. 2010/2011: 43 cases of hospital acquired clostridium difficile Infections.

Hospital acquired clostridium difficile infections 20

15 8 10 5 6 5 5 2 3 5 5 2 4 4 4 4 5 2 4 4 4 5 4 3 4 3 3 3 2 2 2 2 2 1 1 2 1 1 0 Number Number of Diff C infections (n=) Jul-10 Jul-11 Jul-12 Apr-10 Oct-10 Apr-11 Oct-11 Apr-12 Oct-12 Jun-10 Jan-11 Jun-11 Jan-12 Jun-12 Jan-13 Feb-11 Mar-11 Feb-12 Mar-12 Feb-13 Nov-10 Dec-10 Nov-11 Dec-11 Nov-12 Dec-12 Aug-10 Sep-10 Aug-11 Sep-11 Aug-12 Sep-12 May-10 May-11 May-12

Source: Trust infection control database, information services team Source: Trust infection control database, information services team Comment: The above chart demonstrates the number of hospital acquired clostridium difficile infections (C Diff) Comment:since April The 2010. aboveThe vertical chart axis illustrates demonstrates the number theof hospital number acquired of clostridium hospital difficile acquired infections clostridium identified difficilewithin infections the Trust whilst(C Diff) the horizontalsince April axis illustrates2010. The the months vertical this axisinformation illustrates has been the identified number from. of hospital acquiredAs illustrated clostridium in the above difficile chart, infections the target for identified the year was within not achieved. the Trust This was whilst in large the part horizontaldue to the axis illustratesincrease the in monthsC Diff cases this associated information with Norovirus has been and increased identified bed from. occupancy. Work is therefore underway with commissioners to try to maintain bed occupancy levels at 85 per cent or below. In addition, whilst there have As illustratedbeen great in improvements the above in chart, antibiotic the prescribing, target for work the continues year was to address not achieved.this issue. This was in large part dueHas the to quality the increase indicator been in Cchanged Diff casesduring the associated year from that with set in Norovirus last year’s (2011/12) and increased Quality bed occupancy.Account? Work is therefore underway with commissioners to try to maintain bed occupancy levels at 85% or below. In addition, whilst there have been great improvements No, there has been no change to this quality priority during the 2012/13 reporting period. in antibiotic prescribing, work continues to address this issue. Rationale for changing the quality priority for 2013/14: This indicator has not been replaced for 2012/13, however the threshold for clostridium difficile has been reduced from 34 to 30. Has the quality indicator been changed during the year from that set in last years (2011/12) Quality Account? No, there has been no change to this quality priority during the 2012/13 reporting period.

Rationale for changing the quality priority for 2013/14: This indicator has not been replaced for 2012/13, however the threshold for clostridium difficile has been reduced from 34 to 30.

Directorate of Clinical and Quality Assurance, April 2013 Page 26 of 97

159

PS3 – Patient identification incidents

Target:Annual To realise Quality a five per centAccount reduction in patient2012/13 identification incidents. Achievement (April 2012 – January 2013): The following chart illustrates that the monthly targetPS3 – has Patient not been identification met. incidents Target: To realise a five per cent reduction in patient identification incidents. Achievement (April 2012 – January 2013): The following chart illustrates that the monthly target has not been met. Statistical Proces Control (SPC) ‐ Trust 5% planned reduction in patient identification incidents 45

40 (n=)

35 30 25 Patient

incidents 20

of 15 10 5 Number 0 identification 11 11 11 11 11 11 12 12 12 12 12 12 12 11 11 11 12 12 12 13 12 12 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Jul Jul Jan Jan Jun Jun Oct ‐ Oct ‐ Apr Apr Sep Feb Sep Dec Dec Aug Aug Nov Nov Mar May May

Apr‐ May Jun‐ Jul‐ Aug Sep‐ Oct‐ Nov Dec Jan‐ Feb‐ Mar Apr‐ May Jun‐ Jul‐ Aug Sep‐ Oct‐ Nov Dec Jan‐ 11 ‐11 11 11 ‐11 11 11 ‐11 ‐11 12 12 ‐12 12 ‐12 12 12 ‐12 12 12 ‐12 ‐12 13 Trustwide 20 14 13 7 21 11 10 17 12 24 31 29 21 26 27 25 18 19 30 23 16 20 Average (Mean) 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 Target ‐ 5% reduction 18 18 18 18 18 18 18 18 18 18 18 18 18 UCL 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42

Source: DATIX, clinical and quality assurance team Source: DATIX, clinical and quality assurance team Comment: The above chart demonstrates the number of patient identification Comment:incidents within The the Trust. above This is chart expressed demonstrates in an SPC or Statistical the numberProcess Control of patient identification incidents withinChart which the allows Trust. routine This process is expressed data to be calculated in an SPCand interpreted or Statistical using Process Focus Control on: Chart DATIX which allowsstatistical routine rules. The process mean line data demonstrates to be calculated the level of average and interpreted performance whilstusing statisticalA core componentrules. The of meanquality within the linethe upperdemonstrates control limit orthe UCL level sets aof statistically average calculated performance maximum whilst level of the variation upper controlTrust is limit the principle or UCL to ‘dosets no harm’ to athat statistically would be expected calculated within this maximum process. Also level plotted of is the variation target reduction that would be patients expected or service within users. this being aimed for on a monthly basis. This was calculated from information from the Healthcare however is a high risk industry. process.beginning ofAlso April plotted2011. The averageis the performancetarget reduction for this area being was 20aimed therefore for a fiveon a monthly basis. This was One of the Trust’s priorities therefore is to calculatedper cent reduction from target information has been set, from which the equates beginning to a monthly of target of 18. April 2011. The average performance for this area manage this risk. One way of doing this Patient misidentification is part of the Trust Learning Lessons Action Plan, a is using software such as DATIX which wasnumber 20 of thereforeinterventions a have five been per implemented cent reduction to reduce target the number of patient provides the Trust access to incident hasmisidentification been set, incidents,which equates including toarticles a monthly in the Learning target Lessons of newsletter, reporting and adverse event reporting. Focus on: DATIXFrom this system, the Trust is able to 18.internal safety alerts, inclusion of Patient Identification Policy in the local induction monitor, report and more importantly checklist. Further targeted campaigns are planned with the risk and governanceA core component of quality within the learn from any adverse incidents to Patientfacilitators during misidentification 2013/14. is part of the Trust Trust is the principle to ‘do no harm’ to Learning Lessons Action Plan, a number of patients or serviceprevent users. them from re-occurring. Additionally, further work has been undertaken to determine the difference between interventions have been implemented to reduce Healthcare however is a high risk the situations and contexts of internally reported patient identification incidents. In industry. One of the Trust’s priorities theparticular number this has of been patient focussed misidentification around understanding incidents, the difference between those therefore is to manage this risk. One includingreported as a result articles of diagnostic in theinvestigation Learning vs. non-diagnostic Lessons incidents. newsletter, internal safety alerts, inclusion of way of doing this is using software In support of the work undertaken within the Trust, it was highlighted that notsuch all aspatient DATIX identification which provides incidents the Patientwere attributable Identification to the Trust. Policy In some in cases, the although local inductionthe Trust has reportedTrust the incident,access to the incident source hasreporting been and checklist.external to the Further organisation, targeted for instance campaigns incidents haveare beenplanned reported by Pathadverse Links eventthat relate reporting. to samples From this withreceived the from risk external and sources governance which are incorrectly facilitators labelled during with Patient Identifierssystem, themissing Trust or is incorrect. able to monitor, 2013/14. report and more importantly learn from any adverse incidents to prevent them Additionally, further work has been undertaken to from re-occurring. determine the difference between the situations and contexts of internally reported patient 160 Directorate of Clinical and Quality Assurance, April 2013 Page 27 of 97 Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality Account? No, there has been no change to this quality priority during the 2012/13 reporting period. Rationale for changing quality priority for 2013/14: This indicator is now monitored on a monthly basis by individual clinical governance groups and the learning lessons group. Systems have now been put in place that prevents diagnostic tests to be undertaken without an NHS number being present. Any externally identified problems with patient identifiers are escalated to the relevant external bodies for their notification and root cause analysis.

PS4 – Patient medication incidents Target: To realise a downward trajectory in reported incidents where patients are prescribed penicillin where there is a documented penicillin allergy. Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality PS5 – Account?Patient falls Target:Yes, To following realise a reviewa five of per the centmonthly reduction quality report, in the it was number felt that thisof falls indicator per was 1,000 not relevant bed days. for monitoring in the monthly report as it is closely monitored by the safer medications group. AchievementRationale for(April changing 2012 the – qualityJanuary priority 2013): for 2013/14: Performance As clarified sinceabove. April 2012 has not met the target reduction set. PS5 – Patient falls Target: To realise a five per cent reduction in the number of falls per 1,000 bed days. Statistical Process Control (SPC) ‐ Trust (preventable and non‐preventable) Achievement (April 2012 – January 2013): Performance since April 2012 has not met the target reduction set. falls per 1,000 bed days 12.00

10.00 189 175 180 170 163159 178 156 165 161 per 149 152 8.00 150 157 falls (n=) 157

150 150 137 149 146 6.00 133 124 days

Patient

bed

4.00 of

1000 2.00 Number 0.00 10 10 10 10 10 10 10 10 10 11 11 11 11 11 11 11 11 11 11 11 11 12 12 12 12 12 12 12 12 12 12 12 12 13 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Jul Jul Jul Jan Jan Jan Jun Jun Jun Oct Oct Oct Apr Apr Apr Sep Feb Sep Feb Sep Dec Dec Dec Aug Aug Aug Nov Nov Nov Mar Mar May May May

Ap Ma Au Se Oc No De Fe Ma Ap Ma Au Se Oc No De Fe Ma Ap Ma Au Se Oc No De JunJul‐ Jan JunJul‐ Jan JunJul‐ Jan r‐ y‐ g‐ p‐ t‐ v‐ c‐ b‐ r‐ r‐ y‐ g‐ p‐ t‐ v‐ c‐ b‐ r‐ r‐ y‐ g‐ p‐ t‐ v‐ c‐ ‐10 10 ‐11 ‐11 11 ‐12 ‐12 12 ‐13 10 10 10 10 10 10 10 11 11 11 11 11 11 11 11 11 12 12 12 12 12 12 12 12 12 Falls per 1,000 bd 6.1 8.2 7.4 8.2 7.4 7.4 7.1 6.7 8.5 8.5 7.9 8.2 7.8 8.5 9.5 6.8 7.8 8.4 8.3 7.9 8.3 7.3 6.4 6.8 7.3 6.7 8.1 8.4 8.3 7.7 5.7 7.6 8.2 9.1 Mean 10/11 7.6 7.6 7.6 7.6 7.6 7.6 7.6 7.6 7.6 7.6 7.6 7.6 Mean 11/12 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 7.8 Target 5% reduction 7.4 7.4 7.4 7.4 7.4 7.4 7.4 7.4 7.4 7.4 LCL 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 UCL 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10. 10.

Source:Source: DATIX, DATIX, clinical clinical and qualityand quality assurance assurance team team Comment: The above chart illustrates the number of preventable and non-preventable patient falls per 1,000 bed days. The information is expressed in a Statistical Process Control (SPC) chart which allows for routine process Comment:data to beThe interpreted above using chart statistical illustrates rules, as expressed the number by the upper of preventable control limit (UCL) and the non-preventablelower control limit patient(LCL) falls and per the 1,000 mean. Alsobed plotted days. is Thethe target information reduction beingis expressed aimed for, in in this a caseStatistical a five per Process cent reduction Control (SPC) chart which allows for routine process data to be interpreted using statistical rules, as expressed by the upper control limit (UCL) the lower control limit (LCL) and the mean. Also plotted is the target reduction being aimed for, in this case a five per cent reduction161 which was based on the average performance during March 2011 and April 2012. A five per cent reduction aimed for per month was therefore 7.4 falls per 1,000 bed days. NB: The data labels within the above chart refer to the actual number of falls recorded per month. The vertical axis relates to falls per 1,000 bed days. As a result of the previous work undertaken in this area, the DATIX system is now able to provide a single notification on all single falls allowing the lead quality matron to go to that ward immediately with the intention of preventing repeat falls. For ward based falls, a thematic analysis is performed to identify what additional actions are required in these areas to ensure lessons are learnt.

An additional factor which has potentially contributed to increased reporting of falls has been the acute pressures on beds which has put additional pressure on the system and has lead

Directorate of Clinical and Quality Assurance, April 2013 Page 29 of 97 Annual Quality Account 2012/13 which was based on the average performance during March 2011 and April 2012. A five per cent reduction aimed for per month was therefore 7.4 falls per 1,000 bed days. NB: The data labels within the above chart refer to the actual number of falls recorded per month. The vertical axis relates to falls per 1,000 bed days. As a result of the previous work undertaken in this area, the DATIX system is now able to provide a single notification on all single falls allowing the lead quality matron to go to that ward immediately with the intention of preventing repeat falls. For ward based falls, a thematic analysis is performed to identify what additional actions are required in these areas to ensure lessons are learnt. An additional factor which has potentially contributed to increased reporting of falls has been the acute pressures on beds which has put additional pressure on the system and has lead in some cases to a number of ward transfers and in some cases outliers on non-specialty wards. Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality Account? No, there has been no change to this quality priority during the 2012/13 reporting period. Rationale for changing the quality priority for 2013/14: Patient falls have represented a significant priority for the Trust during this financial year. The above falls indicator, although changed, still keeps the focus on this important area. The rationale for the change is to ensure the Commissioning for Quality and Innovation (CQUIN) indicator relating to falls within the NHS Safety Thermometer is appropriately monitored. This refocusing of the indicator allows for the Trust to focus on reducing the number of preventable fallers. This level of specificity has not been available before.

162 News release: Steps being taken to reduce patient falls Steps are being taken to help reduce the number of patient falls at the Northern Lincolnshire and Goole Hospitals NHS Foundation Trust. Bright red slipper socks are being rolled out on the wards at the Trust’s three hospitals in Goole, Grimsby and Scunthorpe. The socks are being handed out to patients who have been identified as being at high risk of slips, trips and falls. The socks have extra grip on them but they also have another purpose, as Melanie Sharp, quality matron at the Trust, explains. She said: “We need and expect all of our nursing staff to be able to identify those patients who are at risk of falling. With the socks being bright red it’s a clear indication which patients on the ward are potential fallers.” Previously the Trust has used red wrist bands to help identify high risk patients, but these were used for a number of other risks, including allergies and so it wasn’t immediately obvious that someone was at a high risk of falling. The consequences of falling can range from distress and loss of confidence, to injuries that cause pain and suffering, loss of independence and, occasionally, death. In addition to the human cost there is also a financial cost, due to things like a resulting longer stay in hospital. One of the first areas to use the socks is the Medical Admissions Unit (MAU) at Grimsby’s Diana, Princess of Wales Hospital, which was chosen because patients tend to go on to other wards from there. The unit had been using a different brand of slipper socks for about six months before receiving the new red socks. If a patient comes into the Trust having previously fallen, whether that be at home or during a previous hospital stay, they are put straight onto the hourly slips, trips and fall pathway and are given a pair of the red socks. The pathway was designed by a health care assistant at the Trust and involves a check list which looks at a range of things from whether the patient can reach the call bell, if their glasses are clean, the bed is at the lowest possible height and if they wearing the correct footwear. As well as helping to keep patients safe the socks are also cost effective as they come in one size fits all, making them less expensive than previous socks purchased. Patient Ian Porteous has been wearing the socks for a few days after he fell when he collapsed in hospital. He said: “I think they are a marvellous idea; they really grip and they’re comfy. I can’t really walk but they give me extra grip when I stand up. I didn’t realise they were red so that staff could keep an eye out for us, that’s a good idea.” All patients have their risk of falling assessed within 24 hours of being admitted to hospital. Other actions taken by the Trust to reduce slips, trips and falls include: •A• ll falls incidents are monitored by the lead quality matron •• A full investigation takes place for any repeat fall or a fall that leads to moderate or severe injury, with lessons learned being shared between wards. •• Dedicated training has been provided to staff around falls risk assessment, falls awareness, falls prevention and steps to take after a fall •N• ew electronic profiling beds with safety sides have been introduced •I• nformation for patients and carers has been produced on how to reduce the risk of falling. The red socks are kept by the patient after they leave hospital so they can continue to be safe out in the community, whether that is at home or in a nursing or care home.

163

PS6Annual – Repeat Qualityfallers Account 2012/13

Target: To realise a five per cent reduction in the number of repeat fallers per 1,000 bed days.PS6 – Repeat fallers

AchievementTarget: To realise a(April five per 2012cent reduction – January in the 2013):number ofThe repeat chart fallers below per 1,000 illustrates bed days. that performance in September,Achievement (April October, 2012 – January November 2013): andThe chart December below illustrates reduced that performance towards in the September, monthly October, target set. However,November and in DecemberJanuary, reduced this rose towards to 1.25 the monthly and at target present set. However, the target in January, is still this not rose being to 1.25 met. and at present the target is still not being met. Statistical Process Control (SPC) ‐ Trust repeat (preventable and non‐

preventable) fallers per 1,000 bed days per

2.00 34 (n=) 1.50 29 fallers 25 27 21 20 23 23 23 27 22 24 days 1.00

repeat 20 20 20 bed 15 16

of 0.50

1000 0.00 Number

Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐ Mar Apr‐ May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ 11 11 11 11 12 12 ‐12 12 ‐12 12 12 12 12 12 12 12 13 Repeat falls per 1000 bd 1.08 1.04 1.26 1.26 0.73 0.77 0.91 0.97 0.92 1.20 1.59 1.40 1.10 1.06 1.17 1.13 1.25 Mean 1.10 1.10 1.10 1.10 1.10 1.10 1.10 1.10 1.10 1.10 1.10 1.10 1.10 1.10 1.10 1.10 1.10 Target 5% reduction 0.96 0.96 0.96 0.96 0.96 0.96 0.96 0.96 0.96 0.96 LCL 0.40 0.40 0.40 0.40 0.40 0.40 0.40 0.40 0.40 0.40 0.40 0.40 0.40 0.40 0.40 0.40 0.40 UCL 1.79 1.79 1.79 1.79 1.79 1.79 1.79 1.79 1.79 1.79 1.79 1.79 1.79 1.79 1.79 1.79 1.79

Data Source: DATIX, clinical and quality assurance team Data Source: DATIX, clinical and quality assurance team NB: The data labels within the above chart refer to the actual number of repeat falls recorded per month. The NB:vertical The axis relatesdata tolabels falls per within 1,000 bed the days. above chart refer to the actual number of repeat falls recordedComment: The per above month. chart illustratesThe vertical the number axis of relates preventable to andfalls non-preventable per 1,000 bed patients days. having repeat falls per 1,000 bed days. The information is expressed in a Statistical Process Control (SPC) chart which allows for routine process data to be interpreted using statistical rules, as expressed by the upper control limit (UCL) the Comment:lower control limit The (LCL) above and the chartmean. Also illustrates plotted is the the target number reduction of being preventable aimed for, in and this case non-preventable a five per patientscent reduction having which repeat was based falls on theper average 1,000 performance bed days. during The theinformation period of September is expressed 2011 and in March a Statistical Process2012. A five Control per cent reduction(SPC) chartaimed forwhich per monthallows was fortherefore routine 0.96 repeatprocess falls dataper 1,000 to bedbe days.interpreted using statisticalAs a result of rules,this focussed as expressed work, the number by the of falls upper is now control able to be limit broken (UCL) down intothe twolower categories control – (1) limit (LCL) andthe un-preventable the mean. Also fall and plotted (2) the preventable is the target fall. Asreduction a result of thisbeing greater aimed specificity, for, in the this lead case quality a five per cent reductionmatron is able which to still further was basedfocus her onefforts the on average those areas performance within the Trust that during require the targeted period support of Septemberand 2011improvement. and March Due to this2012. focus, A the five reporting per centof falls reductionusing the DATIX aimed incident for system per hasmonth also improvedwas therefore and 0.96 therefore increased the number of reported falls. The Trust positively encourages the reporting of any incident or repeatpotential falls incident per as 1,000 pro-active bed work days. can then be undertaken to learn lessons and prevent re-occurrence.

AsHas a the result quality of indicator this focussed been changed work, during the number the year fromof falls that is set now in last able year’s to (2011/12) be broken Quality down into two categoriesAccount? – (1) the un-preventable fall and (2) the preventable fall. As a result of this greater specificity,Yes, in the 2011/12 the quality lead account, quality the matron Trust set isout able the following to still as further a quality focuspriority for her 2012/13: efforts on those areas within“To realise the a five Trust per cent that reduction require in the targeted number of support repeat fallers and with improvement. a downward trajectory Due for to wards this focus, the reportingidentified asof falling falls aboveusing the the upper DATIX confidence incident level systemin the SPC has chart” also improved and therefore increased the number of reported falls. The Trust positively encourages the reporting of any incident or potential incident as pro-active work can then be undertaken to learn lessons and prevent re- occurrence.

164 Directorate of Clinical and Quality Assurance, April 2013 Page 31 of 97 On assessing this indicator in more detail, it was found to be a flawed quality indicator as the number of repeat fallers on a ward would need to be unrealistically high for the ward’s performance to fall outside of the control limits on the SPC chart. Therefore the decision was taken to amend this indicator to allow for a more useful quality indicator to monitor individual ward performance. Rationale for changing the quality priority for 2013/14: Patient falls have represented a significant priority for the Trust during this financial year. The above falls indicator, although changed, still keeps the focus on this important area. The rationale for the change is to ensure the Commissioning for Quality and Innovation (CQUIN) indicator relating to falls within the NHS Safety Thermometer is appropriately monitored. The focussed work undertaken for this indicator allows the Trust to focus on reducing the number of preventable fallers. This level of specificity has not been available before.

PS7 – Falls Root Cause Analysis (RCA) Target: To achieve 100% compliance with undertaking root cause analysis for repeat fallers from April 2012 Achievement (April 2012 – January 2013): At the beginning of the financial year data recording issues posed a problem in accurately measuring this indicator. From October these issues were permanently resolved resulting in four consecutive months of compliance with this target.

匀攀瀀琀 伀挀琀 一漀瘀 䐀攀挀 䨀愀渀 䘀攀戀 䴀愀爀 䄀瀀爀 䴀愀礀 䨀甀渀攀 䨀甀氀礀 䄀甀最 匀攀瀀琀 伀挀琀 一漀瘀 䐀攀挀 䨀愀渀 ㈀㄀ ㈀ ㈀㔀 ㈀㜀 ㄀㔀 ㄀㘀 ㈀ ㈀ ㈀ ㈀㌀ ㌀㐀 ㈀㤀 ㈀㌀ ㈀㌀ ㈀㜀 ㈀㈀ ㈀㐀 一甀洀戀攀爀 漀昀 刀攀瀀攀愀琀 䘀愀氀氀攀爀猀

刀漀漀琀 䌀愀甀猀攀 䄀渀愀氀礀猀椀猀 甀渀搀攀爀琀愀欀攀渀 ㈀ ㌀ 㔀 㠀 㔀 㜀 㤀 㠀 㘀 ㄀㐀 ㈀㈀ ㈀㄀ ㈀㄀ ㈀㌀ ㈀㜀 ㈀㈀ ㈀㐀 昀漀爀 刀攀瀀攀愀琀 䘀愀氀氀攀爀猀 䄀瘀攀爀愀最攀 ㄀ ─ ㄀㔀─ ㈀ ─ ㌀ ─ ㌀㌀─ 㐀㐀─ 㐀㔀─ 㐀 ─ ㌀ ─ 㔀 ─ 㘀㔀─ 㜀㈀─ 㤀㄀─ ㄀ ─ ㄀ ─ ㄀ ─ ㄀ ─

Data Source: DATIX, clinical and quality assurance team, as reported on February 5 2013 Comment: The above table illustrates the numbers of patients having been identified as having a repeat fall per month and of these, the number having had a root cause analysis undertaken to assess if any trends are identifiable to enable remedial action to be taken.

Root Cause Analysis (RCA) outcomes – preventable falls The lead quality matron is supporting proactive work to prevent falls occurring. As part of the RCA work undertaken as a result of a repeat fall, an effort has been made to determine the numbers of potentially preventable falls. This data is illustrated below.

匀攀瀀琀 伀挀琀 一漀瘀 䐀攀挀 䨀愀渀 䘀攀戀 䴀愀爀 䄀瀀爀 䴀愀礀 䨀甀渀攀 䨀甀氀礀 䄀甀最 匀攀瀀琀 伀挀琀 一漀瘀 䐀攀挀 䨀愀渀 ㈀㄀ ㈀ ㈀㔀 ㈀㜀 ㄀㔀 ㄀㘀 ㈀ ㈀ ㈀ ㈀㌀ ㌀㐀 ㈀㤀 ㈀㌀ ㈀㌀ ㈀㜀 ㈀㈀ ㈀㐀 一甀洀戀攀爀 漀昀 刀攀瀀攀愀琀 䘀愀氀氀攀爀猀 ⴀ ⴀ ⴀ ⴀ ⴀ ⴀ ⴀ ⴀ ⴀ ⴀ ⴀ 㠀 㔀 ㌀ 㜀 ㌀ 㘀 倀爀攀瘀攀渀琀愀戀氀攀 ⴀ ⴀ ⴀ ⴀ ⴀ ⴀ ⴀ ⴀ ⴀ ⴀ ⴀ ㈀㄀ ㄀㠀 ㈀ ㈀ ㄀㤀 ㄀㠀 一漀渀 ⴀ 倀爀攀瘀攀渀琀愀戀氀攀

Data Source: RCA records held by quality matron Comment: This table illustrates that in January 75 per cent of all repeat falls were non-preventable. The remaining 25 per cent that were considered to be preventable are then focussed on by the quality matron with the lead for falls and ward specific learning points and interventions are determined with ward staff. This degree of specificity has not been available in previous years, therefore this provides the Trust very useable information with which it can actively focus and work to reduce the number of preventable falls within the organisation.

165 Annual Quality Account 2012/13

Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality Account? undertakenNo, there has beenas a no result change of to allthis repeatquality priority fallers, during will the continue 2012/13 reporting to be monitored period. in collaboration with the findings from this falls related quality priority. Rationale for changing the quality priority for 2013/14: Patient falls have represented a significant priority for the Trust during this financial year. The above falls indicator, although changed, still keeps the focus on this important area. The rationale for the change is to ensure the Commissioning for Quality and Innovation (CQUIN) PS8indicator – Pressure relating to falls ulcers within the NHS Safety Thermometer is appropriately monitored. In addition to this, the number of avoidable falls, as determined from the focussed root cause analysis work undertaken as a result of all Targetrepeat fallers, – To will continue realise to abe monitored five per in centcollaboration reduction with the findings in the from number this falls related of hospital quality priority. acquired pressure ulcers per 1,000 bed days PS8 – Pressure ulcers Achievement (April 2012 – February 2013): The table below illustrates that this indicator hasTarget not – Tobeen realise met. a five per cent reduction in the number of hospital acquired pressure ulcers per 1,000 bed days Achievement (April 2012 – February 2013): The table below illustrates that this indicator has not been met.

Statistical Process Control (SPC) ‐ NLAG pressure ulcers (avoidable and unavoidable) per 1,000 bed days 2.50 44 2.00 33 32 1.50 28 31 27 24 24 23 23 19 29 1.00 17 17 18

14 16 15 1616 0.50 13 11 12 12 13 10 10 9 0.00 10 11 11 11 11 12 10 12 12 10 10 10 10 12 11 13 11 11 11 11 11 11 11 12 12 12 12 12 12 12 12 13 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Jul Jul Jul Jan Jan Jan Jun Jun Oct Oct Oct Apr Apr Sep Feb Sep Feb Sep Feb Dec Dec Dec Aug Aug Aug Nov Nov Nov Mar Mar May May

Au No De Ma Ma Au No De Ma Ma Au No De Jul‐ SepOct Jan Feb Apr Jun Jul‐ SepOct Jan Feb Apr Jun Jul‐ SepOct Jan Feb g‐ v‐ c‐ r‐ y‐ g‐ v‐ c‐ r‐ y‐ g‐ v‐ c‐ 10 ‐10 ‐10 ‐11 ‐11 ‐11 ‐11 11 ‐11 ‐11 ‐12 ‐12 ‐12 ‐12 12 ‐12 ‐12 ‐13 ‐13 10 10 10 11 11 11 11 11 12 12 12 12 12 PU per 1,000 bd 0.4 0.8 0.4 1.0 0.4 0.6 0.6 0.5 0.4 0.7 0.5 1.3 0.7 1.2 0.5 0.9 0.4 0.7 0.7 0.6 0.7 1.6 0.7 1.2 0.8 1.1 1.2 1.4 1.6 1.3 1.2 2.1 Average (mean) 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 Average (Q1 '11) 0.9 0.9 0.9 Target 5% reduction 0.8 0.8 0.8 0.8 0.8 0.8 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 UCL 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9

Source: July 2010 – January 2013: Information services team, intranet collated data, February 2013: Source: July 2010 – January 2013: Information services team, intranet collated data, February 2013: DATIX, clinical DATIX, and clinical quality and assurancequality assurance team team Comment: The above chart illustrates the number of pressure ulcers per 1,000 bed days, including both Comment:avoidable and Theunavoidable. above The chart information illustrates is expressed the numberin a Statistical of Processpressure Control ulcers (SPC) chartper which1,000 allows bed days, includingfor routine process both data avoidable to be interpreted and unavoidable. using statistical rules, The as informationexpressed by the is upper expressed control limit in (UCL) a Statisticalthe Processlower control Control limit (LCL) (SPC) and the chart mean. which Also plotted allows is the for target routine reduction process being aimed data for, to in thisbe caseinterpreted a five per using cent reduction. statistical rules, as expressed by the upper control limit (UCL) the lower control limit (LCL) andNB: Thethe data mean. labels Also within plotted the above is chartthe targetabove refer reduction to the actual being number aimed of hospital for, in acquired this case pressure a five ulcers per cent reduction.recorded per month. The vertical axis refers to the number per 1,000 bed days. NB: The data labels within the above chart above refer to the actual number of hospital acquired pressure ulcers recorded per month. The vertical axis refers to the number166 per 1,000 bed days. The quality matron with the lead for pressure ulcers has been actively reviewing the different data sources within the Trust that are currently supplying information on pressure ulcers. There were three primary sources of data which inform reports such as the monthly quality report. These have been reviewed and reduced to two, namely:

Directorate of Clinical and Quality Assurance, April 2013 Page 34 of 97

1. DATIX Incident Reporting System 2. Root Cause Analysis (RCA) records kept by lead quality matron.

As a resultThe quality of this matron work, with the the leadabove for pressure chart ulcersillustrates has been February’s actively reviewing data, the the different first to data be sources reported within from DATIX.the Trust The that aremove currently to DATIX supplying enables information the on lead pressure quality ulcers. matron There were to overseethree primary the sources numbers of data of hospitalwhich acquired inform reportspressure such ulcers as the monthly on an qualityongoing report. basis These and have react been reviewedaccordingly. and reduced to two, namely: 1. DATIX Incident Reporting System The move to reporting and monitoring this area from one source, DATIX, has resulted in a higher 2. than R previouslyoot Cause Analysis reported (RCA) records incidence kept by oflead hospital quality matron. acquired pressure ulcers. From a review As of a result this of most this work, recent the above data chart and illustrates previously February’s reported data, the positionsfirst to be reported it appears from DATIX. that The these move inconsistenciesto DATIX enables may the have lead quality been matron a result to oversee of previouslythe numbers of under hospital reporting acquired pressure hospital ulcers acquired on an pressureongoing ulcers. basis Asand react a result accordingly. of this work on the data from DATIX and the monitoring processesThe move that tohave reporting now and been monitoring established, this area fromthe oneTrust source, is confident DATIX, has resultedthat the in afigure higher thanas reported previously in DATIXreported is the incidence correct of hospitalone allowing acquired pressurefor proactive ulcers. From work a review to be of this undertaken most recent datain an and attempt previously to improvereported the reported positions positionit appears thatin future these inconsistencies months. may have been a result of previously under reporting hospital acquired pressure ulcers. As a result of this work on the data from DATIX and the monitoring processes that have now been established, the Trust is confident that the figure as reported in DATIX is the correct one Anotherallowing objective for proactive behind work centralising to be undertaken the data in an attemptsource to used improve for the pressure reported positionulcer monitoring in future months. and reporting is to focus on reducing the number of avoidable pressure ulcers. Currently the Another objective behind centralising the data source used for pressure ulcer monitoring and reporting is to distinctionfocus between on reducing avoidable the number andof avoidable un-avoidable pressure ulcers. pressure Currently ulcers the distinction is being between made avoidableas a result and of the rootun-avoidable cause analysis pressure ulcerswork isfor being grade made three as a result and of thefour root pressure cause analysis ulcers work only. for grade This three is andonly four the first step,pressure with ulcers plans only. This being is only made the first to step, assess with plans all being hospital made to acquired assess all hospital pressure acquired ulcers pressure and determineulcers if and they determine were avoidable if they were avoidableor not. Inor not.future In future once once the the process process for for grades grades three three and four and ulcers four ulcers is sustained,sustained, this willthis be will replicated be replicated for grade two.for gradeAt that point,two. the At reporting that point, within the the reporting monthly quality within report the monthlywill quality focus on report those pressure will focus ulcers on considered those pressure to be avoidable ulcers and consideredan improvement to trajectory be avoidable will be used and to an measure this area on an ongoing basis. improvement trajectory will be used to measure this area on an ongoing basis.

HospitalHospital acquired acquired pressure pressure ulcers ulcers by grade by grade

Pressure ulcers by grade (avoidable and unavoidable) ‐ hospital acquired only 40 35 30 25 20 15 10 5 0 Apr‐12May‐12Jun‐12 Jul‐12 Aug‐12 Sep‐12 Oct‐12 Nov‐12Dec‐12 Jan‐13 Feb‐13 Apr‐12 May‐12 Jun‐12 Jul‐12 Aug‐12 Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13 Grade 2 30 15 19 13 21 20 28 29 23 28 34 Grade 3 22733223636 Grade 4 00001000014 Grade not recorded 10030211000

Source: April 2012 – January 2013: Information services team, intranet collated data, February 2013: Source: April 2012DATIX, – Januaryclinical and 2013: quality Information assurance servicesteam team, intranet collated data, February 2013: DATIX, clinical and quality assurance team Please note that some patients have multiple pressure ulcers at different grades, therefore, the numbers detailed within this chart may be higher than the number of patients detailed within the other pressure ulcer charts/table. Please note that some patients have multiple pressure ulcers at different grades, therefore,Comment: the numbersThe above chart detailed illustrates within the number this of hospitalchart mayacquired be pressure higher ulcers than by grades the numbertwo, three of patientsand detailed four. The vertical within axis the illustrates other the pressure number of ulcer pressure charts/table. ulcers whilst the horizontal axis demonstrates the months over which this indicator has been measured, starting in April 2012.

167

Directorate of Clinical and Quality Assurance, April 2013 Page 35 of 97 Annual Quality Account 2012/13

Root Cause Analysis (RCA) outcomes - avoidable grade three and four pressure ulcers As a result of the focussed work undertaken around this area, more specific data is now available to the Trust demonstrating the breakdown of patients with grade three and four pressure ulcers into the avoidable and unavoidable. Work is now underway to refocusing all hospital acquired pressure ulcer data to be available in this format. The information below is taken from records kept by the lead quality matron as a result of the root cause analysis work taking place for patients with grades three and four pressure ulcers. This data is more comprehensive than the information collected via the intranet by a variety of ward staff as this is developed through close collaboration between the lead quality matron and the tissue viability team. As a result you will notice a disparity between the numbers of patients with grades three and four pressure ulcers below compared to the chart above. Work is ongoing to ensure all pressure ulcer data in future comes from one source to ensure accurate data recording/reporting.

Aug Sept Oct Nov Dec Jan Feb Number of grade three and four 7 3 6 5 3 12 13 pressure ulcers

Avoidable 4 0 2 2 2 3 3

Unavoidable 3 3 4 3 1 9 10

Source: Root Cause Analysis (RCA) records kept by lead quality matron Comment: This table illustrates that for February 77 per cent of all grade three and four pressure ulcers were unavoidable. The remaining 23 per cent were considered avoidable. These are then focussed on by the quality matron with the lead for pressure ulcers. Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality Account? No, there has been no change to this quality priority during the 2012/13 reporting period. Rationale for changing the quality priority for 2013/14: Pressure ulcers have represented a significant priority for the Trust during this financial year. For 2013/14 the pressure ulcers indicator will be linked to a reduction in the number of avoidable pressure ulcers as determined from the focussed root cause analysis work undertaken as a result of a grade three or four pressure ulcer.

PS9 – Pressure ulcers for specific conditions Target – To achieve a downward trajectory in the number of pressure ulcers for patients with the following conditions: Parkinson’s, hypothermia, spinal cord compression, dementia and fractured neck of femur. Has the quality indicator been changed during the year from that set in last years (2011/12) Quality Account? Yes, as a result of moving away from reporting this area from any source other than DATIX, the rate of pressure ulcers in these specific conditions is unavailable as a result of the amended information reporting structures. Rationale for changing the quality priority for 2013/14: For 2013/14 the pressure ulcers indicator will be linked to a focussed reduction in the number of avoidable pressure ulcers as determined from the focussed root cause analysis work undertaken as a result of a grade three or four pressure ulcer.

168

PS9 – Pressure ulcers for specific conditions

Target – To achieve a downward trajectory in the number of pressure ulcers for patients with the following conditions: Parkinson’s, hypothermia, spinal cord compression, dementia and fractured neck of femur.

Has the quality indicator been changed during the year from that set in last years (2011/12) Quality Account? Yes, as a result of moving away from reporting this area from any source other than DATIX, the rate of pressure ulcers in these specific conditions is unavailable as a result of the amended information reporting structures.

Rationale for changing the quality priority for 2013/14: For 2013/14 the pressure ulcers indicator will be linked to a focussed reduction in the number of avoidable pressure ulcers as determined from the focussed root cause analysis work undertaken as a result of a grade three or four pressure ulcer.

2.1c PATIENT EXPERIENCE

PE1 –2.1c Overall P satisfactionatient experience with Trust services Target: 85% or more of patients to be satisfied with Trust services. PE1 – Overall satisfaction with Trust services

AchievementTarget: 85 per(April cent or2012 more – of February patients to be 2013): satisfied The with chartTrust services. below demonstrates that this target e

has been met, with six consecutive months above the mean set within the SPC chart. c Achievement (April 2012 – February 2013): The chart below demonstrates that this target has been met, with six consecutive months above the mean set within the SPC chart. n e i

Statistical Process Control (SPC) ‐ overall satisfaction with Trust services r

105 e p x 100

E t (%)

95 n e i

90 t satisfaction a

85 P

Percentage 80

75 13 12 13 12 12 12 11 11 11 12 12 11 10 12 12 12 12 10 11 11 11 11 11 11 12 10 10 10 10 11 10 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Jul Jul Jul Jan Jan Jan Jun Jun Jun Oct Oct Oct Apr Apr Feb Sep Feb Sep Feb Sep Dec Dec Dec Aug Aug Aug Nov Nov Nov Mar Mar May ‐ 12 May ‐ 11 May ‐ 10

Source: Menu card survey, membership office Source: Menu card survey, membership office Comment: The above chart demonstrates on the vertical axis the percentage satisfaction and on the horizontal axis the months over which this indicator has been measured. From September 2012 a run of six consecutive Comment:months Theof above above the mean chart performance demonstrates have been on identified. the vertical axis the percentage satisfaction and onHas the the horizontal quality indicator axis been the changedmonths during over thewhich year fromthis thatindicator set in last has year’s been (2011/12) measured. Quality From SeptemberAccount? 2012 a run of six consecutive months of above the mean performance have been identified.No, there has been no change to this quality priority during the 2012/13 reporting period. Rationale for changing the quality priority for 2013/14: The Trust has consistently performed well with this indicator. As a result of this the patient experience indicator will be refocused to the national use of the friends and family question ensuring that patient experience remains a quality priority. Directorate of Clinical and Quality Assurance, April 2013 Page 37 of 97

169 Annual Quality Account 2012/13

News release: 15 Steps Challenge putting the focus on care

A new initiative has been launched focusing on what good quality care looks, sounds and feels like through the eyes of patients and visitors. The 15 Steps Challenge has been introduced at Grimsby, Scunthorpe and Goole hospitals and involves wards and departments receiving unannounced visits by a small team of people, including a non-medical person. The challenge, which has been designed by the NHS Institute for Innovation and Improvement, aims to capture what good quality care looks, sounds and feels like. The idea came from a parent who said “I can tell what kind of care my daughter if going to get within 15 steps of walking on to a ward.” Dr Karen Dunderdale, chief nurse, said: “First impressions count. When someone walks onto a ward for the first time I want those first 15 steps to inspire confidence and trust in the care they, or their loved one, is going to receive. “The challenge, which supplements our more formal ward review process, looks at walking onto a ward from a patient’s perspective and provides them with a voice.” The purpose of the challenge is to: •H• elp staff, patients, service users and others to work together to identify improvements that can enhance the patient or service user experience. •P• rovide a way of understanding patients’ and service users’ first impressions more clearly. •P• rovide a method of creating positive improvements and dialogue about the quality of care. Quality matron Diane Hughes, who is rolling out the challenge, said: “We know what good care should look and feel like from a healthcare perspective, but this challenge gives us the opportunity to take a step back and look at what is important to a patient or relative when they come into contact with a care setting. Are we giving them the confidence they need to have a positive experience?” Two or three people, including a representative of the Trust’s patient experience group, arrive unannounced at a ward and, using a toolkit with a series of questions and prompts, walk around the area to get a ‘first impression’. The visit looks at four areas – is it welcoming, safe, caring and involving, and well organised and calm? Things to look for include a welcoming reception area, acknowledgement on arrival, contact information, a clean and uncluttered environment, staff interaction with patients, and patients dressed to protect their dignity. Dr Dunderdale added: “Ensuring our patients receive excellent quality care is everyone’s responsibility regardless of the job they do, whether they are a porter or a consultant. The 15 Steps Challenge will provide us with a valuable snapshot of the care being provided on our wards and departments across the organisation.”

170

PE2 – Recommending the Trust to family and friends Target:PE2 90% – Recommending or more of patients theto want Trust to recommend to family andthe Trust friends to family and friends. The chart below demonstrates that this target AchievementTarget: 90% (April or more 2012 of patients – February to want to recommend2013): the Trust to family and friends. has been met, with five consecutive months above the mean set within the SPC chart. Achievement (April 2012 – February 2013): The chart below demonstrates that this target has been met, with five consecutive months above the mean set within the SPC chart.

Statistical Process Control (SPC) ‐ Recommending the Trust to family and friends 100

the (%)

98 family 96 and

94 recommending

friends

to 92 Trust Percentage 90

88 12 12 12 11 11 11 10 13 13 10 12 12 12 12 12 12 12 12 11 11 11 11 11 11 11 11 10 10 10 10 10 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Jul Jul Jul Jan Jan Jan Jun Jun Jun Oct Oct Oct Apr Apr Feb Sep Feb Sep Feb Sep Dec Dec Dec Aug Aug Aug Nov Nov Nov Mar Mar May ‐ 12 May ‐ 11 May ‐ 10

Source: Menu card survey, membership office Comment:Source: TheMenu abovecard survey, chart membership demonstrates office on the vertical axis the percentage of patients who wouldComment: recommend The above chart the demonstrates Trust to on their the vertical friends axis and the percentage family. Onof patients the horizontalwho would recommend axis the monthsthe Trust over to their which friends this and indicator family. On the has horizontal been axis measured the months over is which demonstrated, this indicator has in been this case commencingmeasured sinceis demonstrated, May 2010. in this case commencing since May 2010. Has theHas the quality quality indicatorindicator been been changed changed during the during year from the that year set in from last year’s that (2011/12) set in Quality last years (2011/12)Account? Quality Account? No, there has been no change to this quality priority during the 2012/13No, therereporting has been period. no change to this quality priority during the 2012/13 reporting period. Rationale for changing quality priority for 2013/14: The national use of the friends and family question will Rationalereplace the for local changing questioning quality of patients priorityin regard to forthis question. 2013/14: The national use of the friends and family question will replace the local questioning of patients in regard to this question. Focus on: Menu Card Survey Focus on: Menu Card Survey The menu card survey is an innovative The menu card survey is an innovative way way that the Trust seeks patient feedback that the Trust seeks patient feedback regarding a number of patient experience regarding a number of patient experience indicators. indicators. As the name indicates, this survey is on the As the name indicates, this survey is on the back of the lunch time menu card ensuring back of the lunch time menu card ensuring it it is not far away from patients to ascertain is not far away from patients to ascertain their feedback. their feedback.

Directorate of Clinical and Quality Assurance, April 2013 Page 39 of 97171

PE3Annual – Trust complaints Quality resolution Account 2012/13

Target – 95 per cent of complaints to be closed within the timescale agreed with the PE3complainantPE3 – – Trust Trust complaints complaints resolution resolution TargetAchievementTarget – 95– 95 per per cent (April centof complaints 2012 of complaints – March to be closed 2013): to withinbe The closed the table timescale within below agreed theillustrates timescale with the broad complainant agreed achievement with the of this target during the 2012/13 financial year. complainantAchievement (April 2012 – March 2013): The table below illustrates broad achievement of this target during the Achievement2012/13Jun-11 Jul-11 financial Aug-11 Sep-11 (Aprilyear. Oct-11 2012 Nov-11 – Dec-11 March Jan-12 Feb-122013): Mar-12 The Apr-12 table May-12 below Jun-12 Jul-12 illustrates Aug-12 Sep-12 broad Oct-12 Nov-12achievement Dec-12 Jan-13 Feb-13of Mar-13 this target during the 2012/13 financial year. 100% 100% 100% 100% 100% 100% 96% 95% 100% 100% 96% 100% 100% 96% 100% 100% 100% 97% 94% 100% 100% 100% Source:Jun-11 Jul-11 DATIX, Aug-11 Sep-11live data Oct-11 set Nov-11 reported Dec-11 Jan-12 one Feb-12month Mar-12 in arrears Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Comment:100% 100% 100% The 100% Trust’s 100% 100% contract 96% 95% with 100% commissioners 100% 96% 100% 100% stipulates 96% 100% a target 100% 100% of 97% 95 per 94% cent 100% 100% of 100% complaints being responded to within the timescales agreed with the complainant. The Source: DATIX, live data set reported one month in arrears monthlySource: DATIX, breakdown live data of set complaints reported one closed month within in arrears agreed timescales during 2011/12 to date is Comment:illustratedComment: The in The the Trust’s above Trust’s contract table. contract with commissioners with commissioners stipulates a target stipulates of 95 per cent a target of complaints of 95 being per cent of complaints being responded to within the timescales agreed with the complainant. The responded to within the timescales agreed with the complainant. The monthly breakdown of complaints closed monthlywithin agreed breakdown timescales of during complaints 2011/12 to closed date is illustratedwithin agreed in the above timescales table. during 2011/12 to date is illustratedThe following in the chart above illustrates table. the number of new complaints received, number closed and The following chart illustrates the number of new complaints received, number closed and the ‘net open’ or the the ‘net open’ or the total currently open (including new, unresolved and open or on hold complaints).total currently open (including new, unresolved and open or on hold complaints). The following chart illustrates the number of new complaints received, number closed and the ‘net open’ or the total currentlyNLAG complaints open (includingresolution January new, 2010 unresolved ‐ present and open or on hold complaints). 180 160 NLAG complaints resolution January 2010 ‐ present 180140 160120 140100 12080 10060 8040 6020 400 Ma Ma Ma Jan‐ Feb Mar Apr Jun‐ Jul‐ Aug Sep Oct Nov Dec Jan‐ Feb Mar Apr Jun‐ Jul‐ Aug Sep Oct Nov Dec Jan‐ Feb Mar Apr Jun‐ Jul‐ Aug Sep Oct Nov Dec Jan‐ Feb Mar y‐ y‐ y‐ 20 10 ‐10 ‐10 ‐10 10 10 ‐10 ‐10 ‐10 ‐10 ‐10 11 ‐11 ‐11 ‐11 11 11 ‐11 ‐11 ‐11 ‐11 ‐11 12 ‐12 ‐12 ‐12 12 12 ‐12 ‐12 ‐12 ‐12 ‐12 13 ‐13 ‐13 10 11 12 0 New 42 36 51 40 34 47 46 38 27 42 33 18 29 32 27 15 31 37 32 29 25 23 32 20 35 42 47 32 34 30 43 38 35 52 46 38 48 66 57 Closed 24 44 56 35Ma 34 41 34 46 29 33 34 28 25 26 31 25Ma 35 29 27 25 26 26 25 23 22 17 27 25Ma 34 17 29 19 26 29 60 33 37 33 24 Jan‐ Feb Mar Apr Jun‐ Jul‐ Aug Sep Oct Nov Dec Jan‐ Feb Mar Apr Jun‐ Jul‐ Aug Sep Oct Nov Dec Jan‐ Feb Mar Apr Jun‐ Jul‐ Aug Sep Oct Nov Dec Jan‐ Feb Mar y‐ y‐ y‐ Net open 1048‐10 40‐10 35‐10 40 4010 4610 58‐10 50‐10 48‐10 57‐10 56‐10 4611 50‐11 56‐11 52‐11 42 3811 4611 51‐11 55‐11 48‐11 49‐11 65‐11 5712 62‐12 79‐12 83‐12 63 7612 9512 90‐12 97‐12 90112101103115147160‐12 ‐12 ‐12 13 ‐13 ‐13 10 11 12 New 42 36 51 40 34 47 46 38 27 42 33 18 29 32 27 15 31 37 32 29 25 23 32 20 35 42 47 32 34 30 43 38 35 52 46 38 48 66 57 Closed 24 44 56 35 34 41 34 46 29 33 34 28 25 26 31 25 35 29 27 25 26 26 25 23 22 17 27 25 34 17 29 19 26 29 60 33 37 33 24 Source: DATIX, clinical and quality assurance team Source: DATIX,Net open 48 clinical 40 35 40 and 40 46quality 58 50 48assurance 57 56 46 50 team 56 52 42 38 46 51 55 48 49 65 57 62 79 83 63 76 95 90 97 90112101103115147160 Comment: The vertical axis in the above chart illustrates the number of complaints and the horizontal axis Source:Comment:represents DATIX, the Themonths clinical vertical for and which qualityaxis the in dataassurance the is aboveavailable team chart from, commencingillustrates the in January number 2010. of Thecomplaints chart illustrates and thatthe the number of new complaints has increased leading to an increasing number of net open complaints. horizontal axis represents the months for which the data is available from, commencing in JanuaryThis issue has2010. been The investigated chart illustrates in more detail that and the it appearsnumber that of anew contributory complaints factor has to the increased number of leadingnet Comment:toopen an complaints increasing The is the verticalnumber increasing axisof net complexity in openthe above complaints. of the chartcomplaints illustrates being received, the number and capacity of complaints issues available and tothe horizontalrespond to these. axis Therepresents number of theclosed months complaints for haswhich decreased the data in the is last available months. from, commencing in JanuaryThis issue 2010. has The been chart investigated illustrates in that more the detailnumber and of itnew appears complaints that a has contributory increased factor leading to totheA review an number increasing of the central of netnumber complaints open of complaints net handling open arrangementscomplaints. is the increasing has recently complexity been undertaken. of the Actions complaints underway being received,include: and capacity issues available to respond to these. The number of closed Thiscomplaints issue hashas beendecreased investigated in the last in moremonths. detail and it appears that a contributory factor to the•• T numberhe appointment of net of some open additional complaints temporary is the resource increasing for three complexity to six months ofto help the address complaints the backlog being received,A reviewand assist of and in theaddressing capacity central the complaints issuesincrease available handling to arrangements respond to these. has recently The number been undertaken. of closed Actions underway include: complaints•• Changes thaso some decreased of the (current in the labour last intensive) months. processes in operation within that area A•• reviewReinforcement of the of centralpreviously complaints agreed escalation handling procedures. arrangements has recently been undertaken. ActionsDirectorate underway of Clinical and include: Quality Assurance, April 2013 Page 40 of 97 As part of a review of the Trust’s complaints handling arrangements, representatives from the office of the Parliamentary and Health Service Ombudsman (PHSO) were invited to visit the Trust. This visit was held on Directorate of Clinical and Quality Assurance, April 2013 Page 40 of 97 172 Wednesday April 10 2013. No concerns were raised during the visit but the information provided by the PHSO on complaints referred to them about the Trust supports the findings from the internal review and therefore the actions which are underway to revise and strengthen the Trust’s complaints handling arrangements. A more detailed report and action plan on the work which is underway will be submitted to the quality and patient experience committee in May 2013. This section of the report has focussed specifically on the quantitative data that has been monitored whilst the Trust has tried to meet this quality indicator. It should be stressed that the Trust uses the qualitative feedback from complaints in an effort to constantly improve the service provided to local patients and public. Such information is reported on a quarterly basis within the Trust’s incident and complaints report, received by the Trust’s governance and assurance committee, a sub-group of the Trust Board. Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality Account?

No, there has been no change to this quality priority during the 2012/13 reporting period. Rationale for changing the quality priority for 2013/14: The Trust will still focus on this important area of complaints management and responding to complaints. The new indicators for 2013/14 (see page 176) will focus on reducing the number of re-opened complaints, compliance with agreed timescales for action plans resulting from a complaint and a reduction in the number of complaints received. PE4 – Decision making

Target:PE4 For – Decision 95 per cent making of patients to be as involved as much as they wanted to be in decisions about their care and treatment Target: For 95 per cent of patients to be as involved as much as they wanted to be in decisions about their care and treatment Achievement (April 2012 – February 2013): The following chart illustrates that performanceAchievement in this (April area 2012 has – February exceeded 2013): the The 95following per cent chart target illustrates set. that performance in this area has exceeded the 95 per cent target set.

Question: Were you involved as much as you wanted to be in decisions about your care and treatment? 110%

100% (%) 90% 80% 70% Percentage 60% 11 11 11 11 12 12 12 12 12 13 11 11 11 12 12 12 12 12 12 13 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Jul Jul Jan Jan Jun Jun Oct ‐ 11 Oct ‐ 12 Apr Sep Feb Sep Feb Dec Dec Aug Aug Nov Nov Mar May May

May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐ Mar‐ Apr‐ May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐ ‐11 11 11 11 11 11 11 11 12 12 12 12 ‐12 12 12 12 12 12 12 12 13 13 DPoW 80% 77% 91% 97% 96% 97% 96% 98% 94% 95% 99% 95% 100% 95% 94% 96% 99% 99% 100%100% 99% 100% SGH 86% 87% 95% 73% 88% 100% 96% 97% 99% 98% 100%100% 98% 97% 100%100% 99% 100%100% 98% 99% 99% GDH 81% 97% 97% 96% 96% 100%100% 96% 100% 100%100% 97% 100%100%100%100%100%100%100%100%100% Threshold 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

KEY to abbreviations: Source: Information services, Nursing Dashboard v4.0 DPoW: Diana, Princess of Wales Source: Information services, Nursing Dashboard v4.0 Hospital, Grimsby Comment: The above chart illustrates on the vertical axis the percentage SGH: Scunthorpe General Hospital, KEY toof abbreviations:patients who felt theyDPoW: were involvedDiana, Princess in decision of makingWales Hospital, about their Grimsby SGH: Scunthorpe General Hospital, GDH: Goole and District Hospital care and treatment. To illustrate this data most effectively the vertical axis GDH: Goole and District Hospital in the above chart starts at 60 per cent. The horizontal axis illustrates the months that this data was available for, commencing in May 2011.

Comment: The above chart illustrates on the vertical axis the percentage of patients who felt they were involved in decision making about their care and treatment. To illustrate this data most effectively the vertical axis in the above chart starts at 60 per cent. The horizontal173 axis illustrates the months that this data was available for, commencing in May 2011. The above data is available from the findings of a monthly nursing audit assessing a random sample of patients within the Trust as inpatients.

Has the quality indicator been changed during the year from that set in last years (2011/12) Quality Account? No, there has been no change to this quality priority during the 2012/13 reporting period.

Rationale for changing the quality priority for 2013/14: The Trust has consistently performed well with this indicator, therefore an indicator around staff satisfaction will be incorporated within the 2013/14 quality priorities.

Directorate of Clinical and Quality Assurance, April 2013 Page 42 of 97 Annual Quality Account 2012/13

The above data is available from the findings of a monthly nursing audit assessing a random sample of patients within the Trust as inpatients. Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality Account? No, there has been no change to this quality priority during the 2012/13 reporting period. Rationale for changing the quality priority for 2013/14: The Trust has consistently performed well with this indicator, therefore an indicator around staff satisfaction will be incorporated within the 2013/14 quality priorities. PE5 – Medication side effects

Target:PE5 – MedicationFor staff to tell side patients effects about the medication side effects and what to look for upon discharge in 95 per cent of cases Target: For staff to tell patients about the medication side effects and what to look for upon discharge in 95 per cent of cases Achievement (April 2012 – February 2013): The following chart illustrates that performanceAchievement (April in this 2012 area – February has exceeded 2013): The the following 95 per chart cent illustrates target that set performance in most months. in this area has exceeded the 95 per cent target set in most months.

Question: Did a member of staff tell you about medication side effects and what to watch for upon discharge? 120% 100%

(%)

80% 60% 40% Percentage 20% 0% 11 12 11 11 11 11 12 12 12 11 11 12 12 12 13 12 12 11 12 11 12 13 12 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Jul Jul Jan Jan Jun Jun Oct ‐ Oct ‐ Apr Apr Feb Sep Feb Sep Dec Dec Aug Aug Nov Nov Mar May May

Apr‐ May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐ Mar Apr‐ May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐ 11 ‐11 11 11 11 11 11 11 11 12 12 ‐12 12 ‐12 12 12 12 12 12 12 12 13 13 DPoW 79% 63% 57% 75% 91% 93% 97% 99% 96% 96% 99% 98% 96% 98% 97% 89%100%99% 98%100%100%99%100% SGH 84% 65% 76% 67% 77%100%30% 28% 94% 98% 99%100%97% 97% 94%100%99%100%99%100%99%100%100% GDH 70% 55% 77% 83% 79% 84%100%93% 96%100% 100%89%100%100%100%100%100%95%100%100%100%100% Threshold 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

KEY to abbreviations: Source: Information services, Nursing Dashboard v4.0 DPoW: Diana, Princess of Wales Source: Information services, Nursing Dashboard v4.0 Comment: The above chart illustrates on the vertical axis the percentage of Hospital, Grimsby KEYpatients to abbreviations: who felt they were DPoW: informed Diana, about Princess medication of Wales side effects Hospital, and Grimsbywhat SGH: Scunthorpe General Hospital, to look out for upon discharge. SGH: The Scunthorpe horizontal axisGeneral illustrates Hospital, the months GDH: Goole and District Hospital that this data was available GDH:for, commencing Goole and inDistrict April 2011. Hospital The above data is available from the findings of a monthly nursing audit assessing a random sample of patients within the Trust as inpatients. Comment:Has the quality The indicator above been chart changed illustrates during on the the year vertical from that axis set inthe last percentage year’s (2011/12) of patientsQuality who felt theyAccount? were No, informed there has beenabout no changemedication to this quality side priorityeffects during and thewhat 2012/13 to lookreporting out period. for upon discharge. The horizontal axis illustrates the months that this data was available for, commencing in Rationale for changing the quality priority for 2013/14: The Trust has consistently performed well with this April 2011. The above data is available from the findings of a monthly nursing audit indicator, therefore this indicator will not be monitored within the 2013/14 quality priorities. assessing a random sample of patients within the Trust as inpatients.

Has the quality indicator been changed during the year from that set in last years (2011/12) Quality Account? No, there has been no change to this quality priority during the 2012/13 reporting period. 174 Rationale for changing the quality priority for 2013/14: The Trust has consistently performed well with this indicator, therefore this indicator will not be monitored within the 2013/14 quality priorities.

Directorate of Clinical and Quality Assurance, April 2013 Page 43 of 97

PE6 – Nursing care indicator

Target: For the overall nursing care indicator to be 95 per cent. PE6 – Nursing care indicator AchievementTarget: For the (April overall 2012 nursing – Februarycare indicator 2013): to be 95 The per cent. following chart illustrates that this indicator more recently has on the whole been achieved. This information is monitored within the nursingAchievement dashboard (April by 2012 matrons – February and 2013): so Theany following concerns chart will illustrates be identified that this indicator and addressedmore recently haswith on the whole been achieved. This information is monitored within the nursing dashboard by matrons and so any individual nursing areas. concerns will be identified and addressed with individual nursing areas.

Nursing care indicators ‐ overall score 100 95

90 (%)

85 80

Percentage 75 70 11 12 11 11 12 13 12 12 11 11 11 11 12 12 12 11 11 12 12 12 13 12 12 ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Jul Jul Jan Jan Jun Jun Oct ‐ Oct ‐ Apr Apr Feb Sep Feb Sep Dec Dec Aug Aug Nov Nov Mar May May

Apr‐ May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐ Mar‐ Apr‐ May Jun‐ Jul‐ Aug‐ Sep‐ Oct‐ Nov‐ Dec‐ Jan‐ Feb‐ 11 ‐11 11 11 11 11 11 11 11 12 12 12 12 ‐12 12 12 12 12 12 12 12 13 13 DPoW 86 83 82 87 86 87 87 89 94 95 94 91 89 93 93 90 95 96 96 98 98 96 97 SGH 88 86 87 87 86 82 83 80 94 95 96 91 91 92 87 95 94 95 98 98 97 93 94 GDH 86 83 84 86 86 86 89 90 94 95 92 91 91 92 94 98 95 97 98 97 98 98

Source: Information Services, Nursing Dashboard v4.0 KEY to abbreviations: DPoW: Diana, Princess of Wales Source: Information Services, Nursing Dashboard v4.0 Comment: The above chart illustrates on the vertical axis the percentage Hospital, Grimsby KEY tocompliance abbreviations: with the nursingDPoW: care Diana, indicators Princess overall of Wales score whilstHospital, the Grimsby SGH: Scunthorpe General Hospital, horizontal axis illustrates SGH: the Scunthorpemonths for which General this Hospital,data is available GDH: Goole and District Hospital starting in April 2011. For GDH: most Goole effective and Districtpresentation Hospital of these results the above vertical axis starts at 70 per cent. Has the quality indicator been changed during the year from that set in last year’s (2011/12) Quality Comment:Account? The above chart illustrates on the vertical axis the percentage compliance with the nursing care indicators overall score whilst the horizontal axis illustrates the months for whichNo, this there data has been is available no change tostarting this quality in priorityApril 2011.during theFor 2012/13 most reporting effective period. presentation of these resultsRationale the above for changing vertical the axis quality starts priority at 70 for per 2013/14: cent. No changes, this will be monitored during 2013/14.

Has the quality indicator been changed during the year from that set in last years (2011/12) Quality Account? No, there has been no change to this quality priority during the 2012/13 reporting period.

Rationale for changing the quality priority for 2013/14: No changes, this will be monitored during 2013/14.

Directorate of Clinical and Quality Assurance, April 2013 Page 44 of 97

175 Annual Quality Account 2012/13

2.2: Quality Priorities for 2013/14 Rationale for quality priorities: The quality priorities for 2013/14 have been identified as a result of the Trust’s concentrated monitoring of the previous year’s priorities and are linked to its continuing focus on ensuring patients and service users are provided with safe and effective care and treatment. A number of the new indicators relate to the Trust’s continued attention on identifying and caring appropriately for deteriorating patients. Dementia, falls and pressure ulcers remain as key priority areas along with a renewed assessment and targeting to increase harm free care delivered. Patient experience remains an important area and as such has been focussed on in the form of patient participation in the national friends and family test and a focus on the reduction in the number of complaints. A new indicator for 2013/14 focusses on the Trust’s work with its staff and will outline and track progress of work underway to help improve staff experience and the organisation’s culture. How agreed: The priorities for 2013/14 have been agreed by the Trust Board and by the quality and patient experience committee. They have been identified via a number of mechanisms including the following:- •• Discussions with the governors at the service quality monitoring group •• Discussions with the commissioners •• The findings from the national surveys (outpatient and inpatient) •• The findings from the staff survey •• Findings from the numerous patient satisfactions surveys that are undertaken by the Trust •• The results that are published within our nursing dashboard •• The data provided by our clinical systems where we are identified as being an outlier •• Information from the Care Quality Commission quality and risk profile •• Information from incidents and complaints

•• Comments received from local LINKS as a result of discussions around last year’s quality account. Taking into account the wider public views: The quality indicators are agreed following discussions with governors who represent the interests of their constituents following their election to this role from public members of the Trust. The findings from the inpatient and outpatient surveys are also considered when developing these proposed indicators to take into account the views of the wider public. Feedback and comments from the local overview and scrutiny committees, made up of elected councillors who represent their constituents, is also taken into account when formulating the proposed new quality indicators. How progress will be monitored and measured: Progress against these indicators will be reported monthly using the monthly quality report. The following indicators in most cases include improvement targets to allow for ongoing measurement. A selection of methods will be employed to measure this area including Statistical Process Control (SPC) charts, tables and graphs. The quality and patient experience committee (QPEC) and the Board will receive this report. A governor is a member of the quality and patient experience committee and will report back to the other governors. This report is also shared with the Trust’s commissioners.

176 2013/14 Quality priorities:

Clinical effectiveness CE1 Mortality – the detail of this indicator is being discussed at the mortality performance committee and a recommendation will be made to the Board at a future meeting. CE2 The provider to provide details of the number of patients who should have had a NEWS score, the number of patient who did have a NEWS score, number of patients whose NEWS score was completed correctly and number of patients who were actioned appropriately. CE3 Dementia – CE3.1 90 per cent of patients aged 75 and over admitted as an emergency to be asked the dementia case finding question. CE3.2 90 per cent of the above patients scoring positive on the case finding question to have a further risk assessment. CE3.3 90 per cent of the patients identified as requiring referral following the risk assessment to be referred in line with local pathway. CE4 Evidence based practice – increase compliance with NICE guidance with 90 per cent compliance achieved by the end of March 2014. Patient safety

PS1 MRSA – limit of 0 has been set for 2013/14.

PS2 Clostridium difficile – limit of 30 has been set for 2013/14.

Safety thermometer – increase in harm free care (acute) – target to be agreed once quarter four baseline has PS3 been received. Safety thermometer – increase in harm free care (community) – target to be agreed once quarter 4 baseline has PS4 been received. Falls – reduction in avoidable harm – target to be agreed once quarter four baseline has been received. PS5 Committee to still receive numbers of avoidable falls. Pressure ulcers – reduction in avoidable harm – target to be agreed once quarter four baseline has been PS6 received. Committee to still receive number of avoidable pressure ulcers. Patient experience

Friends and family test – to have a response rate that achieves a response rate in the top 50 per cent which also PE1 improves on the quarter one response rate. Complaints – a reduction in the number of re-opened complaints – target to be achieved once Quarter 4 PE2 baseline has been received Complaints – 90 per cent of action plans following a complaint to be implemented within the agreed PE3 timescales.

PE4 A 10 per cent reduction in the number of complaints received by the Trust by the end March 2014.

PE5 For the overall nursing care indicator to be 95 per cent.

To implement a cultural barometer within the Trust and obtain a baseline reading from which an improvement PE6 trajectory can be set. Quarterly updates will be provided to the committee.

177 Annual Quality Account 2012/13

2.3 Statements of assurance from the Board 2.3a Information on the review of services During 2012/13 Northern Lincolnshire and Goole Hospitals NHS Foundation Trust provided and/or sub-contracted 24 relevant health services. The Trust has reviewed all the data available to them on the quality of care in 24 of these relevant health services. The income generated by the NHS services reviewed in 2012/13 represents 100 per cent of the total income generated from the provision of relevant health services by the Trust for 2012/13. The data reviewed aims to cover the three dimensions of quality – patient safety, clinical effectiveness and patient experience – and indicate where the amount of data available for review has impeded this objective. 2.3b Information on participation in clinical audits and national confidential enquiries During 2012/13, 38 national clinical audits and three national confidential enquires covered relevant health services that Northern Lincolnshire and Goole Hospitals NHS Foundation Trust provides. During 2012/13 the Trust participated in 100 per cent national clinical audits and 100 per cent national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries that the Trust was participated in during 2012/13 are as follows. The national clinical audits and national confidential enquiries that the Trust participated in, and for which data collection was completed during 2012/13, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the teams of that audit or enquiry.

178 National clinical audits

Number Eligible NLAG % of number Action National clinical audit title of cases for NLAG participated required planning submitted

Acute care Adult community acquired Project still Project still pneumonia Yes Yes N/A ongoing ongoing (British Thoracic Society) Adult critical care Yes Yes 871 100% No (ICNARC CMPD)

Emergency use of oxygen Awaiting Yes Yes 24 100% (British Thoracic Society) report Medical and Surgical programme: National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Bariatric Surgery (also known as Medical and No N/A N/A N/A N/A Surgical Clinical Outcome Review Programme, or Patient Outcome and Death) *also confidential enquiry Hip, knee and ankle replacements Awaiting Yes Yes 568 100% (National Joint Registry) report Adult Non-Invasive Ventilation project still project still Yes Yes N/A (British Thoracic Society) ongoing ongoing Renal Colic Yes Yes 100 100% Yes (College of Emergency Medicine) Severe trauma (Trauma Audit and Yes Yes 259 100% Yes Research Network) Blood and transplant Intra-thoracic transplantation No N/A N/A N/A N/A (NHSBT UK Transplant Registry) National Comparative Audit of Blood Transfusion - programme includes the following audits, which were previously listed separately in QA: Yes Yes 100 100% Yes a) O neg blood use b) Medical use of blood c) Bedside transfusion d) Platelet use Potential donor audit (NHS Awaiting Yes Yes 256 100% Blood and Transplant) report

179 Annual Quality Account 2012/13

Number Eligible NLAG % of number Action National clinical audit title of cases for NLAG participated required planning submitted

Acute care Cancer Lung cancer (National Lung Awaiting Yes Yes 313 100% Cancer Audit) report Bowel cancer (National Bowel Yes Yes 204 100% Yes Cancer Audit Programme) Head and neck cancer Yes Yes 52 100% Yes (DAHNO) Oesophago-gastric cancer Yes Yes 91 100% Yes (National O-G Cancer Audit) Heart Acute Myocardial Infarction and Awaiting Yes Yes 248 100% other ACS (MINAP) report Adult Cardiac Surgery Audit (ACS) No N/A N/A N/A N/A Cardiac arrhythmia (Cardiac Yes Yes 397 100% Yes Rhythm Management Audit) Paediatric cardiac surgery (NICOR No N/A N/A N/A N/A Congenital Heart Disease Audit) Coronary angioplasty (NICOR Awaiting Yes Yes 311 100% Adult cardiac interventions audit)* report Awaiting Heart failure (Heart Failure Audit) Yes Yes 201 100% report Cardiac arrest Project still Project still Yes Yes N/A (National Cardiac Arrest Audit) ongoing ongoing National Vascular Registry (elements include CIA, peripheral No N/A N/A N/A N/A vascular surgery, VSGBI Vascular Surgery Database, NVD) Pulmonary hypertension No N/A N/A N/A N/A (Pulmonary Hypertension Audit)

180 Number Eligible NLAG % of number Action National clinical audit title of cases for NLAG participated required planning submitted

Acute care Long term conditions Adult asthma Awaiting Yes Yes 30 100% (British Thoracic Society) report Bronchiectasis Awaiting Yes Yes 14 100% (British Thoracic Society) report Diabetes (Adult) ND(A), includes Awaiting 3218 100% National Diabetes Inpatient Audit Yes Yes report (NADIA) 102 100% Yes Diabetes (RCPH National Awaiting Yes Yes 201 100% Paediatric Diabetes Audit) report Inflammatory bowel disease (IBD) Project still Project still Yes Yes N/A Includes: Paediatric Inflammatory ongoing ongoing Bowel Disease Services National Review of Asthma Project still Project still Yes Yes N/A Deaths (NRAD) ongoing ongoing Pain Database (National Pain Awaiting Yes Yes 90 100% Audit) report Renal replacement therapy (Renal No N/A N/A N/A N/A Registry) Renal transplantation (NHSBT UK No N/A N/A N/A N/A Transplant Registry) Mental health Mental Health programme: National Confidential Inquiry into Suicide and Homicide for people with Mental Illness (NCISH) No N/A N/A N/A N/A (also known as suicide and homicide in mental health, or Mental Health Clinical Outcome Review Programme) National audit of psychological No N/A N/A N/A N/A therapies (NAPT) Prescribing Observatory for Mental Health (POMH) No N/A N/A N/A N/A (Prescribing in mental health services)

181 Annual Quality Account 2012/13

Number Eligible NLAG % of number Action National clinical audit title of cases for NLAG participated required planning submitted

Acute care Older people Carotid interventions audit No N/A N/A N/A N/A (CIA) Fractured Neck of Femur (College of Emergency Yes Yes 50 100% Yes Medicine) Hip fracture (National Hip Yes Yes 506 100% Yes Fracture Database) National Audit of Dementia Yes Yes 80 100% Yes Parkinson's disease (National Awaiting Yes Yes 20 100% Parkinson's Audit) report

Sentinel Stroke SINAP National Audit Programme 269 100% changed to (SSNAP) - programme SSNAP combines the following audits, which were previously listed Yes Yes separately in QA: a) Sentinel stroke audit Project still Project still Project still ongoing ongoing ongoing b) Stroke improvement national audit project Other Elective surgery (National Yes Yes 737 70% Yes PROMs Programme)

182 Number Eligible NLAG % of number Action National clinical audit title of cases for NLAG participated required planning submitted

Acute care Women and Children’s Project still Project still Child Health Programme RCPCH Yes Yes N/A ongoing ongoing Epilepsy 12 – Childhood (RCPH Project still Project still Yes Yes N/A National Audit) ongoing ongoing Maternal, infant and new-born programme (MBRRACE-UK)* (Also known as Maternal, New- born and Infant Clinical Outcome Review Programme) Yes Yes 23 100% Yes *This programme was previously also listed as Perinatal Mortality (in 2010/11, 2011/12 quality accounts) Neonatal intensive and special Awaiting Yes Yes 1521 100% care (NNAP) report Paediatric asthma (British Awaiting Yes Yes 16 100% Thoracic Society) report Feverish Illness in Children/ Paediatric Fever Yes Yes 100 100% Yes (College of Emergency)

Paediatric intensive care (PICANet) No N/A N/A N/A N/A

Paediatric pneumonia (British Awaiting Yes Yes 14 100% Thoracic Society) report Total: 51 Eligible 38

183 Annual Quality Account 2012/13

National Confidential Enquiries

Number Eligible NLAG % of number Action Confidential Enquiry of cases for NLAG participated required planning submitted

Awaiting Subarachnoid Haemorrhage Yes Yes 2 67% results Awaiting Alcohol Related Liver Disease Yes Yes 2 33% results Cardiac Arrest Procedures Yes Yes 4 67% Ongoing Bariatric Surgery No N/A N/A N/A N/A Total: 4

The reports of four national clinical audits were reviewed by the provider in 2012/13 and the Trust intends to take the following actions to improve the quality of healthcare provided: Thematic analysis: Based on the action plans from these projects, the following themes were identified from the national audits undertaken and reported back within the Trust: Increased information to patients/carers •• Development of an information leaflet for parents/careers regarding pyrexia in children •• Improved patient information to be made available in the outpatients department.

Increased awareness and education of staff •• Increased awareness and education for all staff on recording pain score •• Re-education regarding the use of the NICE traffic light system •• Continuing education of AMU and other wards to identify stroke cases, and once identified to inform the stroke unit •• Increase awareness to all staff on recording pain score and the importance of re-evaluating all patients’ pain score and to ensure these are adequately documented within the emergency record.

Identified need for further evaluation/patient surveys •• To develop a questionnaire on patient experience and an annual report based on the results.

Changes to service •• Thrombolysis to be offered from April/May 2013 24 hours a day, seven days a week •• Seven day ward rounds to be provided using telemedicine •• Increase the number of nurses on the stroke unit (Scunthorpe).

Collaborative/MDT working to be improved/discussed •• Invite ambulance Trust representatives and a patient representative to be part of the stroke steering group •• Invite social services representative to be part of the stroke steering group •• A local method of extracting and reporting site specific data had been set up to be presented at general surgery audit meetings in order to increase knowledge of annual performance prior to publication of reports.

184 The reports of 19 local clinical audits were reviewed by the provider in 2012/13 and the Trust intends to take the following actions to improve the quality of healthcare provided: Based on the action plans from these projects, the following themes were identified from these local audits undertaken and reported back within the Trust:

Increased information to patients/carers •• Workshops and advertising to improve awareness relating to ovarian cancer in the community.

Increased awareness and education of staff •• Increased education by including discharge letters as part of the induction programme by the quality and audit team, along with documentation and consent specific educational updates •• General surgery business manager to use two rolling half-day audit meetings to hold a theatre safety event with case discussions and “how to” and “how not to” complete the WHO checklist videos as on the NPSA website •• To present cases (near misses and incidents from this Trust and any other possible/publicised cases) at mortality and morbidity rolling half-day meetings chaired by Dr Liz Scott (medical director) to highlight importance in completing and delivering the checklist in the correct manner •• To play video from NPSA website at mortality and morbidity meetings in August (SGH) and October (DPOW) following case presentations showing how the WHO checklist should be delivered and completed •• The audit department liaised with general surgeons at both sites in order to set up a more robust process where attempts are made to present and discuss all general surgery mortality cases and morbidity cases at audit meetings in an attempt to identify learning •• Pocket sized aide memoire’s to be designed to allow all clinicians to refer to the CNST standards on a daily basis to act as a reminder when documenting in the maternity records thus helping active risk management •• Best practice boards CNST to be developed and altered monthly according to the ‘hot’ topic either highlighted from the audit results or in clinical practice •• Stickers to be used in the maternity records for a number of conditions ie multiple pregnancy and birth to ensure clinicians remember to clearly document a management plan in the records •• Laminated notice to be placed on all CTG machines within maternity to remind clinicians of best practice and to raise awareness of what should be recorded on the CTG eg fresh eyes review or any opinion sought by medical staff, •• Template to be designed to use at the six week post-operative review appointment to aid communication with the patient and provide evidence of discussion in the maternity records •• Algorithm/poster to be displayed in antenatal clinic to raise awareness of CNST requirements and best practice •• Workshops to be provided to clinicians to raise awareness of the guidelines in treating in pregnancy •• Preferred place of care added to the Liverpool Care Pathway in order to prompt discussion and aid documentation •• To be rolled out to community services for inclusion in their Liverpool Care Pathway documentation in order to ensure consistency •• Information leaflet/management of condition/out of hours/holiday cover information given to patients is updated when appropriate and provided and reinforced continuously to patients, where appropriate •• Re-iterate to all staff the use of correct infection control procedures and the use of hand-gel •• New electronic template for the family assessment agreed and to be added to SystmOne •• Ensure correct level of detail is completed to ensure all ‘other’ health professionals reading the record are assured of the level of assessment completed •• Revisit and reinforce the principles of the significant event sheet in order to ensure completion.

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Identified need for further evaluation/patient surveys •• Following changes and evidence of education, re-audit to re-assess compliance •• Following a review of data from the information team as above it was identified that “acute kidney injury” or “acute renal failure” was one of the areas contributing to mortality within this group. The audit department used research and national audits such as NCEPOD acute kidney injury: adding insult to injury, and NHS kidney care to put together a care bundle in order to assess the quality of care for these patients. Following this and a pilot of five cases, three consultants reviewed the care bundle and felt that only one standard should be added to the care bundle. This care bundle was then used to assess the quality of care for the patients that fell in to the acute kidney injury and acute renal failure primary diagnosis area, following review and reporting this care bundle can again be put in to a local guideline for use throughout the trust. •• Supervisors and managers to audit two sets of case notes per month using the electronic audit tool to assess documentation relating to antennal, intrapartum and postnatal care. Supervisors to feed back to the individual midwife/doctor where documentation has been poor and feed. Best practice or good documentation to be provided with a certificate •• Once electronic capabilities established and implemented carry out re-audit in order to compare results (approximately six months following implementation) •• Carry out a snapshot audit on a regular basis to ensure continued improvement and highlight any areas for action. Changes to service •• Amend the electronic discharge letter template to include specific, mandatory questions (duration, INR range, indication etc.) and the prescribing of anti-coagulants •• Amend the electronic discharge letter template to have separate lists for new, continuing and discontinued medication •• Move current pain charts location to ensure it is in the vicinity of the drug chart to improve ergonomics and recording of effectiveness of analgesia •• Pain assessment to be discussed on a compulsory basis at ALERT course •• Acute pain nurses to liaise and have uniform approach to teaching on the use of the pain chart •• To make several physical amendments to the checklist and add signature boxes to the checklist for anaesthetist, ODP, circulating practitioner and surgeon to aid compliance and recording of key information •• Abortion certificates to be stored securely in the health records (not elsewhere in the department) •• Referral information to be date stamped upon receipt from the general practitioners (GP) •• Where the GP has completed signature one, this form should then be utilised by hospital staff with signature two being completed on that same certificate •• Handover tools to be devised based on SBAR to aid verbal handover at time of shift changeover •• To devise a DNA form to be placed in the maternity notes to evidence that the women have been contacted following a missed appointment in the antenatal period •• To ensure privacy is maintained when carrying out immunisations in schools, wherever possible, by ensuring all windows and windows within doors are covered – immunisation team to take paper roll and tape to all sessions and cover windows where required •• In order to ensure privacy is maintained and behaviour is not compromised when children are waiting for their immunisations re-look at the waiting area and discuss with the school the possibility of a different area for children waiting to receive their immunisations. Discuss the number of children being released from lesson and request that no more than 10 children at a time are released and waiting •• Discuss the possibility of recording significant events directly into the patient’s record in SystmOne ie via read-codes •• If the recording of significant events in SystmOne is possible, roll out implementation to all teams •• Devise and distribute a ‘NILL’ report form for use when a full report is not required.

186 2.3c Information on participation in clinical research The total number of patients receiving relevant health services provided or sub-contracted by Northern Lincolnshire and Goole Hospitals NHS Foundation Trust in 2012/13 that were recruited during that period to participate in research approved by a research ethics committee is not known as this data is not collected. However, those patients recruited to NIHR adopted research studies was 577. NB: It should be noted that all studies opened within the Trust are subject to rigorous governance checks before they are opened within the Trust which includes submission to a research ethics committee where required. Thus additional patients will be involved in research studies where by the actual patient accrual is not reported through research and development as a core expectation of the Trust at this time ie in house/academic studies that are not NIHR adopted. The Trust takes part in clinical research, this is because it believes that research is important because it helps to improve healthcare by finding out which treatments work best for patients. It also gives patients the opportunity to access novel and innovative treatments and therapies. Within the department we have adopted the NIHR strapline of ‘Today’s research is Tomorrow’s Treatment’ which captures the essence of what our service is about. The research and development department (R&D)offers a central corporate function within the Trust and takes an organisational-level lead in ensuring that research is conducted and managed to high scientific, ethical and financial standards. The R&D function is delivered from two offices based at the Scunthorpe and Grimsby sites and is led and managed by the head of research and professional development supported by a team of 10 research nurses, three data coordinators and a projects coordinator. Within the research and development department, our aims are •• To increase the number of research studies open within the Trust, including industry studies that may also generate income. Such income is then re-invested within the Trust in the areas of further research and professional development •• To increase the number of patients recruited to studies within the Trust thus increasing the opportunities for patients to access new and cutting edge treatments which may not be offered through routine care delivery •• To improve the time that it takes to open a research study within the Trust. The R&D department are currently supporting a range of research projects. These include, •• National Institute of Health Research (NIHR) portfolio adopted research •• Non-portfolio research •• Commercially sponsored studies •• Academic and in-House research studies.

As at September 2012, there were 99 studies open in the Trust. How the research and development team help to deliver research The team of nurses, data coordinators help to deliver research within our Trust in the following ways: •• By identifying patients suitable for research studies – involvement is entirely voluntary and never undertaken without formal written consent from the volunteers •• By supporting the investigators in delivering the research studies on a day-by-day basis, including seeing patients in clinics and at home where required •• Following-up of the patients involved in the studies once the actual treatment stage has been completed – this can be for a number of years in some studies •• Collecting the data that contributes to the results of studies. This then goes onto changing practices and treatments in the future.

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We currently have research projects open in the following areas:

Oncology Diabetes Dermatology Paediatrics Haematology Gastrointestinal Rheumatology Nursing Stroke Obstetrics ITU Management Cardiology Gynaecology Surgery Neurology

The R&D department is dedicated to supporting and furthering research, development and innovation within the Trust. The department provides assistance and guidance on how to: •• Check whether projects are research, service evaluation or audit •• Help and advice on protocol development, study design, data management and analysis •• Assist in the set up a study •• Coordinate a submission to the research ethics committee (REC) and where necessary Medicines and Healthcare Products Regulatory Agency (MHRA) to facilitate approvals •• Undertake the necessary NHS Trust approval process on behalf of Northern Lincolnshire and Goole Hospitals NHS Foundation Trust. We can also provide information about training courses offered by other training providers in the field of health service research, local and national funding opportunities and research and development publications.

2.3d Information on the Trust’s use of the CQUIN framework A proportion of the Trust’s income in 2012/13 was conditional upon 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 relevant health services, through the Commissioning for Quality and Innovation payment framework. Further details of the agreed goals for 2012/13 and for the following 12 month period are available online at: http://www.monitor-nhsft.gov.uk/sites/all/modules/fckeditor/plugins/ktbrowser/_openTKFile.php?id=3275 The amount of income in 2012/13 which was conditional upon achieving quality improvement and innovation goals was £6.2 million.

The areas of care which were included within the CQUIN scheme for 2012/13 included the following: •• VTE risk assessment •• Patient experience •• Dementia •• NHS Safety Thermometer – utilised in the hospital and in the community •• End of Life Care in the hospital •• Improving hospital discharge

•• Deteriorating patient. The monetary total value for 2011/12 CQUIN indicators that the Trust received payment for was £3.6 million.

2.3e Information on never events The Trust reported three never events during 2012/13. Two related to the never event category ‘retained foreign object post-operation’. In one case this was following an abdominal surgery and in the other case a retained swab was present following a vaginal delivery. The third never event was in the ‘wrong operation’ category and was an incorrect ophthalmic operation.

188 2.3f Information relating to the Trust’s registration with the Care Quality Commission Northern Lincolnshire and Goole Hospitals NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is unconditional. The Care Quality Commission has not taken enforcement action against the Trust during 2012/13. The Trust has not participated in any special reviews or investigations by the Care Quality Commission during the reporting period.

2.3g Information on quality of data Northern Lincolnshire and Goole Hospitals NHS Foundation Trust submitted records during 2012/13 to the secondary uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data. •• The percentage of records in the published data:

•• Which included the patient's valid NHS Number was: •• 99.1 per cent for admitted patient care •• 99.3 per cent for outpatient care 94.9 per cent for accident and emergency care.

•• Which included the patient's valid Registration Code was: •• 99.9 per cent for admitted patient care •• 99.9 per cent for outpatient care •• 99.7 per cent for accident and emergency care.

2.3h Information on information governance The Trust’s information governance assessment report overall score for 2012/13 was 68 per cent and was satisfactory.

2.3i Information on payment by results clinical coding audit The Trust was subject to the Payment by Results clinical coding audit during the reporting period by the Audit Commission. However, at the time of writing this account the Trust has only just received in draft the findings from this. At present some work is ongoing with the Audit Commission to ensure the report is factually correct. Once complete a final report will be issued. At this time therefore the error rates reported in the latest published audit for that period for diagnoses and treatment coding (clinical coding) are not able to be reported. As a result of having not received the final report, Northern Lincolnshire and Goole Hospitals NHS Foundation Trust cannot outline what actions it will be taking to improve data quality.

2.3j Trust performance against a core set of indicators From 2012/13 the Department of Health has requested all NHS organisations to report against a core set of indicators for at least the last two reporting periods (last two years), using a standardised statement set out in the NHS (Quality Accounts) Amendment Regulations 2012. Some of those indicators were not relevant to the Northern Lincolnshire and Goole Hospitals NHS Foundation Trust; therefore the following indicators reported on are only those relevant to the Trust.

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The information has been made available from the Health and Social Care Information Centre, and so where possible a comparison has been made of the numbers, percentages, values, scores or rates of each of the Foundation Trust’s indicators with: a). The national average for the same b). Those NHS Trusts and the NHS Foundation Trusts with the highest and lowest of the same. This information has been presented as follows in table format.

2.3k: Summary Hospital-Level Mortality Indicator (SHMI) The data made available to the Trust by the Health and Social Care Information Centre with regard to: a). The value and banding of the summary hospital-level mortality indicator (SHMI) for the Trust for the reporting period:

Publication Trust Trust National National National Sample time frame date value banding average best worst

October 2011 April 2010 – March 2011 1.14 1 1.00 0.67 1.21

January 2012 July 2010 – June 2011 1.12 2 1.00 0.67 1.21

April 2012 October 2010 – September 2011 1.16 1 1.00 0.67 1.23

July 2012 January 2011 – December 2011 1.16 1 1.00 0.69 1.25

October 2012 April 2011 – March 2012 1.17 1 1.00 0.71 1.25

January 2013 July 2011 – June 2012 1.18 1 1.00 0.71 1.26

April 2013 October 2011 – September 2012 1.15 1 1.00 0.68 1.21

Source: NHS information centre Comment: The above table illustrates the Trust’s performance against the Summary Hospital Mortality Indicator (SHMI). As referred to earlier in this report, the Trust monitors performance against a number of mortality indicators including the Risk Adjusted Mortality Index (RAMI) and the SHMI. Both are Standardised Mortality Ratios (SMR) but both are calculated using different methodologies thus preventing like for like comparison. One key difference between the two indicators is SHMI indicators inclusion of deaths within the community (within 30 days of hospital discharge), whilst the RAMI indicator focusses solely on in hospital mortality. Due to the SHMIs inclusion of community mortality, it requires additional data to that made available by the Trust through routine hospital coding. This indicators reliance on other data sources results in a delayed reporting of the data, as illustrated by the most recent SHMI publication release in April 2013 assessing a time frame of October 2011 – September 2012. This delay in reporting makes it difficult for the Trust to continuously in real time monitor this area using SHMI alone, hence why the Trust uses this in collaboration with other mortality indices such as the RAMI. The table illustrates the Trust reported performance with SHMI and for each quarterly release outlines the average UK performance, the national best and worst. The Trust banding is defined as follows from guidance from The Information Centre: Banding number using the 95% control limit derived from a random effects model applying a 10 per cent trim for over dispersion with: • 1 – higher than expected • 2 – as expected • 3 – lower than expected. b). The percentage of patient deaths with palliative care coded at either diagnosis or speciality level for the Trust for the reporting period.

190 % with palliative care Publication at either diagnosis or National average National highest National lowest date specialty level

October 2011 5.9% 16.7% 38.9% 0.1%

January 2012 6.6% 16.1% 40% 0.1%

April 2012 8.2% 16.6% 41.6% 0%

July 2012 10.6% 17.3% 41.7% 0%

October 2012 12.5% 18.1% 44.2% 0%

January 2013 13.6% 18.6% 46.3% 0.3%

April 2013 13.9% 19.2% 43.3% 0.2%

Source: NHS information centre Comment: The above table illustrates the percentage of patients with a palliative care code used at either diagnosis or specialty level. Palliative care coding is a group of codes used by hospital level coding teams to reflect palliative care treatment of a patient during their hospital stay. The Statistically calculated Standardised Mortality Ratios (SMR) of which the Risk Adjusted Mortality Index (RAMI) and the Summary Hospital Level Mortality Indicator (SHMI) are both a part of all differ in how patients with palliative care codes feature within the indicators. The RAMI indicator excludes all patients who have a palliative care code, however the Trust is required to meet strict rules that govern the use of such codes to only those patients appropriately seen and managed by a specialist palliative care team. The SHMI indicator on the other hand does not exclude this group of patients, rather they are included and the appropriate risk factor for each is statistically determined according to the model. As palliative care coding is a key mortality indicator, the SHMI on publication each quarter include the above breakdown of data for Trusts to see the proportion of palliative care codes being used versus the national average. The above table therefore illustrates the percentage of patients each quarter where palliative care codes have been used in either the patient’s specific diagnosis or at the specialty team level of those caring for the patient. It is noticeable during successive quarters of a gradual increase in the level of palliative care codes being used, this demonstrates some of the work undertaken within the Trust to ensure appropriate palliative care support is provided as and when needed and improving recording systems to ensure when the palliative care specialist team are involved this is accurately captured within the hospital coding. Northern Lincolnshire and Goole Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: •• The Summary Hospital Mortality Indicator (SHMI) is published on a quarterly basis, however as a result of this indicator including community mortality information as well as in-hospital deaths it relies on data from the Office for National Statistics. This incurs a delay resulting in a significant lag in reporting Trust performance. At present the most complete data available to the Trust, at the time of writing this report, was for the period of October 2011 – September 2012. A number of improvements have been made in the recording and capture of key information that is drawn on by SHMI during the last two quarters of 2012. At present, due to the indicator’s time lag, these improvements have not yet shown through in the data •• The Trust has been actively working with this mortality indicator alongside other indicators used internally to monitor performance and as a result a number of improvement projects are currently running assessing data quality, which has a big impact on how these indicators are calculated as well as clinical projects •• The Trust recognises the need to improve palliative care provision and is in active discussion with commissioners. The Trust has taken the following actions to improve the indicator and percentage in a and b, and so the quality of its services by: •• A number of improvement projects have been commenced assessing both data quality and clinical care, this is available within an extensive action plan which is in place to address the higher than expected SHMI, just some of the key points are outlined as follows

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•• A monthly mortality report is produced which provides the mortality performance committee (MPC) and the Trust Board with a monthly breakdown of the Trust’s performance with mortality and an outline of some of the work streams underway to improve this area •• Patients who have died within the organisation are reviewed using the mortality trigger tool with a view to identifying any cases requiring more detailed clinician review by a senior medic or a senior nurse •• As a result of the findings from such quality evaluation work and the monthly data reporting within the mortality report, specific pathway areas are being identified and where necessary quality improvement projects are being developed focussing on the pathway of care and the other key ‘action themes’ from the trigger tool review work •• An external review of the Trust’s assurance mechanisms is planned to take place during May by KPMG •• The Trust is one of the 14 Trusts involved in the Keogh Review which will review: •• Whether existing action by these Trusts to improve quality is adequate and whether any additional steps should be taken •• Any additional external support that should be made available to the Trust to help improve •• Any areas that may require regulatory action in order to protect patients.

2.3l: Patient Reported Outcome Measures (PROMS) The data made available to the Trust by the Health and Social Care Information Centre with regard to the Trust’s patient reported outcome measures scores for: a) Groin hernia surgery b) Varicose vein surgery c) Hip replacement surgery d) Knee replacement surgery during the reporting period.

Trust adjusted National National National Type of surgery Sample time frame average health average highest lowest gain health gain

April 2010 – March 2011 0.121 0.085 0.156 -0.020 Groin hernia April 2011 – March 2012 0.084 0.087 0.143 -0.002

April 2010 – March 2011 0.091 0.155 -0.007 Varicose vein Not available April 2011 – March 2012 0.094 0.167 0.047

April 2010 – March 2011 0.438 0.405 0.503 0.264 Hip replacement April 2011 – March 2012 0.405 0.416 0.532 0.306

April 2010 – March 2011 0.316 0.299 0.407 0.176 Knee replacement April 2011 – March 2012 0.317 0.302 0.385 0.180

192 Source: NHS information centre Comment: The above table shows the Trust’s reported adjusted health gain, which is a measure of the patient’s own reported outcome following surgery within the Trust. The Patient Reported Outcome Measure (PROM)s is a national initiative designed to enable NHS trusts to focus on patient experience and outcome measures. The four areas listed above are nationally selected procedures of which the Trust has no power to influence. This is illustrated in varicose vein surgery, which the Trust does not provide hence why no data is available. Northern Lincolnshire and Goole Hospitals NHS Foundation Trust considers that the outcome scores are as described for the following reasons: •• For some years the Trust has monitored its participation rates and response rates in relation to the completion of pre-operative and post-operative PROMs questionnaires. These rates have been positive when compared to peers within the Yorkshire and Humber region. Quarterly reports are now received from the Quality Observatory that provide progress updates on both the participation rates and the overall health gain reported by patients. The figures noted above evidence the positive performance of the Trust in relation to overall health gain with health gain scores for hip replacement falling slightly below the national average. The Trust has taken the following actions to improve these outcome scores, and so the quality of its services by: The results have been discussed at the surgery and critical care clinical governance group with clinical leads being identified to lead further review work. This additional detailed analysis of patient level data will assist clinical teams to drive further improvements in patient reported outcomes The Trust will also continue to monitor the rate of participation for each clinical procedure and encourage patient participation before and after surgery.

2.3m: Readmissions to hospital The data made available to the Trust by the Health and Social Care Information Centre with regard to the percentage of patients aged: a) 0 to 14; and

b) 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.

Emergency National National National lowest Age group Time frame readmissions (%) re-admissions (%) highest (%) (%)

2010/2011 8.19% 10.15% 25.80% 0.00%

0 to 14 2009/2010 7.93% 10.18% 31.40% 0.00%

2008/2009 7.59% 10.09% 22.73% 0.00%

2010/2011 9.18% 11.42% 22.93% 0.00%

15 or over 2009/2010 8.92% 11.16% 22.09% 0.00%

2008/2009 8.64% 10.90% 29.42% 0.00%

Source: NHS information centre Comment: The above table outlines the percentage rate of emergency admissions to the Trust within two primary age groups (1) 0 – 14 years and (2) 15 years or over. The table also provides peer data with which the Trust can benchmark itself. The table illustrates that the rate of emergency re-admissions within the Trust is lower than that of the national average.

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Northern Lincolnshire and Goole Hospitals NHS Foundation Trust considers that these percentages are as described for the following reasons:

•• The Trust has been consistently below the national rates for re-admissions.

The Trust intends to take the following actions to improve these percentages, and so the quality of its services by: •• The Trust will continue to monitor re-admissions to maintain performance however recognises that re- admissions may see a small increase as ambulatory care and short stay models continue to be implemented.

2.3n: Personal needs of patients The data made available to the Trust by the Health and Social Care Information Centre with regard to the Trust’s responsiveness to the personal needs of its patients during the reporting period.

Average weighted Time frame score of 5 National average National highest National lowest questions

2011/2012 69.0 67.4 85.0 56.5

2010/2011 67.8 67.3 82.6 56.7

2009/2010 67.6 66.7 81.9 58.3

Source: NHS information centre

Comment: The table above highlights the average weighted score for five specific questions. This information is presented in a way that allows comparison to the national average and the best and worst performers within the NHS. The above Figures are based on the adult inpatient survey, which is completed by a sample of patients aged 16 and over who have been discharged from an acute or specialist trust, with at least one overnight stay. The indicator is a composite, calculated as the average of five survey questions from the inpatient survey. Each question describes a different element of the overarching theme, responsiveness“ to patients’ personal needs”.

1. Were you involved as much as you wanted to be in decisions about your care and treatment? 2. Did you find someone on the hospital staff to talk to about your worries and fears? 3. Were you given enough privacy when discussing your condition or treatment? 4. Did a member of staff tell you about medication side effects to watch for when you went home? 5. Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital?

Individual questions are scored according to a pre-defined scoring regime that awards scores between 0-100. Therefore, this indicator will also take values between 0-100. For each provider an average weighted score (by age and sex) is calculated for each of the questions. Trust scores are calculated from a simple average of the question scores. National scores are calculated by a simple average of the trust scores.

194 Northern Lincolnshire and Goole Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: •• The Trust has continued to achieve results that are above the national average and has made positive progress each year. Performance against the first four questions noted above has been monitored on a monthly basis by the quality matrons who have surveyed 10 patients on each ward per month, the outcome being published on the monthly nursing dashboard. This has enabled wards and departments to review progress and identify areas for improvement. The Trust has taken the following actions to improve this data, and so the quality of its services by: The quality matrons will continue to review the Trust’s performance in relation to the personal needs of patients and will also develop systems to ensure that appropriate contact information is given to patients on discharge.

News release: Patients needing joint replacement surgery are recovering quicker and being sent home sooner than traditionally with the introduction of a new way of working. People being admitted to Scunthorpe General Hospital for hip and knee replacements are taking part in an enhanced recovery after surgery programme.

This programme of care – which hinges on patients being active participants before, during and after their surgery – aims to help people recover quickly and safely after surgery. Orthopaedic consultant Mr Peter Molitor said: “As soon as people hear they need a joint replacement they automatically think they will be off their feet for a prolonged period of time. However, it is no longer a case of them coming in, getting in their pyjamas and then being in bed for two weeks. “Now they come into hospital, walk to theatre if they are able to do so, and on the same day of their procedure they get out of bed and use their new joint. They are encouraged to walk about, as the faster they mobilise, the better it is for their recovery.” Patients are often anxious about having undergone major surgery and what pain they will experience. However, the programme ensures they receive clear education and information in clinic and at their pre- assessment, and they are advised of their estimated length of stay in hospital and their date of discharge. In the past, stays in hospital after joint replacement were between 10 to 14 days. On average they are now four to five days but with this new programme they can be as low as two to three days. From a surgical approach, the operation is no different, but the anaesthetic technique has to be modified. Mr Molitor said: “Patients on the programme receive a spinal anaesthetic and specific analgesics. They also receive local anaesthetic directly into the area where the new joint has been inserted. All of these things mean they recover more quickly after the operation.” A multi-disciplinary team works with patients. This includes surgeons, anaesthetists, physiotherapists, discharge planning team, pre-assessment nurses, theatre nurses and ward staff. Mr Molitor added: “Using the enhanced recovery after surgery programme means patients recover quickly following their operation and they can be discharged from hospital and go home, as soon as it is safe for them to leave.”

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2.3o: Staff recommending Trust as a provider to friends and family The data made available to the Trust by the Health and Social Care Information Centre with regard to the percentage of staff employed by, or under contract to, the Trust during the reporting period who would recommend the Trust as a provider of care to their family or friends.

Trust National highest National average National lowest Staff Survey Year performance (acute Trusts) (acute Trusts) (%) (acute Trusts) (%) (%) (%)

2012 55% 65% 94% 35%

2011 54% 62% 89% 33%

2010 54% 63% 89% 38%

Source: NHS information centre Comment: The above table illustrates the percentage of staff answering that they “agreed” or “strongly agreed” with the question: “If a friend or relative needed treatment, I would be happy with the standard of care provided by this Trust”. Northern Lincolnshire and Goole Hospitals NHS Foundation Trust considers that this percentage is as described for the following reasons: •• The Trust is asking ward staff as part of monthly data collection information via the nursing dashboard specific questions regarding their ability to deliver the care they wanted to and if they would recommend their ward to family, appropriate action is taken as a result of this •• Based on the most recent analysis of this data, between September 2012 and April 2013, 1,588 staff would definitely be happy for a friend or family member to receive care on their ward. 503 staff would to some extent be happy for a friend or family member to receive care on their ward. Only 12 staff would not recommend their ward. This positive feedback equates to a percentage of 99.4 % of staff who would be happy for a friend or family member to receive care on their ward •• Staff are also asked if they are satisfied with the care they provide. In response, 1,408 staff are definitely satisfied with the care they provided. 673 were to some extent satisfied with the care they provided. Only 22 staff where not satisfied with the care provided. This equates to a percentage of 99% of staff who are satisfied with the care they provide.

The Trust has taken the following actions to improve this percentage, and so the quality of its services by: •• The Trust is participating in the friends and family test and will be reporting on this monthly through the quality report during 2013/14 •• The organisational development and workforce strategy seeks to motivate staff, stimulate performance, place patients first and drive quality into service delivery. To achieve this strategy the question of a correctly aligned culture becomes relevant. Consequently an organisation wide culture assessment has been undertaken •• During this exercise the Morale Barometer was created. The Morale Barometer is an in-house staff survey tool, locally designed, which looks to determine, at any given time, what is motivating and demotivating staff. The tool also provides a morale gauge to evaluate workforce mood and satisfaction

196 •• The Morale Barometers baseline survey findings became available November 2012. From this, coupled with the outputs from the other culture assessment tools, it has been possible to configure three work streams to stimulate the high performing culture and stimulate/maintain the evident workforce satisfaction and motivation. These three work streams are: 1. Social movement and workforce resilience: To established a common purpose, improve morale and invest in enhanced change management process 2. Leadership style and workforce development: To increase staff engagement, deliver an ’inclusive’ management style, increase safety, and develop internal career progression pathways 3. Reward and recognition: To reward and acknowledge staffing achievements, drive quality and stimulate NHS family inclusivity

2.3p: Risk assessed for venous thromboembolism The data made available to the Trust by the Health and Social Care Information Centre with regard to the percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the reporting period.

Trust National average National highest National lowest Quarter / Year performance (Acute providers) (Acute providers) (Acute providers) (%) (%) (%) (%)

Q3 2012/12 94.4% 94.1% 100% 84.6%

Q2 2012/13 93.2% 93.8% 100% 80.9%

Q1 2012/13 92.8% 93.4% 100% 80.8%

Q4 2011/12 90.8% 92.5% 100% 69.8%

Q3 2011/12 81.0% 90.7% 100% 32.4%

Q2 2011/12 82.5% 88.2% 100% 20.4%

Q1 2011/12 80.1% 84.1% 100% 15.7%

Q4 2010/11 51.2% 80.8% 100% 11.1%

Q3 2010/11 42.9% 68.4% 100% 0%

Q2 2010/11 38.5% 52.5% 100% 0%

Source: NHS information centre Comment: The above table illustrates the percentage of patients admitted to the Trust and other NHS acute healthcare providers who were risk assessed for venous thromboembolism (VTE) since quarter two, 2010/11. As illustrated in the above table the Trust has consistently achieved above 90 per cent since quarter four, 2011/12 and is now performing on par with the national average for this indicator. Northern Lincolnshire and Goole Hospitals NHS Foundation Trust considers that this percentage is as described for the following reasons: •• The Trust has made great improvements in VTE prophylaxis in the last three years, and is currently meeting the Commissioning for Quality and Innovation Scheme (CQUINs) target of 90 per cent. The Trust has taken the following actions to improve this percentage, and so the quality of its services by: •• The Trust reports VTE prophylaxis rates by ward and had action plans to improve those wards with lower rates. These are constantly monitored and re-visited as required.

197 Annual Quality Account 2012/13

2.3q: Clostridium difficile infection reported within the Trust The data made available to the Trust by the Health and Social Care Information Centre with regard to the rate per 100,000 bed days of cases of clostridium difficile infection reported within the Trust amongst patients aged two or over during the reporting period.

Trust performance National average National highest National lowest Time frame per 100,000 bed per 100,000 bed per 100,000 bed per 100,000 bed days days days days

April 2011 – March 2012 19.5 21.8 51.6 0

April 2010 – March 2011 19.1 29.6 71.8 0

April 2009 – March 2010 20.5 36.7 85.2 0

Source: NHS information centre Comment: The above table illustrates the rate of clostridium difficile per 100,000 bed days for specimens taken from patients aged two years and over. The downward trend from the first available data in 2009 is discernible from this table and the Trust compares favourably to the national average for this indicator. Northern Lincolnshire and Goole Hospitals NHS Foundation Trust considers that this rate is as described for the following reasons: •• The Trust has made considerable progress in reducing the number of Clostridium difficile cases and is below the national average. Cases that are deemed to be unavoidable now significantly outnumber those cases felt to be at least partially avoidable. Nevertheless, work continues to reduce these still further. The Trust has taken the following actions to improve this rate, and so the quality of its services by: •• The Trust has an evidence based clostridium difficile policy and patient care pathway •• Multi-disciplinary team meetings are held for inpatient cases to identify any lessons to be learnt and root cause analysis is conducted for every hospital acquired case and a director of infection prevention and control (DIPC) review is held where there has been a breach in practice or the patient has died •• For each case admitted to hospital, practice is audited by the infection prevention and control team using the Department of Health Saving Lives’ audit tools •• Development of a Trust-wide clostridium difficile prevention action plan which is monitored monthly by the Trust Board and infection control committee •• Monthly meetings of site specific clostridium difficile action groups whose remit is to review each case and monitor site specific trends and themes. Local action plans are produced and monitored •• Production of a dash board to monitor compliance with the routine deep clean schedule reviewed by the site specific clostridium difficile action group •• Introduction of a training programme that purely focuses on clostridium difficile issues and care. To support this a monitoring and feedback mechanism to managers regarding the number of staff attending these sessions has been developed •• Introduced an alert sticker for patient medical notes and to fit in with the Trust direction of travel in connection with the development of the Electronic Patient Record, ensured that a clostridium difficile alert icon has been built in to the system being used to host this development •• Introduction of a specific clostridium difficile discharge letter that is sent to GP’s informing them of the patients result and informing them of the potential future risks for the patient •• Introduction of an antimicrobials steering group to monitor the antibiotic side of the clostridium difficile agenda •• Development and implementation of a rolling programme of antibiotic prescribing audits which are reviewed by the steering group and the site specific clostridium difficile action groups •• Appointed a non-executive director (NED) lead for the infection control committee.

198 •• Introduced an infection prevention and control zero tolerance approach (documentary evidence available) •• Development of policies and communication aids for the admission, outlying and transferring of patients with infectious diseases •• To ensure the right level of challenge the infection control committee has formally been made a sub- committee of the Board.

2.3r: Patient safety incidents The data made available to the Trust by the Health and Social Care Information Centre with regard to: a). The number and, where available, rate of patient safety incidents reported within the Trust during the reporting period,

Trust Rate of Large Acute Trust Number Large Acute Large Acute patient safety Trust National of patient National National incidents rate of patient Time frame safety highest lowest rate reported safety incidents incidents rate per 100 per 100 per 100 reported per 100 reported admissions admissions admissions admission October 2012 – 4,941* Not available* Not available* Not available* Not available* March 2013 April 2012 – 4,487 8.78 6.69 13.61 1.99 September 2012 October 2011 – 4,217 8.41 6.22 9.75 1.93 March 2012 April 2011 – 4,033 8.04 5.99 10.08 2.75 September 2011 October 2010 – 3,733 7.25 5.62 9.91 1.79 March 2011 April 2010 – 3,626 7.04 5.25 8.65 1.71 September 2010 October 2009 – 3,069 5.92 5.49 9.19 2.10 March 2010 Source: March 2010 – April 2012, NHS Information Centre, October 2012 – March 2013, DATIX * For the purposes of this report, as national comparative data is unavailable on the NHS Information Centre’s Portal for the most recent period (October 2012 – March 2013) local data from DATIX has been used to indicate the number of patient safety incidents. As the national data is unavailable, only the actual number of incidents reported is available. Comment: The above table demonstrates the total number and rate per 100 admissions of patient safety incidents reported within the period of October 2009 – March 2012. Northern Lincolnshire and Goole Hospitals NHS Foundation Trust average rate of patient safety incidents reported is above the average of other large acute NHS organisations. Within the Trust staff are encouraged to report all incidents, therefore this number should be seen as encouraging that any concern what so ever regarding patient safety is reported for internal escalation and investigation and for remedial action to be taken to ensure any concerns are learnt from thus reducing the chance of these incidents replicating themselves and leading to patient harm. The Trust is continuing to actively encourage and promote incident reporting, and therefore expects the number of incidents reported to remain high and potentially increase in number in order to continue the work streams focussing on learning from incidents. The emphasis continues on reducing harm from patient safety incidents, the number and percentage in figure b) below demonstrates this. b). And the number and percentage of such patient safety incidents that resulted in severe harm or death.

199 Annual Quality Account 2012/13

Large Acute Trust Number Trust Rate of Trust National Large Acute Large Acute of patient patient safety average of Trust National Trust National safety incidents patient safety highest rate lowest rate incidents reported Time frame incidents involving involving reported involving reported severe harm or severe harm or involving severe harm involving severe death death severe harm or or death harm or death (%) (%) death (%) (%) October 2012 – 4* 0.08% Not available* Not available* Not available* March 2013 April 2012 – 8 0.17% 0.71% 2.50% 0.00% September 2012 October 2011 – 10 0.24% 0.75% 3.26% 0.00% March 2012 April 2011 – 8 0.20% 0.77% 2.88% 0.10% September 2011 October 2010 – 5 0.13% 0.92% 4.01% 0.05% March 2011 April 2010 – 6 0.17% 0.75% 2.95% 0.02% September 2010 October 2009 – 9 0.29% 0.64% 1.63% 0.05% March 2010 Source: March 2010 – April 2012, NHS Information Centre, October 2012 – March 2013, DATIX * For the purposes of this report, as national comparative data is unavailable on the NHS Information Centre’s Portal for the most recent period (October 2012 – March 2013) local data from DATIX has been used to indicate the number of patient safety incidents. As the national data is unavailable, only the actual number of incidents reported and the Trust’s rate is available. Comment: The above table demonstrates the total number and rate per 100 admissions of patient safety incidents involving severe harm or death reported within the period of October 2009 – March 2012. Northern Lincolnshire and Goole Hospitals NHS Foundation Trust has a lower than national average of patient safety incidents reported involving severe harm or death. Northern Lincolnshire and Goole Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: •• The Trust undertakes regular analysis of incident data, producing a wide range of monthly, quarterly and annual analysis reports which are shared throughout the organisation via a number of committees/groups/ forums. These reports enable aggregate analysis of data, along with analysis of particular hot-spots and trends. The relevant group/committee review the reports, and consider recommendations, which look to improving patient safety and addressing known risks identified in these reports. The Trust has taken the following actions to improve this number and/or rate, and so the quality of its services by: •• The Trust has formed a number of multi-disciplinary groups focussing on prevention initiatives to reduce the harm from patient safety incidents, and also to reduce the number of incidents. Examples of these work streams are the safer medication group which has a formal work programme in place which is taking forward a number of initiatives and is reviewed on an annual basis to ensure these remain relevant and targeted against known risks. •• The Trust falls prevention group has in place an action plan incorporating and integrating patient safety preventing harm from falls initiatives, environmental risk assessments and health and safety risk management initiatives, all targeted on reducing risk and preventing harm to patients. A key focus group is the learning lessons review group which had developed a formal action plan incorporating a number of patient safety initiatives, including actions to address patient mis-identification.

200 News release: Patients put hydration system on trial Patients at Scunthorpe General Hospital are among the first in the country to trial a new system that aims to improve hydration levels and access to fluids. Northern Lincolnshire and Goole Hospitals NHS Foundation Trust is among 50 Trusts in the country to be chosen to take part in a national pilot project, run by the Department of Health. Three wards are participating in the pilot – 11, 17 and 24, the orthopaedic, diabetes/endocrinology, and cardiac wards. Instead of the traditional cups that might be difficult for patients to reach or are easy to knock over, patients will have their own water bottles clipped to their beds and drinking tubes that they can use to take a sip of their drink whenever they want one. The inventor of the device, Mark Moran, was born in Grimsby. He came up with the idea after suffering from a spinal injury five years ago. He said: “I was laid flat on my back in hospital unable to move and I couldn’t get a drink. Even if I’d been able to reach the cup, I probably wouldn’t have been able to lift it and I didn’t want to bother staff as they were really busy.” Quality matron Hazel Moore, who leads on nutrition and hydration for the Trust, said: “The Hydrant system is very similar to the water bottles that sports people use when they’re on the move and need easy access to fluids. This bottle can be clipped securely to a wheelchair or bed, and the tube can be positioned within easy reach of the patient so they can take a sip without having to call a member of staff to help them. “Good fluid management is essential and we’re confident this system will benefit our patients. Being unable to reach a drink can be frustrating and can also lead to dehydration, which can be very serious. Proper hydration reduces the chance of infection and other illnesses developing, and speeds up recovery.” The bottles can hold one litre of cold or warm fluid. The drinking tube has a bite valve and a small clip to attach the tube to clothing if required. The bottle is hung from the bed, chair or wheelchair and the patient simply takes hold of the tube, inserts the bite valve between their lips then bites and sucks. The bite valve opens under pressure and closes when released so there is no leakage. Jean Ward was the first patient to trial the Hydrant system at the Trust. Having suffered a stroke she finds it difficult to sit up. She said: “I think it’s fantastic, it has made such a difference and has given me a bit of independence back. It’s so much better than using the beaker, which was easy to spill. It’s great to be able to have a drink when I want one without having to move and reach for a cup, or call a nurse.” The Trust will monitor the system and collect data from patients and staff, which will be fed back to the Department of Health. At the end of the pilot, the Trust will decide whether or not to roll out the Hydrant system to other wards across its three hospitals.

201

Part 3: AnAnnual overview Quality of the Account quality of2012/13 care based on performance in 2012/13 against indicators

Part 3: An overview of the quality of care based on 3.1 Performance against 2012/13 indicators performance in 2012/13 against indicators Parts 2.1a, 2.1b and 2.1c of this report outlined progress during 2012/13 towards achieving the priorities3.1 for thisPerformance financial year against just ended 2012/13 which indicators the Trust set out in its previous Annual Quality Account for 2011/12. The quality priorities in part two were presented in three distinct sections: clinicalParts 2.1a, effectiveness 2.1b and 2.1c of this (2.1a), report outlinedpatient progress safety during (2.1b) 2012/13 and towards patient achieving experience the priorities (2.1c). for this financial year just ended which the Trust set out in its previous Annual Quality Account for 2011/12. The quality For these indicatorspriorities in part selected two were presentedby the inTrust, three distinct the fullsections: report, clinical contained effectiveness within(2.1a), patient parts safety 2.1a, (2.1b) 2.1b and 2.1c referand patient to benchmarked experience (2.1c). data, where available, to enable performance compared to other providers.For these References indicators selected to by the the Trust, data the sources full report, usedcontained are within also parts stated 2.1a, 2.1b within and 2.1c theserefer to earlier parts of thisbenchmarked report data, and where where available, relevant to enable this performance includes compared whether to other theproviders. data References is governed to the data by standard nationalsources used definitions. are also stated within these earlier parts of this report and where relevant this includes whether the data is governed by standard national definitions. During 2012/13 the following quality priorities were monitored by the monthly quality report During 2012/13 the following quality priorities were monitored by the monthly quality report which was which was presented presented and reviewed and reviewed on a monthly on basis a by monthly the Trust’s quality basis and by patient the experience Trust’s (QPEC) quality committee and patient and experience the(QPEC) Trust Board. committee A summary of and the Trust’s the performanceTrust Board. against A thesesummary key indicators of the (outlined Trust’s within performance part two in against thesefull) keyare summarised indicators below: (outlined within part two in full) are summarised below: Clinical effectiveness:Clinical effectiveness:

QUALITY INDICATORS AT A GLANCE 2012/13 Indicators

Indicator Period Prev 12 mths Change Jan‐13 Threshold (average) CLINICAL EFFECTIVENESS Trust RAMI reduction of 10 points and CE1a 89 94 100 downward trajectory Trust Stroke RAMI reduction of 10 points CE1b 106 125 100 and downward trajectory Trust Cardiac conditions RAMI reduction CE1c 91 91 100 of 10 points and downward trajectory Trust Respiratory RAMI reduction of 10 CE1d 84 93 100 points and downward trajectory # Prev 12 mths Change Mar‐13 Threshold (average) Implement 'Check Your Charts' element of CE2 100.0% 98.6% 95.0% the Patient Safety First Campaign

Prev 12 mths Change Feb‐13 Threshold (average) DPoW ‐4.8% 95.0% 99.8% CE3 Patient Observations SGH ‐4.6% 93.0% 97.6% 95.0% GDH 10.0% 100.0% 90.0% DPoW 1.9% 94.0% 92.1% CE4 NEWS Scoring SGH ‐0.9% 93.0% 93.9% 95.0% GDH 16.0% 100.0% 84.0%

Prev 12 mths Change Dec‐12 Threshold (average) DPoW 3.5% 14.2% Emergency Re‐admissions Downward CE5 SGH 13.0% 14.8% (dementia) trajectory GDH 13.0% 15.1% Prev 12 mths Change Dec‐12 Threshold (average) DPoW 11.8 9.1 Downward CE6 Length of stay (dementia) SGH 11.2 7.1 trajectory GDH 10 9.4

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Patient safety: Patient safety: Patient safety: QUALITY INDICATORS AT A GLANCE QUALITY2012/13 INDICATORS Indicators AT A GLANCE 2012/13 Indicators Indicator Period Prev 12 mths Indicator MarPeriod‐13 Threshold Prev(average) 12 mths Mar‐13 Threshold PATIENT SAFETY (average) MRSA Bacteraemia Incidence PS1PATIENT SAFETY 0 2 No more than 3 C Difficile Incidence PS2PS1 MRSA Bacteraemia Incidence 40 372 No No more more than than 34 3 PS2 C Difficile Incidence 4 37 No more than 34 Prev 12 mths Jan‐13 Threshold Prev(average) 12 mths Jan‐13 5% reductionThreshold (18 PS3 All patient identification incidents 20 (average)19 5% reductionper mth) (18 PS3 All patient identification incidents 20 19 5% reduction PS5 5% reduction in falls per 1,000 bed days 9.1 7.8 per mth) 5%(7.4 reduction target) PS5 5% reductionreduction inin thefalls number per 1,000 of repeat bed days fallers per 1,000 9.1 7.8 5% reduction PS6 1.25 1.10 (7.4 target) bed5% reduction days in the number of repeat fallers per 1,000 5%(0.96 reduction target) PS6 1.25 1.10 PS7 100%bed days compliance undertaking RCA for repeat fallers 100.0% 50.0%(0.96 100.0% target) PS7 100% compliance undertaking RCA for repeat fallers 100.0% 50.0% 100.0% Prev 12 mths Feb‐13 Threshold Prev(average) 12 mths Feb‐13 5%Threshold reduction PS8 5% reduction in pressure ulcers per 1,000 bed days 2.1 (average)0.8 5%(0.67 reduction target) PS8 5% reduction in pressure ulcers per 1,000 bed days 2.1 0.8 (0.67 target)

Patient experience: Patient experience: Patient experience: QUALITY INDICATORS AT A GLANCE QUALITY2012/13 INDICATORS Indicators AT A GLANCE 2012/13 Indicators Indicator Period Prev 12 mths Indicator Change PeriodFeb‐13 Threshold Prev(average) 12 mths Change Feb‐13 Threshold PATIENT EXPERIENCE (average) PE1PATIENTOverall EXPERIENCE satisfaction with Trust services 8.0% 95.0% 87.0% 85% Recommending the Trust to family and PE2PE1 Overall satisfaction with Trust services 4.0%8.0% 98.0%95.0% 94.0%87.0% 90%85% friendsRecommending the Trust to family and PE2 4.0% 98.0% 94.0% 90% friends Prev 12 mths Change Mar‐13 Threshold Prev(average) 12 mths Complaints responded to within agreed Change Mar‐13 Threshold PE3 1.0% 100.0% (average)99.0% 95% timescalesComplaints responded to within agreed PE3 1.0% 100.0% 99.0% 95% timescales Prev 12 mths Change Feb‐13 Threshold Prev(avera 12 gmthse) DPoWChange 7.6% 100.0%Feb‐13 92.4% Threshold (average) PE4 Care and treatment 95.0% SGHDPoW 6.4%7.6% 100.0%99.0% 92.6%92.4% PE4 Care and treatment GDHSGH 4.4%6.4% 100.0%99.0% 95.6%92.6% 95.0% DPoWGDH 12.9% 4.4% 100.0% 87.1%95.6% PE5 Medication side effects 95.0% SGHDPoW 23.5%12.9% 100.0% 76.5%87.1% PE5 Medication side effects GDHSGH 14.8%23.5% 100.0% 85.2%76.5% 95.0% DPoWGDH 14.8% 8.7% 100.0%97.0% 88.3%85.2% PE6 Nursing care indicator 95.0% SGHDPoW 6.6%8.7% 94.0%97.0% 87.4%88.3% PE6 Nursing care indicator GDHSGH 9.6%6.6% 98.0%94.0% 88.4%87.4% 95.0% GDH 9.6% 98.0% 88.4% 203

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Annual3.2 Performance Quality Accountagainst relevant 2012/13 indicators and performance thresholds

3.2 Performance against relevant indicators Performance against the relevant indicators and performance thresholds set out in Appendix B aofnd the performance Compliance Framework. thresholds Performance against the relevant indicators and performance thresholds set out in Appendix B of the Compliance Framework. Northern Lincolnshire and Goole Hospitals NHS NHS Foundation Trust

MONITOR COMPLIANCE FRAMEWORK SUMMARY Performance Against Key Thresholds For The Period 1st April 2012 To 31st March 2013

TARGET 2011/12 2012/13 2012/13 2012/13 QTR 4 QTR 4 THRESHOLD TO ACTUAL TO FAILURE QTR 4 QTR 1 QTR 2 QTR 3 WEIGHTING DATE DATE WEIGHTING Infection Control * 1 MRSA Bacteraemia G G G G 1.0 3 3 G 2 Clostridium Difficile R G G G 1.0 34 37 R Referral to Treatment Waiting Times 3 Admitted ‐ Maximum waiting time of 18 weeks G G G G 1.0 90.0% 96.0% G 4 Non‐admitted ‐ Maximum waiting time of 18 weeks G G G G 1.0 95.0% 98.0% G 5 Incomplete ‐ Maximum waiting time of 18 weeks G G G G 1.0 92.0% 97.3% G Cancer 6 31 day wait diagnosis to treatment G G G G 0.5 96.0% 100.0% G 7 i) 31 day wait for subsequent treatments ‐ Surgery G G G G 1.0 94.0% 100.0% G ii) 31 day wait for subsequent treatments ‐ Anti cancer drugs GGGG 98.0% 100.0% G 8 i) 62 day wait GP referral to treatment G G G G 1.0 85.0% 91.9% G ii) 62 day wait Consultant screening service referrals GGGG 90.0% 100.0% G 9 i) 2 week wait referral to consultation G G G G 0.5 93.0% 98.6% G ii) 2 week wait breast symptom referrals GGGR 93.0% 95.2% G A&E 10 A&E 4 Hour Wait Compliance G G G G 1.0 95.0% 92.3% R Data Completeness Community Services 11 i) Referral to treatment information N/A G G G 1.0 50.0% 96.0% G ii) Referral Information N/A G G G 50.0% 92.0% G iii) Treatment Activity Information N/A G G G 50.0% 92.0% G Access ** 12 Access to healthcare for people with learning disability G G G G 0.5 Y/N Y G

* Cumulative figures Total Monitor Compliance Score 2.0

** Annual Monitor Compliance Rating Amber Red

Additional community community care care data data completeness completeness indicators: indicators:

Q4 Threshold To Q4 Threshold To Q4 Actual To Date Date Q4 Actual To Date Date Patient identifier completeness 50% 100% Patient identifier completeness 50% 100% End of life patients deaths at home information completeness 50% 80.65% End of life patients deaths at home information completeness 50% 80.65%

NB: 31-dayNB: wait 31-day for second wait or subsequent for second treatment or subsequent comprising radiotherapy treatment is comprising not applicable radiotherapy to the Trust as is not radiotherapyapplicable is not providedto the Trust within as the radiotherapy organisation. is not provided within the organisation. For full details and technical specifications from Monitor guiding NHS Trusts how compliance with the above is to be calculated,For full please details see and annex technical 8. specifications from Monitor guiding NHS Trusts how compliance with the above is to be calculated, please see annex 8.

Directorate of Clinical and Quality Assurance, April 2013 Page 76 of 97

204 3.3 Information on staff survey report Commentary All Trusts are required to undertake a national staff survey in order to determine their staffs perceptions of the Trust as an employer and healthcare provider. Historically the Trust has undertaken a full census survey of all staff but this year moved to a sample survey. The results of the 2012 staff survey have recently become available from which a summary is provided below.

Summary of performance - NHS staff survey Details of the key findings from the latest NHS staff survey: •• Response rate compared with prior year:

Trust improvement/ 2011/12 2012/13 deterioration Response rate National National Trust Trust average average

34% 54% 30% 51% 4% deterioration

•• Areas of improvement from the prior year and deterioration •• Top four ranking scores:

Trust improvement/ 2011/12 2012/13 Top 4 deterioration National National ranking scores Trust Trust Average Average % of staff having well structured 21% 34% 21% 36% No change appraisals in last 12 months % of staff agreeing that their role makes a difference to 89% 90% 84% 89% 5% decrease patients % of staff appraised in last 12 61% 81% 64% 84% 3% increase months % of staff receiving health and 76% 81% 62% 74% 14% decrease safety training in last 12 months

205 Annual Quality Account 2012/13

•• Bottom four ranking scores:

Trust improvement/ 2011/12 2012/13 Bottom 4 deterioration National National ranking scores Trust Trust average average % of staff experiencing physical violence from patients, relatives 4% 8% 9% 15% 5% increase or the public in last 12 months % of staff experiencing harassment, bullying or abuse 10% 15% 23% 30% 13% increase from patients, relatives or the public in last 12 months % of staff experiencing physical violence from staff in last 12 0% 1% 2% 3% 2% increase months % of staff experiencing harassment, bullying or abuse 15% 16% 22% 24% 7% increase from staff in last 12 months

Work toward addressing the above concerns has commenced. This work includes developments within the internal marketing of the staff survey to staff response rates for future years and a significant investment to review the appraisal process. Reviewing the total findings of the staff survey has determined that there is significant synergy between the outcomes of the staff survey and requirements to address any concerns in the survey and the Trust’s established culture change action plan (2012). The culture action plan, endorsed and committed to by the Trust Board focuses on three dominant work streams, these being: •• Social movement and workforce resilience •• Leadership style and workforce development •• Reward and recognition. Combined these three work streams are designed to establish a common purpose through our (soon to be launched) vision and values, to stimulate and improve morale and to review and enhance how we enact change management process. The work streams proactively stimulate staff engagement through initiatives such as ‘An Audience with Karen’, ‘Meet the Chief’ and the ‘Dragons Den’. To compliment this we are investing heavily in internal communications and marketing to increase staff awareness of Trust developments and the opportunities available to them, such as those mentioned above. Turning towards leadership and management style we are reviewing our internal leadership development programmes in order to achieve a greater team orientated, motivational, engaging and inspirational management style. Complementing this investment in management and leadership style and skills the work streams also inject investment in the internal career progression for all staff through the establishment of an internal coaching and mentoring network and the establishment of value led recruitment and value led appraisals, the later interventions coming later this calendar year. Finally the Trust has placed an increased focus on workforce total reward and recognition. The revised reward and recognition strategy is designed to not only acknowledge staffing achievements, drive quality and stimulate NHS Family inclusivity but to also provide rewards which stimulate the desired behaviours which feature in the organisations identified high performing culture. •• Key areas of improvement •• Summary details of any local surveys and results (if applicable); and •• Areas of concern and action plans to address.

206 Future priorities and targets •• Statement of key priority areas •• Performance against priority areas (against targets set) •• Monitoring arrangements •• Future priorities and how they will be measured.

3.4 Information on patient survey report Introduction To improve the quality of services that the NHS delivers it is important to understand what patients think about their care and treatment. One way of doing this is by asking patients who have recently used their local health services to tell us about their experiences Northern Lincolnshire and Goole Hospitals NHS Foundation Trust took part in the national survey for 2012. The report shows how the Trust scored for each question in the survey, compared with the range of results from all other Trusts that took part. It is designed to help understand the performance of individual trusts, and to identify areas for improvement. For each question in the survey, the individual (standardised) responses are converted into scores on a scale from 0-10. A score of 10 represents the best possible response and a score of zero the worst. The higher the score for each question, the better the Trust is performing

Summary of performance – national patient survey Details of the key findings from the latest national patient survey: •• Response rate compared with prior year:

2011/12 2012/13 Comments Response National National rate Trust Trust average average

61% 53% 45% 51%

•• Areas of improvement from the prior year and deterioration

207 Annual Quality Account 2012/13

•• Top four ranking scores:

2011/12 2012/13 Comments Top 4 ranking National National National National scores Trust Trust highest lowest highest lowest Improvement on last Did you feel threatened year’s results. during stay in hospital by 9.8 10.0 9.1 9.9 10.0 9.3 other patients or visitors (This shows only 0.2% felt threatened) Were hand- wash gels Improvement on last available for patients and 9.7 10.0 9.2 9.8 10.0 8.8 year’s results. visitors to use Had the hospital specialist been given all necessary information Not Not measured in - - 9.7 10.0 8.7 about your condition/ asked previous surveys. illness from the person who referred you? Improvement (This shows only 0.6 Was your admission date 9.2 9.8 8.4 9.4 10.0 8.7 had their planned changed by the hospital admission date changed) •• Bottom four ranking scores:

2011/12 2012/13 Comments Bottom 4 ranking National National National National scores Trust Trust highest lowest highest lowest Did you find someone on the hospital staff to talk Decrease from last 6.2 7.9 4.3 5.2 7.8 4.2 to about your worries and year’s results fears? Did you receive copies of letters sent between Decrease from last 4.0 9.3 2.2 3.8 9.1 2.2 hospital doctors and your year’s results family doctor (GP) Did you see, or were you given, any information explaining how to Not Not measured in - - 1.2 5.2 0.9 complain to the hospital asked previous surveys. about the care you received? During your hospital stay, were you ever asked to Improvement from 1.1 4.1 0.4 1.2 3.4 0.5 give your views on the last year’s results. quality of care?

Commentary: This year’s report shows that the Trust performance was comparable to the other Trusts performance in all of the questions. An action plan is currently being collated to look at how we can the improve the service we provide to move us into the ‘best performing Trusts’. This will improve the overall patient experience. The Trust’s focus will be to improve the results for all questions, not only those with the lowest score ensuring the Trust is constantly moving towards becoming one of the best performing Trusts.

208 Annex

209 Annual Quality Account 2012/13

Annex 1: Statements from commissioners Feedback from: NHS East Riding of Yorkshire Clinical Commissioning Group NHS North Lincolnshire Clinical Commissioning Group NHS North East Lincolnshire Clinical Commissioning Group

Comments for publication: Generally, this report reflects an accurate picture of the Trust in relation to quality data indicators. There are a range of data included relating to specific quality indicators and information on positive improvement as well as indicators that have not been met. The contextual information on the key issues of focus for the Trust in 2012-13 is representative of the issues raised by commissioning organisations during the year. Likewise, the priorities for 2013-14 that have been identified for improvement are in-line with the quality priorities of the commissioning organisations. The Trust’s continued focus on patient experience is welcome, as well as the detailed information provided on successful improvement schemes such as the ‘Check your Charts’ and the Early Warning system for deteriorating patients. Commissioners share the Trust’s concerns around the continued raised mortality rates and have been working with the Trust on a comprehensive schedule of work to address the issue; this includes a focus on all measures of mortality, both overall measures and in relation to specific conditions. Commissioners expect that this work will continue to improve quality of care at the Trust, particularly for specific areas where mortality has not fallen, where trends have not shown a marked decrease or where there have been particularly variances in mortality rates over the year, as demonstrated in the data. Commissioners have worked with the Trust to develop a CQUIN scheme for 2013/14 scheme which progresses further work to address the mortality issues particularly in relation to the clinical areas where a higher than expected mortality is being reported. Commissioners are aware that the Trust faces a challenging target to reduce its clostridium difficile rate further next year, having failed to reach its required decrease of cases in 2012-13 and look forward to receiving the Trust plans in respect of achieving a reduction Broadly, the report reflects the data reported to commissioning organisations in 2012-13. It is disappointing that further information is not included in this report regarding the actions taken following the three ‘never events’ that occurred in 2012-13 and what steps have been taken to prevent re-occurrence. The report also does not give comprehensive analysis or narrative in all areas on the work that has been undertaken to improve services against all data sources, including, for example learning and service changes from, patient complaints and incidents. Commissioners feel that this is a missed opportunity to provide further assurance in relation to the work undertaken by the Trust to improve patient experience, quality of care and ultimately reduce mortality rates. The report shows that the Trust reviews a number of indicators for the separate hospital sites. The report does not provide differentiated analysis where there are variances between different hospital sites and much detail on specific actions being taken where an issue is noted at a particular site. Whilst it is appreciated that the purpose of this report is not to over-burden with the level of detail included, commissioners will continue to work with the Trust in 2013-14 to ensure any risks in variation or inequality of quality of service remain an area of focus for the Trust. The report reflects strong improvement in patient satisfaction during the year. The staff survey results are not as strong, both in terms of response rate and some specific issues around appraisal rates and reports of bullying and harassment. The Trust has included narrative on its focus on staff morale, therefore commissioners anticipate receiving assurance in 2013-14 on the results of actions being undertaken by the Trust to address concerns raised by the staff survey results. We note that the report is based on data up to and including the end of quarter three 2012/13 and some year-end data. Taking that into account, we confirm that to the best of our knowledge, the report is a true and accurate reflection of the quality of care delivered by Northern Lincolnshire and Goole Hospitals and that the data and information contained in the report is accurate. The Clinical Commissioning Groups are looking forward to working with the Trust to improve the quality of services available for our patients in order to continually improve patient outcomes and experience.

210 Annex 2: Statement from Healthwatch organisations

Joint statement from North Lincolnshire and East Riding of Yorkshire Healthwatch organisations Healthwatch North Lincolnshire and Healthwatch East Riding of Yorkshire were launched on April 1 2013. At this stage in their development, both Healthwatch organisations are not in a position to provide a statement on the accounts. Both Healthwatch East Riding of Yorkshire and Healthwatch North Lincolnshire would wish to start an engagement process with the Trust so that they can play a part in the production of future Quality Accounts, to ensure they reflects the local knowledge of both Healthwatch organisations of the services provided by the Trust, and to ensure local priorities - as expressed by service users - are being reflected in the improvement priorities being set by the Trust.

Statement from Healthwatch North East Lincolnshire Unfortunately with the change over from NEL LINk to Healthwatch NEL we are not in a position to comment on any of the Quality Accounts. We do look forward to working with you in the future and would very much have liked to had something to submit. We just aren't in a position to at this time. We hope you understand and look forward to hearing from you next year when I am sure we will be better situated to comment.

211 Annual Quality Account 2012/13

Annex 3: Statement from local Council Overview and Scrutiny Committees (OSC) North Lincolnshire Council – Health Scrutiny Panel’s Quality Accounts comments for Northern Lincolnshire and Goole Hospitals NHS Foundation Trust North Lincolnshire Council's Health Scrutiny Panel welcomes the opportunity to comment as part of Northern Lincolnshire and Goole Hospitals NHS Foundation Trust's (NLG) Quality Account. NLAG are a key partner and provider of local services, and members have built a valuable working relationship with Trust personnel over the previous twelve years. During 2012/13 the scrutiny panel has completed some work with the Trust, particularly on the local SHMI rate, so there has been regular contact with key figures. A number of issues have also been discussed, such as dermatology, A&E and urgent care, and other day-to-day enquiries. The scrutiny panel shares the Trust’s concern around the continued unacceptable SHMI rates, but notes the comprehensive work being undertaken across Northern Lincolnshire to tackle this. Despite this, the panel continues to have some concerns that will shortly be published, along with a series of recommendations for improvements. The scrutiny panel is encouraged by recent improvements to observations, charts and recordkeeping across the Trust, and the successful implementation of the NEWS system. We believe this will lead to improved care for the patient, and earlier identification of deteriorating patients. Obviously, the panel has concerns around the higher-than-target clostridium difficile results, although members note the improvement on the previous year’s performance, the better-than-target results on MRSA rates and the actions taken by the Trust in seeking to improve performance on infection control. The Trust kindly agreed that the scrutiny panel could conduct two site visits to Scunthorpe General Hospital in 2012-13 to speak with patients and their families; one in July 2012 and one in October 2012. The visit in July found no concerns on Disney ward, but a number of issues on Ward 28. Encouragingly, feedback to the Trust led to immediate remedial action. The panel revisited Ward 28 in October, where all patients that members spoke to reported that their care was good, that staff were supportive and competent, and that patients’ dignity and safety were maintained. Again, some minor concerns were fed back to the Trust, who followed up and made the necessary changes. The panel notes the findings of the national inpatient survey, which is almost wholly in line with the national average. The panel also notes the 2012 staff survey which is referenced in the Quality Account draft. Clearly, the panel has concerns around the percentage of staff believing their role makes a difference to patients, staff satisfaction with the quality of care they provide, and staff’s recommendations of the Trust as a place to work or receive treatment, all of which are in the lowest quintile. However, the panel notes encouraging performance on keeping staff free from violence, harassment, bullying or abuse. The panel would wish to see improvements on the 30 per cent response rate for the staff survey, and would like to see the Trust take steps to encourage completion to achieve a higher rate in 2013. The panel is aware of acute pressure at the Trust’s A&E sites in quarter four of 2012/13, which led to the four-hour target being missed. Whilst we acknowledge that this was far from a local phenomenon, we look forward to receiving a copy of the local analysis of the reasons for the increased demand, and the actions taken by the Trust. Despite these concerns, our general view is that the Trust is performing well in the majority of its services, and reacting appropriately to the changing environment. The panel notes the recent encouraging figures on patient satisfaction and the number of patients willing to recommend the Trust to family and friends. On work-related issues, the chief executive and key officers provide regular, constructive updates to the panel on ongoing and developing activities, answering members' questions in a frank and open manner. Each contact between the Trust and the panel through the year has been positive and any queries have resulted in a swift and comprehensive response, and we thank the Trust for this.

212 North East Lincolnshire Council – Health, Housing and Wellbeing Scrutiny Panel’s Quality Accounts comments for Northern Lincolnshire and Goole Hospitals NHS Foundation Trust On behalf of the North East Lincolnshire Health, Housing and Wellbeing scrutiny panel, thank you for providing an opportunity to comment on the quality account for Northern Lincolnshire and Goole Hospitals NHS Foundation Trust. Positive outcomes: •• It was encouraging to see the positive patient experience survey results •• It is good to see the actions that are going to be taken to improve the quality of healthcare as a result of clinical audits included in the report. Performance: •• The risk adjusted mortality index is reducing in the Trust. The scrutiny panel has received regular updates around this issue and are aware of the detailed action plan that is in place to reduce mortality rates •• The graph on page seven of the report shows that the stroke risk adjusted mortality index varies quite greatly from month-to-month •• Palliative care still needs to improve •• It is suggested on page 30 (decision making) of the report that an indicator around staff satisfaction be incorporated in 2013/14. It would be useful to have some further information on this •• It is concerning that only 55 per cent of staff would recommend the Trust as a provider of care to their family or friends, but recognise that the Trust is taking action to improve this •• It is concerning to see that the level of harassment is increasing in the staff survey report. Presentation: •• It would have been helpful to include an explanation of the reason why PARs changed to NEWS •• The comments sections provide a helpful interpretation of the graphs •• On page 16 of the report it would have been useful to provide a key to explain the red line •• Gaps in the report make some sections difficult to comment on at this point in time. The scrutiny panel would welcome Northern Lincolnshire and Goole Hospitals NHS Foundation Trust to keep them updated on the progress being made towards the priorities in the quality account. It would also be a good opportunity to have earlier engagement in the development of the quality account for 2013/14.

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East Riding of Yorkshire Council – Health Scrutiny Panel’s Quality Accounts comments for Northern Lincolnshire and Goole Hospitals NHS Foundation Trust East Riding of Yorkshire Council Health, Care and Wellbeing Overview and Scrutiny Sub-Committee would like to thank the Trust for this opportunity to comment on the Northern Lincolnshire and Goole Hospitals NHS Foundation Trust Draft Quality Accounts 2012/13. The sub-committee welcomes the consistent approach to displaying results for 2012/13. The sub-committee also welcomes the fact that the Trust details its performance against last year’s priorities first within the Quality Accounts before then detailing the priorities for the coming year. This makes for a much easier read and clearly shows how the previous year’s priorities have informed the setting of the new priorities. Although the accounts on the whole take a consistent approach to how information is displayed by graph, some of these were difficult to understand (particularly as some lacked an explanation to the meaning of the key and its abbreviations). In addition, some of the data has been broken down to hospital level and the sub-committee would have liked to have seen that for all data. The accounts demonstrate that the Trust is not afraid to acknowledge areas where improvements are needed. In particular, the sub-committee feel that patient safety must be improved and is disappointed to learn that the Trust has failed to meet most of it targets within this priority. It is hoped that patient safety is given further precedence within 2013/14 and the sub-committee are pleased to see that this is reflected in the priorities for the forthcoming year. The sub-committee is aware of the fact that the Trust has been identified as a persistent outlier for mortality statistics and is, therefore, part of a review looking at quality of care and treatment. Members noted that the Quality Accounts indicate mortality rates are falling and hope that they continue to improve over the next 12 months. The sub-committee commend the Trust for meeting most of its targets for patient experience throughout 2012/13. It is always pleasing to hear that patient expectation is being met and that they are satisfied with the service provided and the sub-committee hopes this continues. Staff satisfaction is key for an organisation to achieve its desired goals and ensure customer expectations are met. The sub-committee is encouraged that the Trust is open and honest in detailing the results of its staff survey report and equally pleased to see that the Trust is addressing the issues/concerns raised as a result of the staff survey. The sub-committee welcome the priorities as set by the Trust for 2013/14. Due to the ageing population in the East Riding, the sub-committee is particularly heartened that dementia remains a priority for 2013/14 with a number of related sub-priorities. The glossary made for interesting reading but members felt it needed extending to cover more issues included in the Quality Accounts and also felt it would have also benefited from an abbreviations table. The Trust’s participation in 38 national clinical audits was noted by the sub-committee and in particular, it is pleasing to see that the reports of four national clinical audits and some local clinical audits has prompted the Trust to take action to improve the quality of the healthcare it provides. The sub-committee would like to record its thanks to the Trust for attending a number of meetings of the sub- committee during 2012/13 and looks forward to continuing the good working relationship that has been firmly established between the Trust and the council.

Annex 4: Statement from the Trust Governors’ Service Quality Monitoring Group Thank you for providing us with an excellent and comprehensive explanation of the Quality account. It is an excellent report with good graphics, well presented, to allow the reader to access the information and highlights the Trusts’ achievement and priorities during 2012/13. The glossary section at the back of the report is a valuable tool to allow the governors to understand the detail of the report. We, as governors welcome the opportunity to influence the choice of quality indicators for 2013/14.

214 Annex 5: Statement of directors’ responsibilities in respect of the Quality Report

The directors are required under the Health Act 2009 and the National Health Service Quality Accounts Regulations to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that foundation trust boards should put in place to support the data quality for the preparation of the quality report. In preparing the Quality Report, directors are required to take steps to satisfy themselves that: •• The content of the Quality Report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2012/13 •• The content of the Quality Report is not inconsistent with internal and external sources of information including: •• Board minutes and papers for the period April 2012 to March 2013 •• Papers relating to quality reported to the Board over the period April 2012 to March 2013 •• Feedback from the commissioners dated 23/05/2013 •• Feedback from governors dated 11/05/2013 •• Feedback from Local Healthwatch organsiations dated 15/05/2013 •• The Trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated March 2013 •• The 2012 national patient survey •• The 2012 national staff survey •• The head of internal audit’s annual opinion over the trust’s control environment dated April 2013 •• CQC quality and risk profiles between April 2012 and March 2013. •• The quality report presents a balanced picture of the NHS Foundation Trust’s performance over the period covered •• The performance information reported in the quality report is reliable and accurate •• There are proper internal controls over the collection and reporting of the measures of performance included in the quality report, and these controls are subject to review to confirm that they are working effectively in practice The data underpinning the measures of performance reported in the quality report is robust and reliable, conforms to 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) (published at www.monitor-nhsft.gov.uk/annualreportingmanual) as well as the standards to support data quality for the preparation of the quality report (available at www. monitor-nhsft.gov.uk/annualreportingmanual). The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the quality report. By order of the Board NB: sign and date in any colour ink except black

Chairman Date: 28 May 2013

Chief executive Date: 28 May 2013

215 Annual Quality Account 2012/13

Annex 6: Independent auditor’s report to the Board of Governors on the Annual Quality Report

Independent Auditor’s Limited Assurance Report to the Council of Governors of Northern Lincolnshire and Goole Hospitals NHS Foundation Trust on the Annual Quality Report We have been engaged by the Council of Governors of Northern Lincolnshire and Goole Hospitals NHS Foundation Trust to perform an independent assurance engagement in respect of Northern Lincolnshire and Goole Hospitals NHS Foundation Trust’s Quality Report for the year ended 31 March 2013 (the ‘Quality Report’) and specified performance indicators contained therein.

Scope and subject matter The indicators for the year ended 31 March 2013 in the Quality Report that have been subject to limited assurance consist of the following national priority indicators as mandated by Monitor: 1. Number of Clostridium difficile infections; and 2. Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers We refer to these national priority indicators collectively as the “specified indicators”.

Respective responsibilities of the directors and auditors The Directors are responsible for the content and the preparation of the Quality Report in accordance with the assessment criteria for the indicators specified above (the "Criteria"). The Directors are also responsible for the conformity of their Criteria with the assessment criteria set out in the NHS Foundation Trust Annual Reporting Manual (“FT ARM”) issued by the Independent Regulator of NHS Foundation Trusts (“Monitor”). Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that: •• The Quality Report does not incorporate the matters required to be reported on as specified in Annex 2 to Chapter 7 of the FT ARM •• The Quality Report is not consistent in all material respects with the sources specified below •• The specified indicators have not been prepared in all material respects in accordance with the Criteria. We read the Quality Report and consider whether it addresses the content requirements of the FT ARM, and consider the implications for our report if we become aware of any material omissions. We read the other information contained in the Quality Report and consider whether it is materially inconsistent with the following documents: •• Board minutes for the period April 2012 to the date of signing this limited assurance report (the period) •• Papers relating to Quality reported to the Board over the period April 2012 to the date of signing this limited assurance report •• Feedback from the Commissioners: East Riding of Yorkshire CCG; North Lincolnshire CCG; and North East Lincolnshire CCG •• Feedback from Governors •• The Trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated May 2013 •• The latest national patient survey dated 2012 •• The latest national staff survey dated 2012 •• Care Quality Commission quality and risk profiles dated 01/04/2012-31/03/2013 •• The Head of Internal Audit’s annual opinion over the trust’s control environment dated April 2013.

216 We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with those documents (collectively, the “documents”). Our responsibilities do not extend to any other information. We are in compliance with the applicable independence and competency requirements of the Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team comprised assurance practitioners and relevant subject matter experts. This report, including the conclusion, has been prepared solely for the Council of Governors of Northern Lincolnshire and Goole Hospitals NHS Foundation Trust as a body, to assist the Council of Governors in reporting Northern Lincolnshire and Goole Hospitals NHS Foundation Trust’s quality agenda, performance and activities. We permit the disclosure of this report within the Annual Report for the year ended 31 March 2013, to enable the Council of Governors to demonstrate they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Council of Governors as a body and Northern Lincolnshire and Goole Hospitals NHS Foundation Trust for our work or this report save where terms are expressly agreed and with our prior consent in writing.

Assurance work performed We conducted this limited assurance engagement in accordance with International Standard on Assurance Engagements 3000 ‘Assurance Engagements other than Audits or Reviews of Historical Financial Information’ issued by the International Auditing and Assurance Standards Board (‘ISAE 3000’). Our limited assurance procedures included: •• Evaluating the design and implementation of the key processes and controls for managing and reporting the indicators •• Making enquiries of management •• Limited testing, on a selective basis, of the data used to calculate the specified indicators back to supporting documentation. •• Comparing the content requirements of the FT ARM to the categories reported in the Quality Report. •• Reading the documents. A limited assurance engagement is less in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement.

Limitations Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information. The absence of a significant body of established practice on which to draw allows for the selection of different but acceptable measurement techniques which can result in materially different measurements and can impact comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision thereof, may change over time. It is important to read the Quality Report in the context of the assessment criteria set out in the FT ARM and the Directors’ interpretation of the Criteria specified in the Quality Report. The nature, form and content required of Quality Reports are determined by Monitor. This may result in the omission of information relevant to other users, for example for the purpose of comparing the results of different NHS Foundation Trusts. In addition, the scope of our assurance work has not included governance over quality or non-mandated indicators in the Quality Report, which have been determined locally by North Lincolnshire and Goole NHS Foundation Trust.

217 Annual Quality Account 2012/13

Conclusion 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 specified indicators have not been prepared in all material respects in accordance with the Criteria.

PricewaterhouseCoopers LLP Chartered Accountants Leeds Date: 29 May 2013

The maintenance and integrity of the Northern Lincolnshire and Goole Hospitals 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.

218 Annex 7: Glossary

Benchmark Peer Group: Calderdale and Huddersfield NHS Foundation Trust, Chesterfield and North Derbyshire Royal Hospital NHS Trust, Countess of Chester NHS Foundation Trust, County Durham and Darlington NHS Foundation Trust, Doncaster and Bassetlaw Hospitals NHS Trust, North University Hospitals NHS Trust, North Tees and Hartlepool NHS Trust, Rotherham NHS Foundation Trust, Royal Bolton Hospital NHS Foundation Trust, The Pennine Acute Hospitals NHS Trust, University Hospitals of Morecambe Bay NHS Trust Cardiac bundle: The new bundle is comprised of the following HRG4 subchapters: Procedures: Catheter 19 years and over, Pace 1 - Single chamber or Implantable Diagnostic Device, Pace 2 - Dual Chamber, Percutaneous Coronary Intervention (0-2 Stents), Complex Echocardiogram (include Congenital Transoesophageal and Fetal Echocardiography), Simple Echocardiogram, Electrocardiogram Monitoring and stress testing, Percutaneous Coronary Intervention (0-2 stents) and Catheterisation, Minor Cardiac Procedures, Other Non-Complex Cardiac Surgery + Catheterisation, Pace 1 - Single chamber or Implantable Diagnostic Device and other (Catheterisation; EP; Ablation; Percutaneous Coronary Intervention), Congenital Interventions: Other including Septostomy Embolisations Non-coronary Stents and Energy Moderated Perforation, Pacemaker Procedure without Generator Implant (includes resiting and removal of cardiac pacemaker system), Percutaneous Coronary Interventions with 3 or more Stents, Implantation of Cardioverter - Defibrillator only, Percutaneous Coronary Interventions with 3 or more Stents and Catheterisation, and Intermediate Congenital Surgery. Cardiac disorders: Non interventional acquired cardiac conditions 19 years and over, Arrhythmia or Conduction Disorders without CC, Syncope or Collapse without CC, Actual or Suspected Myocardial Infarction, Heart Failure or Shock without CC, Deep Vein Thrombosis, Syncope or Collapse with CC, Heart Failure or Shock with CC, Hypertension without CC, Arrhythmia or Conduction Disorders with CC, Cardiac Valve Disorders, Hypertension with CC, Endocarditis, Cardiac Arrest, and Non-Interventional Congenital Cardiac Conditions. Commissioning for Quality and Innovation Framework (CQUIN): The CQUIN payment framework enables commissioners to reward excellence, by linking a proportion of English healthcare providers' income to the achievement of local quality improvement goals. Since the first year of the CQUIN framework (2009/10), many CQUIN schemes have been developed and agreed. This is a developmental process for everyone and you are encouraged to share your schemes (and any supporting information on the process you used) to meet the requirement for transparency and support improvement in schemes over time. Common cause variation: an inherent part of the process, stable and “in control”. We can make predictions about the future behaviour of the process within limits. When a system is stable, displaying only common cause variation, only a change in the system will have an impact. Complaints: The NHS Complaints Regulations (England) 2009 require that an offer to discuss the complaint with the complainant is made on receipt of all complaints; the discussion to include the response period (the period within which the investigation is likely to be completed and when the response is likely to be sent to the complainant). The requirement is to investigate the complaint in an appropriate manner, to resolve it speedily and efficiently and to keep the complainant informed as to progress. The response should be within 6 months or a longer period if agreed with the complainant before the expiry of that period. The Complaints Regulations permit extensions to the agreed timescale where this becomes necessary and in agreement with the complainant. The Trust (as outlined within the Policy for the Management of Complaints) expects that any delay to the agreed response time is communicated to the complainant, the reasons explained and an extension agreed. In respect of monitoring, the Regulations require (amongst other points) that the Trust maintain a record of the response periods and any amendment of that period and whether the response was sent to the complainant within the period or any amendment of that period. Key definitions to interpret complaints data: •• NEW: The number of new complaints received in a month regardless of whether or not they were resolved within that month. •• CLOSED: The number of complaints that were resolved within a month regardless of whether they were received within the month or resolved within agreed timescale. •• NET OPEN: The total number of complaints currently open; includes new, unresolved from previous month(s) and complaints open ‘on hold’. •• RE-OPENED: Complaints that have been resolved which for any number of reasons require further review.

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Control limits: indicate the range of plausible variation within a process. They provide an additional tool for detecting special cause variation. A stable process will operate within the range set by the upper and lower control limits which are determined mathematically (three standard deviations above and below the mean). The upper control limit is displayed in blue throughout this report. The lower control limit is displayed in teal throughout this report. Crude mortality rate: The crude mortality rate is based on actual numbers. Unlike the HSMR which features adjustment based on population demographics and related mortality expectations. The local benchmarking rate for crude mortality is adjusted quarterly. The latest adjustment reflects January 2010 data. Fall: A sudden, unintended, uncontrolled downward displacement of a patient’s body to the ground or other object. This includes situations where a patient falls while being assisted by another person, but excludes falls resulting from a purposeful action or violent blow. Unpreventable fall: Impossible to avoid the fall(s) from happening. Recognizes that some of these events are not always avoidable, given the complexity of healthcare; therefore, the presence of an event on the list is not evidence of a systems failure or a lack of due care. Preventable fall: The fall(s) could have been avoided. Describes an event that could have been anticipated and prepared for, but that occurs because of an error or other system failure. Harm: •C• atastrophic harm: Any patient safety incident that directly resulted in the death of one or more persons receiving NHS funded care. •S• evere harm: Any patient safety incident that appears to have resulted in permanent harm to one or more persons receiving NHS-funded care. •M• oderate harm: Any patient safety incident that resulted in a moderate increase in treatment and which caused significant but not permanent harm, to one or more persons receiving NHS-funded care. Locally defined as extending stay or care requirements by more than 15 days; Short-term harm requiring further treatment or procedure extending stay or care requirements by eight - 15 days •L• ow harm: Any patient safety incident that required extra observation or minor treatment and caused minimal harm, to one or more persons receiving NHS-funded care. Locally defined as requiring observation or minor treatment, with an extended stay or care requirement ranging from one to seven days •N• one/ ’Near Miss’ (Harm): No obvious harm/injury, Minimal impact/no service disruption Hospital Standardised Mortality Rate (HSMR): The HSMR is a method of comparing mortality levels in different years, or between different hospitals. The ratio is of observed to expected deaths, multiplied conventionally by 100. Thus, if mortality levels are higher in the population being studied than would be expected, the HSMR will be greater than 100. This methodology allows comparison between outcomes achieved in different trusts, and facilitates benchmarking. Live dataset: A live dataset is one which is continuously added to over time. This means that incidents that are reported relating to a particular point in time can be added whenever they are resolved and arrive for data entry. This means that historic figures can change over time, reflected in subsequent reports. Mortality by diagnosis group: These comparisons can be and are made for a large number of conditions and operations. The three chosen are common conditions affecting many people. Some people with acute myocardial infarction (heart attack), fractured neck of femur (broken hip) and stroke die before they can be admitted to hospital. However, there are variations in hospital death rates among those who survive long enough to be admitted. Some of these deaths may be potentially preventable through faster ambulance response times and effective early treatments, so these figures may be considered as indicative of the overall outcome of care in the Trust. Patient experience: This Trust has set the goal of being the hospital of choice for our local patients. Being the hospital of choice is a far different thing than being the hospital of convenience, proximity or default. We measure patient experience using methodologies employed by the NHS National Patient Experience Survey against two key indicators to help us determine that our hospitals are the ones our patients would choose if the practical factors were removed.

220 The Trust uses The Menu Card Survey which asks five questions relating to patient experience and is attached to inpatients’ menu cards. It measures the patients’ experience in real time. The questions asked are all derived from questions that feature in all National Patient Surveys. The scores depicted in the graphs reflect an absolute figure generated by this methodology (in short – high score is good, 100 per cent would be the maximum achievable score). Patient medication incident: A medication incident is any preventable medication related event that could, or did, lead to patient harm, loss or damage. All medication incidents are recorded on the DATIX Risk Management Software System, which holds a “live” data set which means that monthly figures can change if there are delays in submission of incident report forms by clinical areas. To minimise the amount of fluctuation, data is reported two months in arrears. Pressure ulcer: Definition of avoidable and unavoidable pressure ulcer The Department of Health (DH) has been asked to clarify what an avoidable pressure ulcer is in regards the nurse sensitive outcome indicators. The DH researched the availability of definitions, finding that there are a limited number of definitions in existence to draw from. The Wound, Ostomy and Continence Nurses Society of the US have produced a position paper which points to a clear definition of “avoidable” pressure ulcer (WOCNS) March 2009. However, the DH are using a modified version of the Avoidable d Unavoidable pressure ulcers definitions from the Centre for Medicare and Medicaide (CMS) 2004, to keep with the UK policy Terminology. The modified definitions are: Avoidable pressure ulcer: “Avoidable” means that the person receiving care developed a pressure ulcer and the provider of care did not do ONE of the following: •• Evaluate the person’s clinical condition and pressure ulcer risk factors •• Plan and implement interventions that are consistent with the persons needs and goals and recognised standards of practice within the Trust •• Monitor and evaluate the impact of the interventions •• Revised the interventions as appropriate Unavoidable pressure ulcer: “Unavoidable” means that the person receiving care developed a pressure ulcer even though the provider of the care had done ALL of the following •• Evaluated the persons clinical condition and pressure ulcer risk factors •• Planned and implemented interventions that are consistent with the persons needs and goals and recognised standards of practice within the Trust •• Monitored and evaluated the impact of the interventions •• Revised the interventions as appropriate •• The individual person refused to adhere to prevention strategies in spite of education of the consequences of non-adherence and this was documented. Pressure ulcer gradings from the European Pressure Ulcer Advisory Panel (EPUAP): Category/Grade 1: Non-blanchable redness of intact skin Intact skin with non-blanchable erythema of a localized area usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness or pain may also be present. Darkly pigmented skin may not have visible blanching. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons. Category/Grade 2: Partial thickness skin loss or blister Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister.

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Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. This category/stage should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation. Category/Grade 3: Full thickness skin loss (fat visible) Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough may be present. May include undermining and tunnelling. Further description: The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Grade 4: Full thickness tissue loss (muscle/bone visible) Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining and tunnelling. Further description: The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. Readmission rate (RA): This measure shows the percentage of patients who were readmitted to hospital as an emergency within one month of being discharged. It can serve as an indicator of the quality of care provided and post-discharge follow up. A low readmission rate is an indicator of the quality of care in that it reflects a healthy care balance. Where rates are low, patients are not having to come back to the Trust for care of the same complaint. Conversely, a high readmission rate potentially signals that an organisation is releasing patients home too soon or otherwise not addressing all elements of their clinical condition. Relative risk (RR): The relative risk indicator is calculated by taking the actual number of inpatients and dividing them by the expected number of inpatients expressed as a percentage. A figure less than 100 represents better than expected performance (highlighted in green). Sigma: A sigma value is a description of how far a sample or point of data is away from its mean, expressed in standard deviations usually with the Greek letter σ or lower case s. A data point with a higher sigma value will have a higher standard deviation, meaning it is further away from the mean. Special cause variation: The pattern of variation is due to irregular or unnatural causes. Unexpected or unplanned events (such as extreme weather recently experienced) can result in special cause variation. Systems which display special cause variation are said to be unstable and unpredictable. When systems display special cause variation, the process needs sorting out to stabilise it. This report includes two types of special cause variation, trends and outliers. If a trend, the process has changed in some way and we need to understand and adopt if the change is beneficial or act if the change is a deterioration. The outlier is a one-off condition which should not result in a process change. These must be understood and dealt with on their own (ie response to a major incident). Standard deviation: Standard deviation is a widely used measurement of variability or diversity used in statistics and probability theory. It shows how much variation or "dispersion" there is from the "average" (mean, or expected/budgeted value). A low standard deviation indicates that the data points tend to be very close to the mean, whereas high standard deviation indicates that the data are spread out over a large range of values. Valid Data Set: A minimum of 21 data points is required for a valid data set using the SPC methodology. Identifying Special Cause Variation •• Seven or more points on the same side of a centre line •• Consecutive points going alternately up or down 13 times •• Seven successive points all going up or down •• A point widely different from all the others (such as a point falling outside control limits) •• Points following a cyclical pattern. X (centre line): The SPC charts in this report display the centre line mean in red which is used in identifying types of variation.

222 Annex 8: Mandatory performance indicator definitions

Quality indicator guidance: All foundation trusts are required by the NHS Operating Framework 2012/13 to measure performance against quality, resources and reform. The majority of the mandated performance indicators in the quality report have been defined by the Department of Health in its Technical Guidance for the 2012/13 Operating Framework and/or in its NHS Outcomes Framework 2012/13: Technical Appendix. Extracts of those definitions are attached below and can be assumed to come from the Department of Health’s published guidance unless otherwise indicated.

Acute NHS Foundation Trusts Clostridium difficile Detailed descriptor Number of clostridium difficile infections, as defined below, for patients aged two or more on the date the specimen was taken. Data definition A clostridium difficile infection is defined as a case where the patient shows clinical symptoms of clostridium difficile infection, and using the local Trust clostridium difficile infections diagnostic algorithm (in line with DH guidance) is assessed as a positive case. Positive diagnosis on the same patient more than 28 days apart should be reported as separate infections, irrespective of the number of specimens taken in the intervening period, or where they were taken. In constructing the clostridium difficile objectives use was made of rates based both on population sizes and numbers of occupied bed days. Sources and definitions used are: For acute trusts: The sum of episode durations for episodes finishing in 2010/11 where the patient was aged two or over at the end of the episode from Hospital Episode Statistics (HES). Basis for accountability Acute provider trusts are accountable for all clostridium difficile infection cases for which 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 that trust (where the day of admission is day one). To illustrate: •• Admission day •• Admission day + 1 •• Admission day + 2 •• Admission day + 3 -specimens taken on this day or later are trust apportioned Accountability The approach used to calculate the clostridium difficile objectives requires organisations with higher baseline rates (acute trusts and primary care organisations) to make the greatest improvements in order to reduce variation in performance between organisations. It also seeks to maintain standards in the best performing organisations. Appropriate objective figures have been calculated centrally for each PCO and each acute trust based on a formula which, if the objectives are met, will collectively deliver a further national reduction in cases of 26 per cent for acute trusts and 18 per cent for PCOs whilst also reducing the variation in population and bed day rates between organisations. Timeframe/baseline The baseline period is the 12 months October 2010 to September 2011. This means that objectives have been set according to performance in this period.

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Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers Detailed descriptor PHQ03: Percentage of patients receiving first definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer. Data definition All cancer two month urgent referral to treatment wait Denominator: Total number of patients receiving first definitive treatment for cancer following an urgent GP (GDP or GMP) referral for suspected cancer within a given period for all cancers (ICD-10 C00 to C97 and D05) Numerator: Number of patients receiving first definitive treatment for cancer within 62 days following an urgent GP (GDP or GMP) referral for suspected cancer within a given period for all cancers (ICD-10 C00 to C97 and D05) Accountability Performance is to be sustained at or above the published operational standard. Details of current operational standards are available at: http://www.dh.gov.uk/en/Publicationsandstatistics/ Lettersandcirculars/Dearcolleagueletters/DH_103436

Emergency readmissions within 28 days of discharge from hospital Indicator description Emergency readmissions within 28 days of discharge from hospital. Indicator construction Percentage of emergency admissions to any hospital in England occurring within 28 days of the last, previous discharge from hospital. Numerator: The number of finished and unfinished continuous inpatient spells that are emergency admissions within 0-27 days (inclusive) of the last, previous discharge from hospital (see denominator), including those where the patient dies, but excluding the following: those with a main speciality upon readmission coded under obstetric; and those where the readmitting spell has a diagnosis of cancer (other than benign or in situ) or chemotherapy for cancer coded anywhere in the spell. Denominator: The number of finished continuous inpatient spells within selected medical and surgical specialities, with a discharge date up to March 31 within the year of analysis. Day cases, spells with a discharge coded as death, maternity spells (based on specialty, episode type, diagnosis), and those with mention of a diagnosis of cancer or chemotherapy for cancer anywhere in the spell are excluded. Patients with mention of a diagnosis of cancer or chemotherapy for cancer anywhere in the 365 days prior to admission are excluded. Indicator format: Standard percentage.

224 All NHS Foundation Trusts

Patient safety incidents reported Indicator description Patient safety incidents reported to the National Reporting and Learning Service (NRLS). Indicator construction The number of incidents as described above. A patient safety incident (PSI) is defined as ‘any unintended or unexpected incident(s) that could or did lead to harm for one of more person(s) receiving NHS funded healthcare’. Indicator format: Whole number.

Safety incidents involving severe harm or death Indicator description Patient safety incidents reported to the National Reporting and Learning Service (NRLS), where degree of harm is recorded as ‘severe harm’ or ‘death’, as a percentage of all patient safety incidents reported. Indicator construction Numerator: The number of patient safety incidents recorded as causing severe harm /death as described above. The ‘degree of harm’ for PSIs is defined as follows; ‘severe’ – the patient has been permanently harmed as a result of the PSI, and ‘death’ – the PSI has resulted in the death of the patient. Denominator: The number of patient safety incidents reported to the National Reporting and Learning Service (NRLS). Indicator format: Standard percentage.

i. Cancer referral to treatment period start date is the date the acute provider receives an urgent (two week wait priority) referral for suspected cancer from a GP and treatment start date is the date first definitive treatment commences if the patient is subsequently diagnosed. For further detail refer to technical guidance at http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131880 PHQ03: Percentage of patients receiving first definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer. ii. This definition is adapted from the definition for the 30 days readmissions indicator in the NHS Outcomes Framework 2012/13: Technical Appendix. iii. Monitor has the removed the requirement to report this as a rate per 100,000 population. iv. Monitor has replaced the requirement to report this as a rate per 100,000 population with the requirement to report such incidents as a percentage of all PSIs reported by the trust.

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