Aintree University Hospital NHS Foundation Trust

Aintree University Hospital NHS Foundation Trust

Annual Report & Accounts 2011/12

Presented to Parliament pursuant to Schedule 7, Paragraph 25 (4) of the National Health Service Act 2006

Aintree University Hospital NHS Foundation Trust

Contents

Page No Trust Profile 2

Chairman and Chief Executive’s Statement 4

Directors’ Report 10

• Key Aims & Objectives 10 • Key Achievements against our Goals 11 • Quality Governance 19 • Operational Performance 20 • Financial Performance 26 • Equality of Opportunity 35 • Staff Engagement 42 • Patient & Public Involvement 53 • Raising Standards 57 • Research & Development 59 • Sustainability Report 63 • Current & Future Developments 65 Quality Report 67

Governance & Organisational Arrangements 149

• Board of Governors 149 • Membership 153 • Board of Directors 154 • Audit Committee 161 • Assurance Committee 165 • Remuneration & Nominations Committee 167 • Code of Governance 168 • Remuneration Report 172 • Head of Internal Audit Opinion 177 • Statement of the Chief Executive’s responsibilities as 179 Accounting Officer • Independent Auditors’ Report 181 • Annual Governance Statement 2011/12 183 Accounts 2011/12 199

• Foreword to the Accounts 200 • Accounts for the 12 months April 2011 to March 2012 201

Annual Report & Accounts 2011/12 1 Aintree University Hospital NHS Foundation Trust

Trust Profile

The Directors of Aintree Univ ersit y Hospital NHS Foundation Trust (the ‘Trust’ or ”Aintree”) present to the Members their Annual Report together with the audited accounts for the year ended 31 March, 2012.

Aintree University Hospital NHS Foundation Trust was established on 1 August 2006 as a public benefit corporation authorised under the National Health Service Act 2006.

Foundation Trusts (FTs) • Provide and develop healthcare according to the core NHS principles of free care based on need and not ability to pay • Have greater freedom to decide their own strategy and the way they run their services • Retain any financial surplus at the end of a year • Can borrow to invest in new and improved services for patients and service users • Are accountable to the local community through its Members and Governors, to commissioners through contracts and to Parliament and Monitor, the independent regulator of FTs.

Aintree University Hospital NHS Foundation Trust provides general acute health care to a population of 330,000 people in North Merseyside and surrounding areas, and also works with a range of partners to provide services in the community. The Trust is a major teaching hospital of the University of Liverpool and its tertiary centres provide specialist services to a much wider population of around 1.5 million in Merseyside, Cheshire, South, Lancashire and North Wales.

The Trust serves a population which has some of the most socially deprived communities in the country, with high levels of illness. Merseyside has some of the worst rates for heart disease and cancer in the UK, and has also been associated with a culture among patients of low empowerment over their health.

The Trust is a large hospital providing Accident & Emergency services and a wide range of acute and non-acute specialties, in addition to outpatient and day surgery services. The Trust’s services are managed through Clinical Business Units grouped within three main Divisions – Medicine, Surgery and Clinical Support Services. Specialist services are provided in Respiratory Medicine, Rheumatology, Maxillofacial and Liver Surgery.

The University of Liverpool’s School of Clinical Sciences has a major presence at Aintree University Hospital NHS FT, including Metabolic Medicine, Surgery, Oncology, Head & neck, Endocrinology/Weight Management, Thoracic Medicine and Rheumatology. The Trust is a recognised centre for multidisciplinary health research and enjoys strong relationships with the University of Liverpool, Edge Hill University,

Annual Report & Accounts 2011/12 2 Aintree University Hospital NHS Foundation Trust

Liverpool John Moores University and other NHS Trusts. The Trust is a member of Liverpool Health Partners, the Cheshire & Merseyside Academic Health Sciences System.

The Trust is one of the largest employers locally with more than 4,800 staff and has a close working relationship with staff through the Partnership Forum.

Aintree University Hospital NHS Foundation Trust has 720 inpatient beds. At the end of 2011/12, the Trust had fixed assets of just over £169 million and an annual income in excess of £278 million. During 2011/12 the Trust managed 73,459 spells of inpatient and day case care, 319,613 outpatient attendances and 85,965 attendances to the Accident and Emergency Department.

A summary of the operational and financial results during the year is set out in the review of operational and financial performance on pages 20 and 26.

The Trust’s performance against selected metrics may be found in the Quality Report on pages 67 – 148. .

Annual Report & Accounts 2011/12 3 Aintree University Hospital NHS Foundation Trust

Chairman and Chief Executive’s Statement

The Trust made significant progress in 2011/12 as we moved towards achieving our ambition to be “Fit for the Future” against the backdrop of external change across the health service. As well as facing the challenges in achieving key national targets and in addressing proposed changes to services such as the regional Adult Major Trauma System, the Trust also implemented quality improvements and ward-based safety schemes to improve the delivery of high quality and safe services for our patients. The Health and Social Care Act has laid the foundations for the next stage of development for the NHS. At the heart of this sits clinically-led commissioning and the provision of more meaningful information to patients, thereby empowering them to take ownership of decisions about their own healthcare. The national debate on safety and quality of the patient experience continues and will intensify with the publication of the final Mid-Staffordshire Hospital report in late Autumn 2012. It is expected that commissioners will increasingly seek to establish quality standards and pursue a more outcome-based approach, in addition to performance managing processes driven by key performance indicators. A key lever in this will be the Commissioning for Quality and Innovation (CQUIN) quality payment system, which makes a proportion of healthcare providers’ income conditional on demonstrating improvements in quality and innovation in specified areas of care. The Trust received a CQUIN income of £3.3 million in 2011/12 and anticipates an income of £5.4 million from CQUINs in 2012/13. These new quality indicators also include the patients’ views of their experience. The discussion on quality has also been driven by findings from the Care Quality Commission and national charities’ inspection programmes which found significant failings in services across the country. This context is made more difficult by the demographic changes in our society, particularly the increasing age of our population with the consequent rise in dementia-related conditions. The public health challenge is also becoming more immediate as ill health increases as a consequence of obesity, smoking and alcohol consumption. All of these impact on our local population and, therefore, on our hospital. While much focus has been placed on quality in the last year, there has been a similar focus on finance and performance. The NHS continues its work to save £20 billion by 2015, while ensuring that performance does not suffer and that patients can access care quickly.

Our response to all of these external developments has been on making our Trust “Fit for the Future” to focus on four corporate priorities to deliver the Trust’s vision. These priorities have been shaped by our staff and are designed to make us into an organisation which can respond quickly to external change and opportunities by working closely with our partners.

Annual Report & Accounts 2011/12 4 Aintree University Hospital NHS Foundation Trust

The corporate priorities are to:

• Deliver High Quality Safe Patient Care • Develop Staff’s Potential • Deliver our Targets and Obligations • Develop Effective External Partnerships

This report details the steps which we are taking in all of these areas, but there are key points that we would like to highlight. To support the delivery of High Quality Safe Patient Care, work on our three-year Quality Strategy continued. This has focused on minimising avoidable deaths, reducing serious incidents and improving patient satisfaction levels. Progress continued to be made on all of these fronts. Work is now underway among clinical teams to develop additional outcome-based standards, broadening our focus to include more medical and team quality indicators.

While Aintree continued to receive a good Hospital Standardised Mortality Ratio rating (HSMR), an indication of lower than average mortality, the new indicator, the Summary Hospital Mortality Indicator (SHMI), gave a higher headline figure than expected. There are a number of differences between the two indicators, including how they account for the level of palliative care services at Aintree and levels of social and economic deprivation within a hospital’s catchment area. In addition, the way in which patients’ care is recorded on our systems may be contributing to this difference. We have begun a close examination of the reasons behind our high SHMI score so that we can assess whether we need to make improvements in the care we provide, to ensure that our patients continue to receive good safe care.

This year also saw excellent progress on infection rates, which continue to reduce with Aintree ending the year with 63 hospital-acquired Clostridium Difficile cases against a standard of no more than 64, and four hospital-acquired MRSA cases against a standard of no more than five. This is the lowest number of patients acquiring Clostridium Difficile or MRSA we have ever recorded. However, we are not being complacent and our ward-based education and surveillance programmes continue, with all staff and patients asked to play their part in keeping infections out of the hospital.

Other positive news was that, following a five year study, our clinical teams published data which showed the lowest levels of infection ever published or presented internationally for foot and ankle surgery.

Quality achievements also included the continued success of our Medical Emergency Team (MET) in sustaining a reduction in cardiac arrests in Aintree. The work of the MET, plus other measures, has seen call rates consistently reduced by more than 40% between 2009 and 2011. Our stroke teams had the highest score in Merseyside and the second highest in the North West for access to specialist care in the Stroke Improvement National Audit Programme audit which was published in August 2011.

Annual Report & Accounts 2011/12 5 Aintree University Hospital NHS Foundation Trust

Our three-year relationship with Johns Hopkins Hospital came to a conclusion after more than 1,000 staff from Aintree had been involved in sessions with teams from the United States centre. Developments at Aintree derived from the learning from the Johns Hopkins relationship have included the introduction of Patient Safety Officers on each ward, and unit-based safety programmes; these give ward staff the power to identify problems and come up with their own solutions. Ward staff involved in this work shared their experiences with teams from other trusts at Aintree’s ‘Safe In Our Hands’ conference at Edge Hill University in March 2012. Junior doctors were also given the chance to develop quality and safety projects to both improve services to patients and strengthen their portfolios.

Aintree also saw the quality of its clinical services recognised by gaining status as a specialist centre for two very rare conditions, Bechets, which is a Rheumatology condition, and Neuroendocrine Tumours, which is a cancer affecting just one in 50,000 people. Aintree is among a handful of national centres for both conditions.

Our reputation was further strengthened with a number of external clinical academic appointments, including personal chairs from the University of Liverpool for Professor Terry Jones, of the Head and Neck Service, and Professor Graeme Poston, Consultant Liver Surgeon. In addition, services received commendations in a number of national awards and won several regional awards. These ranged from safety initiatives led by frontline staff, to new multi-organisational clinical network pathway developments.

Maintaining a good reputation also requires us to know what our patients think of our services. New feedback mechanisms to hear patients’ views of services were developed and our innovative work was recognised in the finals of national awards on best practice for establishing patients’ opinions. Directors and senior staff use patient experience stories to drive further improvements to our services, including personal presentations by relatives and patients often through video reconstructions which enable them to share their experiences at the Board of Directors’ meetings, thus bringing their issues to the highest level of the organisation. Patients have also responded well to a new system to highlight staff who have impressed them, with more than 800 Have I Made A Difference cards received through the year.

Our work towards a full Electronic Patient Record continued, supported by strengthened clinical engagement. System C, suppliers of the Sigma patient administration system, has recognised Aintree as a national demonstration site. Hundreds of staff from trusts across the country have visited Aintree to see how we have implemented our IT systems.

A number of capital developments have supported the provision of our clinical services. The four-year, £7 million upgrade of the Radiology Department was completed, giving us one of the best centres in the region. Ward 4 was upgraded and opened to patients, its design supporting high standards of dignity, infection prevention and control and safety.

Annual Report & Accounts 2011/12 6 Aintree University Hospital NHS Foundation Trust

The Board of Directors also agreed a £20 million upgrade of Urgent Care facilities, including the Accident and Emergency Department, the Fracture Clinic, Critical Care, Theatres and Cardiology. In partnership with the Walton Centre NHS FT, we also agreed a £1.9 million link bridge between our two hospitals for the swift transfer of patients with serious head injuries. Planning permission has been granted for both schemes, and work is already underway on both. The link bridge will be completed by August 2012.

At the same time as these quality developments, Aintree also continued to deliver on our targets and objectives set nationally or by local commissioners. Patients regularly tell us that swift access to services and timely treatment is what they expect. Aintree did very well with the management of the caseload for Referral To Treatment times for planned procedures. Quicker access is proving attractive to both referring GPs and their patients, who are receiving treatment well ahead of the national 18 weeks standard.

Aintree also did well on the headline emergency care measure, continuing its performance as the best performing general acute trust in the North West against the four-hour standard for A&E waiting times. This year also saw a renewed focus on clinically-led work to develop further our pathways for unplanned medical care. This will give patients an improved experience as they are transferred from the A&E Department to assessment areas and wards. Additional work is also underway with the North West Ambulance Service to ensure timely patient handover and turnaround times.

A greater challenge came from cancer standards. The Trust achieved 87.5% compliance against the 90% target for 62-day screening over the year. As the locality hub for the Merseyside region, the Trust is being adversely affected by a reallocation of breaches from other provider organisations to Aintree. This is irrespective of whether Aintree has been involved in the treatment pathway. The impact of this has been to reduce Aintree’s performance below the target level of 90%. The Trust is continuing to work with other provider organisations to improve performance. Aintree again had a strong financial performance in 2011/12, supported by increased elective activity and teams working within their budgets. Our two-year Cost Improvement Programme reduced our costs by £17.3 million in the period from April 2010, the largest efficiency gain we have made. Reducing costs while maintaining quality will continue as we move into 2012/13. However, achieving efficiency gains is becoming increasingly challenging, with many of the more obvious savings schemes having been achieved. Clinical engagement is essential, ensuring that suggested schemes make sense both financially and from a quality perspective.

A major piece of work throughout 2011/12 was a review of governance structures in Aintree. This introduced a clear meeting structure to ensure that appropriate systems and processes are in place to provide assurance to the Board that we deliver our services to a high standard of patient quality and safety.

Annual Report & Accounts 2011/12 7 Aintree University Hospital NHS Foundation Trust

All of our achievements are delivered by our teams and we need to ensure we support everyone to achieve their potential. This year has seen a significant change in our approach to leadership. Just as the national move has been towards clinically- led commissioning, we too have moved to a clinical leadership model.

A new structure was created for each of our three operational divisions, Medicine, Surgery and Clinical Support Services. Each division is now led by a Clinical Head of Division (CHOD), an experienced consultant who is now responsible for that division’s work. The CHOD is supported by a Divisional Chief Operating Officer (DCOO), who is a senior general manager, and a Divisional Nurse, a senior experienced nurse.

The divisional model is replicated in our Clinical Business Units, with Doctors or Clinical Heads of Business Units leading them, supported by and working with Clinical Business Managers, plus Clinical Leads and Matrons.

We also completed development work on COMPASS, our electronic staff appraisal system. COMPASS will allow us to set clear objectives for all staff to help everyone understand the role they play in ensuring that patients have the highest possible standards of care. This system will also ensure that their training needs are met and that everyone is equipped to do their job.

The sickness policy was reviewed, with additional support for staff. As a result, our sickness levels, some of the highest in the region, showed signs of reducing towards the end of the year, despite a seasonal increase in winter. The annual flu jab campaign saw record uptakes of 72% of clinical staff, helping protect both the staff and their patients. This figure was a significant improvement on previous years and was one of the highest in the country.

Given the changes in the NHS, all organisations must look to work with partners effectively if we are to deliver high quality services. Our commitment to work with partners was a key theme of the year, and helped deliver some real benefits for patients.

A joint bid with Mersey Care NHS Foundation Trust to provide the Liverpool Community Alcohol Service was successful, and this service went live in August 2011, providing care across the city. Aintree was one of 12 Merseyside trusts to join together to transfer some HR functions to a private provider as part of a local Quality Innovation, Productivity & Prevention (QIPP) programme, set up to prepare the NHS to deliver high quality care in a more challenging economic climate. The programme will help deliver efficiency savings while improving the services required to support our teams.

Aintree also became a founder partner of the Liverpool Academic Health Sciences System (AHSS), which includes the University of Liverpool and five other NHS Trusts. By focusing on carefully selected areas of research, the AHSS will support world-class research, benefitting our patients by giving them access to the latest drugs and clinical developments.

Annual Report & Accounts 2011/12 8 Aintree University Hospital NHS Foundation Trust

Partnership work is continuing in other areas with the Royal Liverpool and Broadgreen University Hospitals NHS Trust. The joint venture for laboratory services and the model for a combined vascular service are currently approved in principle. The vascular changes are currently awaiting the outcome of a regional public consultation. We see further potential for co-operation and partnership working with Royal Liverpool with which we share a number of similar patient pathways and patterns of care.

Aintree, together with the Walton Centre NHS Foundation Trust and Royal Liverpool were chosen to make up the Adult Major Trauma Centre Collaborative for Cheshire and Merseyside, with the strategic intention that the Aintree/Walton site will become the single receiving site in the future. The first stage of the collaborative system is due to go live in June 2012.

As we move forward with these strategic developments we will also keep a clear focus on essential standards in our hospital. We will be launching a three-year improvement programme to ensure essential standards in all of our wards and departments to ensure our patients can rely on the quality of care they will receive every time they are treated at Aintree. This will involve a significant organisational development programme which will engage and equip our staff to deliver this.

We would like to thank our Governors for their support and challenge over the last 12 months. Their engagement work with members has included popular health events and they have been involved in workshops to help shape our strategies and our Quality Account.

Colleagues from across the Trust have worked very hard to ensure we continue to be a successful hospital that is highly regarded by our patients and partners in health and social care. We thank all our staff for their dedication, professionalism and continued commitment to excellence.

Christopher J Baker, MBE Catherine Beardshaw Chairman Chief Executive 30 May 2012

Annual Report & Accounts 2011/12 9 Aintree University Hospital NHS Foundation Trust

Directors’ Report

Key Aims and Objectives

In 2011/12, the Trust carried out a review of its vision, strategic objectives, values and behaviours, in conjunction with the Board of Directors, Board of Governors and senior clinicians, to ensure that Aintree is “Fit for the Future”. These key parties agreed to maintain the Trust’s vision of being a provider of:

“High Quality, Patient-centred Healthcare with a First Class Local, National and International Reputation”

supported by the four corporate priorities to:

• Deliver High Quality Safe Patient Care

• Develop Staff’s Potential

• Deliver our Targets and Obligations

• Develop Effective External Partnerships

and underpinned by the following values and behaviours:

Values Behaviours

Excellence Show Care and Compassion

Respect Be Open to Change

Honesty Take Personal Accountability

Annual Report & Accounts 2011/12 10 Aintree University Hospital NHS Foundation Trust

Figure 1: Aintree – Fit for the Future

The strategic objectives have informed the development of the Trust’s business plan, identifying the prioritised programme of work to be delivered to achieve the Trust’s vision.

The Director’s report provides details of achievements and challenges in relation to the corporate priorities.

Key Achievements against our Goals

• High quality safe patient care

The Medical Emergency Team (MET), which provides senior medical and nursing support to deteriorating patients, sustained its impact since its introduction. The reduction in cardiac arrests was so significant, around 30% compared with the previous year, that the cardiac arrest team was disbanded in April 2011. The ‘call to door’ MET response time is less than five minutes, with immediate access to potentially life-saving equipment and drugs via their rapid response trolleys. By intervening early, the team can prevent patients from deteriorating to the stage that they have a cardiac arrest. There has been a further 15% reduction in calls following this move. Members of the team have now begun advising other hospitals in the region on how to successfully establish a MET.

Annual Report & Accounts 2011/12 11 Aintree University Hospital NHS Foundation Trust

Aintree was confirmed as one of three Rheumatology centres of excellence nationally for Beçhets Disease, a rare multisystem auto inflammatory condition which affects 800 people in UK. The service, commissioned by the National Specialist Commissioners, began in April 2012, with other centres in Birmingham and London. It is anticipated that around 100 patients each year, from across the North of England, will be treated at Aintree.

Following a successful tender, Aintree and Mersey Care NHS Foundation Trust began providing the Liverpool Community Alcohol Service (LCAS) in August 2011. This involves teams of specialist nurses, consultants and alcohol workers ensuring that people living with alcohol problems in the city have community-based access to treatment services and specialist medical care. More than 3,500 people have been referred to the service since its launch. In November 2011, a regional alcohol conference, “Breaking the Cycle” was held at Aintree, featuring national experts in alcohol care. In March 2012, Lord Howe, Minister for Quality, met the LCAS teams on a fact-finding visit and has commented very favourably on the model.

Following a four year, £7 million investment, Aintree’s Radiology department has been transformed, making it one of the best in the North West. The changes will mean quicker diagnosis, reduced waiting times and improved privacy and dignity for patients with a range of conditions, including various types of cancer, strokes, and other health problems. The department now has three Computerised Tomography (CT) scanners and two Magnetic Resonance (MR) scanners for diagnostic purposes.

A study into foot and ankle surgery infection rates which was published this year found that Aintree had the lowest levels ever published or presented internationally. Mr Andy Molloy presented the study into 1,737 elective cases from 2005 to 2010 to the American Orthopaedic Foot and Ankle Society’s conference. The introduction of stricter infection control practices in theatres and wards two years ago, including the nurse-led dressing clinics, saw infection rates reduced from 3.3% for superficial infection and 0.7% for deep infection to 1.6% and 0.3% respectively.

The Care Quality Commission (CQC) undertook an unannounced visit to Aintree in March 2011, publishing its formal report in June 2011. The inspection team visited Wards 31 and 32, checking Dignity and Nutrition standards. This involved observations, staff interviews staff, documentation reviews and discussions with 12 patients and relatives on the wards. The report found that Aintree was compliant with both standards and, although positive, also highlighted areas for action including documentation: while the right things were being done, they were not always being recorded. The CQC has undertaken one unannounced inspection of our Trust during 2011/12 covering five of the essential outcomes – care and welfare of people who use services, meeting nutritional needs, management of medicines, supporting staff and complaints. The report from CQC indicates they identified four moderate concerns and one minor concern (meeting nutritional needs) in the five outcomes they reviewed in March 2012. The Trust has submitted an action plan focussed on addressing these shortfalls to the CQC together with comments on the report. The

Annual Report & Accounts 2011/12 12 Aintree University Hospital NHS Foundation Trust

actions will also be incorporated in the Quality Safety and Patient Experience Improvement Programme. It should be noted that the moderate and minor concerns will not impact on the governance rating for the Trust from Monitor.

Aintree hosted two safety summits in March 2012 to share best practice. A ‘You Said, We Did’ internal event at the Clinical Sciences Centre was attended by 100 staff. The same day also saw a visit from hospital delegates from the national QUEST safety and quality programme for high performing Foundation Trusts. This was followed by “Safe in Our Hands”, a conference held at Edge Hill University. ‘Safe In Our Hands’ attracted a total of 170 external delegates, staff and Edge Hill students to learn lessons from our progress in safety and to spread good practice. Work during the year included a Trust-wide Safety Attitude Questionnaire, which saw clinical teams given a chance to inform Aintree’s focus and priorities to improve patient safety.

Kidney patients at Aintree received a boost in preparing for life-changing transplants. The renal team were among just 21 organisations nationally which were successful in a bid to NHS Kidney Care for support in increasing the number of patients who have kidney transplants sooner, before they require dialysis. Avoiding dialysis means patients do not have to endure the severe diet and fluid restrictions and medication burden, nor do they have to go through lifestyle disruption caused by the time commitments needed for the treatment. Funding from NHS Kidney care supports work to reduce delays and provide greater support to patients, to ensure that they are assessed in a timely manner. Different approaches are being tested at each centre, and the most successful will be rolled out across the country.

A toolkit on tinnitus, developed by an Aintree audiologist and a local GP, has been offered to primary care practitioners across the country help them diagnose the condition. Tony Kay, Head of Audiology Services, and Christopher Dowrick, Professor of Primary Medical Care at the University of Liverpool and GP at the Aintree Park Group practice, developed the system to support Tinnitus Awareness Week in February 2012. The toolkit helps GPs make the most of the often short consulting period available to patients in primary care by targeting key questions. Around 10% of the UK population have tinnitus, which cannot be cured but for which several management techniques exist. The toolkit was shared nationally by the British Tinnitus Association.

Teams from the Head and Neck unit carried out an audit to review use of a DVD aimed at highlighting signs of oral cancer. The five minute film was previously distributed to every dental practice in Cheshire and Merseyside, courtesy of support from the regional cancer network. It featured two patients from Aintree discussing their symptoms and treatment. The results of the audit will help inform future work with dentists to raise awareness of oral cancer symptoms, both among patients and among health professionals. Cases of oral cancer are steadily rising in Merseyside each year across all age groups. The hospital treats around 125 new cases of oral cancer each year making it the busiest unit in the country. Professor Simon Rogers

Annual Report & Accounts 2011/12 13 Aintree University Hospital NHS Foundation Trust

and volunteers from the Head and Neck team also offered free check-ups for mouth cancers and other conditions to shoppers at the Strand Shopping Centre in Bootle in November 2011 as part of Head and Neck Cancer Awareness Week.

External recognition A number of external awards were won by Aintree teams in 2011-12, highlighting the success of staff in a range of areas:

• Health Service Journal Awards November 2011 : o Highly Commended in Quality & Productivity Category - medical model, developed to improve care for patients needing urgent medical care o Shortlisted in Workforce Development Category: Patient Safety Officer system • Advancing Healthcare Awards 2012 : o Winners in Rethinking the Patient Pathway Category - Ear, Nose and Throat team which recognise projects that lead innovative healthcare practice and make a real difference to patients’ lives in the healthcare science and allied health professions. The new ‘fast track service’ gives patients quicker access to specialist support, with highly-experienced physiotherapists and audiologists with extended roles holding their own one-stop clinics for patients. • National Pelvic Floor Conference 2011 : o 1st Prize - Healthy Bowel Clinic service’s poster display study on posterior tibial nerve stimulation • Quality in Care Awards (January 2012) (with North Merseyside Diabetes Network) o Partnership Working of the Year o Best Programme for Specialist Group The network brings together hospital and community teams, and the accolades recognised the success of the network’s Hypoglycaemic Pathway. • Regional Innovation Fund – 3 successful bids of £5,000 each to help share best practice. The Liverpool Project was developed by Dr Nick Rhead and Dr Simon Jackson while medical students, and involves volunteer medical students teaching young offenders basic skills in dealing with trauma from knives or guns. This scheme is now being rolled out to other cities. In addition to teaching the skills, the work aims to deter the young people from being involved in violent crime. The second award went to help share lessons from the implementation of Aintree’s Electronic Prescribing and Medicines Administration system, based on a bid by Wendy Peacock, Electronic Prescribing Pharmacist. The third award was to Dr Richard Cooke, Consultant Medical Microbiologist, to support the development of e-clinics to help improve the management of patients with complicated infections in primary care. The aim of the project is to create virtual clinics by enabling GPs to complete a simple electronic template regarding their patient which is sent to two medical microbiologists who form the Trust’s Antibiotic Management Team. Clinical advice will be issued in 24 hours,

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supporting strong clinical management of infection in primary care, which can reduce antibiotic use, avoid hospital admissions and cut Clostridium Difficile cases. • Patient Experience Network National Awards 2011 : The customer service team were shortlisted for their work on patient feedback, including the Patient Experience Questionnaire, Exit feedback cards and Have I made a Difference cards, which allow patients or carers to nominate staff for good service.

Internal recognition Aintree’s Excellence Awards 2011 took place in November 2011, with categories redesigned to reflect Aintree’s updated corporate priorities, values and behaviours. There were 55 entries, which were of a very high quality. The event, hosted by Roger Phillips of BBC Radio Merseyside, was attended by 250 staff and the sponsors. The Outstanding Team was the Nutrition Collaborative and the Outstanding Individual was Pauline Millikan, Domestic Assistant on Coronary Care Unit. The category results were as follows:

• Quality and Safety : Winner: Nutrition Collaborative; Highly Commended: Critical Care Unit • Staff Development: Winner: NVQ Department; Highly Commended: The Sonographers • Excellence in Service Delivery: Winner: Nephrology; Highly Commended: Healthy Bowel Clinic and the Emergency General Surgery Unit • Partnership : Winner: The Stroke Team; Highly Commended: Aintree LOSS

The winner of the Have I Made a Difference Award, nominated by patients, was Alison Watson, Nursing Assistant. Paul Fletcher, Nursing Assistant was the runner up.

• Develop staff’s potential

A number of external appointments and accreditations for Aintree staff highlighted the quality of their work and of the services their teams provide:

• Professor Graeme Poston received a Personal Chair in the School of Clinical and Cancer Studies at the University of Liverpool and was confirmed as Chair of the NHS HPB Specialised Commissioning Clinical Reference Group for England. • Professor Terry Jones, Head and Neck surgeon, received a Personal Chair at the University of Liverpool, adding to the strong reputation of the Head and Neck Unit. • Mr Chris Butterworth, Consultant in Oral Rehabilitation in the Maxillofacial Unit, was elected as the 59th President of the British Society for the Study of Prosthetic Dentistry. • Dr Richard Cooke, Consultant Microbiologist, was appointed Chair of the Medical Microbiology College Advisory Training Committee by the Royal College of Pathologists.

Annual Report & Accounts 2011/12 15 Aintree University Hospital NHS Foundation Trust

• Mr Tristram Lesser, Consultant Ear, Nose and Throat Surgeon, accepted an Honorary Fellowship of the Hong Kong College of Otorhinolaryngologists. Mr Lesser has done a large amount of voluntary work in the region. • Pam Black, Clinical Business Manager for Radiology, was elected as Vice President of the Society and College of Radiographers (SOR) which represents more than 90 per cent of the diagnostic and therapeutic radiographers in the UK.

Aintree had a record uptake of flu vaccination in the winter of 2011/2012, helping protect staff and patients. The Department of Health's WinterWatch report confirmed that nearly 72% of frontline staff were vaccinated, giving Aintree the 17 th highest rates in the country out of 402 health trusts. The national average level of staff vaccination was 43%.

Aintree has strong ties with the Territorial Army, a number of staff being members of the 208 (Liverpool) Field Hospital (V). Five members of staff began a three-month deployment to Camp Bastion, the main military hospital in Afghanistan, in October 2011. Their work at what is known as the busiest trauma hospital in the world not only helped injured members of the forces and Afghan civilians, but also further developed their skills.

• Deliver our Targets and Obligations

At the end of 2011/12, the Trust delivered the Accident and Emergency Target for 95% of patients to be seen, treated admitted or discharged within 4 hours. It also achieved all the 18-week referral to treatment targets (RTT) for admitted and non- admitted patients (overall target, median waits and 95th percentiles) and met six of the eight key cancer targets applicable to Aintree in 2011/12 (further details are given on page 20).

A national audit by the Royal College of Physicians, published as part of the Stroke Improvement National Audit Programme in August 2011, reported that Aintree was the best performing hospital in Merseyside and the second best in the North West in providing access to care for stroke patients. The audit focused on the first three days of stroke care in acute hospitals when effective treatment for the stroke victim is critical in reducing the chances of future strokes. Aintree scored an average of 76.9 % in 12 key areas, ranging from the time between a patient arriving at hospital and receiving a brain scan to how long it took for patients to undergo thrombolysis, which breaks down blood clots in the brain. Throughout the year, Aintree regularly exceeded the standard for patients spending more than 90% of their time in hospital on the stroke unit.

A joint Care Quality Commission/OFSTED report into child protection in Sefton involved an inspection of Aintree’s Accident and Emergency Department, staff interviews and documentation reviews. More than 10,000 children visit Aintree annually as patients or with parents/carers who are patients. The report said that health agencies including Aintree were “outstanding” and that staff had “a very good awareness and understanding of procedures” relating to safeguarding children.

Annual Report & Accounts 2011/12 16 Aintree University Hospital NHS Foundation Trust

• Develop Effective External Partnerships

Aintree became a partner of the new regional Academic Health Sciences System (AHSS), called Liverpool Health Partners. This brings together Aintree, the University of Liverpool, Alder Hey Children’s NHS FT, Clatterbridge Centre for Oncology NHS FT, Liverpool Women’s NHS FT, Royal Liverpool and Broadgreen University Hospitals NHS Trust and The Walton Centre NHS FT. The AHSS aims to ensure that Trusts can supply world-class research by focusing on areas of excellence and working together. The initial Clinical Academic programmes will be focused on drugs, infections, cancers and Musculo-Skeletal conditions, with other programmes to be added.

Developing external partnerships includes building stronger relationships with Foundation Trust members and our communities. Aintree’s ‘Focus On...’ events give FT members an opportunity to hear about clinical developments in specific areas, courtesy of our clinical teams. A membership survey found that members wanted events to be run through spring, summer and autumn, avoiding the weather problems of the winter, and these were rescheduled for 2011/12. In addition, Aintree is seeking to use social media to open up the events to wider audiences, and to make them more interactive. Professor Rob Moots, Consultant Rheumatologist, gave a presentation on Ankylosing Spondylitis (AS) and other arthritis conditions in the new Elective Care Centre. The session highlighted a new AS clinic which Aintree has introduced. This was supplemented by a Twitter session involving a live Q&A on arthritis, thought to be the first time that the social network has been used in this way by a UK hospital. Professor Moots and his team carry out world leading research into a type of white blood cell called ‘neutrophils’ which may cause rheumatoid arthritis and could lead to new treatments. Other Twitter subjects for Focus On... sessions included one led by Mr Ian Marsh, ophthalmology consultant, on eye and sight care, as part of National Eye Health Week in June 2011.

Respiratory Education UK (REUK), a charity which has worked with the hospital for 12 years, joined with hospital staff to create a special ‘Breathe Easy’ garden exhibit for the Royal Horticultural Society’s Flower Show in Tatton Park in July 2011. Dr Rob Angus, Consultant Physician at University Hospital Aintree and Chair of the Board of Trustees for REUK, said that garden was designed to raise awareness of the respiratory issues affecting the region, particularly as early diagnosis increases the chance of effective treatment. Around 30% of Merseyside residents are at risk of respiratory problems, including asthma, hay fever, bronchitis and emphysema.

Macmillan Cancer Care opened an Information and Support Service at the hospital, which was marked with an open day in June 2011. The new service has two centres at the hospital, one in the main entrance foyer, and the other in the Marina Dalglish Centre. The service provides information and support for anyone who has cancer, their relatives, friends and carers. Alongside a variety of booklets and leaflets, visitors can discuss treatments, side effects and other cancer-related issues with staff, in a private room if necessary.

Annual Report & Accounts 2011/12 17 Aintree University Hospital NHS Foundation Trust

Joint working with Liverpool City Council and Merseytravel helped improve access to the hospital for pedestrians and users of public transport. New traffic lights and crossings improvements totalling £360,000 were installed on Longmoor Lane, and have made the crossing from Fazakerley train station and bus stops to the hospital site much safer for patients and staff.

Aintree supports its local communities in a number of ways, including its apprenticeship scheme. The Learning and Development department, in partnership with Unionlearn, the TUC's learning and skills organisation, has established more than 250 apprenticeships in the last two years, Stephen Twigg, MP for West Derby, visited the hospital in July 2011 to celebrate the success in increasing the number of apprenticeships. The apprenticeships are funded by the Skills Academy for Health and form part of a national initiative to increase levels of numeracy and literacy within the workforce. Mr Twigg met with apprentices working in the domestic and catering teams and then hosted an awards ceremony to celebrate the achievements of the hospital’s apprentices.

Annual Report & Accounts 2011/12 18 Aintree University Hospital NHS Foundation Trust

Quality Governance

The Board takes seriously its commitment to quality governance and ensures that the combination of structures and processes at Board level and below support quality performance throughout the Trust.

The Board has had regard to Monitor’s Quality Governance Framework and details of the four key areas underpinning it i.e. strategy, capabilities and culture, processes and structures and measurement to ensure that the required standards are achieved, action is taken on below standard performance, continuous improvement is planned and taken forward, best practice is identified, shared and delivered and that risks to quality of care are identified and managed. This is managed through various mechanisms including the Trust’s Assurance Framework.

The above is evidenced through the NHS Litigation Authority (NHSLA) risk management standards, which are assessed on four levels (0-3), and which are a key indicator of the safety and quality of a trust’s services. Aintree University Hospital NHS Foundation Trust has Level 3 accreditation which confirms that it monitors the impact of its policies, reviews and changes them when necessary and takes appropriate action when needed. Level 3 involves assessment of 250 criteria across five broad areas; governance, competent and capable workforce, safe environment, clinical care and learning from experience.

Further details of the approach to quality governance within the Trust and the processes adopted to achieve high quality safe patient care may be found in the Quality Report on pages 67 - 148 and the Annual Governance Statement on page 183. Advancing Quality

Further details on Advancing Quality may be found in the Quality Report on page 99.

Annual Report & Accounts 2011/12 19 Aintree University Hospital NHS Foundation Trust

Operational Performance

Waiting times

At the end of 2011/12, the Trust:

• delivered the Accident and Emergency Target for 95% of patients to be seen, treated admitted or discharged within 4 hours

• achieved all the 18-week referral to treatment targets (RTT) for admitted and non- admitted patients, (overall target, median waits and 95th percentiles).

Cancer targets

The Trust has met six of the eight key cancer targets applicable to Aintree in 2011/12.

Table 1: Cancer Targets 2011/12

The Trust achieved 87.5% compliance against the 90% target for 62-day screening to treatment over the year. As the locality hub for the Merseyside region, the Trust is being adversely affected by a reallocation of breaches from other provider organisations to Aintree. This is irrespective of whether Aintree has been involved in the treatment pathway. The impact of this has been to reduce Aintree’s performance below the target level of 90%. The Trust is continuing to work with other provider organisations to improve performance.

Against the 62-day (referral to treatment) cancer target of 85%, the Trust achieved 80.4% compliance for the year. An action plan to improve performance across all

Annual Report & Accounts 2011/12 20 Aintree University Hospital NHS Foundation Trust

departments has been progressed, with the clear aim of ensuring the target is reached before the end of the first quarter of 2012/13. Inpatients and Day Cases

Table 2: Inpatients and Day Cases 2007/08 – 2011/12

Total admissions increased by 2.4% during 2011/12, (2010/11: -3.6%), to 73,459. Of these, 39,829 were admitted for an elective procedure (2010/11: 36,814), of which just under 78% were treated as day cases. Non elective episodes of care decreased by 3.7% to 33,630 (2010/11: 34,908).

Outpatients

Table 3: Comparison of Outpatients’ Data 2007/08 – 2011/12

The number of patients attending outpatient clinics increased by 1.0% during 2011/12 to 319,613 in total, (2010/11: 316,283). Patients attending for a first

Annual Report & Accounts 2011/12 21 Aintree University Hospital NHS Foundation Trust

consultation reduced, offset by an increase in outpatient procedures and follow-up attendances.

Emergency Services

Table 4: Emergency Attendances and Admissions 2007/08 – 2011/12

For the Trust, 85,965 patients attended the Accident and Emergency Department (AED) in 2010/11 a fall of 1.8% on 2010/11, (87,508). Of these, 25,013 patients were admitted to hospital, a small increase from 2010/11 when 24,961 patients were admitted following AED attendance.

97.7% of patients waited less than 4 hours from arrival to admission, transfer or discharge at Aintree, well above the national target of 95.0%.

Efficiency

The Trust strives to secure value for money for the public by delivering good performance at a lower cost to the tax payer. It does this by managing a number of indicators which both improve the patient experience and reduce our costs:

• Average Length of Stay (ALOS) – is the time on average that each patient admitted to the hospital would stay in the hospital. It is variable as some patients stay in hospital much shorter times and others longer. Using Dr Foster data, the ALOS at Aintree increased by 0.1 days to 7.1 days, and remained 0.7 days higher than expected for the acuity of patients admitted to the hospital. The Trust is working closely with identified specialties where ALOS is higher than expected to reduce LOS to expected levels.

• Theatre Utilisation - In order to treat as many patients as possible who need surgery, the Trust is keen to make the best use of our operating theatres as

Annual Report & Accounts 2011/12 22 Aintree University Hospital NHS Foundation Trust

possible. Theatre efficiency at our main theatres, (UHA), and within the Elective Care Centre, (ECC), both showed improvement year on year.

2011/12 2010/11 Movement

UHA ECC UHA ECC UHA ECC

Utilisation of 91.4% 88.2% 88.6% 89.5% +2.8% -1.3% schedule

Utilisation of time 88.0% 86.7% 88.6% 83.9% -0.6% +2.8%

Overall utilisation 80.4% 76.5% 78.6% 75.1% +1.8% +1.4%

Procedures 9,448 6,003 9,369 6,116 +79 -113

Table 5: Theatre Utilisation

• Delayed Transfer of Care (DTOC) – the number of beds affected by delayed discharge in 2011/12 increased to 1.18% of beds available compared to 0.43% in 2010/11.

• Day Case Rate - the Trust’s day case rate was 77.9% for the year, 3.3% higher than that reported last year and above the expected rate of 75.0%. This is considered to be positive.

• Cancellations - During the year 331 operations were cancelled for non- clinical reasons, representing 0.85% of all operations scheduled. This position is similar to 2010/11, when 338 operations were cancelled, 0.82% of all operations.

Hospital outpatient appointments cancelled for non-clinical reasons have reduced from 8.5% to 7.0%.

Clinical Effectiveness

• Mortality - mortality rates are a key quality indicator for the hospital and the Trust compares its mortality with the independent healthcare data provider, Dr Foster. This shows that the mortality rate for the hospital is better than expected with an index rating of 84.8, against a norm of 100 (lower score being better than expected).

• Readmission - The readmission rate is the percentage of patients who were readmitted to hospital as an emergency within 28 days of discharge. Using Dr Foster data to compare its performance against national expectations, this shows that the rate of readmissions fell by 1.0% to 8.4% and is better than Dr Foster expected rates by 0.2%.

Annual Report & Accounts 2011/12 23 Aintree University Hospital NHS Foundation Trust

• Hospital Acquired Infections and Hospital Cleanliness - Improving hospital cleanliness and reducing hospital acquired infections was the top priority for the Trust in 2011/12. The Trust achieved significant reductions in both MRSA bacteraemias and Clostridium Difficile infections over the year and finished the year below the agreed maximum number of cases for both areas. This is the third year in succession which the Trust has reduced these infections.

The Trust recorded 4 cases of MRSA bacteraemias during 2011/12 against the contractual maximum number of cases which were 5 for the year. This represented a reduction of 33.3% from 2010/11 when 6 cases were reported (18 in 2009/10).

Total Clostridium Difficile infections reduced from 80 cases in 2010/11 to 63 cases in 2011/12 and were below the contractual maximum number of cases, which were 64 for the year.

Principal risks

In assessing the principal risks facing the Trust, the factors likely to impact the organisation’s operation were assessed. The key drivers of change, which the Trust believed would present both challenges and opportunities for the organisation, were identified. These are outlined below:

• Failure to provide consistently a high quality patient experience The Trust’s three year Quality Strategy focuses on the requirements to minimise avoidable deaths, reduce serious incidents and improve patient satisfaction levels. Additional outcome-based standards are being developed by clinical teams to encompass medical and team quality standards in addition to nursing standards. Outcomes are assessed through the divisional governance structures, linking across to the Assurance Committee and the Board

• Non-delivery of our targets and obligations The Trust manages this risk through its internal systems and processes which include regular reviews of performance by Executive Directors and with divisional teams. The outcomes of these reviews are incorporated in the Corporate Performance Report and the Monitor Quarterly Report, both of which are submitted to the Board. In addition, real-time monitoring of targets is undertaken through the Aintree Business Intelligence System.

• Inability to develop effective external partnerships We have responded to this through successful liaison and joint planning with commissioners (including Clinical Commissioning Groups), other NHS trusts and private providers. The Board discusses these partnerships on a monthly basis to ensure they align with the strategic vision of the Trust.

Annual Report & Accounts 2011/12 24 Aintree University Hospital NHS Foundation Trust

• Failure to invest in and develop our staff The recent restructuring of our clinical divisions and corporate departments and the introduction of local governance arrangements to manage risks at the divisional level, has led to a risk that, during the transitional period, managers will fail to manage the performance of their staff through effective appraisal and performance management with the consequent risk that staff are not managed and developed effectively.

The Trust will mitigate against this risk through the rollout and monitoring of COMPASS 2, our enhanced electronic appraisal and performance management system. This will enable us to ensure all staff receive an effective appraisal in 2012/13. In addition, minimum managerial standards are being developed for all levels of managers. We have already introduced a leadership development programme for Band 6 and 7 managers which has been well received and are developing a programme for Band 8s and above which will form part of the essential training for all managers in the Trust.

Annual Report & Accounts 2011/12 25 Aintree University Hospital NHS Foundation Trust

Financial Performance

The Trust has had a successful year, achieving an operational surplus of £3.6 million (1.3% of turnover). This represents an improvement of £2.3 million on the original plan, driven principally through increased activity. Earnings before interest, depreciation and amortisation (EBITDA) stand at £16.5 million and the EBITDA percentage is 5.9% against a plan of 5.6%.

During 2011/12, £5.5 million of restructuring costs were incurred to deliver the recurrent cost and efficiency savings of £10.5 million. Of this, £4 million was met through additional support from local commissioners, giving a net exceptional charge of £1.5 million.

In addition, NHS organisations have an obligation to ensure that the balance sheet value of their asset base is kept up to date with a full revaluation every 3 to 5 years. The last full valuation at Aintree was on 1 April 2009. Market conditions since that date have changed and a valuation was undertaken during 2011/12. The valuation was undertaken by Matthews & Goodman, with the final report received in January 2012. The outcome of the valuation was, as expected, a reduction in the value of our asset base and an exceptional net charge of £9.6m was recorded (in relation to an impairment of the holding value of the estate) in the Statement of Comprehensive Income. There was also a £1.3m increase in the value of assets recorded in the revaluation reserve.

Monitor’s Financial Risk Ratings (FRR) exclude both of these items from the operational position which results in a normalised operational surplus (for the purposes of our Regulator) of £3.6m (1.3% of turnover).

CapitaI expenditure totalled £7.2 million for the year and included the completion of the Sleep Laboratory development and investment in ward upgrades. Liquidity improved during the year as cash balances were committed to the capital programme, and the Trust drew down £5 million from the NHSFT Financing facility. Overall, the Trust reported a financial risk score of 3 against Monitor’s compliance framework which is in line with its annual plan submission for the year.

Income and Expenditure

Total income for the year was £278.1 million and was generated in the following areas:

Annual Report & Accounts 2011/12 26 Aintree University Hospital NHS Foundation Trust

Table 6: Total Income 2011/12

Operational expenditure budgets, before exceptional items, totalled £267.0 million and included the delivery of the Service and Financial Improvement Programme, (SFIP), of £10.5 million.

Overall, taking into account both income and expenditure the underlying financial health of the Trust provides a firm basis for the challenges we face in 2012/13 and beyond.

Financial and Operational Risk

There are a number of risks facing the Trust as it moves into 2012/13. The enactment of the Health and Social Care Bill will see a radical change in the commissioning landscape, with local GP Clinical Commissioning Groups (CCGs) taking over the majority of commissioning arrangements for secondary care. We are committed to working with CCGs to ensure the best possible health services are delivered in the most effective way and in the most appropriate settings. We remain confident of Aintree’s ability to work in partnership to help shape the future provision of health services in our community.

On the expenditure side, the impact of statutory and other legislation requirements, increased costs of new drug regimes and technologies, coupled with the requirement to achieve a 4.0% efficiency saving, places further pressure on the system as a whole.

Management of these risks will be achieved through the regular monitoring procedures currently in place. If any of these risks arise through the year, the Trust will introduce contingency plans in order to mitigate the financial impact.

Annual Report & Accounts 2011/12 27 Aintree University Hospital NHS Foundation Trust

Operationally, the Trust has identified the achievement of access times (18-week RTT, Cancer standards and the AED target), and infection control requirements (both C-Difficile and MRSA) as the main operational risks. The Trust is confident it can deliver on all these performance measures.

Private Patient Cap

In accordance with Section 44 of the National Health Service Act 2006, the Trust must not exceed its predetermined private patient cap. This is the proportion of income generated from treating patients to total patient related income compared with the proportion generated at the end of the 2002/03 financial year. Performance was as follows:

2011/12 2002/03(base year) £000 £000 Private Patient Income 553 712 Total Patient Related 242,256 111,823 Income Proportion as a percentage 0.23% 0.64%

Table 7: Private Patient Cap

The Trust stayed within its private patient cap.

Capital Investment

During 2011/12, the Trust invested £7.2 million against a planned capital programme of £10.1 million as follows:

Capital Plan Actual 2011/12 2011/12 £000 £000 Elective Care Centre 803 265 Radiology Expansion 385 846 UHA Outpatients 150 210 refurbishment Medical Equipment 1,646 1,145 Sleep lab development 1,155 1,133 Ward 4 upgrade 1,237 1,390 Surgical forward wait 931 932 Other 3,835 1,280 Total 10,142 7,201

Table 8: Capital Plan 2011/12

Annual Report & Accounts 2011/12 28 Aintree University Hospital NHS Foundation Trust

The capital programme was financed by a combination of the Trust’s own internally generated resources which were supplemented by the drawing down of £5 million from an approved loan organised with the Department of Health. The Trust had an approved prudential borrowing limit of £65.4 million of which £27.7 million has been taken.

Foundation Trust Borrowing Regime

This year has been the third in which the Trust has utilised its specific powers to borrow as identified within the Terms of Authorisation. A loan application was approved and £5 million was drawn down in 2011/12. Compliance against the Prudential Borrowing Code ratios is detailed in the table below:

Prudential Borrowing Regime Actual Ratios Approved 2011/12 PBL ratios 2011/12 Minimum Dividend Cover 3.7 >1 Minimum Interest Cover 14.0 >3 Minimum Debt Service Cover 7.0 >2 Minimum Debt service to 0.8% <2.5% Revenue

Table 9: Foundation Trust Borrowing Regime

Compliance against the Prudential Borrowing Code is an annual measure.

Working Capital Facility and Liquidity

As a Foundation Trust, it is expected that the Trust establishes a committed working capital facility to manage potential shortfalls in operational cash. During 2011/12, the Trust maintained its existing facility with the NatWest Bank which provides access to a £19.6 million committed facility. The Trust did not utilise the working capital facility during 2011/12.

In line with the Trust’s financial strategy, cash drawn against the loan has been matched to expenditure and the Trust’s cash balances have remained close to plan throughout the year as can be seen below:

Annual Report & Accounts 2011/12 29 Aintree University Hospital NHS Foundation Trust

Table 10: Working Capital Actual versus Plan 2011/12

Proactive Treasury Management and the Foundation Trust’s ability to invest excess cash on the financial markets (within the scope of an approved investment policy) generated £131K in interest which was used on patient care .

Events after the Reporting Period

There were no material events after the report period following submission of the 2011/12 accounts.

Going Concern Basis

After making enquires, the Directors have a reasonable expectation that the NHS Foundation Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts.

Audit Information

As far as the Directors are aware, there is no relevant audit information of which the auditors are unaware. The Directors have taken all of the steps that they ought to have taken as Directors in order to make themselves aware of any relevant audit information and to establish that the auditors are aware of that information.

Annual Report & Accounts 2011/12 30 Aintree University Hospital NHS Foundation Trust

Better Payment Practice Code

2011/12 2011/12 Number £000

Total Non-NHS Trade invoices paid in period 60,575 92,007 Total Non-NHS Trade invoices paid within target 56,851 86,244 Percentage of Non-NHS Trade invoices paid within 93.9% 93.7% target 2,628 32,653 Total NHS Trade invoices paid in period 2,487 31,550 Total NHS Trade invoices paid within target 94.6% 96.6% Percentage of NHS Trade invoices paid within target

Table 11: Better Payment Practice Code

The Better Payment Practice Code (BBPC) 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 the later. Towards the end of 2011/12, the Trust implemented a new procurement system and some early teething problems impacted on compliance against the BPPC. These issues have now been resolved, but the impact was to reduce 2011/12 compliance to just below the 95% target. No interest payments were made under the Late Payment of Commercial Debts (Interest) Act 1998.

Joint Ventures and Subsidiary Companies

In July 2007, the Trust established a wholly owned subsidiary company called Aintree Healthcare Limited. The purpose of this company is to provide community healthcare projects. As at 31 March 2012, the company had not commenced trading.

Monitor Compliance Regime

Monitor’s compliance regime requires a quarterly submission of financial and performance data which identifies the overall level of financial risk facing the Trust. The financial risk ratings are measured from ‘1’ (high risk) through to ‘5’ (low risk). The risk ratings for this Trust show us to be operating at a medium level of financial risk, a medium level of governance risk and a low level of mandatory service risk:

Annual Report & Accounts 2011/12 31 Aintree University Hospital NHS Foundation Trust

Annual Q1 Q2 Q3 Q4 Plan 2010/11 2010/11 2010/11 2010/11 2010/11 Financial Risk 3 3 3 3 3 Rating

Governance Risk Green Amber/Red Green Green Amber/Green Rating

Annual Q1 Q2 Q3 Q4 Plan 2011/12 2011/12 2011/12 2011/12 2011/12 Financial Risk 3 3 3 3 3 Rating

Governance Risk Green Amber/Red Amber/ Green Amber/ Rating Green Green

Table 12: Regulatory Risk Ratings

Key:

Financial risk rating 1 Highest risk - high probability of significant breach of authorisation in short term, e.g. less than 12 months, unless remedial action is taken. 2 Risk of significant breach in medium term, e.g. 12 to 18 months, in absence of remedial action. 3 Regulatory concerns in one or more components; significant breach unlikely. 4 No regulatory concerns. 5 Lowest risk - no regulatory concerns.

Governance risk rating (revised from 2010/11)

Red: concern that one or more issues significantly breaches authorisation. Amber-red: material concerns surrounding authorisation. Amber-green: limited concerns surrounding authorisation. Green: no material concerns.

Financial performance during 2011/12 has consistently been in line with the annual plan and the final risk rating for the year was a level of 3 which is deemed to be medium level risk with no increased level of reporting.

All financial monitoring returns were submitted on time and were complete and correct. The public dividend capital dividend was also paid in full on the due date.

Annual Report & Accounts 2011/12 32 Aintree University Hospital NHS Foundation Trust

During 2011/12, the Trust was rated ‘Amber/Red’ by Monitor in Q1 due to failing to meet the targets for C-Difficile, 62-day cancer wait from referral to first treatment and 62-day cancer wait from referral to first treatment screening services. In Q2 the rating improved to ‘Amber/Green’ as the Trust met its C-Difficile milestone target and improved to green in Q3 having met all targets. The Trust anticipates receiving an ‘Amber/Green’ rating for Q4, having failed to meet the 62-day cancer wait from referral to first treatment and the 62 Day Bowel Cancer Screening.

The Board of Governors appointed PricewaterhouseCoopers (PwC) LLP as external auditors of the Trust for a period of three years (commencing 1 April 2007) with an option to extend by a further two years. This option has been exercised and PWC remain the Trust’s auditors for 2011/12. The fee for the audit of the financial statements and the quality report for 2011/12 was £66K. PricewaterhouseCoopers LLP will also undertake the audit of the Trust’s Charitable Funds.

Private Finance Transactions

Private Finance Initiative (PFI) schemes are deemed to be either off or on Statement of Financial Position. The Trust had one PFI scheme, a renal dialysis unit which has previously been deemed on-Statement of Financial Position. However, the primary period of this contract has now ended and, consequently, the contract is no longer classified as on-SOFP. In addition to this change, the sterile services PFI contract has also been reclassified outside of the scope of PFI.

Renal Dialysis Unit

The original contract commenced on 13 April 2005 and was due to end on 12 April 2012, however, a 3-year extension (to 12 April 2015) has been agreed with the Contractor. The scheme involves the provision of a fully staffed and serviced renal dialysis unit which provides dialysis for NHS patients under the care of NHS Doctors. At the end of the contract period, if the service contract is not renewed or passed to another operator, the Trust is committed to acquiring the assets at the written down value from the private sector operator (estimated at £360K). For the first seven years of this contract, the equipment inherent in the service was valued, added to the SoFP and depreciated over the seven year life of the contract. As the contract has entered an extension period with all of the equipment risk falling to the service provider, the service is no longer classified as an on-SoFP PFI.

Sterile Services

The original contract commenced on 24 April 1998 and is contracted to end on 31 July 2013. That contract involved the provision of sterile services for theatre instrumentation from a facility on the Trust site which has been substantially refurbished by the private sector operator in order to comply with the latest standards for sterile instrument processing. However, in July 2011 the service was transferred by the Operator to an existing off-site facility which is used to provide services to a

Annual Report & Accounts 2011/12 33 Aintree University Hospital NHS Foundation Trust

number of other contractors. The significant contractual and service changes resulting from this move have lead to a revision in how the contract is classified and, consequently, the service is no longer classified as PFI.

Improving Efficiency

For 2012/13 NHS provider organisations will receive an embedded reduction of - 1.8% on prices for the forthcoming year and are expected to meet a further 2.2% in pay and price inflation within existing resources. As a result of this, the Trust has a cost improvement target of 4.0%, which equates to £10.2 million for the year.

Accounting Policies

The Trust’s significant accounting policies are set out from page 200 of the full accounts included in this report. There were only minor changes made to the accounting policies and all of the changes implemented were in line with the Foundation Trust Annual Reporting Manual (FT ARM). A change in the national accounting policy for donated assets and government grants resulted in a prior year adjustment which is explained in Note 1 of the Annual Accounts.

Accounting policies for pensions and other retirement benefits are set out in a note to the accounts (note 1.3) and details of senior employees’ remuneration can be found on page 173 of the Remuneration Report.

Compliance with HM Treasury Policy

Aintree University Hospital NHS Foundation Trust has complied with the cost allocation and charging requirements set out in HM Treasury and Office of Public Sector Information Guidance.

Annual Report & Accounts 2011/12 34 Aintree University Hospital NHS Foundation Trust

Equality of Opportunity

The Trust is committed to promoting Equality, Diversity and Human Rights and continues to make good progress in ensuring that the workforce and services meet the needs of all groups. This is central to the Trust’s vision, values and behaviours and fully supported by the Board of Directors.

The Trust has reviewed its governance structures and includes equality and diversity as an important area of work to be effectively performance managed. The Trust’s Director of Nursing & Patient Safety continues to be the Chair of the Equality, Diversity and Human Rights Group (EDHR) supported by the Head of Equality and Diversity. The Board received an annual report on equality and diversity in June 2011.

During 2011/12, the Trust has undertaken a wide range of actions across a number of key areas and some of these are highlighted below:

• A successful week long Diversity Festival “Time to Celebrate – It’s All About You” held in May 2011 as part of promoting equality and diversity. Staff, patients, carers and community groups across the protected groups took part in the festival. Many organisations including NHS partner trusts, Unison and local businesses sponsored the festival. • The Chaplaincy, E&D Department, and Promoting Arts in Aintree (PARTIA), completed a faith wall project as part of enhancing patient experience. The project was part of celebrating the Trust Diversity Festival. • “Listening to You Events” regarding Quality Accounts priorities were held across the 3 Borough’s involving the Local Involvement Networks (LINks) and representative groups and organisations • A Graffiti Wall was set up and proved to be a popular way of obtaining ideas and suggestions from staff, patients, and community about improving patient experience. • A Religious and Cultural Festivals Calendar has been widely distributed. At the request of a member of staff, Pagan festivals were also included in the calendar. • The Disability History Month was marked by a Poetry Workshop and an exhibition and there were a huge number of contributions from patients and staff.

The Trust welcomed the new Equalities Act 2010 and adopted the national NHS Equality Delivery System (EDS) as a framework for improving equality performance, embedding equality into the mainstream business planning processes and activities. The Trust EDS performance was assessed by LINks as overall “developing”. In line with the Equality Act 2010, the Trust has published Equality Analysis Information, including proposed Equality Objectives for 2012/13, in the public domain.

The Trust is developing a Community Engagement Strategy which will strengthen the Trust’s work in community consultation and participation. Meanwhile, we will

Annual Report & Accounts 2011/12 35 Aintree University Hospital NHS Foundation Trust

continue to build strong partnerships with our key stakeholders including our staff, patient representatives, Trust members and Governors. The Trust endeavours to ensure its Foundation Trust membership is reflective of the population served:

The Trust has also continued to develop strong partnerships at local and regional levels with disability organisations. In particular, the Learning Disability Facilitators representing Liverpool, Sefton and Knowsley have played a valuable role in providing immediate and responsive care for patients and carers. The Trust’s resources for catering for patients with learning disabilities continue to be used by members of staff and a carers’ policy has been developed and implemented. The Trust Equality & Diversity Advisor who specialises in disability issues also supports staff and patients with disability-related queries.

The Trust is committed to providing healthcare services that are appropriate and culturally sensitive and, in this regard, profiles groups that are accessing healthcare services. The table below shows the diversity of patients who choose to be treated by the Trust.

elective in non patient elective day cases ETHNIC CATEGORY % % % WHITE - BRITISH 87.17 94.45 89.56 NOT STATED / UNKNOWN 9.22 2.91 6.77 WHITE - ANY OTHER WHITE BACKGROUND 1.73 1.22 2.31 WHITE - IRISH 0.44 0.36 0.26 OTHER ETHNIC GROUP - ANY OTHER 0.25 0.34 0.19 OTHER ETHNIC GROUP - CHINESE 0.30 0.14 0.23 ASIAN OR ASIAN BRITISH - INDIAN 0.12 0.12 0.19 ASIAN OR ASIAN BRITISH - BANGLADESHI 0.08 0.08 0.07 ASIAN OR ASIAN BRITISH - OTHER ASIAN BACKGROUND 0.18 0.08 0.09 ANY OTHER MIXED BACKGROUND 0.07 0.07 0.05 BLACK OR BLACK BRITISH - OTHER BLACK BACKGROUND 0.08 0.07 0.04 BLACK OR BLACK BRITISH - AFRICAN 0.09 0.04 0.06 ASIAN OR ASIAN BRITISH - PAKISTANI 0.06 0.03 0.03 BLACK OR BLACK BRITISH - CARIBBEAN 0.04 0.03 0.05 WHITE AND BLACK AFRICAN 0.04 0.02 0.04 WHITE AND ASIAN 0.06 0.02 0.03 WHITE AND BLACK CARIBBEAN 0.08 0.01 0.02 TOTAL 100.0 100.0 100.0

Table 13: Ethnicity Profile of Groups Accessing Healthcare (%)

Annual Report & Accounts 2011/12 36 Aintree University Hospital NHS Foun dation Trust

elective in patients non elective day cases MALE 52.92% 48.31% 49.40% FEMALE 47.07% 51.67% 50.60% TOTAL 100.00% 100.00% 100.00%

Table 14: Gender of Patients April 2011 to March 2012

The Trust has a comprehensive Interpretation and Translation service (ITS). To further enhance the ITS, the Trust is developing a Sign translate facility to meet the needs of deaf users and carers. We plan to roll out this provision throughout the wards wi thin the Hospital following a pilot study . During the course of the year , a wide range of languages were accessed by patients and carers as shown in the chart below:

Figure 2: Languages Requested - August 2011-March 2012 (Interpretation & Translation Service)

The Hospital Chaplaincy Department represents a range of diverse faiths and believes that religious and spiritual needs a re part of a holistic approach to patient care. When required, t he department provides support to patients, their relatives and friends and staff, whether or not they profess a faith or belief.

The Learning and Development team provides regular reports which are available to managers on staff compliance with mandatory training. Equality & Diversity Training is being reviewed through these reports and this will inform the updated training plan. The Trust’s appraisal system , COMPASS, provides an opportunity for staff to

Annual Report & Accounts 2012011/12 37 Aintree University Hospital NHS Foundation Trust

discuss with their manager their performance and to identify any areas of development.

The Trust continues to build an inclusive workforce and ensures that equality and diversity is central to the Trust’s employment policies and practices. We continue to work towards achieving a culture that ensures staff are treated with dignity and respect, by promoting the Trust’s values and behaviours and by challenging any form of discrimination. We have several Bullying and Harassment officers from diverse backgrounds who act as a contact for staff. The Trust also has a Black & Minority Ethnic (BME) Staff Network which meets on a regular basis and is open to all members of staff within the Trust.

The Trust’s workforce profile is published on the Trust website and a range of information is produced and analysed to highlight any disparities and identify where improvement needs to be made. Summary details of the Trust’s workforce profiles are at Table 15 overleaf.

Annual Report & Accounts 2011/12 38 Aintree University Hospital NHS Foundation Trust

Staff Staff Membership Membership Category 2010/11 % 2011/12 % 2010/11 % 2011/12 % AGE 0-16 0 0 0 0 6 0.08 12 0.13 16-20 9 0.2 8 0.18 93 1.22 268 2.91 21-25 364 7.91 301 6.81 294 3.84 560 6.09 26-30 529 11.49 500 11.31 291 3.8 470 5.21 30-35 514 11.16 485 10.97 224 2.93 425 4.62 36-40 577 12.53 569 12.87 269 3.51 424 4.61 41-45 664 14.42 591 13.37 324 4.23 474 5.15 46-50 718 15.6 723 16.35 470 6.14 618 6.72 51-55 630 13.68 615 13.91 503 6.57 611 6.64 56-60 411 8.93 434 9.82 532 6.95 629 6.84 61-65 174 3.78 183 4.14 621 8.11 683 7.43 66+ 14 0.3 12 0.27 2474 32.32 2471 26.87 Not stated 0 0 0 0 1553 20.29 1543 16.78 Total 4604 100 4421 100 7654 100 9197 100 ETHNICITY White 4247 92.25 4073 92.13 5293 70 6859 74.6 Mixed 19 0.41 22 0.50 9 0.1 27 0.30 Asian or Asian 226 4.91 205 4.64 50 0.7 178 1.9 British Black or Black 62 1.35 59 1.33 21 0.3 103 1.1 British Other 50 1.09 62 1.4 21 0.27 36 0.39 Not stated 0 0 0 0 2260 29.53 2158 23.46 Total 4604 100 4421 100 7654 100 9197 100 GENDER Male 1047 22.74 992 22.44 2493 32.57 2762 30.03 Female 3557 77.26 3429 77.56 5043 65.89 6302 68.52 Transgender 0 0 0 0 0 0 0 0 Not stated 0 0 0 0 118 1.54 133 1.45 Total 4604 100 4421 100 7654 100 9197 100 RECORDED 34 33 9 12 DISABILITY

Table 15: Equality and diversity: staffing and membership profile 2010/11 and 2011/12

Annual Report & Accounts 2011/12 39 Aintree University Hospital NHS Foundation Trust

Aintree University Hospitals NHS Foundation Trust - Staff in Post - 31st March 2012 (FTE)

Prof/Tech/Scient Admin & Clerical 733.13 702.05 19% 19%

Ancillary 371.86 10%

Clin/Specialist Manager 46.05 1% General Manager 51.88 1% Maintenance Medical 47.20 Nursing 373.76 1% 1459.51 10% 39%

Figure 3: Staff in Post to 31 March 2012

Aintree University Hospitals NHS Foundation Trust - Staff in Post 31/03/2012 (headcount) Black and Minority Ethnic Staff Breakdown Mixed - White & Black Mixed - White & Black African Not Stated Caribbean 3% 7% 0% Mixed - White & Asian Mixed - Any Undefined 1% other mixed Chinese 1% background 3% 1% Black or Black British - Any other Black backgroun 1% Any Other Ethnic Group 8%

Black or Black British - African 15% Asian or Asian British - Indian 49%

Black or Black British - Caribbean 1%

Asian or Asian British - Any other Asian or Asian British - Asian backgroun Bangladeshi 5% 1% Asian or Asian British - Pakistani 4%

Figure 4: Staff in Post to 31 March 2012 (Black & Minority Ethnic Staff Breakdown)

Annual Report & Accounts 2011/12 40 Aintree University Hospital NHS Foundation Trust

The Trust welcomes complaints from all sections of the population and has a Comments, Concerns, Compliments and Complaints (the ‘4Cs’) procedure in place which is reported on a quarterly basis to the Board of Directors. The procedure is available in an accessible format on request and any information received relating to the 4Cs is recorded by ethnicity, wherever possible (see Table 16 below). It is recognised that there are some sections of the population where more work will be done to ensure that everyone regardless of their background are able to express their opinions. Number of 4Cs Patients Patient Ethnicity

Compliments 201 not stated

3 white - British

Comments 80 not stated

Concerns 669 white - British

106 not stated

7 other ethnic category

1 white - Irish

2 any other white

Complaints 239 white - British

32 not stated

1 any other white

Table 16: Patient ethnicity breakdown of the 4Cs

Patient Experience Questionnaires (PEQs) continue to be collected and monitored in order to improve services for all sections of the community. The Trust uses a range of information to improve patient experience including findings from internal and external inpatient and outpatient surveys including LINks visits which this year covered a review of the Trust’s Discharge arrangements.

In order to ensure any developments and opportunities to improve patient experience are dealt with effectively, the Trust has set up two key groups, the Patient Experience Sub-Committee, chaired by the Director of Nursing & Patient Safety, which reports to the Board, and the Patient Experience Group, whose members include service users, carers and representatives of LINks. Both groups focus on the delivery of the Trust’s Patient Experience & Engagement Strategy and the Customer Services Charter.

Annual Report & Accounts 2011/12 41 Aintree University Hospital NHS Foundation Trust

Staff Engagement

Statement of Approach to Staff Engagement

The Trust has continued to maintain strong partnership working with its trade union partners at both a strategic and operational level through the formal Staff Partnership Group and the Local Negotiating Committee for medical and dental staff. In addition, we have worked in close collaboration with our staffside colleagues on a number of major service restructures such as the introduction of electronic patient records (EDMS) which has resulted in our being able to achieve major service redesign and significant cost savings whilst successfully redeploying the displaced staff. We also have a jointly funded post to maximise our ability to offer apprenticeships to local people and we have achieved national recognition for this scheme.

We have regular informal partnership meetings and have given dedicated facility time to both our local staffside Chair (Unison) and the lead Royal College of Nursing representative and they are actively working with us in partnership to plan and implement workforce changes.

The Trust took the decision to delay the 2011 round of annual appraisals using COMPASS our electronic appraisal system, to allow for further development of the system to improve usability and include individual objective setting aligned to the Trust corporate objectives and mandatory training records. This delay has resulted in there being a significant drop in the rate of appraisal which is reflected in our staff survey results for 2011 (see Table 17 below). The new system and process, however, is now ready for use and appraisals are being carried out again.

We recognised the need to revise our approach to ensure greater staff involvement and inclusion and have been developing a new Engagement Strategy and action plan to give individual stakeholders greater involvement in developing our services and policies. To enable this, we have restructured our clinical divisions placing a much greater emphasis on Clinical Leadership and engagement. We have also introduced a Workforce Sub Committee of the Board of Directors which has agreed the principles for future workforce engagement and this will be rolled out in 2012.

2010/11 2011/12 Trust Improvement/Deterioration Response Trust National Trust National rate Average Average 45% 52% 44% 52% 1% deterioration

Table 17: Summary of performance – Results from the NHS Staff Survey 2011/12

Annual Report & Accounts 2011/12 42 Aintree University Hospital NHS Foundation Trust

2010/11 2011/2012 Trust Improvement/ Deterioration

Top 4 Ranking Trust National Trust National Scores Average Average

KF22 3.48% 3.45% 3.53% 3.46% 0.05% improvement compared with the Fairness and 2010/11 survey (0.7 effectiveness of better than national incident average for acute reporting trusts) procedures

KF30 30% 26% 31% 26% 1% improvement in Percentage of percentage points staff reporting compared with the good 2010/11 survey(5% communication better than national between senior average for acute management trusts) and staff

KF37 91% 90% 92% 90% 1% improvement in Percentage of percentage points staff believing compared with the the trust 2010/11 survey (2% provides equal better than national opportunities for average for acute career trusts) progression or promotion

KF26 11% 15% 14% 16% 3% deterioration in Percentage of percentage points staff compared with the experiencing 2010/11 survey (2% harassment, better than national bullying or average for acute abuse from staff trusts). in last 12 months

Table 18: Summary of the Top 4 Ranking Scores (Staff Survey 2011/12)

Annual Report & Accounts 2011/12 43 Aintree University Hospital NHS Foundation Trust

2010/11 2011/12 Trust Improvement/ Deterioration

Bottom 4 Trust National Trust National Ranking Average Average Scores

KF 12 80% 78% 55% 81% 25% deterioration in Percentage of percentage points staff appraised compared with the in last 12 2010/11 survey. months KF 14 67% 66% 43% 68% 24% deterioration in Percentage of percentage points staff appraised compared with the with personal 2010/11 survey. development plans in last 12 months

KF 18 30% 28% 33% 29% 3% deterioration in Percentage of percentage points staff suffering compared with the work-related 2010/11 survey. stress in the last 12 months

KF 20 36% 37% 40% 34% 4% deterioration in Percentage of percentage points staff witnessing compared with potentially 2010/11 survey. harmful errors, near misses or incidents in last month

Table 19: Summary of the Bottom 4 Ranking Scores (Staff Survey 2011/12)

Prior to and during the 2011 National Staff Survey period, Aintree used a number of different methods to increase the response rate of the staff survey.

Different options for the delivery of the 2011 staff survey were used to ensure that staff received the survey. The initial survey and first reminder was distributed to payslip addresses via internal mail. The second reminders were distributed by line managers directly to staff on wards and departments. There was also extensive promotion of the survey through Trust media, via hard copy posters and flyers and the weekly staff electronic newsletter. Managers were contacted throughout the survey period with requests to encourage staff to complete the survey. Staff who

Annual Report & Accounts 2011/12 44 Aintree University Hospital NHS Foundation Trust

completed and returned their survey were included in a confidential prize draw conducted by our external survey administrator for the opportunity to win one of 10 prizes of £100 of high street shopping vouchers.

To encourage competition to increase response rates, league tables of divisional response rates were produced and distributed on a weekly basis throughout the survey period. Where possible, clinical business unit response rate league tables were also produced and distributed.

In the 2011 survey, when compared to all other acute Trusts, out of the 38 Key Findings Aintree was above average in 15 key findings, average in 8 key findings and below average in 15 key findings.

In comparison to the 2010 staff survey results for Aintree staff, in 2011 there had been no statistically significant change in 35 key findings. Three key findings had deteriorated since 2010.

The 4 key findings where Aintree compared most favourably with other acute trusts in 2011 were:

• Fairness and effectiveness of incident reporting procedures

In this area, Aintree’s score has improved since 2010 and was in the best 20% compared with other acute trusts.

This key finding assesses the culture of incident reporting in trusts. The scale measures the extent to which staff are aware of the procedures for reporting errors, near misses and incidents, to what extent they feel the Trust encourages such reporting and then treats the reports fairly and confidentially and to what extent the Trust takes action to ensure that such incidents do not happen again

• Percentage of staff reporting good communication between senior management and staff

In this area, Aintree’s score has improved since 2010 and is better than average compared with other acute trusts in 2011.

This key finding measures the number of staff who agree or strongly agree with at least 4 of the following statements “ senior managers here try to involve staff in important decisions ”, ”communication between senior management and staff is effective ”, “senior managers encourage staff to suggest new ideas for improving services ”, “I know who the senior managers are here ”, “Healthcare professionals and managers in non-clinical roles work well together in my area of work ” and “senior manages act on staff feedback ”.

Annual Report & Accounts 2011/12 45 Aintree University Hospital NHS Foundation Trust

• Percentage of staff believing the trust provides equal opportunities for career progression or promotion

In this area of questioning, Aintree’s score has improved since 2010 and is better than average compared with other acute trusts in 2011

This key finding measured the extent to which staff said their trust acts fairly with regards to career progression/promotion regardless of ethnic background, gender, religion, sexual orientation, disability or age.

• Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months

In this area, Aintree’s score has deteriorated since 2010 but is better than average compared to other acute trusts in 2011.

This is the percentage of staff who, in the previous 12 months, had experienced harassment, bullying of abuse from colleagues or managers.

Areas where the staff survey identified staff experience has improved

The CQC staff survey report did not identify any areas where there had been statistically significant improvement in staff experience since the 2010 survey.

There were, however, 14 key findings where there were slight improvements in the Aintree score since the 2010 survey.

Local surveys and results

During 2011, in addition to the National Staff Survey, the Trust also undertook a safety attitude questionnaire to measure the safety culture of Aintree hospital staff who work in clinical environments. This involved 1800 short questionnaires being sent out across 41 departments. This survey achieved a response rate of 63%.

The themes the survey covered were teamwork, safety, morale/job satisfaction, stress recognition, perceptions of hospital management, working conditions. The results of this survey were received in November 2011 and were available at ward and department level. Action plans were produced at ward level to address the findings of the survey.

Areas of concerns and action plans to address these

Following a review of the results of the 2011 staff survey, the Trust has produced an action plan for Board approval based on areas in the staff survey where Aintree scores were significantly worse than other acute trusts or where the score has deteriorated since 2010.

Annual Report & Accounts 2011/12 46 Aintree University Hospital NHS Foundation Trust

The action plan will be monitored on a regular basis by the Improving Working Lives Management Group.

Action points which relate to areas of concern contained in the action plan are detailed below.

• Response rate

The response rate from Aintree staff in the 2011 staff survey was in the lowest 20% compared to all other acute trusts.

Actions identified against this point within the 2012/2013 staff survey action plan are:

“Lunch and learn” events for staff to find out about the value of completing the survey and actions taken from staff survey results in the past
Bespoke letter attached to all staff surveys on the benefit of completing the survey
Provision of response rates to Divisions during survey period
Weekly articles in All About Aintree during survey period including “myth busting” and promotion of actions taken from results of past surveys
Promotion of staff survey within Divisions through senior managers
Staff survey intranet page updated through survey period and promotion on home page
Promotion of staff survey in conjunction with the Trust flu campaign
All Trust staff to be surveyed in 2012 to give this a higher priority

• Percentage of staff appraised in the last 12 months with a well structured appraisal and a PDP

In the 2011 survey, Aintree’s scores in the 3 areas covering having an appraisal within the previous 12 months, the appraisal being well structured and being appraised with a personal development plan were all in the worst 20% of acute trusts and had significantly deteriorated since 2010.

Actions identified against this point within the 2012/2013 staff survey action plan are:

Re-launch of COMPASS appraisal system
Monthly reporting of COMPASS compliance figures to Board.
Electronic monitoring of completion of PDPs. Completion levels reported to Board and made available to all staff levels within the Trust

• Percentage of staff suffering work related stress in the last 12 months

In the 2011 survey, Aintree’s score was in the worst 20% compared to all other acute trusts. Actions identified against this point within the 2012/2013 staff survey action plan are:

Annual Report & Accounts 2011/12 47 Aintree University Hospital NHS Foundation Trust

Promotion of the new Employee Assistance programme including access to 24 hour telephone counselling
Promotion of Trust counselling service
Stress management guides provided through All About Aintree
Resilience training to be included in Band 6/7 Leadership Training Programme.
Links provided for managers who attend band 6/7 training to enable cascade of resilience training to their staff

• Staff motivation to work

In the 2011 survey, Aintree’s score was in the worst 20% compared to all other acute trusts.

Actions identified against this point within the 2012/2013 staff survey action plan are:

Focus groups to explore issues of staff motivation
Distribute internal electronic survey though Trust media to identify specific concerns regarding motivation
Feedback to Divisions on results of focus groups and internal survey results
Divisional specific action planning to address areas of concern regarding motivation

• Percentage of staff witnessing potentially harmful errors, near misses or incidents in the last month

In the 2011 survey, Aintree’s score was in the worst 20% compared to all other acute trusts.

Actions identified against this point within the 2012/2013 staff survey action plan are:

Review analysis of reported incidents by divisions to identify main types of errors, near misses or incidents occurring.
Production of action plans to reduce errors, near misses and incidents from analysis of incidents provided to Divisions through Safety and Risk Sub Committee
Conduct focus groups with staff and ward patient safety officers across the Trust for input on ways to reduce errors, near misses and incidents
Raise profile of monthly Patient Safety Newsletter to increase staff awareness of safety issues and lessons to be learned

Annual Report & Accounts 2011/12 48 Aintree University Hospital NHS Foundation Trust

• Percentage of staff using flexible working

In the 2011 survey, Aintree’s score was in the worst 20% compared to all other acute trusts.

Actions identified against this point within the 2012/2013 staff survey action plan are:

Analysis of ESR data to identify number of part time staff
Promotion of Flexible Working Policy through Trust Media
Focus groups to identify possible concerns regarding flexible working

• Percentage feeling pressure in last 3 months to attend work when feeling unwell

In the 2011 survey, Aintree’s score was in the worst 20% compared to all other acute trusts.

Actions identified against this point within the 2012/2013 staff survey action plan are:

Use of flyers, and intranet on how work can be good for you.
Promotion of lifestyle health assessments
Monitoring of recommendation of phased return to work

Policies in relation to disabled employees and equal opportunities

• Policy for Supporting Staff with Disabilities – aims to provide a framework for good practice relating to the employment of people with disabilities which complies with relevant legislation

• Attendance Management Policy – provides information in relation to support and fair treatment of sick employees with the necessity to take account of any sickness related to disability. The Line Managers Toolkit for Managing attendance supports this policy and provides detailed guidance in relation to the management of sickness for staff who have a disability.

• All Trust Policies contain an equality diversity and human rights statement and are required to undergo an equality impact assessment prior to publication.

Actions taken by the Trust to maintain/develop the provision of information to, and consultation with employees

• Trust media - All about Aintree (weekly electronic bulletin), team brief (monthly bulletin), Aintree News (quarterly) Trust intranet

Annual Report & Accounts 2011/12 49 Aintree University Hospital NHS Foundation Trust

• Staff Partnership Group – formal forum held every two months to enable management and staff side representatives to consult on areas related to employee relations

• Informal HR/staff side monthly meeting – informal meetings to allow for timely discussion between management and staff side representatives on areas of employee relations.

• Team Brief meeting – cascade of meeting from executive to local team level to enable discussion of issues identified in the team brief bulletin and executive team brief plus discussion of local issues.

• Local Negotiating Committee – quarterly formal forum for management and elected medical representatives to consult on issues relevant to medical staff at Aintree.

Occupational Health Service

The Occupational Health Services (OHS) are delivered from a purpose built Health Work and Well-being Centre. The centre affords excellent, fully accessible accommodation and has dedicated car parking to the rear of the building for service users.

The OHS is delivered Monday to Friday between 8.30am and 4.30pm, although flexibility for early or late clinics / walkabouts is offered to accommodate night staff or campaigns such as the flu vaccination programme.

The Trust Intranet page provides information about the OHS, health events, guidance or health issues. Additionally an external facing Health Work and Wellbeing website is currently being updated to include organisational password protected pages which outline the specific services available to staff.

The OHS Clinical and Strategic Lead is provided by an in-house Consultant who is an Accredited Specialist in OH Medicine with service management provided by a Clinical Nurse Specialist in OH. The OH team has a comprehensive skill mix and includes:

Annual Report & Accounts 2011/12 50 Aintree University Hospital NHS Foundation Trust

Nursing Clinical Nurse Specialist OH Occupational Health Nurse Occupational Health Technician Medical Consultant Occupational Physician Admin & Clerical Office Supervisor/Admin Team Management Occupational Health Manager Business Administrator

Table 20: Occupational Health Team

To promote service continuity and delivery, dedicated named nurses are allocated to each Division within the Trust.

A significant success during 2011-2012 was the flu campaign, with the best ever year with an uptake of 71.7% which placed Aintree in the top 20% of Trusts nationally. This was achieved by having regular drop-in clinics at various locations within the Trust, a large number of flu link nurses based within wards and departments, ward and department visits, flexible hours to accommodate night and weekend staff combined with a joint advertising campaign with the Trust Communications Team.

2011 saw the introduction of a web based online management referral system. This speeds up the entire process from referral to receipt of the report which, in turn, assists in the reduction of prolonged absence from work. The referring manager is able to track the referral which provides them with up to date information that may assist their management of the employee; the report can also be viewed by the respective HR link as provided by the manager.

In addition to the core OHS, which include new employee health assessments, management referrals and immunisation / vaccination programmes, other services offered to staff from the Health Work and Well-being (HWWB) Centre are physiotherapy, counselling, lifestyle health assessments, alternative therapies, weight management programmes, smoking cessation and alcohol support services.

As a result of an analysis of referral reasons to OHS, a competitively priced Employee Assisted Programme was commissioned and introduced for employees of Aintree University Hospital in early 2012.

Aintree has, during the past year, been working towards Safe Effective Quality Occupational Health Service (SEQOHS) accreditation and are currently awaiting a date for assessment.

A range of comprehensive guidance leaflets, advice notes and protocols and policies are available to staff in either paper (available via the HWWB centre, trust induction and strategic points within the Trust) or in electronic format via the Trust Intranet.

Annual Report & Accounts 2011/12 51 Aintree University Hospital NHS Foundation Trust

Sickness Absence

The sickness level average for 2011/12 was 4.60% compared to an average of 4.89% in 2010/11, as shown in Figure 4 below:

Quarterly Sickness Absence - 01/04/2010 - 31/03/2012 5.50 %

5.23 % 5.25 %

5.00 % (2010/2011 Year = 4.89 % ) 4.82 % 4.72 % 4.72 % 4.72 %

(2011/2012 Year = 4.60 % ) 4.50 % 4.39 %

4.15 %

4.00 %

3.50 %

3.00 % Quarter 1 Quarter 2 Quarter 3 Quarter 4 April 2010 / March 2011 2010/2011 April 2011 / March 2012 2011/2012 Figure 5: Quarterly Sickness Absence Data 2010 - 2012

Annual Report & Accounts 2011/12 52 Aintree University Hospital NHS Foundation Trust

Patient and Public Involvement

This year, the Customer Services Department has supported changes in the way complaints are managed. The Clinical Divisions have taken local ownership of their complaints and investigate these locally, putting in place local improvement plans to address shortfalls in care.

The Trust also invested in complaint handling and investigation training for all its managers which was delivered and facilitated by the National Complaint Management Group in June 2011. The Policy for the Management, Investigation and Resolution of Complaints and Concerns was revised and the new complaints process came into operation on 1 July 2011. As part of the new process, digital recording of all formal complaints meetings was introduced. This provided the Customer Service Officers and complainants with an accurate record of their meetings in a timely and efficient manner.

The inaugural meeting of the Patient Experience Sub Committee was held on 24 November 2011. Its aim is to offer assurance to the Board of Directors that the Organisation is actively enhancing patient services in response to user views. It provides a forum to debate patient experience with Aintree staff, Trust Patient Governors and representatives from partnership organisations, such as LINks. The role of the Sub Committee is in part to ratify new and existing patient experience policies, ensure that the organisation is aware and responds to national and local patient experience initiatives, establish performance indicators and monitor these on behalf of the Board of Directors reporting through the comments, compliments, concerns and complaints, the “4Cs” report. The Patient Experience and Engagement Strategy (2011) and the Patient Charter (2011) were both approved at the inaugural meeting of the Patient Experience Sub Committee in November.

The Trust has a number of different procedures and data capturing mechanisms in place for obtaining patient feedback. Some of the main patient feedback mechanisms are:

• The Patient Experience Questionnaire (PEQ) • Exit Cards for patients to complete on discharge • 'Have I Made a Difference?' cards (HIMAD) • Patient Stories • Graffiti Wall • Focus Groups

The Exit Cards are given to patients preparing for discharge asking three questions:

• What did we do well? • What could we do better? • Would you recommend the service to others?

Annual Report & Accounts 2011/12 53 Aintree University Hospital NHS Foundation Trust

The feedback enables ward staff to make the changes highlighted.

Patient and Carer stories have been shared in a variety of ways; through the use of poetry, presentations at the Board of Directors, as part of a teaching programme about the care of older people, and at complaint and being open meetings.

Introduction of a graffiti wall has enabled staff to have a greater understanding of their patients’ needs. This approach allowed patients, relatives, visitors and staff to record their comments, feelings and suggestions about the service that they received and experienced within specific wards and departments.

The Trust’s external website includes a Patient and Public Involvement page identifying that the Trust obtains feedback on its services from people through:

• Trust Membership • LINks representatives attend Board meetings • Focus Groups • Board of Governors • Volunteer Work Programme • Patient Experience Surveys • Patient Comment and Suggestion Leaflets • Patient Opinion Website

The Trust set a target to increase by 20% the number of patients who rate their experience as good or excellent by March 2012 based on the October 2009 baseline of 69%. We achieved 94.69% rating, 5.69% above the trajectory target for March 2012.

The Board of Directors regularly reviews patient feedback through the “4Cs” quarterly report, introduced at the beginning of 2011. This report details the comments, compliments, concerns and complaints received and associated service changes and lessons learnt by the Trust. The Board of Directors, Patient Governors and Divisions receive and review the 4Cs report quarterly. Ward Nurse Managers now have access to electronic `real time’ feedback from their patients through the Aintree Business Intelligence System (ABI).

A close working relationship has developed with the local LINks providing regular patient experience feed back to the Trust. This has been through their “Enter and View” visits during April and October 2011. On a monthly basis, LINKs provide valuable feedback from patients and visitors visiting their stand, situated in the Elective Care Centre and, more recently, the discharge lounge. LINks reports are discussed at the Patient Experience Sub Committee on a bi-monthly basis.

In total, 2,356 in-patients have participated in the Trusts Patient Experience Questionnaire, 94.69% rated their experience as good or excellent, 96.77% recorded

Annual Report & Accounts 2011/12 54 Aintree University Hospital NHS Foundation Trust

they would choose to come to Aintree again and 97.2% said they would recommend Aintree to their family or friends.

The Trust makes every effort to ensure that lessons are learned from patient feedback through a variety of initiatives:

• Business cards have been introduced for patients to give them a contact point to discuss any ‘worries and or concerns’ they may have during their hospital admission and on discharge. The cards contain details of a member of ward staff with whom patients and relatives can discuss any concerns and encourage them to be involved in decisions about their treatment and care. • All patients discharged during August 2011 received a letter from the Chief Executive highlighting the forthcoming National Inpatient Picker Survey, encouraging people to respond because this will inform the actions to improve patient care • A fridge magnet was included in every patient’s discharge medications (TTOs), together with a lime green sticker both of which highlighted the common side effects of medicines and a contact `help line’ number if they have any worries or wanted any further advice. • Within the Accident & Emergency Department, red privacy and dignity signs are used to secure the curtains during examination. Further work is ongoing around a dignity’ observation of care’ exercise and badges are provided for domestic staff/volunteers to encourage patients to ask if they have any concerns. • Senior nurses carried out a `patient telephone’ follow-up call after discharge from hospital within a 1-5 week time scale. The purpose of the trial was to improve the overall patient experience by providing an opportunity for patients to reflect on their experience and to ask any outstanding questions relating to their hospital stay.

Customer Service (PPI) Audit

RSM Tenon, Internal Auditors, conducted a Customer Services and Patient Experience function audit in April 2011. The Department received an ‘Amber/Green’ rating with a recommendation to implement the Patient Experience and Engagement Strategy. This has now been reviewed by the Chief Executive and the new Trust values and behaviours have been added to the strategy which was approved in November 2011.

Aintree Volunteer Scheme

The Volunteer Department provides a well respected service with local and national recognition particularly for its positive contribution to the patient journey and development opportunities for the local population. There are now almost 900 people volunteering for the Trust in a variety of ways by providing support for public events, conferences and health promotion days. Volunteers have been an invaluable support for ward and department staff, patients, relatives and visitors. Having them available

Annual Report & Accounts 2011/12 55 Aintree University Hospital NHS Foundation Trust

to help visitors with directions around the hospital, being there to listen and provide refreshments are just a few of the activities they undertake. 108 Volunteers have continued to provide a refreshment service to both relatives and patients every day of the week in the Accident & Emergency Department.

The Trust is always looking for new opportunities for the volunteering scheme and future plans include new initiatives such as `End of Life Volunteering’ and supporting patients with dementia in a hospital setting. This will involve recruiting new and existing volunteers to support patients and their relatives during such challenging and emotional times.

Recreational activities for volunteers continue to include weekends away, training courses and recognition of volunteering need. Volunteers are well supported and recent research indicates that Aintree Volunteers are happy in their roles and have an enhanced sense of well being as a result of their voluntary work.

Annual Report & Accounts 2011/12 56 Aintree University Hospital NHS Foundation Trust

Raising Standards

The Trust remains committed to pursue a strategy to improve clinical outcomes, quality of care and patient experience through setting and monitoring standards across the organisation. The Trust has adopted a “Just Culture” approach which it believes, will promote and support an open, transparent culture whereby low and medium harm incidents are identified and acted upon before they become a major harm.

Weekly Meeting of Harm – The Datix database, used to report incidents, is regularly reviewed and identified incidents and trends are considered at the weekly meeting of harm. This group, led by the Director of Nursing & Patient Safety and the Medical Director, consider all reported incidents and advise on actions to be taken. Examples from the current year include change in practice in the use of patient- controlled analgesia apparatus; faulty chest drains were removed from clinical usage; changes were made to the whole term checklist and to the consent procedure; all to improve the quality and safety of the care given to our patients.

NHS Litigation Authority accreditation – Having successfully achieved Level 3 accreditation in 2009, the Trust is preparing for a re-accreditation visit in June 2012. The 50 exacting standards have been reviewed by the NHS Litigation Authority and new standards have been introduced, reflecting the complaints and claims made by patients and relatives nationally.

External Visit – The Trust has received visits from the Cancer Peer Review Team, Care Quality Commission, General Medical Council and Mersey Deanery. Each visit looked at different elements of the Trust’s processes and procedures in delivering care to patients.

Where actions are identified, the Trust has systems and processes in place to monitor and manage these and give assurance that they have been implemented.

Medicines Management – Prompted by recent media interest in the topic and an internal investigation the Trust has conducted an audit of medicines management. No serious concerns were raised, although there is evidence of lax procedures in certain parts of the process. These gaps are being dealt with through a Task and Finish Group.

An external review is planned to confirm progress made and to provide assurance to the Trust Board that systems are in place and are being followed.

Mandatory Training – compliance against mandatory training is seen as a proxy for good quality of care. The Trust has now embedded compliance with mandatory training as a key domain in its revised COMPASS appraisal system. Moreover, Consultant medical staff now have to demonstrate compliance with mandatory training as part of the process to support revalidation due to start in 2013.

Appraisal – During 2010 more than 90% of all members of staff completed an appraisal. This figure has fallen during 2011 owing to the work being completed to

Annual Report & Accounts 2011/12 57 Aintree University Hospital NHS Foundation Trust

improve the COMPASS appraisal system. This system is due to go live in April 2012 after which time it is anticipated appraisal compliance is confidently expected to achieve and surpass previous levels.

Comprehensive Unit Based Staff Programme (CUSP), Patient Safety Officers (PSO) and Corporate Safety Champions – Recognising the importance of embedding a patient-safety culture amongst front line staff, a series of initiatives have been introduced. These include CUSP, which identifies potential harm at ward level; establishing a PSO in each clinical area whose remit it is to promote patient safety; and Corporate Safety Champions who are doctors, charged with promoting a patient safety culture, emphasising the importance of systems, understanding Human Factors and personal responsibility.

Service Reviews – A number of internal service reviews have been conducted in response to incidents identified from the weekly meeting of harm and complaints.

The success of these reviews has led to a decision to commission a small number of external service reviews which will provide independent assurance of the quality and safety within clinical directorates. If successful, this methodology may be rolled out to all clinical directorates on a rotating basis.

Clinical service quality indicators - Clinical leaders are developing a small number of medical quality indicators which, with associated metrics, will give a quantitative view of the quality of patient care delivered by medical staff. These indicators are likely to be different across the divisions and directorates, but certain basic elements are expected, including completion of a senior medical review, physiological review and documentation completeness.

Public Enquiry into events at Mid Staffordshire NHS Foundation Trust – The second Francis Report is due to be published in October. The Trust has delivered the outstanding actions arising from the initial Francis Report, and will produce a similar action plan when the final report is published.

.

Annual Report & Accounts 2011/12 58 Aintree University Hospital NHS Foun dation Trust

Research and Development

Doubling recruitment into high quality clinical research studies over a five year period is a goal set for the NHS by the Department of Health. The Trust is committed to contributi ng to this by ensuring that research is embedded within the organisation and patients are informed about suitable trials during their visit to the Trust. It is an aim of the research department to offer a clinical research study to all NHS patients when vi siting Aintree University Hospital. The Trust aims to have a balanced portfolio of activity with a diverse range of studies available for patient participation when visiting the Trust.

Translational Research

National Investigator Institute for Led Health Research Research

Commercial Trials

Figure 6: Balanced Portfolio of Research Activity

The Trust was involved in conducting 290 clinical research studies during 2011/12. Aintree used the national systems to co -ordinate the studies in proportion to risk using the NIHR Research Support Services Framework. Of the open and recruiting research studies, there was an approximate 50 -50 split between NIHR portfolio studies and non NIHR portfolio studies, demonstrating a balanced portfolio.

Annual Report & Accounts 2012011/12 59 Aintree University Hospital NHS Foun

Figure 7: Clinical Research Studies

The Trust is monitoring the NHS recruitment into high quality research studies over a 5 year period with an aim to double recruitment from the baseline data of 2008 This targeted recruitment is following the expected trajectory and in Year 2011 was above target. Below is the forecast based on the current infrastructure and capacity within the Trust.

Figure 8 : Aintree Recruitment Figures 2009

This increase in accrual has been in part due to the ongoing integration of research within the core business of the Trust. This high quality research is at the core of activity in the Trust and ensures the best possible care and treatment for patients.

There are over 100 staff at Aintree involved with research studies covering over 15 specialities acro ss the Trust namely: Cardiology, Stroke, Gastroenterology, Respiratory, Musculoskeletal, Diabetes & Endocrine and Respiratory Infection

Annual Report & Accounts 201 Aintree University Hospital NHS Foun

45 41 40 35 30 25 21 20 15 8 8 10 3 3 5 0 Number of NumberStudies Cardiology Critical care Dermatology Haematology Diabetes &Diabetes Endocrine Clinical Pharmacology

Table 21 : Number of Studies by Clinical Department Accrual across the Region

The Trust has an ongoing programme of within the Trust. This ensures that all studies are open on time and achieve the expected target recruitment. Aintree provides NHS Permission on all studies within the expected 35 days with a median time of 25 days.

This close monitoring of activity has provided Aintree with the second highest number of open studies to recruitment across the region.

Table 22 : Number of Studies Open to Recruitment across the Region

Annual Report & Accounts 201 Aintree University Hospital NHS Foundation Trust

Ongoing Developments within Research and Development

Over the past year at Aintree there has been progress in many areas, with many successful grant applications and publications such as:

• NIHR Research for Patient Benefit Grant • NIHR Fellowship Grant • NIHR Professorship [in application] • Behçet’s Disease. NHS National specialist commissioners funded • 3 Liverpool Health Partners applications for a Clinical Academic Programme Lead • 105 Publications in high profile scientific and medical journals

Annual Report & Accounts 2011/12 62 Aintree University Hospital NHS Foundation Trust

Sustainability

Aintree University Hospital NHS Foundation Trust recognises the part it can play in contributing to improving the sustainability of the wider city region and how this can help to reduce health inequalities. The Board of Directors has approved a Sustainability Strategy, Travel Plan and Carbon Reduction Plan to provide a framework to support its objectives in this area.

The Trust has developed a detailed action plan to support the delivery of its strategy and to improve its sustainability performance. This action plan will ensure that by being a “Good Corporate Citizen” the Trust can be confident that its actions will benefit rather than harm the environment in which we operate.

The Board of Directors is very supportive of this agenda and has been fully engaged throughout the development of the strategy receiving regular updates on progress. A Sustainable Development Group is operating which has both Executive and Non Executive Director membership. This group will oversee the implementation and monitoring of the Sustainable Development Plan. The group has submitted annual reports to the Board of Directors and Board of Governors on progress against the plan.

Area 2010/11 2011/12 Expenditure Expenditure 2010/11 2011/12

Waste Waste Waste £463,000 £429,111 minimisation produced by produced by & Trust: 1,928 Trust: 1918 management tonnes tonnes

Methods of Disposal: High temperature incineration, heat treatment, WEEE and landfill.

Finite Resources

AHT total utilities usage and costs 2010-11 and 2011-12

Utility Units Usages Costs

2010/11 2011/12 2010/11 2011/12

Water M3 186,304 177,219 £ 495,698 £414,683

Electricity GJ 29,025 37,146 £ 646,550 £963,836

Gas GJ 215,443 163,637 £1,382,849 £1,242,546

Oil GJ 1,953 1,660 £ 32,569 £34,321

Table 23: Reducing carbon emissions: summary performance 2010/11 & 2011/12

Annual Report & Accounts 2011/12 63 Aintree University Hospital NHS Foundation Trust

The following key areas are being targeted to further reduce our carbon footprint:

• Energy and carbon management – working with the Carbon Trust to develop a carbon management implementation plan; designing and developing a new Combined Heat & Power (CHP) to reduce energy and carbon consumption across the site. The Trust became a member of the Liverpool NHS Carbon Collective • Procurement and food miles – including clauses in the tender process to ensure environment standards; ensuring priority is given to local business to enforce our Corporate Responsibility Statement and working with the North West Development Agency to educate small and medium enterprises; evaluation of supplier location to reduce Carbon footprint in delivering; reviewing on a monthly basis the menu options to ensure local fresh healthy options with a variety to cater for all dietary needs and promoting the use of ethically traded products in future catering specifications • Travel and transport – refreshing and updating the Travel Survey and Travel Plan and exploring new initiatives • Water – monitoring water use and implementing a plan to reduce use; creating a workgroup to ensure the estate is clean and the Trust complies with legislation; continuing to recycle all medicine that can be re-used. • Waste – investigating the recycling of WEE equipment to a company that accepts diminished liability; investigation the segregation of waste through in-house initiative and locally contracted services, maximising waste recycling in order to help maintain local markets for reusable commodities and investigating the streaming of clinical waste into offensive waste to avoid incineration

2011/12 has seen the Trust recognised for cutting its carbon emissions by the Carbon Trust through participation in the Public sector Carbon Management Programme. Also, as part of the Liverpool Carbon Collective, we are working with Liverpool City Council and other NHS Trusts locally to significantly reduce our combined carbon impact.

We frequently engage with our community through our Artwork projects and various employment initiatives and we aim to build on these successes to play a wider role in our local community through our Community Engagement Strategy.

Annual Report & Accounts 2011/12 64 Aintree University Hospital NHS Foundation Trust

Current & Future Developments

During 2011/12 several significant projects have been completed:

• We have completed the final phases of the upgrade and expansion of our Radiology Departments with over £6.5 million being spent including 5 new CT and MR scanners

• We have invested over £1 million improving the environment, privacy and dignity on many of our wards

• We are now producing significantly less carbon dioxide following the completion of our £2.0 million decentralisation scheme improving our green credentials and saving money

• Our Sleep and Respiratory patient laboratories have been expanded and modernised onto Ward 18 at a cost of approximately £1 million

• The upgrade of our Tower Block wards continues to improve the quality of inpatient care with Ward 4 being the most recent upgrade

• A bespoke discharge unit has been created on Ward 14 at the cost of £0.25 million

• Two dedicated theatre forward wait areas have been created to improve patient experience in our surgical departments at a cost of £1.25 million

We are about to commence on a busy and exciting period of development during 2012/13 which will see major changes to Aintree University Hospital campus:

• Complete upgrade of our Accident and Emergency Department (AED) so that we can provide more space and, therefore, maintain better patient flow at times of high demand

• Creation of a new hospital access road which will do much to alleviate traffic congestion both on and off site at peak times

• Increase the size and quality of our Critical Care Unit to ensure we provide the highest standard of care possible whenever needed

• Review and consolidate our cardiology services into purpose designed accommodation on Wards 8 and 9

• Construct a high level walkway to the Walton Centre to allow easy transfer of patients between the two hospitals

Annual Report & Accounts 2011/12 65 Aintree University Hospital NHS Foundation Trust

• Increase of our operating theatre capacity with the creation of at least two additional state of the art operating theatres

• Upgrade and reconfigure many of our outpatients’ areas

• Creation of a dedicated Fracture clinic to allow the expansion of our AED and Medical Assessment Unit departments.

• Planning to expand and consolidate our Research, Education, Training and development services with a major investment plan

• Invest in our infrastructure to ensure the site can continue to meet the growing demands of a modern Acute Hospital.

Aintree University Hospital NHS Foundation Trust continues to invest in the future of local health care provision to care for the community it serves.

Annual Report & Accounts 2011/12 66 Aintree University Hospital NHS Foundation Trust

Quality Report

2011/12

Annual Report & Accounts 2011/12 67 Aintree University Hospital NHS Foundation Trust

Contents

Part One: Statements on Quality …………………………………………………….. 70 1.1 Statement from the Chief Executive 70 1.2 Trust Profile 73 Part Two: Priorities for Improvement, Statements of Assurance from the Board …… 74 2.1 Priorities for Improvement 74 2.1.1 Progress against Key Priorities for Action 2011/12 74 2.1.2 Key Priorities for Action 2012/13 75 2.2 Statements of Assurance from the Board 77 2.2.1 Review of Services 77 2.2.2 Participation in Clinical Audits and National Confidential Enquiries 77 2.2.3 Actions Arising from Clinical Audits and National Confidential Enquiries 78 2.2.4 Participation in Clinical Research 78 2.2.5 Use of CQUIN Framework 79 2.2.6 Registration with the Care Quality Commission 84 2.2.7 Information on the Quality of Data 85 Part Three a: Overview of the Quality of Care …………………………………………. 88 3.1 Patient Safety 90 3.2.1 Infection Prevention and Control – MRSA 91 3.2.2 Infection Prevention and control – Clostridium Difficile 92 3.2.3 Nutrition 93 3.2.4 Falls 94 3.2.5 Safety Thermometer 96 3.2.6 Transparency Study Pilot 97 3.2.7 Reduce Grade 3 & 4 Hospital Acquired Pressure Ulcers 98 3.3 Clinical Effectiveness 99 3.3.1 Advancing Quality 99 3.3.2 VTE Risk Assessment 101 3.3.3 Rescuing the Acutely Ill Patient 102 3.3.4 Reducing COPD Readmissions 104 3.3.5 Reducing Readmissions within 48 Hours to Critical Care 105 3.3.6 Redesign of ENT Services for Deafness, Tinnitus and Balance 106 3.4 Patient Experience 107 3.4.1 Patient Experience Feedback 107 3.4.2 Improving Patient Experience in Endoscopy 109 3.4.3 Nursing Care Assessment through Comfort Rounds 110

Annual Report & Accounts 2011/12 68 Aintree University Hospital NHS Foundation Trust

3.4.4 Improving Access to Audiology Services for Patients with Learning Disabilities 111 3.4.5 The Productive Ward Programme 111 3.4.6 Improving Communication between Patients and Staff 112 3.4.7 Patient Experience Questionnaire (PEQ) 113 3.4.8 “Have I Made a Difference” Cards 114 Part Three b: Performance against Key National Priorities and National Core Standards 115 3.5 Key National Priorities – Department of Health’s Operating Framework 115 Annex A: Statements from PCTs, LINKs and Overview and Scrutiny Committees… 118 Annex B: Statement of Directors’ responsibilities in respect of the Quality Report… 128 Annex C: Participation in Clinical Audits and National Confidential Enquiries during 2011/12……………………………………………………………………….. 130 Annex D: Actions Arising as a Result of National and Local Audits ………………. 133 Annex E: Performance against key national priorities ……………………………… 143 Annex F: Limited Assurance Report on the content of the Quality Reports ……… 145 Glossary ………………………………………………………………………………………. 148

Annual Report & Accounts 2011/12 69 Aintree University Hospital NHS Foundation Trust

Part One: Statements on Quality

1.1. Statement from the Chief Executive

Aintree University Hospital NHS Foundation Trust has a clear vision to be a provider of high quality, patient-centred healthcare with a first class local, national and international reputation. Our staff strive to uphold the highest values of respect, honesty and excellence by showing care and compassion, being open to change to meet patient needs and take personal accountability for their actions. Ultimately, the quality of services the Trust provides relies on the dedication and professionalism of our staff in reviewing our services closely to identify areas for further improvement, monitoring our clinical outcomes and our patient satisfaction ratings. This is evident in the achievements recorded in this Quality Account.

During 2009/10 a Quality Improvement Programme for the period 2010-2012 was developed. The Trust is now able to report that the three priority goals of the Trust’s Quality Strategy have been successfully delivered. During the three year period we are proud to report that we have maintained a better than average performance in our Hospital Standardised Mortality Ratio (HSMR) score, reduced moderate and severe patient safety incidents from 268 at baseline to 150 and improved patient experience ratings as good or excellent from 69% to 91%.

Safety is a cornerstone to delivering quality services and the Trust has now completed a three year safety programme with John Hopkins Hospital, Baltimore, which has been voted the safest hospital in the USA for the last twenty years. Over the programme, 1500 staff have learnt from, and been involved in, introducing an innovative safety programme at Aintree. The Trust has invested in over forty Patient Safety Officers on our wards and departments in addition to appointing three Corporate Safety Champions from the Consultant Workforce. Each will develop the safety agenda for their relevant Division and work closely with the medical workforce in delivering safer patient care.

In addition, the Trust is a member of QUEST, a membership group of 13 high performing Foundation Trusts whose aim is to enhance the safety of their patients. Over the last year the focus has been on delivering Safety Express, preventing falls and avoiding re-admissions to hospital. Quality improvement success has been achieved through the focussed activities of leadership, measurement, building capability within the workforce and a programme of projects following review of services. Our achievements can be explored further in Part 3 commencing on page 88.

A number of these projects were included as CQUIN initiatives within the 2011/12 Acute Services Contract for the Trust. Our performance in relation to these initiatives is detailed in Section 2.2.5 of Part 2 commencing on page 74. Where the Trust has underachieved against these initiatives, they will remain a key priority for improvement during 2012/13.

The following achievements should be noted: • MRSA bacteraemia infections – The Trust’s target for 2011/12 was to maintain progress and report no more than 5 cases; only 4 cases have been reported this year.

Annual Report & Accounts 2011/12 70 Aintree University Hospital NHS Foundation Trust

• CDifficile – the Trust’s target for 2011/12 was to report no more than 64 cases; 63 cases were reported. This reflected an 85% reduction in cases over the last 3 years. • Greater harm free care being delivered from the initial results from the Safety Thermometer and Transparency Study Pilots. • Since December 2011, over 95% of patients have had VTE risk assessments completed. • During the last six months there has been an 18% decrease in cardiac arrests within the Trust now that the Medical Emergency Team is attending all clinical emergency calls. • Aintree’s Ear Nose & Throat (ENT) Service Redesign Team won the “Rethinking the patient pathway” category at the 2012 Advancing Health Care Awards for Allied Health Professionals. • The introduction of Comfort Rounds in all wards as a result of listening to patient feedback at the Trust’s Reaching Out Events. • Our monthly Patient Experience Questionnaire is consistently reporting patient satisfaction above 95% in many key areas.

There were a number of patients and some staff members affected in three confirmed Norovirus incidents in April 2011. The Trust maintained its normal practice in infection prevention and control by restricting admissions to affected areas, closing wards, if appropriate, and ensuring that, before any area is reopened, it is subject to a comprehensive clean. It had been recognised that there were risks to the delivery of the 62 Day classic cancer target during the summer of 2011. A Task and Finish Group was put in place focussed on improving patient pathways and strengthening the administrative support for the Multi-Disciplinary Teams. To ensure that these were the appropriate actions, the Trust invited the National Cancer Intensive Support Team to visit the Trust in early 2012. The consequent report has confirmed that the approach and actions taken by the Trust are entirely in line with good practice. As evidence of the improvements, the Trust delivered the 62 Day classic cancer target in March and early indications are that this position will be maintained in April 2012.

The Trust achieved 87.5% compliance against the 90% target for 62-day screening over the year. As the locality hub for the Merseyside region, the Trust is being adversely affected by a reallocation of breaches from other provider organisations to Aintree. This is irrespective of whether Aintree has been involved in the treatment pathway. The impact of this has been to reduce Aintree’s performance below the target level of 90%. The Trust is continuing to work with other provider organisations to improve performance.

The Trust takes note of all feedback from patients, staff and wider stakeholders and uses this as a basis for planning further improvements. Throughout 2011/12, the Trust held three public reaching out events which have provided extremely valuable feedback on what is important to our patients. The areas identified for improvement are meeting nutritional needs, reducing falls, improving further infection control and providing better communication when discharging patients from hospital. These areas have all been fed into the Trust’s business planning process before being agreed in the 2012/13 CQUIN schemes with our Commissioners. They will also be included in the new 3-year Quality Improvement Strategy which will be launched in 2012/13.

Annual Report & Accounts 2011/12 71 Aintree University Hospital NHS Foundation Trust

This position provides a solid foundation upon which to build a sustainable, ambitious and cohesive approach to the delivery of high quality care. The Board is in the process of agreeing a wide range of essential standards across the domains of patient safety, patient experience and clinical effectiveness. These will be widely consulted on during 2012. We believe that this 3 year improvement programme will enable Aintree to be regarded amongst the best Trusts in the country for patient safety, clinical quality and a good patient experience.

I am delighted to write this foreword of the Trust’s account of the quality of NHS services provided during 2011/12.

Catherine Beardshaw, Chief Executive, Aintree University Hospitals NHS Foundation Trust

Annual Report & Accounts 2011/12 72 Aintree University Hospital NHS Foundation Trust

1.2 Trust Profile

Aintree University Hospital NHS Foundation Trust was established on 1st August 2006 as a public benefit corporation authorised under the National Health Service Act 2006.

The Trust provides general acute health care to a population of 330,000 people in North Merseyside and surrounding areas, and also works with a range of partners to provide services in the community. The Trust is a teaching hospital of the University of Liverpool and its tertiary centres provide specialist services to a much wider population of around 1.5 million in Merseyside, Cheshire, South, Lancashire and North Wales.

Aintree University Hospital serves a population which has some of the most socially deprived communities in the country, with high levels of illness. Merseyside has some of the worst rates for heart disease and cancer in the UK, and has also been associated with a culture among patients of low empowerment over their health.

Aintree University Hospital is a large hospital providing Accident & Emergency services and a wide range of acute and non-acute specialties, plus outpatient and day surgery services. The Trust’s services are managed through Clinical Business Units grouped within three main Divisions – Medicine, Surgery and Clinical Support Services. Specialist services are provided in Respiratory Medicine, Rheumatology, Maxillofacial and Liver Surgery.

The University of Liverpool School of Clinical Sciences has a major presence at Aintree University Hospital. A number of Professorial Units within the divisions of Infection and Immunity, Metabolic Medicine and Surgery and Oncology are situated exclusively at Aintree University Hospital. The Trust is a recognised centre for multidisciplinary health research and enjoys close collaboration with the University of Liverpool, Edge Hill University, Liverpool John Moores University and other NHS Trusts. The Trust is a member of Liverpool Health Partners, the regional Academic Health Sciences System.

The Trust is one of the largest employers locally with more than 4,000 whole time equivalent (WTE) staff and has significant recognition for its support for staff through its policies, initiatives and partnership working approach.

Aintree University Hospital has 720 inpatient beds. At the end of 2011/12 the Trust had fixed assets of just over £169 million and an annual income in excess of £278 million. During 2011/12 the Trust handled 73,459 spells of inpatient and day case care, 319,613 outpatient attendances and 85,965 attendances to the Accident and Emergency Department.

Annual Report & Accounts 2011/12 73 Aintree University Hospital NHS Foundation Trust

Part Two: Priorities for Improvement, Statements of Assurance from the Board

2.1 Priorities for Improvement

2.1.1 Progress against Key Priorities for Action 2011/12

Patient Safety: To reduce the number of moderate or severe clinical incidents by 20% by 2012.

Improvement work commenced in September 2009 therefore the number of patient safety incidents reported for Sept 2008 to August 2009 was 268 which has been used to set the baseline for improvement.

Progress in 2009/10: Patient safety incidents reported in January 2009 was 366 against 312 reported in January 2010.

Progress in 2010/11: Patient safety incidents reported between April 2010 - March 2011 was 172 (not 254 as previously reported in the 2010/11 Quality Account) against the year’s target of no more than 250 to be reported.

(The number of patient safety incidents reported in the 2010/11 Quality Account differs from the numbers reported this year as a result of the Trust implementing recommendations from a falls and pressure ulcer audit undertaken by RSM Tenon our internal auditors. This has resulted in retrospective separation of collision incidents and reclassification of some pressure ulcers from the patient safety incidents data).

Progress in 2011/12: Patient safety incidents reported between April 2011 – March 2012 was 150 against the year’s target of no more than 232 to be reported.

This remains a key priority in 2012/13. The Trust has agreed to maintain current performance therefore no more than 150 moderate or severe patient safety incidents are to be reported.

(Data source: Datix internal reporting system which is not governed by a standard national definition)

Clinical Effectiveness : By 2012, to save an additional 300 Lives over 3 years. The predicted Hospital Standardised Mortality Ratio (HSMR) for a hospital is 100.

Progress in 2009/10: For the period February 2009 to January 2010 Aintree’s HSMR was 85.4.

Progress in 2010/11: For the period February 2010 to January 2011 Aintree’s HSMR was 77.0.

Annual Report & Accounts 2011/12 74 Aintree University Hospital NHS Foundation Trust

Progress in 2011/12: For the period February 2011 to January 2012 Aintree’s HSMR was 84.8.

(Data source: Dr Foster, All Diagnosis which is not governed by a standard national definition)

Patient Experience: By 2012, to increase by 20% the number of patients who rate their experience as good or excellent

Progress in 2009/10: In the 2009/10 National In-Patient Survey 69% of patients rated their experience as good or excellent.

Progress in 2010/11: In the 2010/11 National In-Patient Survey 89.8% of patients rated their experience as good or excellent.

Progress in 2011/12: In the 2011/12 National In-Patient Survey 91% of patients rated their experience as good or excellent. The Trust is performing above the average as the score for all Trusts is 90%.

This compares with the findings of the Trust’s internal patient experience questionnaire in which 94.69% of patients rated their experience as good or excellent in March 2012.

(Data sources: Picker Results 2011; aBI which is not governed by a standard national definition)

Progress made in 2011/12 and previous years against quality improvement initiatives that contribute to the delivery of the Trust’s overarching priorities which were identified for action in the 2010/11 quality report can be found in Part Three – Overview of the Quality of Care on pages 88 and 89.

2.1.2 Key Priorities for Action 2012/13

The Trust Board in consultation with local PCTs, LINks and the Governors has identified three overarching priorities for quality improvement during 2012/13 aligned to the Trust’s Safety Strategy. These priorities are derived from three sources: the Trust’s performance over the past year against its quality and safety indicators; national and regional priorities and finally from trend and risk analysis undertaken on patient, staff and public feedback.

The Trust’s overarching three priorities for 2012/13 remain:

Annual Report & Accounts 2011/12 75 Aintree University Hospital NHS Foundation Trust

Priority 1: Saving lives (Clinical Effectiveness) - The Trust will maintain current performance in saving additional lives. This is measured and triangulated through the monthly monitoring of Hospital Standardised Mortality Ratio, Summary Hospital-Level Mortality Indicator (SHMI) using national systems and crude death numbers.

Priority 2: Patient safety – To maintain the current reduction in the number of moderate or severe clinical incidents. Progress is monitored using recorded incidents via the Trust incident reporting system (Datix).

Priority 3 : Patient experience – To maintain current performance of the number of patients who rate their experience as good or excellent. Information relating to patient experience is captured each month using the new patient experience questionnaires and the patient exit cards.

Performance against these three overarching priorities is monitored by the Board through the receipt of a monthly Corporate Quality Report. Aintree continues to receive a good Hospital Standardised Mortality Ratio rating (HSMR), an indication of lower than average mortality, but the new indicator, the Summary Hospital Mortality Indicator (SHMI), gave a higher headline figure than expected. The new indicator does not take account the level of palliative care services nor of deprivation levels within a hospital’s catchment area. In addition, the way in which patients’ care is recorded may be contributing to this higher rating. We have begun a close examination of the reasons behind our high SHMI rating so that we can be reassured that our patients continue to receive good safe care. The Trust has agreed to commence internal reporting on the Department of Health core set of indicators which includes SHMI to the Board via the relevant Sub- Committee from April 2012 and to include performance against these indicators in the 12/13 Quality Account.

The Trust will be undertaking a number of service improvement projects and improving the skills of its workforce to deliver these overarching goals in 2012/13.

Priorities for delivery include: • Safety & Quality Strategy • CQUIN Goals • Patient Experience Strategy • Care & Compassion Strategy • Infection Prevention and Control Annual Plan • Ward Re-Engineering Programme • Quality Assurance & Accreditation Framework • Progress against the Trust’s agreed Equality Objectives

Annual Report & Accounts 2011/12 76 Aintree University Hospital NHS Foundation Trust

2.2 Statements of Assurance from the Board

2.2.1 Review of Services

Aintree University Hospital NHS Foundation Trust is a large teaching hospital with approximately 720 in-patient beds. The Trust provide a range of services and provide specialist care to people who need expert help with kidney, liver, intestine and respiratory conditions or treatment for Head and Neck Cancer.

During 2011/12 Aintree University Hospital NHS Foundation Trust has provided 36 NHS services. The Trust Board has reviewed all the data available to them on the quality of care in all of these services through the monthly Corporate Report. This report includes data on three dimensions of quality – patient safety, clinical effectiveness and patient experience.

The income generated by the NHS services reviewed in 2011/12 represents 100% of the total income generated from the provision of NHS services by Aintree University Hospital NHS Foundation Trust for 2011/12.

2.2.2 Participation in Clinical Audits and National Confidential Enquiries

During 2011/12 33 national clinical audits and 1 national confidential enquiries covered NHS services that Aintree University Hospital NHS Foundation Trust provides.

During 2011/12 Aintree University Hospital NHS Foundation Trust participated in 76% of the national clinical audits and 100% of the national confidential enquires that it was eligible to participate in.

The national clinical audits and national confidential enquiries that Aintree University Hospital NHS Foundation Trust was eligible to participate in during 2011/12 are listed in Annex C.

The national clinical audits and national confidential enquiries that Aintree University Hospital NHS Foundation Trust participated in during 2011/12 are listed in Annex C.

The national clinical audits and national confidential enquiries that Aintree University Hospital NHS Foundation Trust participated in, and for which data collection was completed during 2011/12, are listed in Annex C alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.

The high level of participation in clinical audit which is observed across the Trust demonstrates the commitment of our clinical staff to improving the quality of care they provide.

NICE provides guidance on a range of treatments and drug regimes. In 2011-12, Aintree was 80% compliant with NICE guidance; 50% of the non-compliance relates to the Trust deciding to work with regional and local best practice standards. The remaining 50% had associated funding shortfalls and, in the business planning process carried out within the operational divisions, these areas were not deemed to be as high a priority as other clinical risks identified.

Annual Report & Accounts 2011/12 77 Aintree University Hospital NHS Foundation Trust

2.2.3 Actions Arising from Clinical Audits and National Confidential Enquiries

The Trust Board has delegated authority for clinical audit to the Trust Assurance Committee. Through this delegation the reports of 10 national clinical audits were reviewed by the provider in 2011/12 and the Trust intends to take the following actions to improve the quality of healthcare provided as listed in Annex D

In addition, the reports of 70 local clinical audits were reviewed by the provider in 2011/12. Aintree University Hospital NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided as listed in Annex D

2.2.4 Participation in Clinical Research

The number of patients receiving NHS services provided by Aintree University Hospital NHS Foundation Trust in 2011/12 that were recruited during that period to participate in research approved by a Research Ethics Committee was 2585. Out of this total 738 were recruited into studies adopted by the NIHR and 1847 were recruited into non NIHR studies.

Participation in clinical research demonstrates Aintree’s commitment to improving the quality of care we offer and to making our contribution to wider health improvement. Active participation in research clinical research ensures our clinical staff stay abreast of the latest possible treatment possibilities and this leads to successful patient outcomes.

Aintree was involved in conducting 290 clinical research studies during 2011/12. Aintree used national systems to co-ordinate the studies in proportion to risk, when they met the NIHR eligibility criteria for inclusion in the NIHR clinical research network portfolio. Of the 290 studies open at Aintree 138 met the NIHR national adoption criteria and 138 of those studies have been approved and opened using the NIHR Coordinated Systems for gaining NHS permission (CSP). Of the eligible studies coordinated through CSP 100% were given permission to start within 35 days with a median time of 25 days. All of the studies were established and managed with the use of model Clinical Trial/Clinical Investigation Agreements which speed up contracting between companies and the Trust. All studies are closely monitored within the Research & Development Department to ensure that studies are recruiting on time to meet the target recruitment. All studies have undergone research governance review to ensure research passports/letter of access are issued appropriately. This initiative streamlines HR arrangements across organisations to make it easier and quicker to begin approved studies. The improvement in patient health outcomes in Aintree demonstrates that a commitment to clinical research leads to the best possible care and treatment for patients. High quality research at the core of activity at Aintree will ensure the best possible care for patients, promote the reputation of Aintree as a centre of excellence (driving patient and purchaser choice) and facilitate the recruitment and retention of the highest calibre of staff. We have over 100 staff at Aintree involved with research studies covering over 15 specialities over the Trust namely: Cardiology, Stroke, Gastroenterology, Respiratory, Musculoskeletal, Diabetes & Endocrine, Cancer (Head & Neck,

Annual Report & Accounts 2011/12 78 Aintree University Hospital NHS Foundation Trust

Haematology, and General Surgery), Urology, General Surgery, Critical Care, Dermatology, MFU, Respiratory Infection, Ophthalmology and Pharmacogenetics.

Over the past year at Aintree there has been progress in many areas, with many successful grant applications such as an NIHR Research for Patient Benefit Grant, NIHR Fellowship Grant and an NIHR Professorship in application stage. We have had over 105 publications of work in high profile scientific and medical journals associated with NIHR studies, and presentations of work at scientific meetings in the UK and internationally, namely India, China, Europe and Latin America to name just a few. 2.2.5 Use of CQUIN Framework

A proportion of Aintree University Hospital NHS Foundation Trust income in 2011/12 was conditional upon achieving quality improvement and innovation goals agreed between Aintree University Hospital NHS Foundation Trust and its coordinating commissioner (Sefton PCT) and all its associate commissioners, through the Commissioning for Quality and Innovation payment framework. Further details of the agreed goals for 2011/12 are detailed below. For the following 12 month period the agreed goals are available electronically at http://www.institute.nhs.uk/commissioning/pct_portal/cquin_schemes_11%1012.html During 2011/12 the total income associated with the achievement of quality improvement and innovation goals amounted to £3.150M. Aintree University Hospital NHS Foundation Trust received £2.814M income for the successful achievement of some of these goals. An overview of the initiatives taken forward during 2011/12 and the rationale for choosing these goals is outlined in the table below. More information about their contribution to improving patient care and how we endeavor to improve our performance is outlined in Part three – Overview of the Quality of Care.

CQUIN Initiative Aims & Objectives Achievement

VTE Risk Venous-Thromboembolism Achieved: Assessment (VTE, blood clot in the vein) The Trust risk is a significant cause of assessed over 90% mortality, long-term disability of patients on and chronic ill health. The admission for VTE aim of this CQUIN goal is to each month in the reduce avoidable death and final quarter (Jan-Mar long term disability from VTE 2012) therefore by ensuring that all patients achieved the are risk assessed for risk of required CQUIN VTE on admission to target. Further hospital. Those that are details of the project considered to be at risk are achievements can be then provided with found in Chapter appropriate drug therapy to Three. VTE remains

Annual Report & Accounts 2011/12 79 Aintree University Hospital NHS Foundation Trust

prevent a blood clot a key priority for occurring. 2012/13.

Improving High Quality Care for All Achieved: patient (Darzi, 2008) highlighted the The Trust scores in experience and need to view patient all of the 5 key responsiveness experience of care as questions within the important as clinical National In-Patient outcomes. The compassion, Survey have dignity and respect with improved delivering which patients are treated the required 5% ‘can only be improved by composite analysing and understanding improvement to patient satisfaction with their achieve the CQUIN own experiences’. The aim target. This remains of this CQUIN goal is to a key priority for collect feedback from 2012/13. patients on their experience of care and to take appropriate action to improve any shortcomings that have been identified.

Advancing Advancing Quality is an NHS Partially Achieved: Quality Northwest CQUIN schemes. The Trust is currently The aim is to improve the achieving the quality of care across five process scores in clinical pathways; heart four of the clinical attack, heart failure, stroke, pathways but is pneumonia and hip & knee underachieving on surgery. The rationale that is pneumonia and the adopted is that if patients are recording of the provided with the right care patient experience at the right time in their care measure. This pathway it will reduce remains a key priority mortality, reduce re- for 2012/13. admission rates and reduce complications in procedures and the time patients have to spend in hospital. A patient experience measure is also required.

Trauma Audit Every year across England Partially Achieved: and Research and Wales, 10,000 people The latest Network die after injury. It is the performance data (TARN) leading cause of death available from the

Annual Report & Accounts 2011/12 80 Aintree University Hospital NHS Foundation Trust

among children and young Trauma Audit and adults of 44 years and Research Network is under. In addition, there are December 2011. This many thousands who are left data indicates that severely disabled for life. the Trust is achieving The aim of the Trauma Audit the required standard and Research CQUIN is to for data encourage clinicians and completeness, hospital Trusts to provide holding trauma clinical information to meetings, greater Trauma and Audit Research than 50% of patients Network. Ultimately the seen by a Consultant analysis of this date will in A&E and recording support clinicians in the grade/specialty of improving their trauma care doctor in patients services. with an injury severity score (ISS) greater than 15 but not achieving the Data Accreditation and median time to CT indicators. This remains a local priority for 12/13.

Promoting Safe The aim of this CQUIN is to Partially Achieved: Discharge improve discharge Achievement of 95% communications. The safe targets has been discharge of patients is an very challenging due area of high priority from to technical issues. both a patient safety and In March 51% of all governance perspective. in-patient discharges The delivery of timely, high had an e-discharge quality discharge information summary within the both supports the patient, by hospital IT system of giving them information these 33% were sent about their care and informs electronically within the patient's GP as to the 24 hours and 49% of care delivered and is patients received a essential for the ongoing copy of their support and management of discharge summary. the patient in primary care. Results show that 100% of out-patient letters comply with the minimum data set although results of how many of these were received in general practice with

Annual Report & Accounts 2011/12 81 Aintree University Hospital NHS Foundation Trust

2 weeks will not be known until May. A remedial action plan is in place and this remains a key priority for 2012/13.

Reducing Falls The aim of this CQUIN is to Under Achieved: reduce severe and moderate At the end of March inpatient falls thereby the Trust has increasing patient safety by reported 10 severe or reducing subsequent injury moderate falls and avoid deterioration in the against a target of recovering patient. 9.75. The latest cumulative position is that 97.6% of falls risk assessments have been performed. This means that the Trust has only partially achieved its CQUIN target. This remains a key priority for 2012/13.

Acquired Pressure ulcers are most Achieved: Pressure likely to affect those with March 2012 data Ulcers poor mobility who spend indicates that the prolonged periods in bed or Trust has achieved a chair, particularly if they're the 25% reduction in unable to change their grade 3 and 4 position. They are a common pressure ulcers at problem in hospitals year end. The latest especially when people are cumulative position is too unwell to get out of bed, that 97.6% pressure or undergo a lengthy ulcer risk operation. The aim of this assessments have CQUIN is to reduce the been performed. prevalence of pressure sores Therefore the Trust’s which will improve patient CQUIN targets have outcomes in terms of been fully met. This experience, safety and remains a key priority length of stay by avoiding for 2012/13. complications.

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Improving End It is recognised that there is Achieved: of Life Care a significant difference The Liverpool Care between where people say Pathway is now in they would like to die and use across all wards where they die. This often including ICU. At the leads to inappropriate end of March 2012, admissions and upset for 43% (against a target families and carers. It also of 35%) of patients has a significant impact on had their end of life costs. People often do not care appropriately have the opportunity to managed in discuss this through accordance with the advanced care planning Liverpool Care of the which is considered gold Dying Pathway. standard practice. An Advanced Care Planning Tool has been developed along with a staff education program. To date 74% of nursing and 75% of medical staff have been trained this is an improvement on Qtr 3 performance which was 64% and 67% respectively. Therefore, the Trust CQUIN targets have been fully met. This remains a key priority for 2012/13.

Offering Renal This scheme is to encourage Achieved: Home Therapy the delivery of care closer to In March 3.6% of or at home to maximise renal patients are convenience for the patient. documented as This will reduce the need to receiving home access hospital based haemodialysis and services therefore reduce 9.1% patients are patients’ exposure to risk of documented as infection and manage costs receiving peritoneal of anticipated growth of 3% dialysis. The Trust in the dialysis cohort over has provided the next 5 years. validated data demonstrating that all appropriate patients were offered the

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choice of home therapy and the Trust continues to do so. The Trust CQUIN targets have been fully met. This remains a key priority for 2012/13.

2.2.6 Registration with the Care Quality Commission

Aintree University Hospital NHS Foundation Trust is required to register with the Care Quality Commission and its current registration is unqualified. Aintree has no conditions on registration.

The Care Quality Commission has not taken any enforcement action against Aintree University Hospital NHS Foundation Trust during 2011/12.

The Trust has participated in one unannounced inspection by the Care Quality Commission relating to the following areas during 2011/12: • Outcome 4 (Care and Welfare of people who use services) • Outcome 5 (Meeting Nutritional Needs) • Outcome 9 (Management of Medicines) and • Outcome 17 (Complaints)

The report from the Care Quality Commission (CQC) indicates they identified four moderate concerns and one minor concern (meeting nutritional needs) in the five outcomes they reviewed in March 2012. The Trust has submitted an action plan focussed on addressing these shortfalls to the CQC together with comments on the report. The actions will also be incorporated in the Quality, Safety and Patient Experience Improvement Programme. It should be noted that the moderate and minor concerns will not impact on the governance rating for the Trust from Monitor. The Care Quality Commission’s Dignity and Nutrition for older people review of compliance in June 2011, found the Trust was meeting both of the essential standards of quality and safety for: • Outcome 1 (People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run) and • Outcome 5 (Food and drink should meet people’s individual dietary needs).

Although the formal report was positive, it also highlighted areas for action including documentation: while the right things were being done, they were not always being recorded.

The Trust was acknowledged by the Care Quality Commission for its participation in one special review during 2010/11 relating to support for families with disabled children.

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2.2.7 Information on the Quality of Data

NHS Number and Aintree University Hospital NHS Foundation Trust General Medical submitted records during 2011/12 to the Practice Code Validity 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: 99.05% for admitted patient care; 99.1% for outpatient care; and 97.0% for accident and emergency care • Which included the patient's valid General Practitioner Registration Code was: 99.85% for admitted patient care; 99.8%; for outpatient care; and 99.94% for accident and emergency care

Information Aintree University Hospital NHS Foundation Trust Governance Toolkit Information Governance Assessment Report Attainment Levels overall score for 2011/12 was 74% and was graded Green, satisfactory.

Improving Data Aintree University Hospital NHS Foundation Trust Quality is taking the following actions to improve data quality:

• Maintain and continue the stated intentions regarding data quality from the previous years’ quality submission • Following the reorganisation of the Trust at Divisional Level, review the Trust Data Quality Strategy and ensure that it still meets with Corporate Objectives • Use Executive approval to extend the Data Quality Team, managing data quality issues proactively, from an identification and management perspective and reactively supporting users operationally in the field to rectify data quality issues • Review the existing data quality reporting mediums and extend the data quality key performance indicators to include an increased number of key data sets • Create and distribute guidance to users regarding data quality matters through corporate storage methods such as the

Annual Report & Accounts 2011/12 85 Aintree University Hospital NHS Foundation Trust

Trust’s internal website.

Aintree University Hospital NHS Foundation Trust has taken the following actions to improve data quality:

• Secured Executive Level commitment and guidance to support the Data Quality Strategy Implementation at a Trust wide level. • Secured Executive Level leadership to support a review and subsequent reorganisation of the data quality programme focusing upon a shift towards operational implementation, through the setting up of a dedicated data quality team (with both a technical and operational data quality manager), managed not by the informatics service but by operational management. • Undertaken an extensive review of the data flows supporting the Quality Account making recommendations to improve the robustness of the data capture and reporting element to provide the Chief Executive with assurance regarding the sign off of the Quality Account • Undertaken a series of data quality initiatives to support various specialties and divisions within the Trust. This has included the accuracy and completeness of data appertaining to Ward Attendances and the subsequent financial recharging for such activity and the accuracy and timeliness of data appertaining to local activity such as Diabetic and Dermatology • Supported the Divisional Surgical Performance Team and Assistant Director of Performance by providing Data Quality key performance indicators regarding missing outcomes. • Liaised with the Audit Commission to develop a series of activity protocols to support users within the Trust to understand different types of activity and the importance of recording activity accurately and consistently. • Supported the Trust recovery programme regarding the Referral to Treatment Times key performance indicator by applying a

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project management approach to identification, coordination and resolution of issues impacting upon the target delivery. • Supported improvement of outpatient follow up waiting list management through an analysis of follow up flows and the developed of closed loops to ensure accurate, effective and efficient follow up processes.

Clinical Coding Aintree University Hospital NHS Foundation Trust was subject to the Payment by Results clinical coding audit in March 2012 by the Audit Commission. Gastroenterology services were subject to a review of 100 FCEs and the same number across other random specialities. The Trust is unable to report on the error rate as the formal report is still awaited from the Audit Commission.

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Part Three a: Overview of the Quality of Care

Aintree Hospital NHS Foundation Trust has published Quality Accounts for three years and has developed an ongoing process for establishing the quality priorities. Last year the Trust agreed the following priorities for improvement from its performance dashboard: patient satisfaction, falls and pressure ulcers. Venous- Thromboembolism and patient experience were identified as national priorities and Advancing Quality was highlighted as a regional priority.

From feedback from stakeholders identified below and trend risk analysis the following priorities were identified: • infection prevention and control, • catheter associated urinary tract infections, • rescuing acutely ill patients, • reducing critical care readmissions, • reducing Chronic Obstructive Pulmonary Disease readmissions, • making improvements to Ear Nose & Throat, Audiology and Endoscopy services, • increasing nutritional assessments and • inclusion of patient sensitive indicator assessments into comfort rounds.

The list of contenders had to contribute to the delivery of the Trust’s three overarching priorities indentified for action in the 2010/11 quality report, of which progress can be found on page 79. The Trust found that the final selection became virtually self-selecting following this process in that there was wide consensus on what should be the final priorities.

Throughout the year feedback on areas for improvement has been requested from:

• Liverpool, Sefton and Knowsley LINks through the Patient Experience Sub Committee and through Trust quality progress presentations to LINk members • Trust Governors through Board of Governor meetings and Joint Governor/Non-Executive Director/Executive Director Workshops • Lead Commissioner, Associates and local GP Clinical Commissioning Groups at PCT CQUIN meetings and Quality Review Meetings • Trust Staff at Nurse Focussed Groups, Chief Executive Monthly meetings with Consultants, Senior Management Team Meetings including clinical leaders and the Quality Board • Customer Care Reports • External Reports i.e. Picker Survey • Local Community Reaching Out Event Events including Equality and Diversity targeted groups

This year, the Customer Services Department has supported changes in the way complaints are managed. The Clinical Divisions have taken local ownership of their complaints and investigate these locally, putting in place local improvement plans to address shortfalls in care. The Trust also invested in complaint handling and investigation training for all its managers which was delivered and facilitated by the National Complaint Management Group in June 2011. The Policy for the Management, Investigation and Resolution of Complaints and Concerns was revised and the new complaints

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process came into operation on 1 July 2011. As part of the new process, digital recording of all formal complaints meetings was introduced. This provided the Customer Service Officers and complainants with an accurate record of their meetings in a timely and efficient manner. The Trust welcomes complaints from all sections of the population and has a Comments, Concerns, Compliments and Complaints (the ‘4Cs’) procedure in place which is reported on a quarterly basis to the Board of Directors. The procedure is available in an accessible format on request and any information received relating to the 4Cs is recorded by ethnicity, wherever possible (see Table 24 below). It is recognised that there are some sections of the population where more work will be done to ensure that everyone regardless of their background are able to express their opinions.

Number of 4Cs Patients Patient Ethnicity

Compliments 201 not stated

3 white - British

Comments 80 not stated 669 white - British Concerns 106 not stated

7 other ethnic category Table 24: Patient ethnicity 1 white - Irish breakdown of the 4Cs 2 any other white

Complaints 239 white - British 32 not stated 1 any other white

This section of the Quality Account aims to present an overview of progress against the quality improvement initiatives and of the quality of care provided during 2011/12 under the key headings of: patient safety, clinical effectiveness and patient experience.

Each of the following quality improvement initiatives are subject to the relevant accountability and assurance structure governed under Safety & Risk, Clinical Effectiveness, Patient Experience and Workforce which includes:

• Weekly/Monthly Operational Working Groups • Monthly/Bi-monthly Sub Committee Meetings • Monthly progress updates to the Trust Assurance Committee • Quarterly report to the Audit Committee

In addition, the following priority areas have been subjected to further independent audit/review: • MRSA • C Diff • Advancing Quality • Customer Services and Patient Experience function audit

An assurance opinion on data quality within the Quality Report is also provided by External Auditors who are required to perform audit work on two mandatory

Annual Report & Accounts 2011/12 89 Aintree University Hospital NHS Foundation Trust

performance indicators and one local indicator which is chosen by the Trust Governors. The performance indicators and their criteria are as follows:

Mandatory Performance Indicators

MRSA - Indicator criteria An MRSA bacteraemia is defined as a positive blood sample test for MRSA on a patient. MRSA cases disclosed include all MRSA positive blood cultures detected in the laboratories, whether clinically significant or not and whether treated or not, acquired in the Trust (any time 48 hours after admission). Positive results on the same patient more than 14 days apart are reported as separate episodes.

Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers - Indicator criteria Number of patients receiving first definitive treatment for cancer within 62-days following an urgent GP referral as a percentage of the total number of patients receiving first definitive treatment for cancer following an urgent GP.

Local Performance Indicator

C. Difficile - Indicator criteria: C. Difficile is defined as a case where the patient shows clinical symptoms of C. Difficile infection and has a positive laboratory test result recognised as a case according to the Trust's diagnostic algorithm. Positive results on the same patient more than 28 days apart should be reported as separate episodes, irrespective of the number of specimens taken in the intervening period or where they were taken. The limited assurance opinion from the External Auditors can be found in Annex F.

3.1 Patient Safety

Following the completion of a three year Safety Programme with Johns Hopkins Hospital, Baltimore, USA, the Trust is proud of the infrastructure implemented to monitor patient safety:

• Introduction of a Patient Safety Officer on every ward, in theatres and pharmacy. • Weekly Meeting of Harm, mirroring the Johns Hopkins model, chaired by the Medical Director where all incidents of Harm are reviewed. The Trust has improved safety by consequent changes to practice. • Introduction of Comprehensive Unit Based Safety Programmes (CUSPs), where multi-disciplinary teams of staff including house keepers, porters and clinical staff ask themselves the following questions: o How will our next patient be harmed? o How can we prevent that harm? This initiative has been introduced on 9 wards this year and is planned to be rolled out to all 34 wards.

Annual Report & Accounts 2011/12 90 Aintree University Hospital NHS Foundation Trust

3.2.1 Infection Prevention and Control – MRSA Safety Improvement Area: Reducing the risk of meticillin resistant Staphylococcus aureus (MRSA) blood stream infections Why: Around 10% of the population may be colonised with MRSA in their noses and on their skin. Some of these carriers go on to develop a clinical infection requiring treatment and a very small proportion go on to develop a significant infection requiring blood cultures to be taken to help guide treatment. MRSA infections are significant as they are resistant to some antibiotics and may be more difficult to treat although there are currently no known strains that are untreatable. What : To sustain a reduction in the HA MRSA Cases preventable MRSA 60 cases How much: The target for 50 2011/12 was to have 40 no more than 5 hospital attributable 30 cases 20

By When: March 2012 of NumberCases 10

Outcome: 4 hospital attributable 0 cases Progress: Target Achieved  Improvements Achieved: • We have introduced a more specific plan of care for peripheral cannulae (peripheral cannulae were particularly linked to MRSA bloodstream infections in reviews of cases) • The Trust has introduced a non-ported safety cannulae (ported cannulae are shown to increase the likelihood of bloodstream infections) • The relevant wards and departments audit their practices at least monthly and address non-compliance • There have been drives to improve compliance with MRSA admission screening in line with the national and Trust guidance Further Improvements The Trust target for 2012/13 is to have no more than 2 hospital Identified: attributable cases • The Trust is establishing a vascular access group to review policy, guidance, education and surveillance of key practices related to bloodstream infections • The Trust is evaluating new products related to the risk of blood stream infections such as standardised needleless connectors for all vascular devices • The IPC team will be encouraging greater involvement for staff in the delivery of safe care in their wards/departments specifically related to IPC (Data source: Health Protection Agency which is governed by a standard national definition)

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3.2.2 Infection Prevention and Control – Clostridium difficile Safety Improvement Reducing the risk of Clostridium difficile toxin related infections Area: Why: A significant proportion of the hospital patient population (around 3- 8%) harmlessly carry C. diff in their gut, the prevalence is as high as 30% in patients aged 75 years and older. Following antibiotic use, this harmless carriage can swiftly develop into serious and sometimes life-threatening infections. Once in the environment, the bacteria can survive for prolonged periods as a spore before infecting other patients leading to cross-transmission and secondary cases. What : To sustain a reduction in the preventable C. diff HA CDT Cases cases 400 How much: The target for 2011/12 was to have 350 no more than 64 300 hospital attributable 250 cases 200 By When: March 2012 150

Number of NumberCases 100 Outcome: 63 hospital attributable cases 50 Progress: 0 Target Achieved  2008/9 2009/10 2010/11 2011/12

Improvements Achieved: • We have maintained surveillance regarding the appropriate and safe use of antimicrobials and amended prescribing guidelines in line with reviews of previous cases • We have increased the scrutiny on cleanliness specifically related to near-patient equipment • The findings and themes from case reviews are shared across the Trust Further Improvements The Trust target for 2012/13 is to have no more than 53 hospital Identified: attributable cases • The Trust is continuing with the annual deep clean programme which is planned to commence in May • The Trust is going to pilot a new way of using hydrogen peroxide vapour technology to decontaminate patient equipment without such a significant impact on the patient experience and with less impact on operations • The antibiotic review process will be reviewed to be more directed and deliver better feedback for clinical staff • The testing process will be amended to help identify carriers without infection who are still potentially infectious; this should help to manage currently ‘unseen’ cross-transmission (Data source: Health Protection Agency which is governed by a standard national definition)

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3.2.3 Nutrition Safety Improvement Area: Identification and Treatment of Malnourished Patients Why: Around 36% of patients admitted to UK hospitals are malnourished (BAPEN, 2010). Malnutrition increases morbidity and mortality, increases length of hospital stay by an average of 1.4 days (NICE, 2006) and is estimated to cost the UK £13.6 billion per year in associated costs. What : 1. 95 % patients have MUST screen within 6 hours of admission 2. All patients with a MUST score of 2 or more are referred to Dietetics and are seen within 48 working hours 3. All inpatients are rescreened weekly. How much: See above By When: March 2012 and ongoing Outcome: Only have data for dietetic response time. All referred patients seen within 48 working hours (98-100% compliance) Progress: Target achieved for Dietetic response time  Behind schedule for electronic audit data to assess progress with other targets Improvements Achieved: • The MUST screening tool has been integrated into the electronic patient record. • All inpatient wards have received training and are aware of screening targets • Ongoing training is being delivered via clinical skills programmes and nutrition link nurse forums • Quality of dietetic referrals has improved and facilitated easier prioritisation of referrals • Ward 2 and Dietetics have adapted the tool for patients with Amputations • Patient information leaflet developed. Further Improvements • MUST proforma requires further adaptation to allow data Identified: extraction for audit reporting. This is a priority as unable to assess screening compliance at present. • Explore the option of developing a trigger to screen alerts • Use the MUST proforma as a template for other screening and assessment tools, e.g. manual handling, waterlow. • Develop process for delivery of patient information leaflet to patients. • Once inpatient reporting process is finalised then plan to adapt and implement electronic MUST in outpatients.

(Data source: Health Protection Agency which is not governed by a standard national definition)

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3.2.4 Falls Safety Falls Prevention – The number of falls reported in the 2010/11 Quality Improvement Account differs from the numbers reported this year as a result of the Trust Area: implementing recommendations from a falls and pressure ulcer audit undertaken by RSM Tenon our internal auditors. This has resulted in retrospective separation of collision incidents from the falls data. Why: The NHS Litigation Authority (NHSLA) state that patient falls are the most common patient safety incidents reported from inpatient services in the NHS, and they require each Trust to assess, manage and reduce the risk of all slips, trips and falls involving patients.

What : During 2010 a Falls Collaborative was developed Reported Falls Incidents by as part of the Trust’s Quality Strategy, with the overall aim of enhancing patient safety, Reported Falls Incidents by reducing harm and Month subsequently improving clinical 170 quality and patient experience. 160 150 Although the collaborative 140 initially concentrated on the 130 three wards with the highest 120

number of falls, during 2011 of Falls No 110 this workstream was rolled out 100 to other areas within Aintree. 90 80 Changes to practice arising as Jul Jan Jun Oct Apr Feb Dec Aug Nov Mar May a result of the collaborative Sept include: 08/09 09/10 10/11 11/12

- Providing an accurate risk assessment tool - A new care plan to reduce time spent on completing Overall, during the four year period April 2008 documentation to March 2012 there has been a 14.17% - A post fall action plan decrease in falls at Aintree (see below): - Enhanced awareness of falls incidents by using the ‘safety huddle’ Reported Falls Incidents by Year (Apr - - Rollout of the ‘blue dot system’ - staff activates a blue dot on the Trust’s ‘live’ Reported Falls Incidents by Year electronic patient (Apr-Mar) whiteboard to indicate that 1700 a patient is at risk of falling. - Linking of the Trust incident 1600 reporting system (Datix) to 1500 the Business Intelligence 1666 1663

System to produce a live of No.Falls 1400 ‘Falls Dashboard’ 1452 1430 - Improved risk analysis for 1300 08/09 09/10 10/11 11/12 ‘moderate and above’ falls as part of the NHS N W

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Transparency Study How much: Using April 08–March 09 as a benchmark, there has been a year on year reduction in the number of falls incidents at Aintree (see graph): • Apr 09-Mar 10 - 0.2% decrease on previous year • Apr 10-Mar 11 - 12.7% decrease on previous year • Apr 11-Mar 12 - 1.5% decrease on previous year

By When: Ongoing Outcome: During the four year period from April 2008 to March 2012 there has been a 14.17% decrease in the number of falls at Aintree (see graph). Progress:  Target Achieved Improvements • Improved analysis of falls risk via the NHS North West Transparency Achieved: Study. This study looks specifically at the incidence of falls (moderate and above) as reported to Risk Management through Datix. Patients within areas that report incidents are asked a series of questions relating to care, and staff in the same areas are asked questions relating to working practices. The nursing documentation of the patient who sustained the fall is also reviewed to ensure that appropriate measures were taken. Root Cause Analysis is completed on all cases reported and all information is made available to the public through NHS North West. • Introduction of ‘Safety Thermometer’; a monthly point prevalence indicator which measures the level of harm (including falls) within 100% of in-patients clinical areas. The aim of Safety Thermometer is to identify areas for improvement (harm reduction) and to achieve a high level of harm free care. • Introduction of the Aintree Post Fall Emergency Response Algorithm to assure compliance against NPSA Rapid Response Report NPSA/2011/RRR001 • Access to low rise beds Further • Plans to restructure the role of the Specialist Falls Practitioner including Improvements the launch of a Nurse Led Falls Clinic Identified: • The purchase of ‘safer slippers’ for in-patients following identification via the collaborative that one of the high risks of falls to our patients was the use of inappropriate footwear. Prior to the procurement of new slippers there were a number of different trials completed on single use fitted slippers. • Procurement of 20 additional ‘Crash Mats’ for patients assessed as being at risk of falling from bed but who are unable to have ‘cot sides’ in place due to confusion.

Monitoring compliance, identifying new ways of working and reducing incidents and harm to patients at risk of falling will always be a priority at Aintree. The collaborative project and changes will be audited on a monthly basis and any increase in the number of falls incidents will be reported to the Falls Steering Group, to Matrons and via link nurses and Patient Safety Officers workshops. (Data source: Datix which is not governed by a standard national definition)

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3.2.5 Safety Thermometer Safety Improvement Safety Thermometer (NEW) Area: Why: Point prevalence indicator which measures the level of harm within 100% of in-patients clinical areas (catheter associated UTI, falls, pressure ulcers & VTE) What : To identify areas for improvement (harm reduction) How much: Baseline measurements from March 2012 (100% of areas) By When: Year on year reduction to be agreed Outcome: To achieve a high level of delivering harm free care Progress: Target Achieved  Piloted on four wards and now being completed by 100% of in-patient areas, including Theatre Recovery

Improvements • Collecting baseline data Achieved: • Piloted on four wards in August 2011 (ongoing) • All clinical areas have electronic access to the tool • Data collection by patient safety officers • 100% of data collected on same day Further • Improvements to be agreed Improvements • Will be an ongoing priority for the Trust for 12/13 Identified: • New version to be implemented from April 2012 (in progress) • Matrons given access to review individual ward harms • Engage with Business Intelligence to create a Dashboard (Data source: NHS Information Centre which is governed by a standard national definition)

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3.2.6 Transparency Study Pilot Safety Transparency Study (E4E) Piloted by NHS North West (NEW) Improvement Area: Why: Harm Free Care is aimed at reducing complications associated with pressure ulcers, falls, urinary catheters and blood clots as the Department of Health estimates that 200,000 patients are affected each year. Harm Free Care is monitored through the Safety Thermometer which is a prevalent audit that literally ‘takes the temperature of the ward’. A range of simple assessments are put in place that are aimed at preventing these complications from occurring. The Transparency Pilot looks specifically at pressure ulcers & falls that are hospital attributable. Each case that is reported has a mini RCA completed, staff from the area that has reported the case are asked if they would recommend the hospital as a place of work and patients on the ward are asked a series of questions relating to their care. This information is then published on the hospital’s website.

What : To improve standards and inform the public Count of Falls & Pressure (transparency) Ulcers to Feb 2012 How much: Aintree was one of the 30 pilot sites in phase 1 commencing in 25 November 2011 20 By When: More sites coming on board for phase 2 in April 15 Fall's 2012 PU's Outcome: To improve standards 10 and being open to the of NumberCases public through 5 transparency data 0 Progress: Phase 1 pilot was first Nov-11 Dec-11 Jan-12 Feb-12 published in February 2012 Improvements • Tissue Viability Nurse reviews all pressure ulcers (grade 2 and Achieved: above) • Wards reporting high numbers of incidence have developed action plans to prevent further cases • Board level engagement Further • Improvement programmes to be agreed Improvements • Wards to complete Root Cause Analysis (RCA) for grade 2 Identified: pressure ulcers (not done previously) • Will be an ongoing priority for the Trust for 12/13

(Data source: NHS North West which is governed by a standard national definition)

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3.2.7 Reduce Grade 3 & 4 Hospital Acquired Pressures Ulcers Safety Improvement To reduce the number of hospital acquired grade 3 & 4 pressure Area: ulcers (NEW) Why: Pressure ulcers are clearly an issue for patient safety. Pressure ulcers have been estimated to cost the NHS £1.4-2.2 billion per annum. 4% of the NHS budget is spent on the care of pressure ulcers. In addition to financial cost of pressure ulcers, there is also the negative impact on quality of life. What : To reduce the Total Pressure Ulcers number of hospital Grade 3/4 acquired pressure 45 ulcers (grade 3 &4) 40 How much: Grade 3 & 4 by 25% 35 from 2010/11 30 25 baseline 20

By When: March 2012 Incidents 15 Outcome: No grade 3 or 4 10 pressure ulcers in last 5 0

quarter … … - - 10 10 10 11 11 11 10 11 11 12 ------Progress: - - - -  Target Achieved Aug Aug Jun Jun Oct Oct Apr Apr Feb Feb Dec Dec

Improvements • Implementation of the Safety Cross, Skin Bundle and comfort Achieved: rounds • Introduction of a preliminary pressure ulcer assessment in MAU, SAU, HAC • Development of an electronic waterlow risk assessment tool (being piloted) • Review of all incidents recorded on Datix by TVN to verify all hospital acquired pressure ulcers (transparency study) • E learning package for pressure ulcers Further • Reduce the incidence of hospital acquired grade 2 pressure ulcers Improvements from current baseline Identified: • Electronic risk assessment tool to be launched trust wide • Review & update the current skin bundle • Implementation of a 7 day technician service to ensure pressure relieving mattresses are available out of hours and at weekends • Ongoing involvement with the Transparency study • Review the documentation for discharge for those patients with pressure ulcers • Review the management and storage of static mattresses in line with BHTA guidelines (protect, rinse and dry) • Link nurses and Tissue Viability Nurses to be more proactive and carry out monthly spot checks and audit documentation against care given • Tissue Viability Nurse & link nurses/cascade trainers to raise awareness and promote the effective use of slide sheets for those patients at risk of pressure ulcers

(Data source: Datix which is not governed by a standard national definition)

Annual Report & Accounts 2011/12 98 Aintree University Hospital NHS Foundation Trust

3.3 Clinical Effectiveness

3.3.1 Advancing Quality Clinical Advancing Quality Effectiveness Improvement Area: Why: The Advancing Quality Programme which commenced in 2008 is a regional scheme promoted across NHS North West. It currently covers five clinical focus groups (Acute Myocardial Infarction, Heart Failure, Pneumonia, Stroke, Hips and Knees). The aim is to deliver continual improvements in health outcomes and experience for patients.

The principles of the programme are that if patients are provided with the right care at the right time in their care pathway it will reduce: • mortality • re-admission rates • complications • and the length of time patients spend in hospital

This project is a collaborative approach by hospitals across the North West of England that promotes the sharing and delivery of best practice. What : Evidence indicates that when patients are given appropriate ‘care bundles’ it improves both patient experience and patient outcomes. Each of the five clinical focus groups has a defined set of interventions which are included within the ‘care bundle’. How much: Performance is Postion from Clinical Area 2009/10 2010/11 2011/12 assessed on the 10/11 basis of the AMI 12.2% 9.1% 6.1% composite process Heart Failure 10.4% 13.7% 13.5% score. Mortality Hip & Knee 0.0% 0.2% 0.3% • Hip and Knee Pneumonia (Target 95%) 19.3% 19.2% 21.2% • Heart Failure AMI 10.6 9.8 10.1 Heart Failure 13.5 15.3 14.1 (Target 86.73%) Length of Stay • Pneumonia Hip & Knee 6.4 5.9 5.7 (Target 85.21%) Pneumonia 11.5 10.2 11.2 • AMI (Target AMI 13.1% 15.5% 14.1% 95%) Heart Failure 23.5% 14.5% 13.9% Readmissions • Stroke (Target Hip & Knee 10.5% 9.8% 9.8% 90%) Pneumonia 15.3% 15.0% 15.2% By When: Cumulative

performance at the Increase of 5% or more end of Qtr 4 in Increase of less than 5% 11/12 Stayed the same or improved Outcome: Improvements in the quality of care and patient outcomes are evidenced by reductions in mortality, reduced

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patient readmissions, and reductions in length of stay. Progress: Partially  Achieved Improvements The percentage of patients receiving the right care at the right time in their care Achieved: pathway has been maintained for 3 of the five clinical focus groups (heart attack, hip & knee surgery and stroke). Composite Process Apr - Dec 2010/11 Score_10/11 2011/12 Cumulative Cumulative Position Position Pneumonia Denominator 1864 1702 Rate (%) 84.6% 76.7% Hip and Knee Denominator 2835 2468 Rate (%) 93.7% 93.8% AMI Denominator 516 388 Rate (%) 98.8% 98.7% Heart Failure Denominator 637 398 Rate (%) 88.4% 83.4% Stroke Denominator 1189 1815 Rate (%) 89.8% 90.1% TOTAL Denominator 7041 6771 Rate (%) 90.5% 88.2%

Further During 2012/13 the Trust will explore options for real time data collection so that Improvements clinicians can review performance and implement changes to improve the Identified: quality of care in a timely manner.

Trust clinicians will also be encouraged to share best practice across each of the clinical focus groups and to attend the North West collaborative meetings so that best practice from other organisations can be adopted within Aintree. The following measures are to be taken in order to improve the AQ pneumonia performance in 2012/13: • Greater Consultant leadership of AQ Pneumonia: • Greater engagement with Accident and Emergency: • Consultants to review pneumonia patients case notes to ascertain whether the outcomes for AQ Pneumonia are being recorded properly i.e. antibiotics and to understand better areas for improvement • To continue to deliver teaching to medical staff in A&E, MAU and to the FY1 and FY2 doctors in the most appropriate care pathway for community acquired pneumonia.

(Data source: Dr Foster & Clarity Assure which is not governed by a standard national definition)

Annual Report & Accounts 2011/12 100 Aintree University Hospital NHS Foundation Trust

3.3.2 VTE Risk Assessment Clinical VTE Risk Assessment Effectiveness Improvement Area:

Why: Venous thromboembolism (VTE) is a term that covers both deep vein thrombosis and its possible consequence: pulmonary embolism (PE). A deep vein thrombosis (DVT) is a blood clot that develops in the deep veins of the leg and if the blood clot becomes mobile in the blood stream it can travel to the lungs and cause a potentially fatal blockage (PE). In 2005 the House of Commons Health Committee reported that an estimated 25,000 people die from preventable hospital-acquired VTE in the UK every year. The risk of hospital-acquired VTE can be greatly reduced by risk assessing patients and prescribing them appropriate prophylaxis (preventative measures). What : Implement a Trust wide VTE risk assessment tool to ensure in-patients at risk of VTE are identified and receive correct treatment How much: 90% of patients risk assessed for VTE on admission By When: Throughout AINTREE HOSPITALS NHS FOUNDATION TRUST Qtr 4 in 11/12 VTE Risk Assessment Apr 11 - Mar 12 Outcome: 95% of 100.0 patients have 80.0 VTE risk assessment 60.0 completed 40.0 92% of patients are 20.0 receiving 0.0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

appropriate risk % assessment prevention 11 11 11 11 11 11 11 11 11 12 12 12 Progress: Target  Achieved Improvements • VTE assessment proforma and electronic capture system on Sigma Achieved: launched in November 2011 • Interim solution established whereby Ward Clerks/Super Admin Users are trained across the Trust to input completed paper risk assessments directly onto Sigma • Tools including process flow charts, “how to” guides and a patient exclusion list have been developed to support staff • Training for Junior Doctors on induction • VTE champions introduced on each ward as part of patient safety officer role • Ward Managers along with Matrons monitor daily performance for their own wards/areas. Further • From April 2012 Doctors will have the responsibility of completing the Improvements risk assessment on admission to 90% of eligible in-patients directly into Identified: Sigma each month as this is an ongoing priority for the Trust.

(Data source: Unify2 which is governed by a standard national definition)

Annual Report & Accounts 2011/12 101 Aintree University Hospital NHS Foun dation Trust

3.3.3 Rescuing the Acutely Ill Patient Clinical Effectiveness Rescuing the Acutely Ill Patient - The Aintree Medical Emergency Team Improvement (MET) Area: Why: Any patient in hospital may become acutely ill. However, the recognition of deterioration is often delayed and its subsequent management inappropriate, resulting in late referral to critical care, avoidable cardiac arrests and unnecessary patient deaths. NICE Clinical Guideline 50 (Recognition and Response to Acutely Ill Patients in Hospital – 2007) recommends the provision of a Team with appropriate Critical Care competencies and skills to respond to deteriorating and acutely ill patients. What : In Nov ember 2 009 Following the introduction of the Aintree Medical Aintree University Emergency Team and prior to disbanding of the Cardiac Hospital NHS Arrest Team, there was a 33= % reduction in cardiac Foundation Trust arrest calls in Year 1 with an additional 16% reduction in established a the first four months of Year 2 (see below). Medical Emergency Team with the overarching Arrest Calls Pre & Post MET – Yr 1 and Yr 2

aim of providing 24 hour, 7 days per week critical care Cardiac Arrest Calls Pre & Post expertise to all Introduction of MET acutely ill patients 50 regardless of their geographical 40 location wi thin the hospital. The 30 Medical Emergency 20 Team also aimed to: • Achieve a year 10 on year 0 reduction in the of No. Cardiac Arrest Calls number of Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov cardiac arrest Pre MET Dec 08 - Nov 09 Dec 09 - Nov 10 calls within the Dec 10 - July 11 hospital • Provide senior clinical support to ward based In April 2011 the Cardiac Arrest Team was disbanded nursing staff and although calls were still being received until July 2011 junior doctors until the new system was completely embedded. The • Improve the MET now attend all clinical emergency calls within the education of Trust. During the last six months there has been an 18% medical and decrease in cardiac arrests within t he Trust when nursing staff in compared with the same period in 2010/11 (see below). the recognition These figures exclude ‘non-preventable’ cardiac arrests in and the Coronary Care Unit or Critical Care Department. management of acute illness

Annual Report & Accounts 2012011/12 102 Aintree University Hospital NHS Foundation Trust

How much: The target was a Six month comparison of 6/12 Cardiac Arrest activity year on year reduction in cardiac arrest rates within the hospital 14 13 By When: Ongoing 12 12 Outcome: 32% reduction in 10 10 10 cardiac arrest calls 9 in Yr 1 with an 8 7 additional 16% 6 6 6 reduction in the first 5 4 4 4 four months of Yr 2. of NumberCalls 18% decrease in 2 cardiac arrests Aug 0 11 – Jan 12 when Aug Sept Oct Nov Dec Jan compared with the same period Aug 10 to Jan 11 Aug 11 to Jan 12

2010/11 Progress:  Target Achieved The Aintree MET was ‘Highly Commended’ at the 2011 National Patient Safety Awards. Improvements Achieved: • Initial MET Audit showed that 38% of patients who required a call did not have oxygen in place when the Team arrived. Based on this data, the Aintree Modified Early Warning System (MEWS) Procedure now includes an algorithm for Nurse Led Response to Deterioration which empowers nurses to administer unprescribed oxygen to patients who meet the MET Calling Criteria. • Patient Group Directions for emergency oxygen and intravenous fluid therapy have been developed to ensure that initial treatment is delivered by ward nurses in a timely manner. • The 2011 MET Audit indicates that these developments have led to an 11% decrease in the number of patients who did not have oxygen in place when the MET arrived. • The Aintree MET Model has now been adopted at Whiston Hospital and the MET Co- ordinator has been asked to present the Aintree experience to the Trust Board, Warrington Hospital. • The Aintree MET will be showcased at the annual NICE Conference in May 2012 as a successful model for the implementation of NICE Clinical Guidance. Further Improvements Identified: • Refocus on MEWS to ensure that acutely ill patients get identified in a timely manner • MEWS relaunched. Specific re-launch day in April 2012 with distribution of MEWS Information Spinners, MEWS Stickers and MEWS Mouse mats. • Monthly random MEWS audits – checking the accuracy of four random charts each month in each clinical area. • Trust wide redistribution of MEWS Competency form with a commitment that all individuals performing patient observations and scoring MEWS are competent to do so. (Data source: National Cardiac Arrest Audit which is not governed by a standard national definition)

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3.3.4 Reducing COPD Readmissions Clinical Effectiveness Quest Reducing Avoidable Readmissions (within 30 days of Improvement Area: discharge) (NEW)

Why: COPD patients has been identified as the single largest patient group of patients who are readmitted to the Trust within 30 days of discharge What : To develop of improvement process to prevent avoidable COPD readmissions How much: To reduce the readmission rate by 2% from a baseline of COPD Readmissions 27.2% (agreed by the Trust Board) (Nov 2010 - Oct 2011) By When: 2% reduction by 20 15 14 13 13 13 15 October 2012 10 10 9 9 10 Outcome: Baseline established in 5 2011/12. COPD 0

readmission rate will be of NumberCases reduced to 25.2% from 27.2% Progress: Quest COPD GP Practices readmission working group developed, first meeting was in Jan 2012 with meetings scheduled every two weeks throughout 2012/13

Improvements • Attend Quest Learning Sessions (next meeting April 2012) Achieved: • Data obtained from Business Intelligence & Dr Foster • Multidisciplinary working group set up • Chest business unit engagement (Consultant representative on the group) • Patient involvement • PCT/GP involvement • Developing a COPD care bundle • Engage with Quest through WebEx learning Further Improvements • Design the COPD care bundle for Aintree Identified: • Complete a test of change • Involve patient group (Sefton Breathe Easy) • Implement COPD care bundle • Priority for 2012/13

(Data source: Sigma which is not governed by a standard national definition)

Annual Report & Accounts 2011/12 104 Aintree University Hospital NHS Foundation Trust

3.3.5 Reducing Readmissions within 48 Hours to Critical Care Clinical Reducing Re -admission within 48 hours to Critical Care Department Effectiveness (NEW) Improvement Area: Why: The Critical Care AQUIPS Team identified an issue relating to the number of patients returning from the wards following their transfer, which was felt to be unsatisfactory and chose to review current practice in relation to preparing patient for transfer. What : The overall aim of this project was to reduce the number of patients returning to Critical Care within 48 hours. This would be achieved through developing a discharge process/policy that facilitated improved patient safety and enhanced the patient’s experience. How much: 30% reduction Readmissions within 48hrs from 2011 2010 baseline 3.5

By When: March 2012 3

Outcome: Reduction in 2.5 early re- 2 admissions to CCD with 1.5 Patients 48 hours has reduced by 1 50% 0.5

Progress: 0 Target April May June July August Sept  Achieved Month

Improvements • New transfer checklist approved by Clinical Standards Group Achieved: • Revised transfer policy approved by Clinical Governance Team • All medical staff trained in the application of prescribing software for all transfers • New bed side nurse to nurse handover involving patients/families Further • Engaging with all members of the multi-professional team has given a Improvements greater understanding of the existing systems of work and therefore Identified: greater visibility of the gaps/risks to patient safety. A whole systems approach has meant that sustainable safety improvement that crosses clinical boundaries is achievable. • The new transfer process has been extended throughout the Trust. We will continue to drive and monitor this improvement through audit on a monthly basis as a Departmental Key Performance Indicator.

(Data source: Sigma which is not governed by a standard national definition)

Annual Report & Accounts 2011/12 105 Aintree University Hospital NHS Foundation Trust

3.3.6 Redesign of ENT Services for Deafness, Tinnitus and Balance Clinical Effectiveness Redesign of ENT services for deafness, tinnitus and balance Improvement Area: (NEW) Why: Following the retirement of the Consultant Audio-vestibular Physician roles have been extended in physiotherapy and audiology to provide streamlined services for balance, deafness and tinnitus patients in redesigned “one stop” clinics working to best practice within a multi-disciplinary team.

What : The multidisciplinary ENT service redesign Picture below: Jan Sobieraj (interim team audited existing Managing Director of NHS and Social practice and produced Care Workforce), Tony Kay (Head of a model of best practice Audiology Services at Aintree) and which streamlines the Nova Mullin (Specialist Physiotherapist service and improves at Aintree) the patient journey without compromising on quality. How much: 3 audiology led clinics per week and 3 physiotherapy led clinics per week set up in April 2011 By When: Review by March 2012 Outcome: Only about 15% of cases need to be referred onto an ENT Surgeon. Clinics have been successfully running for 12 months

Progress: Target Achieved  Improvements Achieved: • A patient satisfaction survey showed that all patients were satisfied with the new service with over 90% giving top marks. • The project was shortlisted for Aintree’s team awards in 2011 for the Rethinking the patient pathway category and was the successful winner of the 2012 Advancing Health Care Awards for AHP. Further Improvements • Ongoing priority Identified: • Further service evaluation and audit will help streamline even further • Other trusts have shown interest in the Aintree model

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3.4 Patient Experience

3.4.1 Patient Experience Feedback Patient Experience Learning From Patient Experience Feedback (NEW) Improvement Area:

Why: Quality of care includes quality of caring. This means how personal care is – the compassion, dignity and respect with which patients are treated. It can only be improved by analysing and understanding patient satisfaction with their own experiences. What : Monitoring and gathering evidence on patient experience from Aintree aiming for gold standard care a variety of sources enables the Trust to measure the service it provides for patients in a particular way by identifying trends in areas of good and poor practice which can then be addressed. How much: Sharing and reviewing Patient Feedback across Organisational Boundaries By When: March 2012 and beyond Outcome: Learning lessons and improving practice Progress: Ongoing Improvements Achieved: New Trust wide complaints process came into operation on the 1st July 2011 with Divisional complaint management, ownership and understanding of local themes and trends.

Digital recording of all formal complaints meetings was introduced providing complainants with an accurate record in a timely and efficient manner.

Patient Experience Sub Committee inaugural meeting held November 2011. Actively enhancing patient services in response to user views, provides a forum to debate patient experience with Aintree staff, Trust Patient Governors and representatives from partnership organisations, such as LINks. A close working relationship with local LINk’s member of Trusts new patient experience group, providing regular patient experience feed back to the Trust on a monthly basis, undertaking “Enter and View” visits. Patient feedback used throughout the Trust:

Annual Report & Accounts 2011/12 107 Aintree University Hospital NHS Foundation Trust

• The Patient Experience Questionnaire (PEQ) • Exit Cards • 'Have I Made a Difference?' cards (HIMAD) • Patient Stories • Graffiti Wall

Patient and Carer stories shared in a variety of ways; through the use of poetry, presentation at Trust Board, teaching programmes for the care of older people, patients experiences recorded on tape and through mind maps at complaint and being open meetings as well as the use of focus groups and using their LINk representative. Introduction of a graffiti wall enabled staff to have a greater understanding of their patients’ needs. Patients, relatives, visitors and staff recorded their comments, feelings and suggestions about the service that they received and experienced within specific wards and departments. Ward Nurse Managers now have access to electronic `real time’ feedback from their patients through the Aintree Business Intelligence System (aBI).

The Trust makes every effort to ensure that lessons are learned from patient feedback through complaints or national and local in patient and out-patient surveys through a variety of initiatives/ways:

• Business cards introduced for patients to enable them to have a contact point to discuss any ‘worries and or concerns’ they may have during their hospital admission and on discharge. • Patients received a letter from the CEO highlighting the forthcoming National Inpatient Picker Survey and how valuable their feedback will be to assist with improving the quality of care delivered. • A fridge magnet was included in every patient’s discharge medications, together with a lime green sticker both of which highlighted the common side effects of medicines and a contact `help line’ number if they have any worries or wanted any further advice. • Pop up banner together with vinyl banners clearly invited patients to offer their feedback on Aintree Hospital services. In each ward bay a bright green and yellow signs are displayed inviting patients and relatives to talk to the ward manager or nurse in charge if they wished to raise any aspect of the patients care. • Within the Accident & Emergency Department (AED), red privacy and dignity signs are used to secure the curtains during examination. Further work is ongoing around a dignity’ observation of care’ exercise and badges for domestic staff/volunteers which encourage patients to ask if they have any concerns.

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• Senior nurses carried out a `patient telephone’ follow up call after discharged from hospital within a 1-5 week time scale. The purpose of the trial was to improve the overall patient experience by providing an opportunity for patients to potentially be more honest about their experience and to ask any outstanding questions relating to their hospital stay. The Trust Board, Divisional Governance meetings, Governors, LINks receive quarterly report detailing comments, compliments, concerns and complaints called the 4C’s report. This report includes associated service changes, lessons learnt and all patient experience initiatives. Further Improvements • All initiatives ongoing throughout 2012/13 and reported Identified: through to Patient Experience Sub Committee • The National Picker surveys inpatient, outpatient and AED will generate actions plans that will be reported from Patient Experience group through to Patient Experience Sub Committee

3.4.2 Improving Patient Experience in Endoscopy Patient Experience Patient Experience in Endoscopy (NEW) Improvement Area: Why: The Patient Experience Department is constantly expanding the areas that are covered by the Exit cards What : Exit cards are now completed in significant February 2012 - 36 responses, all numbers in Endoscopy positive How much: In the last two full March 2012 - 38 responses, all months 74 Exit cards positive have been completed By When: We are aiming for 120 cards by the end of April 2012 Outcome: The Exit cards give us valuable information about what we doing well and what needs to be improved. Aintree aiming for gold standard care Progress: We are on target Improvements Achieved: • Positive feedback shared with the staff in the department. In times of low moral being praised for doing an excellent job is a great motivator. Further Improvements • As the Exit Cards identify areas for improvement they will Identified: be actioned.

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3.4.3 Nursing Care Assessment through Comfort Rounds Patient Experience Introduction of Comfort Rounds (NEW) Improvement Area: Why: Comfort Rounds is a system where patients are checked regularly to ensure their care needs are met. The system originated in Kentucky USA and the intention is for nurses to have clear aims which are measured to ensure all the fundamental care needs are met and patient receives a positive experience and their dignity is maintained. This initiative was introduced as a result of listening to patient feedback at the Trust’s Reaching Out Events held in the community. What : Rounding occurs on all patients. Explain process to patients on admission. Use key words ‘our goal is to provide better than expected care’. Schedule: Nurses round every 2 hours Rounding Checklist: • Pain Assessment • Toileting – Assist patient to restroom • Positioning • Environmental scan • Fall risk hazards: • Bed in low position, cords secured • Ensure items are within reach: phone, water, tissue, urinal, bedside table, trashcan, & call light within reach • Comfort: temperature of room, blankets, pillows • Ask “Is there anything else I can do for you? I have the time.” • Remind the patient that a staff member (let them know who) will be back in about an hour to round on them again.

How much: All wards have introduced comfort rounds By When: Completed by December 2011 Outcome: Reduced pressure ulcers, Complaints, Falls and improve patient experience during hospital stay Progress: Target Achieved  Improvements • All wards have introduced comfort rounds Achieved: Further • To measure falls. pressure ulcers to see if there has been a reduction Improvements: • To evaluate patient experience through patient survey

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3.4.4 Improving Access to Audiology Services for Patients with Learning Disabilities Patient Experience Improving access to Audiology Services for patients with Improvement Area: Learning Disabilities (NEW) Why: Studies have shown that up to 50% of adults with learning disabilities have a hearing loss. Referrals to audiology for hearing aid assessments are very low. What : We have developed good links with the community Audiology Referrals for patients with speech and language Learning Disabilities therapists to ensure that all patients they see have 16 a discussion regarding 14 possible hearing loss and 12 a GP referral is actioned. 10 How much: Referrals in 2010 for 8 assessments was 5, for 6 2011 it was 15 and to 4 date in 2012 it is 5 in the Referrals of Number 2 first 3 months 0 By When: March 2012 2010 2011 Outcome: Improve access to audiology services and hearing aid use to reduce communication difficulties. Progress: Target Achieved  Improvements Achieved: • Increase in the number of patients referred for assessment and hearing aid use. • Increased long term use of hearing aids and amplification devices. • Poster presented at Aintree’s Care and compassion conference Further Improvements • Area for improvement is for outpatient departments and Identified: wards to be identify patients with a possible hearing loss and initiate a referral to Audiology services.

(Data source: Sigma which is not governed by a standard national definition)

3.4.5 The Productive Ward Programme This initiative is now fully rolled out across all wards within the Trust. It is fully embedded in the Trust’s standard operating procedures and monitoring is captured in the Matrons Ward Checklist.

Annual Report & Accounts 2011/12 111 Aintree University Hospital NHS Foundation Trust

3.4.6 Improving Communication between Patients and Staff Patient Experience Patient Experience – Improving Communication Improvement Area: Why: Clear communication between patients and staff is a key factor in improving the patient experience during their hospital stay by keeping them informed about their care. What : Four key areas of communication were identified for improvement from the results of the 2009 national in-patient survey. How much: From a baseline of 69% to improve by 20% in the 4 key questions within 24 months By When: 2011 National Picker in-patient survey (results available in February 2012) Outcome: Patients have reported that communication has improved in the 4 key communication questions Progress:  Target Achieved

Patient Experience Results on the 4 key areas around communication

% Target March % Target March for March 2011 for March 2012 2011 2012

Q1 . Patients felt that nurses did 79% 83.71% 82.8% 85.8% have knowledge/or a good awareness of their condition Q2 . Patients understood the 79% 80% 82.8% 93.6% answers nurses provided Q3. Patients understood the 79% 79.39% 82.8% 93.5% answers doctors provided Q4. Patients felt involved in 79% 79.69% 82.8% 88% discussions with the doctor about their care

Improvements Achieved: • Customer Care training available on induction and within the Trust’s ongoing training and education programme • Positive feedback shared with the staff Further Improvements • All improvement areas highlighted from the survey have Identified: been incorporated into an action plan and progress is monitored by the Patient Experience Sub Committee.

(Data source: aBI in March 2011, not governed by a standard national definition and Picker Survey in March 2012 which is governed by a standard national definition)

Annual Report & Accounts 2011/12 112 Aintree University Hospital NHS Foun dation Trust

3.4.7 Patient Experience Questionnaire (PEQ) Patient Experience Patient Experience (NEW) Improvement Area: Why: The Trust has a moral, commercial and legal duty (e.g. Health and Social Care Act 2012) to take the view of local patient into account when delivering services What : Patient Feedback collected via the Patient Experience Questionnaire How much: Between March 2011 and March 2012 ( the period under review 2627 PEQ were collected By When: 1/3/2011 - 31/3/2012 Outcome: Improved patient satisfaction Progress:  Target Achieved

Improvements On average 9 out of 10 patients rate us either good or excellent in the following Achieved: areas: “Putting You First” (good and excellent score = 95%. 80% of the scores in this field were excellent; 15% were good. Only 5% felt we didn’t put them fir st ‘sometimes, rarely or never” ). There was a similar story with “ Receiving prompt attention” ( 77% ‘Excellent’ and 17% ‘Good’) and also with “ Showing we care” ( 82% ‘Excellent’ and 13% ‘Good’)The 2627 patie nts surveyed over the last year gave the Trust an average of 8. 74 out of 10. Further The Trust realises that some part of these very high scores may be due to Improvements patients being asked there opinion whilst still on the wards, by ward clerks and Identified: housekeepers. Therefore we have a trial running with a company called ‘Free Range People’ who are offering a service where patient feedback can be collected via text; email or web to an independent contractor. The results are conveyed back to t he Customer Services department a nd then to ward managers in real time via a ‘dashboard’. The advantages of this system are that it is independent and does not impact on ward duties; results can be obtained rapidly and is reasonably cost effective. The Tr ial on Ward 16; in AED and in Critical Care has been running since March 2012 and is schedule to last for 3 months. (Data source: aBI which is not governed by a standard national definition )

Annual Report & Accounts 2012011/12 113 Aintree University Hospital NHS Foundation Trust

3.4.8 “Have I Made a Difference” Cards Patient Experience Patient Experience: “Have I made a Difference cards” (NEW) Improvement Area: Why: The Trust uses a system of ‘ have I made a difference cards’ which capture what patients say about staff who have exceeded their expectations What : The cards are available throughout the hospital on wards and in public areas

How much: Between March 2011 and March 2012 ( the period under review 755 HIMAD CARDS were collected By When: These comments are from a period March 2011- October 2011

Outcome: Two staff, in particular, were judged to have delivered excellent customer service over the period due to comments below received from patients: Progress: Target Achieved  Improvements Paul Fletcher, (Health Care Assistant), Achieved: Ward 16 “Nothing is too much trouble for Paul” “Paul is a natural carer and is kind and thoughtful” “He has the extra factor” “Paul listened when I needed it” “Paul picks up your mood”

Picture right: Jill Byrne, Director of Nursing presenting Paul Fletcher with the Trust’s Excellence Award Alison Watson, (Health Care Assistant), Ward 15: “Alison is cheerful and helpful” “Nothing is too much trouble for Alison” “Alison made me feel good” “I would love to have Alison look after me if I ever returned (to the ward).” “Even though the ward was really busy Alison took the time and made me feel better”

Picture right: Jill Byrne, Director of Nursing presenting Jackie Phillips on behalf of Alison Watson with the Trust’s Excellence Award Further Both members of staff were honoured at the Trust Quality Award evening Improvements in November 2011. The ‘Have I made a Difference’ award was such a Identified: success that it will be held as an annual event. Nominations are currently being collected for the 2012 event.

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Part Three b: Performance against Key National Priorities and National Core Standards

3.5 Key National Priorities – Department of Health’s Operating Framework

The 2011/2012 Department of Health Operating Framework identified a number of key areas of focus relating to the maintenance of service quality, a summary of the performance in these key areas is provided below: Referral to Treatment Times Throughout 2011/2012 the Trust has performed consistently well in ensuring patients are treated in a timely manner. A review of the annual performance of the Trust indicates that all Referral to Treatment time thresholds have been met, further detail is set out below:

Admitted clock stops: • Median Wait –Target 11.1 Weeks – Performance = 10.9 weeks, • 95 th Percentile – Target 23 Weeks – Performance = 21 Weeks Non admitted clock stops: • Median Wait – Target 6.6 weeks - Performance = 4.4 weeks • 95 th Percentile - Target 18.3 weeks - Performance = 16 weeks The Trust has also performed well against the developing target of ensuring that greater than 92% of incomplete pathways are less than 18 weeks – March 2012 figures indicate that 96.1% of patients are waiting less than 18 weeks. Accident and Emergency Services During 2011 / 2012 the Trust was once again the best performing non specialist Trust in the North West with performance reported at 97.70% for the year.

The Trust has been closely monitoring the College of Emergency Medicine clinical indicators and has made significant improvements in patient access, compliance and wait times. AED wait times have consistently been below the target of 240 minutes, in 11 of the 12 months last year, fewer people left the department without being seen than the target of 5% (monthly average 4.1%). Unplanned follow up reattendances (i.e. those returning for treatment for the same condition) were consistently below the 5% target at 2% although the rate of all re attendances to AED was above target each month at 7.9% (a trend shared across the majority of AED departments). The Trust is committed to ensure that patients are seen by senior decision making clinicians at every attendance and as such, given the significant demands the department faces the median time to see such senior staff has been consistently above the 60 minute target at 89 minutes. All patients arriving by emergency ambulance are immediately triaged and seen by a decision-making clinician within the 15 minute target. Healthcare Associated Infections As with previous years the Trust has continued to reduce health care associated infections. Both hospital acquired Clostridium Difficile infections and MRSA infections are below the thresholds set by the Department of Health and the lowest for 4 years. 63 cases of CDT were reported and 4 MRSA cases in the year.

Annual Report & Accounts 2011/12 115 Aintree University Hospital NHS Foundation Trust

During 2011/2012 the Trust has developed the SIGHT programme, to maintain this performance and effectively manage patients with unexplained diarrhoea appropriately.

Eliminating Mixed Sex Accommodation During 2011 / 2012 the Trust has reported 90 Mixed Sex Accommodation breaches. These breaches mainly relate to patients requiring transfer to another ward following treatment within an intensive care facility (which is generally exempt from MSA requirements due to the nature of the area). The Trust is in the process of extending the Critical Care bed base in autumn 2012 and as such, reducing the likelihood of breaches in the future.

End of Life Care The Trust is a pioneer in the delivery of End of Life care, with an active consultant led specialist palliative and end of life care team. Working closely with Woodlands Hospice (which is on site), primary care and the inpatient teams, the Trust aims to provide high quality supportive care to people and their families living with long term and end of life conditions. Cancer Reform and Screening Over 2011 / 2012 apart from the 62 day classic and screening treatment targets, the Trust has consistently met the Cancer waiting times targets. As the Trust only screens patients with bowel cancer (breast and cervical cancer screening is done elsewhere) achieving the screening target has been problematic due to low numbers. During the year the Trust appealed to the Department of Health for a revision of this target and this has been upheld by the Department and Monitor, although a revised target has yet to be issued.

In February 2012, the Trust invited the NHS Intensive Support Team to independently review cancer services and processes for administering pathways, to ensure that everything that could be done to improve performance is being done. The team supported the work being done at the Trust and came up with a number of recommendations, which may help improve performance. The Trust has developed an action plan and will be working closely with the IST to further develop services.

Stroke The average monthly performance of the Trust, in ensuring that 80% of patients spend 90% of their time on an acute Stroke unit is 83.2%, with only May and August showing a drop just below the target level. The Trust is a Hyper Acute Stroke Centre and work is ongoing in the development of clinical partnerships with the Royal Liverpool University Hospital. The Trust continues to be one of the national high performers in terms of the timeliness of thrombolysis following admission for Stroke. The Trust is on target to implement a 24 hour, seven day a week Stroke nurse clinician service from the 01 August 2012. This will further improve and enhance an already excellent service.

Emergency Readmissions Using Dr Foster Intelligence (DFI) data as a comparison, between December 2010 and November 2011, the 28 day emergency readmission rate at the Trust was 8.5%, taking into account case mix adjustment, which is comparable to that expected by DFI (8.5%) (6141 readmissions against 6113 expected). The Trust is working closely with primary care and PCT colleagues to further improve readmission rates.

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An overview of performance in 2011/12 against the key national priorities from the Department of Health in accordance with the key indicators in Annex B of Monitor’s compliance framework is shown in Annex E

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Annex A: Statements from PCTs, LINks and Overview and Scrutiny Committees

118 Aintree University Hospital NHS Foundation Trust

Liverpool LINk - University Hospital Aintree NHS Foundation Trust - Quality Account Commentary 2011/12

Liverpool LINk welcomes the greater opportunity for engagement facilitated by the trust's initiatives during 2011/12. LINk representatives have been invited to two key patient experience sub committees. Communication with some named senior managers has greatly improved and concerns are now dealt with promptly. However there is still scope for further development in this area. The trust has held consultation events and it has surveyed service users and staff concerning the quality priorities. In the matter of protected groups under equality legislation such as disabled people, ethnic minorities, gender, sexual orientation, religion and transgender, there is still work to be done in achievement of full accreditation as set by Equality Delivery Systems requirements. This development status was recently acknowledged by the trust. In terms of our commentary the requirements were partially met. It is clear that stakeholders including LINks were circulated concerning Quality Account priorities. Since the previous QA public input has improved. Enhancement of participation has presented the LINk with a much clearer picture of how feedback is being used to improve service delivery. This process must be extended and be sustained. Within the specified parameters the trust has met with the requirements on priorities. They are issues that service user would expect to be selected. The Quality Account contains a wealth of detail that helps the public to understand how well it is doing. Although extensive in factual content the quantity of information might be confusing to a general reader. The trust has taken up suggestions by the LINk partners to produce a more accessible version of the Quality Account which service users or other interested parties might read. The Account focuses on improvement issues and this is backed up with evidence. The trust has made significant progress in infection control, harm free care, VTE risk assessment, cardiac arrests and patient satisfaction. A real improvement was recorded in treatment of cardiac arrests and Liverpool LINk also recognises Aintree's achievements in reducing readmissions to the Critical Care Unit (reduced by 50% against a target of 30%) and improving 'good' or 'excellent' Picker In-Patient Survey ratings from 69% to 91% over three years.

There was an increase in the Hospital Standardised Mortality Ratio compared to 2010/11 but it is still possible for the trust to achieve its target. The format of the Quality Account has improved this year with more appropriate use of graphs and colour coding.

The key priorities for action in 2012/13 remain unchanged from 2011/12 under the headings 'saving lives', 'patient safety' and 'patient experience' and the Trust has specified a number of strategies and plans by which these should be achieved over the coming year. In terms of patient safety the 2011/12 target was achieved in the number of incidents reported and pleasing progress was again recorded in patient experience. The trust has set very high safety standards and is still doing considerable development work in this area.

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The draft Quality Account is still not fully accessible in terms of plain English and no information is given as how to obtain translated versions. Previously recorded concerns about the format of the Quality Account are being taken on board. A short executive summary has been introduced at the start of the account. Data presentation has improved although some graphs suffer from a limited vertical scale and inappropriate use of colour. Liverpool LINk Quality Accounts Commentaries are restricted in scope to commenting on issues pertaining to individual Quality Accounts. The presentation of the Quality Account by UHA NHS FT shows continued progress from 2010/11 and pleasing achievements in priority areas which the public greatly value.

Edwin Morgan, Liverpool LINk

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Aintree University Hospitals NHS Foundation Trust Quality Account Commentary Knowsley LINk

Knowsley LINk welcomes the opportunity to provide this commentary in support of the Aintree University Hospitals NHS Foundation Trust Quality Account for 2011/12. The Quality Account report was provided to LINks in a timely manner and presented thoroughly during a question and answer session held in May. It was pleasing to note that the comments LINks members raised regarding last year’s presentation had been listened to and the content presented for this Quality Account was more user friendly.

During the last twelve months the partnership working and challenges provided through Knowsley LINk has been welcomed by the Trust. Knowsley LINk members have attended the Patient Experience Sub-Committee and the Patient Experience Group; these groups have proved to be a good point of contact with the Trust. In addition, we have jointly hosted a reaching out event with the Trust and worked in partnership with our neighbouring LINks to hold patient experience information stands at the Hospital.

It is felt that the Priorities for Improvement identified for the coming year are both challenging and reflective of the issues Community Members, Service Users and LINk members are keen to see addressed. The priorities to reduce hospital acquired infections and falls are both welcomed by Knowsley LINk and we will support initiatives taken to eliminate these devastating events. We particularly welcome the planned improvements to food delivery and will monitor with interest the developments regarding serving moulded food to people who have difficulty swallowing. We will also look forward to seeing evidence of improvements to the food that is served to all patients, which the Trust has committed to this year.

Knowsley LINk would also challenge the Trust to ensure that in the service redesign, for the Ear, Nose, and Throat Department and in their commitment to the Advancing Quality Agenda, a focus is maintained on the specific needs of the areas they provide services to and they continue to gain an understanding of the local communities which they serve.

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Knowsley Overview and Scrutiny Board

Commentary to Aintree University Hospital

“The Knowsley Overview and Scrutiny Board welcomes the opportunity to provide a commentary on Aintree University Hospital NHS Trust’s Quality Account.

Knowsley Overview and Scrutiny Board delegated responsibility for considering Quality Accounts to the Chair of the Overview and Scrutiny Board in consultation with the Lead and Deputy Lead Member for the Wellbeing theme. A meeting was convened on Wednesday 9 th May to consider the Quality Account document received by Aintree University Hospital Trust. The three Members spent time considering the document and made a number of observations which have formed the basis of the Board’s commentary, as set out below.

We focussed our discussions around three priority areas. Our first was the Trust’s Improvement Priorities for 2012-2013 and their achievements highlighted over the previous year. We also considered if there where areas to be commended and whether there were areas where more information could be provided. Our final observations referred to the layout, style and format of the document, particularly focussing on how the document related to and/or involved the public.

Whilst we supported the priorities for improvement outlined on page 79, we would have appreciated a full explanation as to the rationale behind them. We noted the positive reduction in the number of hospital acquired infections over the past 5 years and support the Trust in its ambition to continually improve in this area. We also recognised the significant improvement made by the Trust in preventing the number of patient falls and commend the Trust for developing the Falls Collaborative and for its work with the John Hopkins Hospital in Baltimore. We did feel it was important for the Trust to ensure its data was up to date in relation to the targets around the identification and treatment of malnourished patients and we were pleased that the Trust had put this as a priority.

We were heartened to read of the variety of ways in which patients could express their views or share their experiences. We support the existence of a Patient Experience Sub Committee and we hope that it is able to report on any persistent issues which arise. We thought the introduction of comfort rounds were an excellent way of ensuring patient experiences were positive and nursing care was of a high standard.

We noted the number of mixed sex accommodation breaches but recognised that this was inevitable in critical situations. We commend the Trust for looking to extend the Critical Care bed base in autumn 2012 to reduce the likelihood of breaches in the future.

The layout and style of the report, particularly the achievements section was excellent. The graphs were clear and understandable and showed progression over time. The report was easy to read and accessible for a lay person.

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On behalf of the Knowsley Overview and Scrutiny Board we would like to thank the Trust for its interesting report and welcome future engagement in order that we can provide a fair and balanced commentary on the Trust’s achievements in the future.”

Commentary provided by Councillor Mal Sharp (Chair of Overview and Scrutiny Board), Councillor Bob Swann (Lead Member for Wellbeing) and Councillor Kay Moorhead (Deputy Lead Member for Wellbeing) on behalf of Knowsley Overview and Scrutiny Board.

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Aintree University Hospital NHS Foundation Trust – Quality Account Commentary.

Sefton LINk would like to thank the Trust for their continued partnership work with the LINk over the past 12 months. This response was completed following a review of the draft copy of the Quality Account and from LINk members receiving a presentation.

It is pleasing that the Trust has achieved the target for Venous- Thromboembolism (VTE risk assessment), risk assessing 90% of patients on admission and also in ‘Improving patient experience and responsiveness.

We have worked with the Trust to ensure that issues relating to nutrition and access to food have been addressed. Members note the work of the Trust in redesigning food for patients who have swallowing difficulties.

The introduction of ‘Comfort Round’s’ is an excellent initiative, and the Trust should be commended for this work. We have recommended that questions relating to nutrition could be included within the checklist to ensure that nutritional needs are being met.

We welcome the introduction of the ‘Quality Assurance & Accreditation Framework’ and look forward to being updated on progress.

It was pleasing to note that this target was partially achieved and the Trust is continuing to work to promote safe discharge as a priority for next year. This target for improved communication between the hospital and the local General Practitioners (GPs) is an area which we would be keen to monitor over the coming year and look forward to working with the Trust on this.

Improving patient experience will remain a key priority for 2012/13. The Trust has set up a ‘Patient Experience Sub Committee’ and a ‘Patient Experience Action Group’ where we have been able to undertake some joint work to improve the quality of services.

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We were pleased to note the work with ‘Free Range People’ on a patient satisfaction survey. This is evidence of the Trust valuing patient experience.

During 2012, the Trust worked with us to hold a listening event to share information around quality priorities and to hear from community members. Reaching out to the community and listening to patients was an innovative method of engagement however, the follow up event “You Said, We Did” has been postponed on two occasions. We appreciate that low numbers may be a factor in this follow up event not going ahead but believe the actions taken by the Trust could have put into a report and shared with local people in the interim.

The document itself is well structured and easy to understand, however some of the indicators need to be made clearer on graphs and charts. The graph which shows reported ‘Falls Incidents by Year’ needs to include the data for 2010-11 and 2011-12 to show the total falls in order that the data can be compared to previous years, perhaps one bar with two colours (falls no harm and falls with harm).

Tables with actions are clearly identified. The Trust has been proactive and has held 2 sessions with members to look at how the Trust can produce an easy to read summary document. This is welcomed.

We look forward to our work with the Trust over the coming 12 months to ensure that local people receive quality services.

Prepared by Sefton LINk.

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Sefton Council Governance & Civic Services

www.sefton.gov.uk Corporate Commissioning Department Town Hall Lord Street Southport PR8 1DA

To: - Date: 19 th June 2012 Aintree University Hospital Foundation Trust Our Ref: Your Ref:

Please contact: Debbie Campbell Contact Number: 0151 934 2254 Fax No: 0151 934 2034 e-mail: [email protected]

Dear Sir / Madam,

Draft Quality Account 2011/12

Please find attached a copy of the relevant Minute from the meeting of this Council’s Overview and Scrutiny Committee (Health & Social Care), held on 29 th May 2012, when the Committee considered your Trust’s draft Quality Account.

Yours faithfully,

Debbie Campbell

Overview & Scrutiny Officer

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OVERVIEW AND SCRUTINY COMMITTEE (HEALTH AND SOCIAL CARE) – TUESDAY 29TH MAY, 2012

5. AINTREE UNIVERSITY HOSPITAL FOUNDATION TRUST

The Committee received a presentation from Carolyn Fox, Deputy Director of Nursing (Interim) and Angela Whittaker, Assistant Director of Planning and Commissioning, Aintree University Hospital Foundation Trust, on the Trust’s draft Quality Account for 2011/12, and the work of the Trust in general.

The presentation outlined the following:-

• Key facts about the Trust; • The format of the Trust’s 2011/12 Quality Account; • Priorities for Improvement and the Trust’s overarching three priorities for 2011/12; • An overview of the quality of care offered by the Trust, based on the performance of nineteen improvement initiatives chosen through stakeholder consultation during the previous year; • Patient safety and progress on infection prevention; • Patient safety with regard to falls; • Clinical effectiveness and risk assessment; and • Patient Experience and the introduction of “comfort rounds”.

The Committee had previously been supplied with the full version of the Trust’s draft Quality Account.

Members requested additional information on numbers of falls and training of staff taking blood.

RESOLVED

That the draft Quality Account for 2011/12 from the Aintree University Hospital Foundation Trust be received.

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Annex B: 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 2010 as amended to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS Foundation Trust boards on the form and content of annual Quality Reports (which incorporate the above legal requirements) 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 2011-12 ;

• 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 2011 to June 2012 ; - Papers relating to Quality reported to the Board over the period April 2011 to June 2012 ; - Feedback from the commissioners dated 28 th May 2012; - Feedback from governors dated 22 nd February 2012; - Feedback from LINks dated 28 th May 2012; - The Trusts complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, over the period April 2011 to March 2012; - The Picker Institute national patient survey published in February 2012; - The 2011 CQC national staff survey; - The Head of Internal Audit’s annual opinion over the Trust’s control environment dated 3 rd May 2012; - Care Quality Commission quality and risk profiles dated 29 th February 2012;

• The Quality Report presents a balanced picture of the NHS foundation Trusts 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

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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

Date: 30 May 2012 Chairman

Date: 30 May 2012 Chief Executive

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Annex C: Participation in Clinical Audits and National Confidential Enquiries during 2011/12.

National Clinical Audits Participation % Cases Comment Submitted Acute Care Emergency use of oxygen (British No NA Thoracic Society) Adult community acquired pneumonia Yes 100% (British Thoracic Society) Non invasive ventilation (NIV) - adults No NA British Thoracic Society) Pleural procedures (British Thoracic No NA Society) Cardiac arrest (National Cardiac Arrest Yes 100% No minimum Audit) requirement Severe sepsis & septic shock (College of Yes 100% Emergency Medicine) Adult critical care (ICNARC CMPD)) Yes 100% No minimum requirement Potential donor audit (NHS Blood & No NA Transport) Seizure management (National Audit of Yes 100% Seizure Management) Long Term Conditions Diabetes (National Adult Diabetes Audit) No NA Ulcerative colitis & Crohn's disease (UK Yes 100% IBD Audit) Parkinson's disease (National Parkinson's Yes 100% Audit) Adult asthma (British Thoracic Society) No NA

Bronchiectasis (British Thoracic Society) No NA Elective Procedures Hip, knee and ankle replacements Yes 100% (National Joint Registry) Elective surgery : Yes Hip replacement, 79% Knee replacement, 71% July-December Hernia, 47% 2011 Varicose veins 11% (National PROMs Programme) Peripheral vascular surgery (VSGBI Yes 100% Vascular Surgery Database) Carotid interventions (Carotid Intervention Yes 100% Audit) Cardiovascular Disease

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National Clinical Audits Participation % Cases Comment Submitted Acute Myocardial Infarction & other ACS Yes 100% (MINAP) Heart failure (Heart Failure Audit) Yes 99% Acute stroke (SINAP) Yes 100% No minimum - 1009 submitted in last 3 quarters Cardiac arrhythmia (Cardiac Rhythm Yes 100% All cases Management Audit) submitted, 244 for 2011/12 Renal Disease Renal replacement therapy (Renal Yes 100% 25 cases Registry) Cancer Lung cancer (National Lung Cancer Audit) Yes 100% Submission exceeds requirement Bowel cancer (National Bowel Cancer Yes 96% 6 months data Audit Programme) only August to January 2012 211/220 cases submitted Head & neck cancer (DAHNO) Yes 0% Data for 2011/12 unavailable Oesophago-gastric cancer (National O-G Yes 0% Data only Cancer Audit) available for August to January 2012 Trauma Hip fracture (National Hip Fracture Yes 100% Submission Database) exceeds requirement Figures from last 3 quarterly reports Severe trauma (Trauma Audit & Research Yes 100% Submission Network) exceeds requirement Blood Transfusion Bedside transfusion (National Yes 100% Comparative Audit of Blood Transfusion) Medical use of blood (National Yes 21% Comparative Audit of Blood Transfusion)

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National Clinical Audits Participation % Cases Comment Submitted Health promotion Risk factors (National Health Promotion in No NA Hospitals Audit) End of Life Care of dying in hospital (NCDAH) Yes 100% National Confidential Enquiries Alcohol Liver Related Disease Yes NA Data collection ongoing

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Annex D: Actions Arising as a Result of National and Local Audits NATIONAL AUDIT ACTIONS Adult Community Acquired Pneumonia • Introduction of pneumonia feedback letters sent to individual clinicians whenever any of the pneumonia quality indicators have or have not been achieved. These feedback letters provide positive and negative feedback and offer individual clinicians the opportunity to discuss any aspect of pneumonia management with the clinical director. • Training sessions for junior doctors on ‘pneumonia management’ have been implemented. Vital Signs in Majors • Recommended:- All majors patients should have observations performed within 20 minutes of arrival. If abnormal, these should be repeated within one hour. All observations should be recorded including GCS. If abnormal observations are identified, action taken should be documented in the notes. If observations are abnormal there should be documented evidence that the nurse in charge was made aware. • Planned:- To improve documentation of observations and perform all initial observations within 20 minutes. Document that senior nurse was made aware of abnormal observations and acted upon appropriately. ICNARC – Adult Critical Care • Actions are in progress over the next 6-24 months to improve the following:- - Admission data collection - Delayed discharges - Collection for organ support - Microbiology data • Action has been implemented to improve inaccurate data on withholding/withdrawal of care. National Re -audit for Falls and Bone Health in Older People 2010 • A questionnaire is being developed and introduced to ARDU. • Reinforcement of current policies and introduction of new Trust wide policy. • Consideration of employing physiotherapy 7 days a week on the hip fracture unit. • Employment of fracture liaison nurse being arranged. • Increased education. • Audit to be undertaken in AED to review effectiveness or referral • Physiotherapist nominated to attend training. • Therapists to assess in AED and refer to community, ARDU or falls clinic. • New Casualty Card pro-forma to be introduced to identify fallers and arrange referral. • New preliminary risk assessment tool being developed – Re-audit planned. • Leaflet produced and now available on the intranet. Use of Platelets in Haematology • Until revised BCSH guidelines on the use of platelet transfusions are available, local guidelines should be based on current BCSH guidelines and, in particular, should specify that a platelet transfusion is not required routinely:- o Prior to bone marrow aspiration and biopsy. o As routine prophylaxis in stable patients with long term bone marrow failure. • The reason for transfusion should be clearly documented in the notes/patient’s record including any individual threshold platelet count agreed for that patient. • All patients should have a platelet count within a few hours prior to prophylactic platelet transfusion. As a minimum this should be within 24 hours for an in-patient and 48 hours for an out-patient. • If platelets are required pre-procedure they should be transfused close to the procedure to obtain

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maximum benefit but allow time for a post transfusion platelet count to be taken to assess response. A platelet count taken 10 minutes after a platelet transfusion has been shown to be equivalent to the 1 hour platelet count increment. National Heart Failure Audit We need to focus our attention on improved uptake and up-titration to target dose of the medical therapies – an area where the Heart Failure Specialist Nurse undoubtedly play an important role and improve our links with community services. The dataset should be expanded to the use of non- pharmacological treatments such as cardiac resynchronisation therapy and implantable defibrillators. MINAP The non-emergency transfer of patients to LHCH for in-patient PCI procedures is facilitated by having a designated doctor (joint appointee in interventional cardiology with LHCH) but unacceptable delays do occur when he is on leave however, the Business Unit is developing an action plan to resolve this. This issue has been the subject of a prior local audit at Aintree. Peri -operative Care: Knowing the Risk The report has only recently been published and an action plan is in development. National Lung Cancer Audit (LUCADA) • The Clinical Nurse Specialist (CNS) complement is due to increase from 2.0 to 2.5 WTE from March 2012. • An operational plan has been devised to ensure that inpatients with lung cancer (38% of lung cancer patients present acutely) will be reviewed. Our Multi Disciplinary Team (MDT) operational policy has been changed accordingly after this was agreed at the 2011 MDT annual meeting. • Ensuring that patients have a lung cancer specialist nurse present at the time of diagnosis requires not only increased CNS time but also band 4 support from an administrator. It requires significant changes to how our rapid access clinic is templated and runs in addition to better coordination with the wards. Currently the post has been approved. National Care of the Dying Au dit – Hospitals (NCDAH) Round 3 Results • Continue Trust support for specialist palliative care team • Education and training should be mandatory for all staff caring for dying patients and their families • Liverpool Care Pathway facilitator role has not been extended by Merseyside and Cheshire Cancer Network beyond 31.3.2012-Aintree need to address this locally • Local audit team to consider and implement more in depth at goals around hydration • Better information for patients and relatives around End of Life to be available • Better compliance with completion of Liverpool Care Pathway LOCAL AUDIT ACTIONS

Venous Thromboprophylaxis (VTE) Risk Assessment form Completion Ward 9 • The findings of the audit to be highlighted at a Cardiology Directorate Audit Meeting and staff reminded to comply with the VTE prophylaxis protocol. Re -audit of P3NP Monitoring and NPSA Booklet/Methotrexate Guidance • Changes in Practice: To follow the P3NP guidelines in particular doing a baseline P3NP and repeat 3 monthly. To take action according to the guidelines if P3NP levels are abnormal. Re -audit of the Diagnosis and Management of Clostridium Difficile Toxin (CDT) Infection • No Change - All the standards had been met. Effectiveness of -Training in DME (Junior Doctors) • To devise a formal rota for specialist registrars and consultants to provide ward based teaching.

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Also to discuss about changing the induction timetable to cover two topics per session. Management of Delirium • Changes in Practice: A new risk factor assessment tool has been developed and added to the admission pro- forma. • Planned Changes in Practice: New guidelines are being developed for the nursing staff on the management of delirium. Management of Vertebral Fractures • Planned Changes in Practice: The osteoporosis nurse specialist to review the notes of patients with vertebral fractures reported from radiology in order to establish where these patients are being identified and therefore ensure that they receive the treatment. Arrange teaching sessions for radiologists to aid in the recognition and reporting of vertebral fractures in accordance with the International Osteoporosis Foundation. Develop an automated reporting system from radiology so that all vertebral fracture reports are sent to the osteoporosis specialist nurse or designated doctor. Nutritional Re -audit • Changes in Practices The use of manual white boards has been stopped, there has been more staff education regarding awareness of the screening tools and guidelines and there is increased dedication from staff members to provide help with feeding. Parkinson’s Disease Management Against NICE Guidance • Planned Changes in Practice To produce a new pro-forma for use in the clinic to prompt certain areas to be documented in relation to the NICE guidance. Re -audit of the Rapid Referral Stroke Clinic • Changes in Practice: Cancelled clinics are now reassigned to other stroke consultants who have availability and a new TIA referral form is now in use. • Planned Changes in Practice: Patients with an ABCD2 score greater than or equal to four need to be seen within 24 hours of symptom onset, and will be seen on the ward/MAU if no clinics are available. Also that there needs to be continued education for GP’s and AED staff. In addition that smoking cessation advice will be provided and documented in the notes. Stroke Review Clinic • Reasons for No Changes in Practice Since the results there have been no changes in practice implemented as we need to consider the options available and the review as part of the Stroke Improvement process. Stroke Thrombolysis Hyperacute Care Audit • Changes in Practice: Since the results changes in practice have been implemented. Recommendations have been made to the Stroke Board regarding the implementation of a Stroke Emergency Team to raise awareness with the MDT of an incoming patient with a stroke onset. Re -audit of VTE Prophylaxis in the DME Department • Changes in Practice: Since the results there is continued education on the importance of a VTE risk assessment and prophylaxis. Compliance with the New Screening Tool • Changes to Practice: There is now ongoing monitoring on a monthly basis via the electronic system.

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Global Rating Scale – Colonoscopic Dilation • Planned Changes in Practice: To alter the administrative process for booking colonosopic dilations to allow for additional clinical review of the indications and plan for the targeting of procedures to specific lists and operators. Global Rating Scale – Colonoscopy: Comfort and Sedation • Changes in Practice: All colonoscopists have received a copy of their personal data and feedback. In addition action has been taken for two operators with personal rates consistently or significantly below the Global Rating Scale standards; one has ceased to perform colonoscopies and one has received educational supervision and skills improvement training. Global Rating Scale – Colonoscopy: Quality of Bowel Preparation • No changes in practice as required standards are being met. Global Rating Scale – Re -audit of the Did Not Attend Rates for Endoscopic Procedures • Changes in Practice A review of the new booking system where patients book their own appointments directly after their clinic appointment was done in December 2011 and the DNA Policy was reviewed. Global Rating Scale – Percutaneous Endoscopic Gastrostomy • No changes in practice as required standards are being met. Re -audit of the Dietician Led Clinic for Patients with Coeliac Disease • Changes in Practice: Patients are now automatically booked into group sessions when the referral is received by the department unless the patient contacts the department to opt out. This will reduce the waiting times to less than 12 weeks. A new tick box has been introduced on the initial pro-forma for the option of the patient to refuse bloods and to mark the BMI as ‘not applicable’ if unable to measure weight. In addition the dietician indicates on the blood request forms as correspondence that the patient has attended the celiac clinic to facilitate the consultants when reviewing outcomes. Consultants also refer patients to the dieticians as soon as a celiac diagnosis is made which will improve waiting times from diagnosis to initial dietetic assessment. Patient Satisfaction Survey of patie nts using the 9am to 9pm Bay on the Haematology Ward • No Changes in Practice required Audit has shown the 9-9 service has been well received by patients. We are also compliant with Department of Health recommendations as we have shown continued improvement in the quality of care provided. Compliance with Venous Thromboembolism (VTE) Risk Assessment on Medical Assessment Unit (MAU) • Changes in Practice VTE risk assessment tools are now attached to the medical clerking pro-forma. Audit of Red Card DNAR – Trust Pilot on Ward 20 • Changes in Practice When patient is discharged to ensure that the red card is deleted and placed in the back of the notes. Ward Clerk to ensure that this is happening. Education regarding awareness of DNAR order and MET calls. Red card is a facilitation tool! This change is ongoing. • Planned Changes in Practice Trust wide roll out following pilot in DME/respiratory and surgical ward. Discrepancies in Medication Lists f or Mainstream Haemodialysis Patients • Changes in Practice: As a result of this audit a letter was sent to all dialysis patients in the three Dialysis Units

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asking them to inform the nurses every month of their current medications and also to notify them of any changes as and when they occur in order that the medications list on the Cyber REN system can be kept up to date. In the future it is intended to explore the possibility of downloading medications on the Cyber REN system via the SIGMA Cyber REN interface to facilitate wider access to dialysis patients’ medications lists. GP Referrals to Nephrology Out Patient Clinic • Changes in Practice Results to be taken to Kidney Care Network for consideration of revision of these guidelines and guidelines used in other UK regions to be reviewed. An audit of Vascular Access and eGFR Value • Changes in Practice Consideration of lower eGFR level which should trigger a referral for vascular access surgery. Does Peer -Led Education have a role in teaching Medical Students about Palliative Care? – The Evaluation of an Examination Question Writing Task • Reason for No Change in Practice The results of this service evaluation have demonstrated that question writing is popular with students. However, future research with validated pre and post knowledge tests are required before recommendations about the educational benefit of this exercise can be made. Re -audit of Out of Hours Working in Palliative Care • Reason for No Changes in Practice Since the audit there have been no changes in practice as this is a reactive service that responds to demand. Changes in staffing are likely to occur in the future but not at present. Evaluation of Beh çet’s Clinic: Diagnosis and Drug Use • There are no changes in practice as the results will go to build a business case for Aintree to become a National Centre for Behçet’s Disease. Tocilizumab Prescribing in Rheumatoid Arthritis • There have been no changes in practice as we are currently compliant with the NICE guidance. Re -audit of the Management of Distal Radius Fractures in Accident and Emergency (AED) • The audit has shown that the method used remains the most effective both in terms of patient comfort and outcome therefore there are no changes in practice resulting from this audit Head Injury Management • There has been no change in practice due to the limitations of the audit. A prospective audit of all Trauma patients is to be undertaken. An Assessment of Bispectral Index (BIS) Monitoring During Major Surgery • Planned Changes After the audit it is intended to purchase BIS electrodes to allow regular BIS monitoring of selected cases and thus improve the quality of anaesthesia. However, this is dependent upon the availability of funding. Re -audit of the Use of Volatile Anaesthetic Agents and Appropriate Gas Flow Rates • Changes in Practice After the audit it was agreed that a recipe for the optimal use of anaesthetic agents and breathing circuits would be compiled. Daily Changes Audit March/April 2011 • Changes in Practice Following the audit a new data collection form has been designed and implemented and staff are undergoing additional training to highlight the importance of recording accurate data once PBR is introduced.

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Outcomes Following University Hospital Aintree Pre -Operative Protocols for Liver Resections • In November 2011 it was decided that CPET will be conducted on all patients undergoing liver resection. Fear of Recurrence (FOR) in Patients attending Maxillofacial Oncology Out -Patient Clinic • Planned Changes in Practice It is planned for a widespread adoption of the PCI in all Head and Neck Oncology clinics in Aintree Hospital NHS Trust. There will be MDT staff education around the finding of the PCI to raise staff awareness. Also there is a National PCI workshop planned and organised to be hosted at Aintree Hospital NHS Trust. Post -Operative Complications against the EIDO Leaflet • Changes in Practice Following the dissemination of these results, it was decided that clinicians reviewing these types of patients would enter data regarding cataract complications onto the Medisoft system. Complications of Volar Plating of Distal Radial Fractures • There has been no change in practice due to the significant improvement in complication rate, which is now within published levels of expectation. Consent • Planned Changes in Practice Improve documentation management at pre-op. Hospital Acquired Pneumonia • Planned Changes in Practice Implement the use of the scoring form and undertake a prospective audit. Blood Transfusions in Elective Total Hip and Total Knee Replacements • Planned Changes in Practice From January 2012 there will be improved flow of information from pre-op. Re -audit of the Management of Foot and Ankle Surgical Patients who need Physiotherapy • There are no changes in practice needed as results have improved since the previous audit. The pre-operative physiotherapy service should continue as it is and a re-audit will be done to ensure results continue to improve. Referral of Fifth Metacarpal Fractures to the Fracture Clinic • Planned Changes in Practice Education and a flow chart with an information sheet will be designed and given to AED to prevent unnecessary referrals to the fracture clinic. North West Regional Renal Stone Re -audit • Changes in Practice The guidelines for the management of stones have been amended and ratified in accordance with the results and they have been implemented. Surgical Management of Female Stress Incontinence • Changes in Practice As a result of this audit a consultant surgeon has been nominated as the clinical lead for female urinary incontinence at UHA and all cases of female urinary incontinence are referred to this nominated clinical lead consultant. There is a minimum of two years clinic follow up for all urinary incontinence surgery and physiotherapy is commenced immediately after the first clinic visit. Patient Satisfaction with the Audiology Led Deafness and Tinnitus Clinic • Changes in Practice Discussions have been held with estates regarding the lack of signposting to the elective care centre and the audiology department. There is no problem in increasing the number of signs.

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Evaluation of the Benefit Gained from fitting a Hearing Aid to Patients with Very Mild Hearing Losses (less than 30dB over 0.5, 1.2 and 4 KHz) • There were no changes in practice indicated as a result of this audit showed that it was already practice to offer hearing aids to any patient with a degree of hearing loss. The audit confirmed that this practice should be continued as even in cases of very mild hearing loss, the fitting of a hearing aid can be very beneficial. Time Saved when Patients Complete History Questionnaires Prior to Attending their Clinic Appointment • Changes in Practice Trial shorter appointment times with patients whose GP’s indicate a mild hearing loss with no previous ear disease. Would it be Beneficial to Introduce Patch Testing for Allergies to Acrylic in Audiology? • Changes in Practice The results were disseminated to staff who was made aware of the different non-allergic moulds on offer and to consider this when ordering them in future. After a group discussion it was decided to remain with the current ear mould manufacturer but carry out a re-audit if comfort continues to be an ongoing problem. Audit of Toxic Alcohol Requesting 2009 -2010 • Changes in Practice A regional Standard Operating Procedure has been developed for the Referral of Toxic Alcohol Samples. Turnaround for Drugs of Abuse Screen • Changes in Practice There now is a system for recording faults on the internal lab system called Q-pulse and all staff are encouraged to record equipment failures on this system. Aintree SWMS Weight Management Patient Satisfaction • Changes in Practice Leaflets have been reviewed, a patient focus group has been held to receive comments and feedback and there has been an increase in the out of hour’s sessions. • Planned changes in practice. A multidisciplinary group and clinic sessions are planned to commence and the processes for completing the survey will be improved. Re -audit of Evaluation of Attendance and Patient Pathway within UHA Dietetics Weight Management Clinics • Since the results there have been no changes in practice as clinic pathways are running effectively and within service targets. Nutrition Collaborative Opinions of Nursing Staff and Patients Regarding Hospital Nutrition and Current Practice (Red Tray Audit) • Changes in Practice There is ongoing work with the nutrition collaborative e.g. catering and nursing staff to develop ideas to overcome problems identified in the results. • Planned Changes The protected mealtimes policy and red tray system will be amended, redeveloped and re- launched. Patient Satisfaction of the Dietetic Service Provision for Patients on Home Dialysis • Since the results there have been no changes in practice. Patients will continue to be offered a choice of clinic and telephone or day case follow up with the renal dieticians. This topic will be re-audited when there is a larger sample of patients to complete the questionnaires.

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Patient Satisfaction on Home Enteral Feeding Discharge Information • Changes in Practice As a result of this audit the home enteral feeding discharge information has been updated. Patient Satisfaction within the Aintree Weight Management Service • Changes in Practice Since the results changes in practice have been implemented. ‘Bite size’ training has been offered to healthcare assistants who work regularly on the weight management clinic and an information leaflet has been developed and disseminated to people working on the weight management clinic describing the desired conduct in the clinic. Patient’s Gaining Weight within the Aintree LOSS Weight Management Service • Changes in Practice The following changes in practice have been implemented. GP referral weights are no longer recorded on the patient’s notes as this was leading to some patients appearing to gain weight when they were actually losing weight in the service. • Planned changes in practice. A review of patients seeking surgery at their initial appointment will be determined and relevant information such as initial weight will be recorded to compare to those patients not seeking surgery. Management of Familial Hypercholesterolemia (FH) • Changes in Practice Improved records of cascade family screening DNA is offered selectively. Recording of baseline ECG in the notes is encouraged. Re -audit of Pain and Disability Score Index • Changes in Practice Since the results changes in practice have been implemented. The KSP is now a six week programme instead of four weeks and the topic discussion has increased from four to six topics. In addition the structure has been tightened regarding exercise circuits and these are now timed. Physiotherapists have also been re-informed about the KSP format and appropriate patients. Re -audit: Physiotherapy Outpatients Rehabilitation Gym Patient Satisfaction Survey • Changes in Practice A log book has been put in place to record any complaints received from patients or staff. The temperature in the rehab gym will continue to be monitored and it is now practice to ask patients whether they are warm enough prior to getting them to undress. In addition “Gym 2” has been added to patient’s appointment cards. Discussion has taken place with the rehab gym team, regarding the need to limit the number of people who accompany patients in the rehab gym. Also a policy has been agreed whereby a patient can only have a person accompany them into the rehab gym. If the need is identified by the patient’s treatment plan. In addition the current questionnaire has been adapted. Outcome Measures following Completion of Tone Up/Feel Good (TUFG) Group Sessions • Changes in Practice The short physical performance battery (SPPB) was piloted in LOSS in August 2011 and has now been rolled out to Aintree weight management service. Tone Up Feel Good – Patient Evaluation • Changes in Practice Since the results there have been changes in practice. A new set of outcome measures have been implemented.

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Audit of Liver Radiofrequency Ablation (LFA) Service • Changes in Practice Following the audit there is now direct communication between liver medical and surgical specialist nurses when cases are referred for RFA from clinic and patients are now assessed prior to the procedure to consider ultrasound or fusion Dyna CT imaging. Re -audit of Use of Radiology Clinics by Clinicians • Changes in Practice The Radiology Clinic service has been withdrawn because the results showed that there had been a significant drop in the use of radiology clinic access by clinicians since previous audit in 2007-2008 that no longer justifies the commitment of 2 radiology registrars manning the clinic during their lunch hours, and has largely been superseded by faster turnaround imaging and reporting times and other point of contract phones for various modalities. The registrars did not perceive this to have any further educational benefit. Speech and Language Therapy Documentation • Changes in Practice All staff have been given the findings of the audit and individual feedback on their notes with area for improvement. Texture Modified Meals for Patients with Dysphagia on Ward 33 • Changes in Practice Since the results changes in practice have been implemented. Results have been disseminated to the speech therapists and it has been agreed that they will only use nationally recognised descriptions in the recommendations. Meeting have taken place with the catering manager regarding the provision of pureed meals and fork mashable diets. This will be ongoing. In addition there is ongoing training for Aintree staff and volunteers regarding dysphagia feeding. Re -audit of the Modified Early Warning System (MEWS) 2011 • Changes in Practice MEWS competency sheets have been re-issued via the ward managers to all who complete the MEWS. • Planned Changes in Practice A prompt will be added to the printed MEWS chart so that a reason for omission of daily MEWS or a non-recording of MEWS should be recorded. MEWS competencies for relevant members of staff will be assessed by the ward manager or patient safety officer. There will also be spot checks of the completed MEWS competency sheets to be undertaken on each ward. In addition awareness will be raised through a presentation at Grand Round and a MEWS sticker will be introduced and inserted in the case notes of patients who ‘trigger’ MEWS. Audit of compliance with Do Not Attempt Resuscitation (DNAR) policy • To remind relevant staff of the content of the policy , with regard to DNAR orders (i.e. that all DNAR decisions should only be made by a registrar grade or above and should be documented), the results of the audit will be presented at the Emergency Team (MET) operational meeting and to all doctors at the Grand Rounds.. • Staff DNAR training to be reviewed with the aim of increasing staff awareness of the DNAR requirements/ implementation of the requirements, for example by ensuring specific DNAR training is included in mandatory training (including induction). • Junior doctors’ induction booklet to include DNAR Guidance • Relevant clinical staff to send an email to all consultants and Clinical Governance leads in all Directorates to highlight lack of clarity of recording of DNAR (only 89%) • The policy to be reviewed and amended as necessary to ensure that it states very clearly where DNAR decisions need to be recorded • Systems and processes for recording DNAR Orders should be reviewed with the aim of standardising the approach across the Trust. DNAR Working group to be review systems and processes for DNAR.

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Audit of compliance with Transfusion Policy • Awareness raising via article featured in the Patient Health and Safety newsletter March 2012 highlighted the following:- o Observations/MEWS must be recorded pre, at 15 minutes and post transfusion for all blood and blood components. MEWS is not required in areas where the patient is constantly monitored i.e. Theatre, Critical Care, or Medical Day Case Unit. o The patient must be wearing an ID wristband (or alternative form of ID) unless the patient is in a life-threatening situation where a delay in treatment could be incurred by adding an ID wristband. o Ideally a single practitioner checking is recommended although there is no ‘bar’ on a second checker; these checks however should be done independently of each other. o If the patient is being transferred from one area to another it is the responsibility of the transferring area to ensure that the blood or blood component pack is connected to the patient, (the unit must be attached to the patient during transfer) and that a clinical handover has been given (i.e. observations, how many units have been transfused and the start time of the transfusion.) Upon transfer of the patient it is the receiving area’s responsibility to take over the care of monitoring the transfusion. o Fluid balance recording is essential for all blood and blood components – a number of serious adverse reactions to blood and blood components relate to pulmonary complications which due to poor recording, we are currently unable to provide an accurate account of. • Transfusion Practitioner to continue to highlight these requirements to staff within the training sessions. • Transfusion Practitioner to provide transfusion training update to Critical Care Staff • Transfusion Practitioner to review staff competencies and training. • Transfusion Practitioner to recommend to FBC booklet authors about adding a section related specifically to recording blood component input at next review. • A communication board to be added as a reminder for all laboratory staff to place a sticker on the blood tag to indicate the blood is compatible where blood group of the patient and unit are not identical.

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Annex E: Performance against key national priorities

Green ratings indicate that the Trust met the target, amber that the target was only partially met and red that the target was under achieved.

Targets and Indicators 2011/2012 Thresholds and Performance Aintree University Hospital NHS Foundation Trust Performance RA RA RA RA Annual RA Area Indicator Threshold Qtr 1 G Qtr 2 G Qtr 3 G Qtr 4 G G As per trajectory agreed with PCT Clostridium Difficile (64 cases in the (Hospital Acquired year) - Safety Infection) Cumulative 20 R 32 G 48 G 63 G 63 G As per trajectory MRSA (Hospital (6 cases in year) Safety Acquired Infection) - Cumulative 1 G 1 G 2 G 4 G 4 G Cancer - 31 day wait for second 94% of patients treatment - treated within 31 Quality Surgery days 94% G 96.60% G 98.80% G 98.8% G 98.5% G Cancer - 31 day wait for second 98% of patients treatment - Drug treated within 31 Quality treatment days 100% G 100% G 100% G 100% G 100% G Cancer -31 day 96% of patients wait from diagnosis treated within 31 Quality to first treatment days 97% G 97.70% G 98.10% G 97.9% G 97.5% G

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Cancer -2 week wait from referral 93% of patients to first seen - all seen within 2 Quality cancers weeks 94% G 95.10% G 96.80% G 95% G 95.5% G Cancer -2 week wait from referral to first seen - breast 93% of patients symptomatic seen within 2 Quality patients weeks 99% G 99.70% G 100% G 99% G 99.6% G Cancer - 62 day 85% of patients wait for first treated within 62 80.96 Quality treatment days 82.40% R 82% R 85.10% G 72.3% R % R Cancer - 62 day wait for first 90% of patients treatment from treated within 62 consultant days (target Quality screening service under review) 78.80% R 87% R 95.70% G 85.7% R 87.5% R Total time in 95% of patients Accident and waiting less than Quality Emergency 4 hours. 97.90% G 98.60% G 97.30% G 97.1% G 97.7% G Referral to 95% of patients Patient treatment waiting waiting less than 21.3 21.9 21 20.5 20.8 Experience times - admitted 23 weeks. weeks G weeks G weeks G weeks G weeks G Referral to Treatment waiting 95% of patients Patient times - non waiting less than 18 16.6 15.7 15.4 15.9 Experience admitted 18.3 weeks weeks G weeks G weeks G weeks G weeks G

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Annex F: Independent Auditor’s Limited Assurance Report to the Board of Governors of Aintree University Hospital NHS Foundation Trust on the Annual Quality Report

We have been engaged by the Board of Governors of Aintree University Hospital NHS Foundation Trust to perform an independent assurance engagement in respect of Aintree University Hospital NHS Foundation Trust’s Quality Report (the ‘Quality Report’) and specified performance indicators contained therein.

Scope and subject matter

The indicators in the Quality Report that have been subject to limited assurance consist of the national priority indicators as mandated by Monitor:

• MRSA; and • Annual outturn in relation to maximum 62 day waiting time 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 referred to in on page Annex B of the Quality Report (the "Criteria"). The Directors are also responsible for their assertion and 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”). In particular, the Directors are responsible for the declarations they have made in their Statement of Directors’ Responsibilities.

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 materially inconsistent with the sources specified below; and • 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:

• Board minutes for the period April 2011 to March 2012; • Papers relating to Quality reported to the Board over the period April 2011 to March 2012; • Feedback from the Commissioners dated 28/05/2012; • Feedback from LINKS dated 28/05/2012; • The Trust’s 4C’s reports for each quarter during 2011/12 which include the detail on complaints which will be The Trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009; • Latest national and local patient survey dated February 2012 (inpatient survey) and November 2011 (outpatient survey); • The 2011 national staff survey;

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• Care Quality Commission quality and risk profiles dated 29/02/2012; and • The Head of Internal Audit’s annual opinion over the trust’s control environment dated 03/05/2012.

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 Board of Governors of Aintree University Hospital NHS Foundation Trust as a body, to assist the Board of Governors in reporting Aintree University Hospital 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 2012, to enable the Board 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 Board of Governors as a body and Aintree University Hospital 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 indicator 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 in Annex B of the Quality Report. Annual Report & Accounts 2011/12 146

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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/organisations/entities.

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 Aintree University Hospital NHS Foundation Trust.

Conclusion

Based on the results of our procedures, nothing 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 materially inconsistent with the sources specified above; and • the specified indicators have not been prepared in all material respects in accordance with the Criteria.

PricewaterhouseCoopers LLP Chartered Accountants 101 Barbirolli Square Lower Mosley Street Manchester M2 3PW

30 May 2012

The maintenance and integrity of the Aintree University Hospital 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.

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Glossary

aBI Aintree Business Intelligence AMI Acute Myocardial Infarction AUH Aintree University Hospital NHS Foundation Trust BSI Blood Stream Infections cc Complications and Co-morbidities C. difficile Clostridium Difficile CQUIN Commissioning for Quality and Innovation payment framework CSP Co-ordinated Systems for gaining NHS Permission COPD Chronic Obstructive Pulmonary Disease CQC Care Quality Commission DME Department of Medicine for the Elderly DNAR Do Not Attempt Resuscitation E4E Energise for Excellence ENT Ear, Nose and Throat EQUIP Electronic quality information for the public FY1 Foundation year one doctor FY2 Foundation year two doctor GP General Practitioner HCAI Healthcare Associated Infections HRG Health Related Resource Groups HR Human Resources HSMR Hospital Standardised Mortality Rate IPC Infection Prevention and Control LINk Local Involvement Network MET Medical Emergency Team MFU Maxillo Facial Unit MRSA Methicillin-Resistant Staphylococcus Aureus MUST Malnutrition Universal Screening Tool NCEPOD National Confidential Enquiry into Patient Outcome and Death NICE National Institute for Clinical Excellence NIHR National Institute for Health Research NHS National Health Service NPSA National Patient Safety Agency NSF National Service Framework PALS Patient Advice and Liaison Service PCT Primary Care Trust PEQ Patient Experience Questionnaire PROMS Patient Reported Outcome Measures PbR Payment by Results R&D Research and Development RCA Root Cause Analysis RTT Referral to Treatment SHA Strategic Health Authority Sigma Hospital Patient Administration System USA United States of America UTI’s Urinary Tract Infections VTE Venous-Thromboembolism WTE Whole Time Equivalent

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Governance & Organisational Arrangements

Corporate governance relates to the processes, customs, policies, laws, and institutions which have impact on the way an organisation is controlled .An important theme of corporate governance is the nature and extent of accountability of people in the business, and mechanisms that try to decrease the risks. This section details the organisational arrangements in place to deliver good corporate governance.

Board of Governors

The Trust’s relationship with its Governors, and through them with its members, is constructive and useful. It provides valuable public accountability for the work of the Trust.

The Board of Governors and the Board of Directors have a clear understanding of the roles and responsibilities of each party in accordance with the constitution. The Board of Directors’ role is to manage the business of the Trust and the Board of Governors is responsible for representing the interests of patient, public and staff members, and local partner organisations in the governance of the Trust and has specific responsibility for the appointment of the Chairman and Non-Executive Directors, and the Trust’s auditors. The Board of Governors also approves the appointment of the Chief Executive, the remuneration and terms of office of the Chairman and Non-Executive Directors, and receives the Trust’s annual report and accounts and gives views and advice on the forward plans of the Trust.

Members of the Board of Directors regularly met with Governors at the public Board of Governors meetings and receive copies of Board of Governors’ papers and minutes of meetings. The Board of Governors and the Board of Directors hold a joint Board meeting on an annual basis in order to ensure that the Board of Directors, and the Non Executive Directors in particular, understand the views of the Governors and members. The Governors hold informal meetings between Board of Governors meetings to discuss upcoming agendas and raise any issues requiring clarification or action. These meetings were chaired by the lead governor who feeds back information to the company secretary.

The Governors and Non Executive and Executive Directors also hold three joint workshops per year to consider strategic issues.

The Board of Governors consists of the Chairman of the Trust and 31 elected and appointed Governors. During 2011/12 the following four Public Governors were re-elected for a further three-year term to 31 July 2014:

Gordon Harrison Anthony Kneebone John Rimmer Brian Worster Davis

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Three new Public Governors, Frank Cooke, John Johnson and Stephen Thornhill, were elected for a three year term to 31 July 2014. Ann Mallanaphy was elected as a Patient Governor for a three year term also to 31 July 2014. Barry Cave, Patient Governor, stood for re-election but was not successful.

Olwen Jones and Brian Lawlor, Public Governors, retired at the end of July 2011.

The following members of Trust staff were elected as Staff Governors for the three year period to 31 July 2014:

Lindsay Tilston Jones (All Other Staff) Dr Gilly Ennals (Medical Staff) (Uncontested) Tracey McLoughlin (Nursing Staff) (Uncontested) Lorraine Harris (Allied Health Professionals / Scientists)

Pamela Black, Lorraine Brinkley, Terry Owen and Dr Robert Thompson, Staff Governors, retired at the end of July 2011.

Rose Milnes was appointed by Woodlands Hospice to replace Renee Brenner, Ian Davies was reappointed by Knowsley PCT, Marie Rice replaced Fiona Clark as the NHS Sefton Appointed Governor and Katherine Sheerin replaced Leonie Beavers as the Liverpool PCT Appointed Governor.

Councillor Brenda Porter, Councillor Jayne Aston and Councillor Louise Ashton-Armstrong were reappointed by, respectively, Sefton MBC, Knowsley MBC and Liverpool City Council.

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Elected Governors Patient Governors Term of Expiry Date Attendance at Public (3 seats) Office Board of Governors Meetings Doreen Brown 3 years 31 July 2012 4/4 Barry Cave 3 years 31 July 2011 3/3 Gerry Hill 3 years 31 July 2012 3/4 Ann Mallanaphy 3 years 31 July 2014 2/2 Public Governors (14 seats) Frank Cooke 3 years 31 July 2014 2/2 David Cowan 3 years 31 July 2012 4/4 Ronald Denton 3 years 31 July 2012 3/4 Norman Falder 3 years 31 July 2012 4/4 Gordon Harrison 3 years 31 July 2014 3/4 Diane Hart 3 years 31 July 2012 3/4 John Johnson 3 years 31 July 2014 2/2 Arthur Jones 3 years 31 July 2012 4/4 Olwen Jones 3 years 31 July 2011 1/2 Anthony Kneebone 3 years 31 July 2014 4/4 Brian Lawlor 3 years 31 July 2011 1/2 Peter Mayne 3 years 31 July 2012 3/4 Pamela Peel 3 years 31 July 2012 4/4 John Rimmer 3 years 31 July 2014 4/4 Stephen Thornhill 3 years 31 July 2014 1/2 Brian Worster-Davis 3 years 31 July 2014 4/4 Staff Governors (5 seats) Pamela Black 3 years 31 July 2011 1/2 (AHP/Scientists) Lorraine Brinkley 3 years 31 July 2011 1/2 (Nursing Staff) Dr Gilly Ennals 3 years 31 July 2014 2/2 (Medical Staff) Lorraine Harris 3 years 31 July 2014 1/1 (AHP / Scientists) Tracey McLoughlin 3 years 31 July 2014 0/1 (Nursing Staff) Lindsay Tilston Jones 3 years 31 July 2014 1/2 (All Other Staff) Terry Owen 3 years Resigned 2/2 (All Other Staff) 31 July 2012 Dr Robert Thompson 3 years 31 July 2011 0/2 (Medical Staff) Jeanette Wilding 3 years 31 July 2012 3/4 (Nursing Staff)

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Appointed Governors (9 seats) Term of Expiry Date Attendance at Public Office Board of Governors Meetings Cllr Louise Ashton- 3 years 31 July 2012 1/4 Armstrong, (Liverpool City Council) Cllr Jayne Aston 3 years 31 July 2012 1/4 (Knowsley MBC) Cllr Brenda Porter 3 years 31 July 2012 1/4 (Sefton MBC) Leonie Beavers 3 years 31 July 2011 1/2 (Liverpool PCT) Katherine Sheerin 3 years 31 July 2014 1/2 (Liverpool PCT) Fiona Clark 2 years 31 July 2011 0/1 (NHS Sefton) Marie Rice 1 year 31 July 2012 2/3 (NHS Sefton) Ian Davies 2 years 31 July 2013 3/4 (Knowsley PCT) Mair Ning 3 years 31 July 2012 4/4 (Edge Hill University) Professor Robert Moots 3 years 31 July 2012 1/4 (University of Liverpool) Renee Brenner 3 years 31 July 2011 2/2 (Woodlands Hospice) Rose Milnes 3 years 31 July 2014 1/2 (Woodlands Hospice)

Pamela Peel is the Deputy Chair of the Board of Governors and Lead Governor.

Members of the public can gain access to the Register of Governors Interests by writing, telephoning or emailing the Trust Headquarters: Aintree University Hospital NHS Foundation Trust, Aintree Lodge, Lower Lane, Liverpool L9 7AL. Telephone: 0151 529 6474, e-mail: [email protected] , [email protected] or [email protected] .

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Nominations Committee

The Board of Governors Nominations Committee met three times in 2011/12 and made recommendations to the Board of Governors in relation to the reappointment of two Non Executive Directors and to the process to recruit replacements for two Non Executive Directors retiring in 2012/13. The Chief Executive attended all Committee meetings. Members’ attendance was as follows:

Member Attendance Christopher Baker, Chairman 3/3 Renee Brenner, Appointed Governor 1/1 Brian Lawlor, Public Governor 1/1 Anthony Kneebone, Public Governor 3/3 Diane Hart, Public Governor 2/2 Mair Ning, Appointed Governor 2/2

Membership

Membership of the Trust is open to anyone who is either a resident of the North West of England, a patient of the Trust and/or their carer, who is aged 16 and above, and all members of staff.

The Trust aims to build a successful Membership Scheme as an integral part of its vision of providing high quality, patient-centred healthcare and proactively enhancing the Trust’s local, national and international reputation.

The Board of Governors established a Membership Committee to lead the process of developing the Membership Scheme and ensuring a representative membership. In September 2011, the Committee agreed a strategy of increasing and maintaining the public and patient membership at 9,000, and increasing membership from under- represented groups, including young people (16 – 21 years), males, BME groups and Knowsley residents. The success of the strategy will be reviewed in September 2012.

In 2011/12 there was an increase in the Trust’s public and patient membership of 1,536.

Staff members with a permanent contract or fixed term contract of a minimum of 12 months, are automatically registered as members of the Trust.

A copy of the Membership Recruitment and Engagement Strategy is available on request.

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Membership Numbers (31 March 2012)

Constituency Membership Numbers Public 7,583 Patient 1,607 Medical Staff 374 Nursing Staff 1,459 Allied Health Professionals/ 733 Scientists All Other Staff 1,219 TOTAL 12,975

Members of the public wishing to contact Governors or Directors can do so by writing, telephoning or emailing the Trust Headquarters: Aintree University Hospital NHS Foundation Trust, Aintree Lodge, Lower Lane, Liverpool L9 7AL. Telephone: 0151 529 6474, e-mail: [email protected] , [email protected] or [email protected] .

Board of Directors

The Board of Directors comprises seven Non Executive Directors, including the Chairman and up to six Executive Directors, including the Chief Executive. The Board of Directors has overall responsibility for strategic development, approving policy and monitoring performance. This includes ensuring the delivery of effective financial stewardship, high standards of clinical and corporate governance and promoting effective relations with the local community served by the Trust.

The Board has a formal schedule of matters reserved for Board decisions. Some decisions are delegated to its Board committees and these are clearly set out in those committees’ terms of reference, which are reviewed regularly by the Board. The Board has the following Committees:

• Audit • Assurance • Remuneration and Nominations (for Executive Director appointments) • Charitable Funds

All Directors have full and timely access to relevant information to enable them to discharge their responsibilities. The Board of Directors meets monthly and at each meeting reviews the Trust’s key performance information, including reports on quality and safety, patient experience and care, operational activity, financial analyses and strategic matters.

The Board of Directors monitors compliance with the Trust’s objectives and is responsible for approving major capital investment and any borrowing. It meets with the Trust’s Board

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The Board of Directors considers that it is appropriately composed with a balanced spread of expertise to fulfil its function and terms of authorisation, with the Chairman and Non- Executive Directors meeting the independence criteria laid down in the NHS Foundation Trust Code of Governance. The performance of the Executive Directors is evaluated by the Chief Executive, and that of the Chief Executive and Non Executive Directors by the Chairman, on an annual basis. Non Executive Director appointments may be terminated on performance grounds or for contravention of the qualification criteria set out in the Constitution, with the approval of three-quarters of the members of the Board of Governors, or by mutual consent for other reasons.

The Trust’s Executive Team provides organisational leadership and takes appropriate action to ensure that the Trust delivers its strategic and operational objectives. It maintains arrangements for effective governance throughout the organisation, monitors performance in the delivery of planned results and ensures that corrective action is taken when necessary.

Board Leadership and Development

In 2010, the Board took part in a programme of work, carried out by the Boston Consulting Group (BCG) and endorsed by Monitor, on developing the Role of the Board in Patient Safety. BCG carried out a follow-up of this work in November 2011. The aim was to assess the Trust’s progress against the 5 priorities it had set as well as review overall commitment to patient safety and to feed back to the board.

The prioritised interventions focused on improving junior doctor engagement, standardisation of patient handover, visibility of safety metrics, incident follow-up and review of the resources dedicated to leading patient safety initiatives.

BCG carried out a series of interviews, a web survey and a document review and reported significant improvement against all five of the safety measures.

This work has been used by the Board to raise their awareness and further develop their role as patient safety champions and has shaped the focus of our new safety priorities for 2012/13.

The Board held two development sessions at its Away Days in 2011-12. At the first session, the Board considered its approach, as a unitary board, to the challenges ahead and the Board’s role in addressing these. It also considered its strategic intent regarding current and future partnerships and the opportunities for collaboration. At the second session, the Board discussed evaluation of Board performance and that of the Non Executive and Executive Director roles. This was perceived as a precursor for further development work in 2012/13.

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The performance of the Board Committees was kept under review through regular reports submitted to the Board of Directors and through a review of their terms of reference.

Directors may seek individual professional advice or training at the Trust’s expense in the furtherance of their duties. The Board has direct access to advice from the company secretary who is responsible for ensuring compliance with relevant regulations and that Board and committee procedures are followed. The proceedings at all Board and committee meetings are fully recorded, enabling any concerns of Directors to be minuted. The appointment or removal of the company secretary is a matter for the Board as a whole.

There is a clear division of responsibilities between the chairman and chief executive, which has been agreed by both parties and the Board. The chairman is responsible for the leadership of the Board of Directors and Board of Governors, ensuring their effectiveness individually, collectively and mutually. The chairman is also responsible for ensuring that members of the Board of Directors and Board of Governors receive accurate, timely and clear information appropriate for their respective duties and for effective communication with patients, members, clients, staff and other stakeholders. It is the chairman’s role to facilitate the effective contribution of all directors, ensuring that constructive relationships exist between them and the Board of Governors. The chief executive is responsible for the performance of the executive directors , the day to day running of the Trust and implementing approved strategy and policy.

Directors Pen Portraits

Committee membership is indicated by the following symbols:

Audit Committee ▲ Assurance Committee 

Remuneration & Nominations Committee □ Charitable Funds Committee  Christopher Baker MBE – Chairman □ Chris Baker was a civil servant in his early career before moving into corporate finance, initially in London and then in the North West as corporate finance partner with Coopers & Lybrand, before joining Littlewoods as Corporate Strategy Director in 1993. Since 2000 he has worked as a freelance consultant and Non Executive Director and serves on the Boards of two of the region’s PLCs. He was until 2012 Chair of the Training and Development Agency for Schools, and was previously Chair of Business Liverpool where he was responsible for business support in Liverpool and promoting the city as a world class city for business. Chris joined the Board in January 2008 and was reappointed by the Board of Governors for a further three year term to 31 st December 2014.

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Rayna Dean – Senior Independent (Non Executive) Director (to September 2012) ▲(to July 2011)  (from October 2011)  (to October 2011) Rayna Dean is a chartered accountant and former partner with Price Waterhouse. She has extensive experience of service businesses and having worked as an independent consultant, now chairs a start up company. She is also a member of the Tax Tribunal. Rayna served as a Non Executive Director of Christie Hospital NHS Trust for eight years and has extensive knowledge of risk management and corporate governance. She joined the Board in October 2005, was reappointed for a second term in October 2009 and will serve until September 2012.

Rayna is the Vice Chairman of the Trust, Chair of the Assurance Committee and the Senior Independent Director.

Patrick Hackett* - Independent Non Executive Director □ ▲(from October 2011) Patrick Hackett is Chief Operating Officer at the University of Liverpool. An Architect by profession, he has previously worked at Royal Holloway and the University of Reading, as well as Currie and Brown, where he established their Facilities Management Consultancy division. In his current role he leads on the University’s international developments, and directs a Professional Services Team of over 1,400 focused on delivering key priorities in research performance, globalisation, knowledge excellence, student experience and widening participation. Patrick has a particular interest in education and research related to healthcare.

He joined the Board in January 2009 and was reappointed for a second term from January 2012 to December 2014.

* Notwithstanding Patrick’s appointment with the University of Liverpool, he has no other connection with the Trust. For this reason the Board considers him to be independent.

George Marcall - Independent Non Executive Director ▲□ 

George Marcall has extensive Executive and Non-Executive experience in the private sector. He was instrumental in setting up the Marketing Division within Marks & Spencer, was Group Sales and Marketing Director with Airtours plc and latterly was Chief Executive of Glyn Webb Ltd, DIY retailers. He has held Directorships with the Yates Group plc and is currently a Non-Executive Director of Park Group plc and NUS Services Ltd. In the public sector he has served as a Non-Executive Director with Marketing Manchester. He joined the Board in April 2008, was reappointed for a second term in March 2010 and will serve until March 2013. George is the Chair of the Audit Committee and Charitable Funds Committee.

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Frank McKenna - Independent Non Executive Director □ Frank McKenna is the Chairman of private sector lobby group and networking club Downtown Liverpool in Business. He was previously a politician, serving as the Deputy Leader of Lancashire County Council; the leader of the Northwest Regional Assembly; and a Parliamentary Assistant. He has been described by the Liverpool Daily Post as one of the most influential businessmen in the region and he is a regular contributor to local, regional and national media. He joined the Board in April 2008 and has been reappointed for a second three year term until September 2013.

Sally Merriman – Independent Non Executive Director ▲□ Sally Merriman is a solicitor and senior lecturer at the Liverpool John Moores University School of Law. She started her career in nursing and worked as a staff nurse at the Royal London Hospital and with the Medical Air Service Australia before commencing her legal training. As a solicitor she worked in a leading North West clinical negligence department dealing with complex medical litigation and also cases involving abuse and neglect of children. She currently teaches post graduate law students training to be solicitors and is a quality assurance assessor for the Solicitor’s Regulatory Authority. She joined the Board in October 2005, was reappointed for a second term in October 2009 and will serve until March 2012.

Maureen Murphy – Independent Non Executive Director □  (from October 2011)

Mo Murphy is a communications consultant and former board director of a global top-ten PR agency. She set up her own agency in 2001 and provides independent counsel and implementation of stakeholder communications to blue chip and start up organisations across Europe and USA. She joined the Board in April 2008 and has been reappointed for a second three year term until March 2014.

Catherine Beardshaw – Chief Executive  Catherine Beardshaw took up the post of Chief Executive on 1 March 2011. She qualified as a Radiographer in 1974 and spent the next 18 years working in clinical and clinical service manager roles across Yorkshire. She moved into general management in 1995 in Leeds Teaching Hospital NHS Trust and held a range of senior manager posts in the then largest Trust in the United Kingdom until becoming Director of Operations in 2002. During this period Catherine also received an MBA from Durham University.

In 2006 Catherine was appointed as CEO of North Cheshire Hospitals NHS Trust and led the Trust from financial turnaround to Foundation Trust status in 2008 when it became known as Warrington and Halton Hospitals NHS Foundation Trust.

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Jill Byrne – Director of Nursing  Jill Byrne has been Director of Nursing at the Trust since June 2008. Her nursing career spans 34 years. She was Director of Nursing at Stockport NHS Foundation Trust and, prior to that, Assistant Chief Executive at St Helens and Knowsley Hospital NHS Trust. She previously worked as a Review Manager with the Commission for Health Improvement. Jill is a Registered Nurse, State Certified Midwife and achieved a MSc in Clinical Nursing in 1996.

Dr Gary Francis – Medical Director 

Dr Gary Francis graduated from the University of London (Westminster Medical School) in 1979. He was appointed Consultant Neuroanaesthetist at Central Sheffield University Hospital in 1991. Following a period as Clinical Director for Anaesthesia and Operating Theatres (1995 – 2001), Gary became Deputy Medical Director at the then recently merged Sheffield Teaching Hospitals in 2001. He took up his appointment as Medical Director at the Trust at the end of July 2008.

Steve Warburton – Director of Finance & Business Services / Deputy Chief Executive    Steve Warburton took up post as Director of Finance & Business Services in July 2006. He was previously Director of Finance & Performance/Deputy Chief Executive at South Sefton Primary Care Trust and before that he was Deputy Director of Finance at the Royal Liverpool Children’s NHS Trust. Steve qualified as an accountant in 1993.

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Board Committees

Member Board of Committees Board of Directors Governors Audit Remuneration Assurance Charitable & Nominations Committee Funds Committee Christopher Baker 10/10 - 2/2 - - 4/4

Rayna Dean 10/10 1/2 2/2 6/6 3/3 4/4

Patrick Hackett 8/10 2/2 0/2 - - 2/4

George Marcall 9/10 4/4 2/2 - 4/4 3/4

Frank McKenna 7/10 - 1/2 - - 1/4

Sally Merriman 9/10 2/4 2/2 - 1/4 1/4

Mo Murphy 9/10 - 2/2 6/6 - 1/4

Catherine Beardshaw 10/10 - - 4/6 - 4/4

Jill Byrne 9/10 - - 4/6 - 3/4

Dr Gary Francis 10/10 - - 6/6 - 2/4

Mike Frayne 4/4 - - - - 2/2

Steve Warburton 10/10 - - 6/6 - 3/4

Directors’ interests

The Board of Directors annually reviews its Register of Declared Interests. The Directors are required to make known any interest in relation to any matters being discussed at a meeting of the Board, and any changes to their declared interests. The Register of Declared Interests for the Board of Directors is held by the Trust Company Secretary and is available for public inspection.

Members of the public can gain access to the Register of Directors Interests by writing, telephoning or emailing the Trust Headquarters: Aintree University Hospital NHS Foundation Trust, Aintree Lodge, Lower Lane, Liverpool L9 7AL. Telephone: 0151 529 6474, e-mail: [email protected] , [email protected] or [email protected] .

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Audit Committee

The role of the Audit Committee is to provide to the Board of Directors an independent and objective review over the establishment and maintenance of effective systems of integrated governance, risk management and internal control across the organisation’s clinical and non-clinical activities. It also provides assurance on the independence and effectiveness of both external and internal audit and ensures that standards are set and compliance with them is monitored in the non-financial and non-clinical areas of the Trust that fall within the remit of the committee. The Audit Committee is significantly instrumental in reviewing the integrity of the Annual Accounts, Quality Accounts and related External Auditor’s Reports. In addition, it reviews the Annual Governance Statement prepared by the Chief Executive in her role as the Accounting Officer plus related internal audit reports. The Audit Committee takes a risk based approach to its work.

In October 2011, a revised governance structure was introduced to ensure that the Board’s Committee structure was fit for purpose, used the time of the non-executive directors productively and efficiently and that the structure reflected current best practice in corporate governance. This revised structure resulted in the creation of the Assurance Committee (previously the Clinical Governance Board and Risk Management Steering Group) with the following sub-committees reporting into it – Safety and Risk, Clinical Effectiveness, Patient Experiences and Workforce. The Chairmen of both Committees have worked closely to ensure that the new structure is effective in delivering assurance to the Board on risk profiles and governance.

Composition of the Audit Committee

The Audit Committee operates in accordance with the Terms of Reference agreed by the Board of Directors. It has met on four occasions during the last financial year and details of each member’s attendance at these meetings are provided below. The committee membership comprises at least two Non Executive Directors including one with “recent and relevant financial experience”.

The Audit Committee Members are:

Rayna Dean FCA - Chair of Committee (to July 2011) Sally Merriman - Member of Committee (retired March 2012) George Marcall - Member of Committee (Chair from August 2011) Patrick Hackett - Member of Committee (from October 2011)

In addition to the committee members, standing invitations are extended to the Director of Finance, the Medical Director, the Chief Executive (for specific items), Internal Auditors, External Auditors, Local Counter Fraud Specialist, Board Secretary and the Head of Corporate Finance (in the capacity of Secretary to Audit Committee). Other officers of the Trust may be invited to the Committee to answer any points which may arise.

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A Key Issues Report and minutes of the meetings are considered at the Board of Directors’ meetings following each Audit Committee meeting and the Committee Chair brings any significant matters to the attention of the Board.

Audit Committee Activities

In discharging its duties, the Committee meets its responsibilities through utilising the work of Internal Audit, External Audit and other assurance functions, together with assurances from Trust officers (where required) and directing and receiving reports from the auditors and fraud specialists.

Financial

The Audit Committee has played a key role in endorsing the accounting policies in operation at the Trust and in reviewing both the annual accounts and the external audit review of the accounts.

The Audit Committee reviewed the 2011/12 annual accounts at its meetings on 3 May 2012 and 30 May 2012 and subsequently recommended their adoption to the Board of Directors.

Quality Account

Following the introduction of a mandatory Quality Account, the Audit Committee has reviewed the 2011/12 Quality Account and the Annual Governance Statement at its meetings on 3 May 2012 and 30 May 2012 and subsequently recommended their adoption to the Board of Directors.

Data Quality

The Trust has adopted a formal programme to support the continued improvement in data quality across the organisation. All data quality initiatives are centralised through this programme, using the Data Quality Steering Group to provide operational, clinical and informatics expertise. The group reports via the Director of Informatics to the Executive team and Audit Committee. The Trust has dedicated data quality staff to co-ordinate activity, review procedures and provide reporting to support data quality initiatives.

Non-Financial

The Audit Committee has gained assurance by reviewing the following:

• Minutes from the Assurance Committee on significant matters arising from its meetings • The Annual Governance Statement

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• Regular reports from both Internal and External Audit in relation to the adequacy of the systems of internal control • Information Security Presentation • Trust relation ship with North Mersey Health Informatics Service (HIS) • Trust Policies

Since October 2011, following the establishment of the Assurance Committee, the Audit Committee has received assurance on all areas within its remit. The Audit Committee Chair has attended two of the Assurance Committee meetings to ensure that the process of gaining assurance in non-financial matters is in line with the Audit Committee’s responsibility to discharge its duties to the Board correctly.

The Trust Annual Governance Statement was considered at the meeting held on 3 May 2012 and recommended to the Board of Directors for approval following the meeting on 30 May 2012.

External Audit

The provision of external audit services is currently delivered by PricewaterhouseCoopers LLP (PwC). Their work focussed upon the audit and opinion on the financial statements.

In January 2012, the Committee approved an External Audit Plan for the year to 31 March 2012 and have received regular updates on the progress of work. In addition, reports and briefings (as appropriate) have been received from PwC in accordance with the requirements of the Audit Code.

An unqualified opinion (and audit certificate) on the accounts of the Foundation Trust for 2011/12 was given to the Trust on 30 May 2012.

In addition to the audit of the annual accounts, PwC has also undertaken assurance work on the Trust’s Quality Account Report for 2011/12 in accordance with the guidelines set out by Monitor in the Annual Reporting Manual (ARM). On 30 May 2012 the auditors issued a limited assurance report on the contents of the Quality Report and mandated indicators, and a report to Governors covering external assurance on two mandated and one locally selected indicator.

Internal Audit

Our Internal Audit service is provided by RSM Tenon. Their role is to provide an independent and objective appraisal service embracing two key areas:-

• The provision of an independent and objective opinion to the Accounting Officer, the Board of Directors and the Audit Committee on the degree to which risk management, control and governance support the achievement of the organisation's agreed objectives.

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• The provision of an independent and objective consultancy service specifically to help line management improve the organisation's risk management, control and governance arrangements.

The Internal Audit Plan was driven from the risks set out in the Trust's own Assurance Framework and was subsequently approved by the Audit Committee.

During the course of the year, the Committee ensured that regular progress reports were received on the delivery of the Internal Audit Plan. As part of this process, the Committee has influenced changes to the plan to direct work to risk areas identified during the course of the year.

In 2011/12, the Committee focused on the planned work of Internal Audit on Data Quality in order to undertake a review of some of the Trust’s CQUINS indicators and Care Quality Commission outcomes.

The key conclusion from their work for 2011/12, as provided in the Head of Internal Audit Opinion and Annual Report, was that 'Significant Assurance' was given that the Trust has a generally sound system of Internal Control.

Fraud

As with the Internal Audit Service, RSM Tenon is the service provider for the Local Counter Fraud Service (LCFS).

The Committee regularly reviews the risk of fraud. It also considered the time and resources allocated to Counter Fraud against the risk profile.

The Trust improved its NHS Protect Quality Assessment from a level 1 to a level 2.

As requested by the Committee, to meet mandated requirements, an Annual Report was provided outlining the delivery of the fraud plan. The report highlighted that, in addition to the work on the prevention and detection of fraud, no cases of potential fraud had been referred for criminal investigation during the year. In addition to Criminal Fraud Investigations carried out on behalf of the Trust, the LCFS also liaises closely with the Trust’s Human Resources department in order to identify and assist with any disciplinary or internal investigations, where required. The Committee received updates as appropriate on each of these issues during the course of the year.

Committee Developments

In the forthcoming year focus will be given to the following areas:

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• Obtaining Independent Assurance in non-financial areas with the assistance of the Assurance Committee • Appraisal of Audit Committee effectiveness – completed on 3 May 2012 – the outcome of which will be considered during 2012/13 • Audit Committee Development particularly in the field of IT • Data Quality • Partnership Governance Arrangements (Capita / HIS / Pathology)

George Marcall Chair, Audit Committee May 2012

Audit Committee attendance

Member Actual/Possible Rayna Dean (Chair to July 1/2 2011) Patrick Hackett 2/2 George Marcall (Chair from August 4/4 2011) Sally Merriman 2/4

Assurance Committee

The Assurance Committee was established in October 2011 as a Committee of the Board. It is chaired by a non-executive director, has one or more non-executive directors as members and seven executive directors. It has co-opted as a member Professor Hugo Mascie -Taylor, Medical Director of the NHS Confederation and former Medical Director of Leeds Teaching Hospitals. Clinical Heads of Division, Divisional Chief Operating Officers and the Assistant Director of Clinical Governance, attend the meetings.

The purpose of the Assurance Committee is to provide assurance to the Board of Directors that mechanisms are in place to address, monitor and manage safety, quality, effectiveness, patient and staff experience and workforce issues within the organisation, that the key organisational risks are being identified and managed appropriately and that the most efficient, effective and economic risk, control and governance processes are in place and the associated assurance processes are optimal.

The purpose of the report is to provide assurance that the Committee has discharged its duties as identified in its Terms of Reference and delivered its business plan in 2011-12.

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Review of Effectiveness and Attendance

The Committee conducted a review of its effectiveness in March 2012 and a report on the outcome was submitted to its meeting in April 2012. This showed that this Committee was felt to be an improvement over the previous system, with appropriate terms of reference. It is helping the Board to obtain Assurance, and bringing more challenge to the organisation. It still needs to mature and improve to focus on whether we have the right systems in place to identify and manage risk effectively. Key Performance Indicators for the Committee still need to be developed.

Average attendance was 62% and the majority of members exceeded the 75% attendance specified in the terms of reference.

Work carried out and Achievements

There was 80% compliance with NICE and CEPOD guidelines. The Committee recommended to the Board that the policy be changed so that every non-compliance had to be sanctioned by the Board, and this recommendation was accepted.

The Committee developed key issue report formats which were fit for purpose and adopted. The Committee received key issues reports from each of the sub-committees that report to it (Safety & Risk, Clinical Effectiveness, Patient Experience and Workforce) on a monthly basis. The minutes of each of these sub-committees are made available for reference.

Guiding principles for the Committee were agreed which are to be cascaded throughout the Trust.

Presentations were received on QUEST, orthopaedic surgery team evaluation, and mortality data. Work was commissioned to triangulate mortality data and investigate apparent discrepancies. The risks arising from a Clinical Audit Gap Analysis were identified and a workstream established to address these risks and reference such audit to the Assurance Framework.

The Committee agreed to review the Risk Register in October 2011. Subsequent re- presentation of the Register and the Assurance Framework on a quarterly basis showed significant improvement in identifying and quantifying risks and the degree of both internal and external assurance given. The Committee recommended the Assurance Framework to the Board as providing sufficient assurance for the Chief Executive to sign the Annual Governance Statement.

The Committee received regular updates on the process towards the reaccreditation of NHSLA Level 3. It monitors management of high profile inquests, complaints, incidents and legal cases and receive completed SUI reports and high profile case reports

The Chair of the Audit Committee attended the Assurance Committee on two occasions. This facilitated cross-reference between the two Committees

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The Committee receives at each of its meetings Trust-wide policies and standard operating procedures (SOPs) for validation.

Rayna Dean Chair, Assurance Committee April 2012

Assurance Committee Attendance

Member Title Actual/Possible Rayna Dean (Chair) Senior Independent Director 6/6 Catherine Beardshaw Chief Executive 4/6 Jill Byrne Director of Nursing & Patient 4/6 Safety Paul Fitzpatrick Director of Estates & Facilities 6/6 Gary Francis Medical Director 6/6 Debbie Fryer Director of HR & OD 5/6 Mo Murphy Non Executive Director 6/6 Jeremy Tozer Interim Chief Operating Officer 2/6 Steve Warburton Director of Finance & Business 6/6 Services

Remuneration & Nominations Committee

The purpose of the Remuneration Committee is to decide the pay and allowances and other terms and conditions of the executive directors. Membership of the Remuneration Committee wholly comprises non executive directors, who are viewed as independent. The Committee is chaired by the Trust chairman with all non executive directors invited to attend. Members of the Committee had no financial interest in matters to be decided. The chief executive and director of human resources & organisational development normally attend committee meetings, except where their own salaries are discussed. The Committee met twice in the year. The Remuneration Report is set out on page 168.

Remuneration & Nominations Committee attendance

Member Actual/Possible Christopher Baker 2/2 (Chair) Rayna Dean 2/2 Patrick Hackett 0/2 George Marcall 2/2 Frank McKenna 1/2 Sally Merriman 2/2 Mo Murphy 2/2

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Code of Governance

The Trust is required to make a two part statement in respect of the NHS Foundation Trust Code of Governance. In the first part, it is to report on how it applies the main and supporting principles of the Code. In the second part, it confirms that it complies with the provisions of the Code or where it does not, provides an explanation.

Part one statement: application of the main and supporting principles of the NHS Foundation Trust Code of Governance

The Board confirms that the Trust complies with the main and supporting principles of the Code.

Sections A and B, governors and directors

The Board of Governors effectively represents the interests of Trust members and partner organisations within the health economy. The Board of Governors holds the Board of Directors to account for the performance of the Trust, in particular in relation to the outcomes of Monitor’s Risk Ratings and the NHS Litigation Authority assessment of risk management systems.

Executive directors make regular presentations to the Board of Governors concerning the Trust’s performance and forward planning, providing the governors with frequent opportunities to raise issues, question performance and seek further advice. The governors, in turn, recognise their responsibility for regularly feeding back this information about the Trust, its vision and performance to their constituencies and partner organisations.

The governors are involved in annual discussions with the Board of Directors on the priorities for development and improvement of the organisation, as seen by their constituencies and partner organisations. This information impacts positively and materially on the preparation of the Trust’s Annual Plan. Each year the governors and members are presented with the Annual Report and Accounts and the Annual Plan at public meetings. The governors are consulted by the Trust on any significant changes to the delivery of the Annual Plan.

Section C, appointments and terms of office

The Trust has a formal, rigorous and transparent procedure for the appointment of directors, both executive and non executive. Appointments are made on merit, based on objective criteria. Assurances are sought from non executive director candidates that they have sufficient time to fulfil their duties. Appointments among non executive directors are reviewed annually and their terms of office are staggered over three years to ensure an orderly succession to the Board.

All elected governors have three year terms of office to a maximum of eight consecutive years which provide for an annual refreshing by the various electorates of up to one third of the elected members of the Assembly. All elections for appointment as an elected

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Aintree University Hospital NHS Foundation Trust governor are administered by Electoral Reform Services Ltd in accordance with the model election rules in the Trust’s constitution.

Section D, information, development and evaluation

The Board of Directors and Board of Governors regularly review their information needs. Directors and governors have a clear induction programme upon appointment and are encouraged to request further information according to their needs, which may be above and beyond information routinely supplied by management. Directors and governors are encouraged continually to update their skills, knowledge and familiarity with the Trust, using the organisation’s own resources and facilities as well as external learning opportunities.

The chief executive appraises each of the executive directors and submits an appraisal summary to the Remuneration Committee, which determines executive remuneration based on a broad range of factors. The chairman leads the appraisal of each non executive director and the senior independent director leads the appraisal of the Trust chairman. Summary outcomes of the evaluation of non executive directors, including the chairman, are shared with the governors. In 2011.12, governors were actively involved in the appraisal of the chairman through a 360 process.

Section E, director remuneration

The Trust sets the remuneration of executive directors in order to balance the need to attract, retain and motivate directors of the quality required while avoiding paying more than is necessary for this purpose. In the year under review, no part of any executive director’s remuneration comprised performance related pay. The Remuneration Committee commissions remuneration advice periodically, and not less than once in every three years, to gain assurance that executive pay within the Trust remains competitive and in line with peers in the upper quartile of FTs. No director is involved in setting his or her own remuneration. The mechanisms for considering and deciding on both executive and non executive pay are documented, open and transparent. Care is taken to avoid any possible conflict of interest in relation to the Trust chairman, who chairs the Governors’ Nominations Committee, and the director of human resources & organisational development, who provides advice to the Remuneration Committee.

Section F, accountability and audit

The Trust recognises the value of making reporting and accounting information available for the general public and the Trust’s partners, stakeholders, clients, service users and regulators, which is appropriate to their needs, in accessible formats and fulfils statutory requirements. Meetings of the Board of Governors are open to the public, except for reserved business, and presentations are regularly made at Board of Governor and members’ meetings and regular public education events.

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The Board maintains a system of internal controls to safeguard the Trust’s assets, patient safety and service quality. All tiers of management and staff are aware of the methods, policies, procedures and communications mechanisms, which are used to control resources and activity. The Board believes this system of internal control is effective and it retains an internal auditor, RSM Tenon, working under the direction of the director of finance & business services, to report on different aspects of internal control across the Trust.

The Audit Committee tests systems and controls in response to reports commissioned from RSM Tenon. The committee, in particular the chair, and the director of finance & business services, who is not a member of the Audit Committee, maintain a regular, clear relationship with the Trust’s external auditor, PricewaterhouseCoopers LLP. The external auditor is appointed by the Board of Governors and reports to the governors annually concerning the audit of the Trust’s financial statements. Following a competitive tender, the Trust reappointed its external auditors, PricewaterhouseCoopers LLP, on 4 April 2012 for a period of 3 years and the option to extend for a further 2 years.

The Trust reported one incident involving data loss through estates works to the Information Commissioner’s Office (ICO) in August 2011. In May 2012, the ICO requested further information around the steps taken to prevent loss through similar works in the future.

Section G, relationships with stakeholders

The Trust has multiple contacts, involvements and links across North Merseyside and beyond, with members, patients, clients and other participants in the health economy. These contacts complement the role of governors and those organisations nominating a governor to the Board of Governors. The Board recognises that further work will need to be done in the future to maximise the benefits of these relationships and to ensure that it builds on the most appropriate forms of engagement at relevant levels. Each member of the Board understands his/her role in this process. The Trust’s approach to engagement can be demonstrated by the initial consultations with the local community and local councillors in 2011/12 to share the plans for the new development for the Accident & Emergency Department.

The Trust is committed to further developing the value of membership, both to members and to the Trust, with particular emphasis on improving the extent to which the membership reflects the served community.

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Part two statement: compliance with the provisions of the NHS Foundation Trust Code of Governance and exceptions

The Board confirms that the Trust complies with all provisions of the Code of Governance with the exceptions set out below.

A.1.10 In relation to the policy of openness and transparency in the Board’s proceedings, the issue of whether Board meetings are held in open session was kept under review subject to the outcome of the Health & Social Care Act pertaining to public Board meetings. Although Board meetings are not open to the public, the Trust’s public governors are invited to attend the Board meetings on a quarterly basis.

B.1.7 Although there is no written policy for engagement between the Board of Governors and the Board of Directors, the Trust has appointed a Senior Independent Director on the Board of Directors who is available to members for those circumstances when they have concerns about the performance of the board of directors, compliance with the terms of authorisation or other matters related to the general wellbeing of the Trust.

E.2.2 For the purpose of remuneration, ‘senior manager’ within the Trust refers only to Executive members of the Board of Directors i.e. those members with voting powers. The Trust adopts the ‘persons discharging managerial responsibility’ definition of ‘senior manager’ as those persons who have the power to make managerial decisions affecting the future development and business prospects of the Trust. The organisation is not compliant with this provision because the level and structure of remuneration for the managers who hold senior positions, but who are not Board members, is dealt with by the executive team, rather than the Remuneration Committee. The Trust believes this is an appropriate arrangement because of the familiarity of the executive team with the performance of those managers. There are a small number of exceptions to this statement, being those members of staff holding senior positions, but whose terms and conditions are not subject to national Agenda for Change terms. The Remuneration Committee considers the annual increment in salary of this group of staff as a whole, in relation to guidance provided by the Senior Salaries Review Body.

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Remuneration Report

The remuneration and expenses for the Trust Chairman and Non-Executive Directors are determined by the Board of Governors, taking account of relevant available guidance and benchmarking with comparable organisations.

Remuneration paid to Executive Directors is determined by the Remuneration and Nominations Committee, whose membership comprises the Trust Chairman, the Non- Executive Directors and the Chief Executive. Attendance at the Committee is detailed on page 160. Pay levels are informed by salary surveys conducted by independent consultants and comparisons with salary scales for similar posts within the NHS. Directors’ remuneration is not subject to performance related pay but performance is managed through a process of objective setting, linked to the organisation’s strategy and business plans, and annual appraisals.

When determining Directors’ remuneration, the Remuneration and Nominations Committee takes into account the pay and employment conditions applicable to the Foundation Trust’s workforce i.e. Agenda for Change and Medical & Dental staff. Directors’ employment conditions virtually mirror Agenda for Change.

Appointments to Executive Director posts are made in open competition and can only be terminated by resolution of the Board other than in cases of normal resignation. Directors hold permanent contracts with a standard six month period of notice. Non Executive Directors are appointed for a period of three years. The Trust’s normal disciplinary policies apply to Executive Directors, including the sanction of instant dismissal for gross misconduct. The Trust’s redundancy policy is consistent with NHS redundancy terms for all staff.

Details of remuneration, including the salaries and pension entitlements of the Board of Directors, which have been subject to audit, are set out overleaf.

HM Treasury requires disclosure of the median remuneration of our staff and the ratio between this and the mid-point of the banded remuneration of the highest paid director.

The median remuneration has been calculated based on full time equivalent staff at the year end on an annualised basis. This equates to a median of £22,412.

The highest paid director is Dr G Francis (Medical Director) and the mid-point of his banded remuneration is £187,500.

Therefore, the ratio between the median remuneration and the highest paid director is 8.4.

In 2011-12, two (2010-11, five) employees received remuneration in excess of the highest- paid director. Remuneration ranged from £222k to £256k (2010-11 £190k –£267k).

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Salary and Pension Entitlements of Senior Managers (Audited by PwC LLP)

A) Remuneration

2011/2012 2010/2011

Salary Other Benefits Total Salary Other Benefits in Total (bands of Remuneration in Kind (bands of Remuneratio Kind Name and Title £5000) (bands of Rounded (bands of £5000) n (bands of Rounded (bands of £5000) to the £5000) £5000) to the £5000) nearest nearest £100 £100

£000 £000 £ £000 £000 £000 £ £000

Baker C, 40-45 0 0 40-45 40-45 0 0 40-45 Chairman

Hackett P, 10-15 0 0 10-15 10-15 0 0 10-15 Non Executive Director

Marcall G, 10-15 0 0 10-15 10-15 0 0 10-15 Non Executive Director

McKenna F, 10-15 0 0 10-15 10-15 0 0 10-15 Non Executive Director

Merriman S, 10-15 0 0 10-15 10-15 0 0 10-15 Non Executive Director

Murphy M, 10-15 0 0 10-15 10-15 0 0 10-15 Non Executive Director

Dean R, 15-20 0 0 15-20 15-20 0 0 15-20 Non Executive Director Beardshaw C, 165-170 0 0 165-170 25-30 0 0 25-30 Chief Executive Annual Report & Accounts 2011/12 173

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2011/2012 2010/2011

Salary Other Benefits Total Salary Other Benefits in Total (bands of Remuneration in Kind (bands of Remuneratio Kind Name and Title £5000) (bands of Rounded (bands of £5000) n (bands of Rounded (bands of £5000) to the £5000) £5000) to the £5000) nearest nearest £100 £100

Byrne J, 105-110 0 0 105-110 100-105 0 0 100-105 Director of Nursing & Patient Safety

Francis G, 185-190 0 0 185-190 185-190 0 0 185-190 Medical Director

Warburton S, 120-125 0 0 120-125 115-120 0 0 115-120 Director of Finance & Business Services

Birrell J, N/A N/A N/A N/A 155-160 0 0 155-160 Chief Executive

Frayne M, 50-55 0 0 50-55 120-125 0 0 120-125 Chief Operating Officer

Notes M Frayne left the Trust on 18 September 2011 S Merriman left the Trust on 31 March 2012 J Birrell retired on 7 March 2011

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B) Pension Benefits “As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments in to the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations.”

Real Total Real Related Cash Cash Real Employers Increase Accrued Increase lump sum Equivalent Equivalent Increase / Contribution in Pension in at age 60 at Transfer Transfer Value (Decrease) to Pension at age 60 related 31 March Value at 31 at 31 March in Cash Stakeholder at age at 31 lump 2012 March 2012 2011 (To Equivalent Pension 60 March sum at (bands of (To nearest nearest £1000) Transfer To nearest (bands 2012 age 60 £5000) £1000) Value £100 of (bands of (bands (To nearest £2500) £5000) of £1000) £2500)

£000 £000 £000 £000 £000 £000 £000 £

Beardshaw C, 5-7.5 75-80 17.5-20 230-235 1667 1425 198 0 Chief Executive Byrne J, 2.5-5.0 35-40 7.5-10 110-115 715 596 101 0 Director of Nursing & Patient Safety Francis G, 0-2.5 70-75 0-2.5 215-220 1507 1398 66 0 Medical Director Warburton S, 0-2.5 30-35 2.5-5 100-105 557 450 93 0 Director of Finance & Business Services Birrell J, N/A N/A N/A N/A N/A 0 N/A N/A Chief Executive Frayne M, 0-2.5 35-40 0-2.5 110-115 504 462 13 0 Chief Operating Officer

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Notes: M Frayne left the Trust on 18 September 2011 J Birrell retired on 7 March 2011

During 2011/12 there was a change in the Government Actuary Department (GAD) factor tables used to calculate the CETVs, which impacted upon the Pensions and CETV figures disclosed above. It can be confirmed that NHS Pensions used the most recent set of actuarial factors produced by GAD with effect from 8 December 2011 when calculating the above.

As Non Executive members do not receive pensionable remuneration, there will be no entries in respect of pensions for Non Executive members.

A Cash Equivalent Transfer Value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member's accrued benefits and any contingent spouse's pension payable from the scheme. A CETV is a payment made by a pension scheme, or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which the disclosure applies. The CETV figures, and from 2004-05 the other pension details, include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries.

Real Increase in CETV - This reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another pension scheme or arrangement) and uses common market valuation factors for the start and the end of the period. Changes occurred in the factors used to calculate CETVs when the Occupational Pension Scheme (Transfer Value Amendment) regulations came into force on 1 October 2008. Further regulations from the Department for Work and Pensions to determine the CETV from Public Sector Pension Schemes came into force on 13 October 2008.

In his budget of 22 June 2010 the Chancellor announced that the uprating (annual increase) of public sector pensions would change from the Retail Prices Index (RPI) to the Consumer Prices Index (CPI) with the change expected from April 2011. As a result the Government Actuaries Department undertook a review of all transfers factors. The new CETV factors are lower than the previous factors; therefore the value of the CETVs for some members has fallen since 31/03/2010.

Chief Executive - 30 May 2012

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Aintree University Hospital NHS Foundation Trust Annual Internal Audit Opinion 2011/2012

1. THE HEAD OF INTERNAL AUDIT OPINION

The purpose of my annual HoIA Opinion is to contribute to the assurances available to the Accounting Officer and the Board which underpin the Board’s own assessment of the effectiveness of the organisation’s system of internal control. This opinion will in turn assist the Board in the completion of its AGS.

My opinion is set out as follows: Based on the work undertaken in 2011/12, significant assurance can be given that there is a sound system of internal control which is designed to meet the organisation’s objectives, and that controls are being consistently applied in all the areas reviewed.

1.1 Issues judged relevant to the preparation of the Annual Governance Statement Based on the work we have undertaken on the Trust’s system on internal control we do not consider that within these areas there are any issues that need to be flagged as significant internal control issues within the AGS. Whilst not as a result of our work, based on our knowledge of the Trust we would also expect the Trust to reflect its Cancer Target performance.

1.2 The Basis of the Opinion

The basis for forming my opinion is as follows:

An assessment of the design and operation of the underpinning Assurance Framework and supporting processes;
An assessment of the range of individual opinions arising from risk based audit assignments reported throughout the year. This assessment has taken account of the relative materiality of these areas and management’s progress in addressing control weaknesses; and
Any reliance that is being placed upon third party assurances.

1.3 Information Supporting the Opinion The commentary below provides the context for my opinion and together with the opinion should be read in its entirety.

1.3.1 The design and operation of the Assurance Framework and associated processes The review of the Trust’s Assurance Framework concluded that the design and operation was adequate to support the Trust’s Annual Governance Statement.

Good progress had been made with revising the Assurance Framework in light of the new governance structure in place within the Trust. We noted that the new governance structure was still in the process of being embedded at the time of our audit and further amendments were due to be made to the Assurance Framework. The Quarter 4 Assurance Framework Update identified that further enhancements have been made to the Framework, although this is an on-going process as the new governance structure becomes further embedded within the Trust.

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1.3.2 The range of individual opinions arising from risk based audit assignments, contained within the risk based plans that have been reported throughout the year The internal audit plan was driven by the Trust’s key risks as identified by management and was further driven by the need to review key financial systems to ensure that continued External Audit reliance is placed upon our work. Discussions were also held with the Director of Finance and Business Services during the year to ensure that any key emerging risks for the Trust were included in the plan. All the reports issued within the year resulted in positive opinions, with all but one resulting in a “green” or “amber / green” opinion. The one “amber / red” opinion was in relation to the CyberREN renal system, which identified that there was no formal mechanism in place for reporting CyberREN system faults to management; no contract was in place with the system vendor; the Tenants Agreement, which seeks to clearly define usage of the CyberREN system, was in draft at the time of the audit in September 2011; and the action plan from the Business Impact Assessment that was carried out by the Information Security Manager needs to be completed. However, at the time of our audit in May 2011, the CyberREN system had been implemented at the Trust for a year and our review of helpdesk records indicated that there were no serious functionality issues being reported within the first year of operation. The recommendation tracking process has confirmed that the actions identified within this report have now been completed. We also undertook a CQC Assurance Review during the year. The overall opinion in this review was positive and an overall sound system of control was in place. Monthly self-assessments are performed by wards / units to identify the level of compliance with CQC requirements. Spot checks are then undertaken by management on wards / units to verify that the self-assessments are accurate. All of the internal financial control opinions for the work undertaken in 2011/12 have resulted in “green” or “amber / green” opinions as in 2010/11. A comparison between years is provided in Section 4.2, which shows that the number of “amber / green” opinions is above the previous year. However, this is due to a change in the profile of the work being undertaken. It must be noted that in this area all work in this area has resulted in a positive opinion. A summary of the assurance provided across the year is provided at Appendix A. Details of our reviews, including the opinions given and the numbers of recommendations made is provided at Appendix B. Common Weaknesses There have been no common weaknesses identified throughout our reviews . Acceptance of Recommendations All of the recommendations made within our finalised reports have been accepted by management. Recommendations Not Receiving Adequate Management Attention Management have considered and responded to all our recommendations in respect of our 2011/12 work. 1.3.3 Reliance Placed Upon Work Of Other Assurance Providers In forming our opinion we have not placed any direct reliance on other assurance providers. However, we have liaised with the Trust’s LCFS and External Auditors throughout the year to reduce the risk of any duplication of effort.

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Statement of the Chief Executive’s Responsibilities as the Accounting Officer of Aintree University Hospital 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 Aintree University Hospital 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 Aintree University Hospital 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; and • Prepare the financial statements on a going concern basis.

The Accounting Officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS Foundation Trust and to enable 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.

The accounts are prepared by the Directors of the NHS Foundation Trust and reviewed by the Audit Committee. The Board of Directors adopts the accounts following recommendation by the Audit Committee and once it is satisfied that the accounts give a true and fair view of the Trust’s state of affairs.

After making enquiries, the Directors have a reasonable expectation that the NHS Foundation Trust has adequate resources to continue in operational existence for the

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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.

Catherine Beardshaw Chief Executive

Date: 30 May 2012

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Independent Auditors’ Report

Independent Auditors’ Report to the Board of Governors of Aintree University Hospital NHS Foundation Trust

We have audited the financial statements of Aintree University Hospital NHS Foundation Trust for the year ended 31 March 2012 which comprise the Statement of Comprehensive Income, the Statement of Financial Position, the Statement of Cash Flows, the Statement of Changes in Taxpayers’ Equity and the related notes. The financial reporting framework that has been applied in their preparation is the NHS Foundation Trust Annual Reporting Manual 2011/12 issued by the Independent Regulator of NHS Foundation Trusts (“Monitor”).

Respective responsibilities of directors and auditors As explained more fully in the Statement of the Chief Executive’s responsibilities, the directors are responsible for the preparation of the financial statements and for being satisfied that they give a true and fair view in accordance with the NHS Foundation Trust Annual Reporting Manual 2011/12. Our responsibility is to audit and express an opinion on the financial statements in accordance with the NHS Act 2006, the Audit Code for NHS Foundation Trusts issued by Monitor and International Standards on Auditing (ISAs) (UK and Ireland). Those standards require us to comply with the Auditing Practices Board’s Ethical Standards for Auditors.

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

Scope of the audit of the financial statements

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

Opinion on financial statements In our opinion the financial statements:

• give a true and fair view, in accordance with the NHS Foundation Trust Annual Reporting Manual 2011/12, of the state of the NHS Foundation Trust’s affairs as at 31 March 2012 and of its income and expenditure and cash flows for the year then ended ; and

• have been properly prepared in accordance with the NHS Foundation Trust Annual Reporting Manual 2011/12.

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Opinion on other matters prescribed by the Audit Code for NHS Foundation Trusts

In our opinion

• the part of the Directors’ Remuneration Report to be audited has been properly prepared in accordance with the NHS Foundation Trust Annual Reporting Manual 2011/12; and

• the information given in the Directors’ Report for the financial year for which the financial statements are prepared is consistent with the financial statements.

Matters on which we are required to report by exception

We have nothing to report in respect of the following matters where the Audit Code for NHS Foundation Trusts requires us to report to you if:

• in our opinion the Annual Governance Statement does not meet the disclosure requirements set out in the NHS Foundation Trust Annual Reporting Manual 2011/12 or is misleading or inconsistent with information of which we are aware from our audit. We are not required to consider, nor have we considered, whether the Annual Governance Statement addresses all risks and controls or that risks are satisfactorily addressed by internal controls;

• we have not been able to satisfy ourselves that the NHS Foundation Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources; or

• we have qualified our report on any aspects of the Quality Report.

Certificate

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

Rachel McIlwraith (Senior Statutory Auditor)

For and on behalf of PricewaterhouseCoopers LLP Chartered Accountants and Statutory Auditors Manchester 30 May 2012 Notes:

(a) The maintenance and integrity of the Aintree University Hospital NHS Foundation Trust 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.

(b) Legislation in the United Kingdom governing the preparation and dissemination of financial statements may differ from legislation in other jurisdictions.

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Annual Governance Statement

Scope of responsibility

As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS foundation trust’s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the NHS foundation trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum .

The purpose of the system of internal control

The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of Aintree University Hospital NHS Foundation Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in Aintree University Hospital NHS Foundation Trust for the year ended 31 March 2012 and up to the date of approval of the annual report and accounts.

Capacity to Handle Risk

Leadership: I am directly accountable to the Board of Directors in relation to the performance of the Trust. The authority for decision-making is, however, delegated to individual managers through the Trust’s Scheme of Delegation, and through the committee structure as per the terms of reference detailed in the Trust’s Standing Orders and the Trust‘s Risk Management Strategy.

Roles and Responsibilities

Responsibility for the risk management process is delegated to Executive Directors who were supported in this by their own teams. Specific responsibility is as follows:

• co-ordination of all non-financial risk management, clinical governance, assurance & legal services – Clinical Governance Department, under the direction of the Medical Director

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• financial and business development risk management - Director of Finance and Business Services • health and safety - Director of Estates and Facilities • safeguarding children & adults, patient safety and experience - Director of Nursing and Patient Safety

In 2011-12, a new leadership structure was introduced with 3 Divisions – Surgery, Medicine and Support Services. Each Division has a Divisional Management Group with clinical leadership provided by a triumvirate team of a Clinical Head of Division, a Divisional Chief Operating Officer and a Lead Nurse/Allied Health Professional .

Committee Structures

Also in 2011-12, revised governance arrangements were introduced to ensure that the Board’s Committee structure was fit for purpose, used the time of Non-Executive Directors productively and efficiently and that the structure reflected current best practice in corporate governance. It not only took into account existing FT guidance, wider corporate governance publications and arrangements adopted by peer FTs but took note of the advice and recommendations of Deloitte’s review of the Trust’s Board Committee structure undertaken in 2010.

Risk is managed, on behalf of the Board, through the Trust’s Committee Structure of the Audit Committee and the new Assurance Committee (previously the Clinical Governance Board and the Risk Management Strategy Group) with the following sub-committees reporting into it – Safety and Risk, Clinical Effectiveness, Patient Experience and Workforce.

The Trust also introduced new divisional governance structures that mirrored the Trust’s organisational governance structure. The Divisions now have their own Divisional governance meetings to ensure that there is a comprehensive and integrated approach to the management of risk within the Divisions. At each management level within the Trust, managers have responsibility for the implementation of Trust objectives and the Trust Risk Management Strategy.

Reporting mechanisms

During 2011/12, the Board of Directors monitored the key risks associated with the achievement of the Trust’s objectives through the Assurance Framework and the monthly Corporate Performance Reports, with less significant risks being addressed through normal performance management arrangements. Throughout the year, the Board received regular reports on the key risks facing the organisation and the action taken with regard to the most significant risks.

Training: the Trust’s training policy takes into consideration national imperatives and advice/guidance from professional bodies, for example, the Postgraduate Medical Annual Report & Accounts 2011/12 184

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Education & Training Board. The annual review of the policy includes the identification of statutory and mandatory training which forms the essential training matrix aimed at improving knowledge and understanding and increasing awareness of risk issues at all levels of the organisation. To support new staff in dealing with risk management issues, the Trust's mandatory induction programme covers a wide range of subjects and includes a presentation by a member of the Board of Directors.

Attendance at the Trust’s mandatory risk management training programme is monitored by the Workforce Sub-Committee and the programme is reviewed and updated annually.

Both induction and the mandatory training programme are aligned to statutory requirements, best practice and Trust policy. The training programmes are available to volunteers who work for the Trust. Dependent on their role, further bespoke training may be undertaken.

Other risk management training is provided on a formal and ad hoc basis as part of the corporate learning and development programme. These include training on investigation techniques (including root cause analysis) to review serious incidents, health and safety, complaints and risk management training for directors and senior managers in the Trust.

Guidance: The Trust maintains a robust system of managing its policies to ensure appropriate guidance is available for all staff. This year saw the implementation of the new Document Management System which provides staff with access to all approved Trust policies, procedures, guidance in one location on the intranet. Trust policies are reviewed and updated regularly and staff are informed of new or reviewed policies through the Trust Brief which is cascaded to all staff, and other reporting mechanisms. There is a clear process to monitor policies and ensure that they are current and relevant.

Learning: good practice is shared through a range of methods including Team Brief, Trust meeting structures, professional meetings e.g. Aintree Nursing Forum, Grand Round, and through the divisional governance arrangements. The Trust has a Comprehensive Unit Safety Programme (CUSP) which involves ward-based staff in developing new safety initiatives and sharing these in their clinical areas. There are patient safety officers in all ward areas. Lessons learned from a variety of local and national sources on incidents, complaints, concerns, claims and audits are shared through the Safety Newsletter. Lessons and shared learning are also taken through key Trust reports e.g. the quarterly Risks Report and the 4Cs (comments, compliments, concerns and complaints) report, both of which are submitted to the Board. The Trust organised an internal conference in March 2012 on Patient Safety which combined with a visit from QUEST, a membership group of 12 high performing NHS Foundation Trusts in terms of quality and patient safety, to share learning across our economies. Another conference “Safe in Your Hands” was organised in March 2012 with one of our key education partners with the intention of informing the next generation of nurses about the quality and safety agenda.

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The Risk and Control Framework

Risk appetite can be defined as the amount of risk, on a broad level, that an organisation is prepared to accept in seeking to achieve its strategic objectives. Factors which influence this risk appetite are the external environment, people, business systems and policies.

The Trust recognises that it is impossible and not always appropriate to eliminate all risks. Systems of control must be balanced in order that innovation and the use of limited resources are supported when it is used to achieve increased health benefits for the local population. Additionally, the Trust may be willing to accept a certain level of risk when the cost of mitigating the risk is high in comparison to the potential severity of the risk and the likelihood of occurring. As a general rule, therefore, the Trust will seek to eliminate or control risks that have the potential to:

• harm patients, staff, volunteers, visitors, contractors and other stakeholders • harm the reputation of the organisation • have a severe financial consequences that would prevent the trust from carrying out its function.

Risk Management Strategy

The Trust is committed to provision of high quality and safe services and it does this under the umbrella of the Risk Management Strategy. The Risk Management Strategy is reviewed and endorsed by the Assurance Committee on behalf of the Board of Directors. The Chair of the Assurance Committee regularly provides assurance to the Audit Committee that risk is being managed appropriately within the Trust.

The key elements of the strategy include a description of individual and collective responsibilities of the Board of Directors, its committees and other groups within the Trust that are concerned with risk management.

The process of identification of risk from various sources encompasses:

• the Trust’s assurance framework & Risk Register • incidents and near misses • complaints and claims • audit findings • external reviews and accreditation visits • ad hoc risk assessments • inspection process • process for learning.

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Assurance Framework

A new Assurance Framework was developed in response to the Trust objectives for 2011/12. This was reviewed by each lead director on a quarterly basis. The Assurance Framework allows the Board to focus on the risks which may prevent it from meeting its strategic objectives. All risks are assessed for gaps in control and assurance, and action plans are established and monitored during the year by the Assurance Committee and the Board of Directors.

Risk Identification and Management

Risks are identified as a result of incidents, complaints, claims or by proactive risk assessment, and are scored using the Trust’s risk scoring 5x5matrix. Those that score 15 and above are entered on the Trust’s Risk Register and are escalated to the Board. The risk escalation process makes it explicit how risks are identified, recorded, managed and escalated at all levels in the Trust. The management and mitigation of these risks is determined by the risk score, for example, a low level risk may be managed within a department whereas a medium and high level risk would be managed within the Divisions and escalated onto the Risk Register.

There is a clear process for escalation of risks through to the Safety & Risk Sub- Committee, the Assurance Committee and the Board of Directors.

Incident Management

The Trust encourages incident and near miss reporting in line with Trust policies and guidance. Any member of staff can log an incident on the electronic database. There are clearly identified processes for the review and management of specific incidents through divisional and corporate structures. The seriousness of the incident will determine the actions taken and how it is investigated, managed and escalated. For example, a serious incident would necessitate a full root cause analysis investigation whereas other incidents may be reviewed using theming and trending. If appropriate, the Trust commissions independent external senior health professionals to carry out a review. The Patient Safety Officers play a key role internally in reviewing incidents at a local level and sharing the key messages with staff.

Incidents are monitored through a quarterly risk report which identifies key themes and consequent actions that have been undertaken to reduce the likelihood of these events re- occurring. This report is presented to the Safety & Risk Sub-Committee, through the Assurance Committee to the Board of Directors. Monthly figures of incidents are also reported to the Board via the Corporate Performance Report. The lessons learned from incidents are shared with the Divisions and the wider Trust through the Safety Newsletter, Trust Brief and through Trust Safety Alerts.

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The Trust continued with its safety initiative of weekly meetings of harm. These are attended and chaired by the Director of Nursing & Patient Safety and the Medical Director. Their role is to review key incidents and near misses every week and to ensure appropriate actions are taken. Due to the success of this process, this has now been rolled out at a Divisional level.

Any Serious Untoward Incidents are managed in close liaison with the Trust’s lead Primary Care Trust and detailed reports regarding causes are presented to the Safety & Risk Sub- Committee with a summary report submitted to the Assurance Committee and the Board of Directors. Key actions and changes to practice are monitored and followed up through the Safety & Risk Committee as well as by the lead Divisions.

Stakeholder Involvement

The Trust wishes to understand and learn from patient experience and, therefore, encourages feedback in a variety of different ways. These are underpinned in the Patient Experience & Engagement Strategy. To support this, the Trust has a Patient Experience Action Group which reports to the Patient Experience Sub-Committee which, in turn, reports to the Assurance Committee. The latter has representation from the Local Involvement Networks (LINk) and Governors.

The Customer Services Department, which includes the Patient Advice and Liaison Service (PALS), is usually the first point of contact for patients or relatives to express their views or raise concerns about care. These are addressed immediately and contribute to the "lessons to be learned". Complaints and comments received by the Trust are also reviewed in order to prevent similar experiences occurring in the future.

The Trust has a “Being Open” Policy which sets out how the Trust supports and communicates with patients and relatives following an incident. This ensures their participation and involvement in the process and enables the Trust to share learning. This philosophy is reflected by the use of patient stories at the Board of Directors meetings.

The Trust participated in national patient and staff surveys, the results of which were used to develop action plans for improvements in services. Reports obtained from external assessors are presented to appropriate entities as outlined in the External Reports Standard Operating Procedure (SOP).

Staff associations and trade unions are represented on the Partnership Forum and the Health & Safety Forum and directly contribute to the development of procedures and remedial action for risk reduction. A proactive Occupational Health Service, based in the Trust’s bespoke Health, Work and Well-being Centre, is provided to all Trust employees with the primary aims of maximising their health and well-being and minimising risks to health to which employees may be exposed in their working environment. Health and safety incidents are monitored in accordance with the Risk Management Strategy and escalation process.

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A number of groups and committees exist across the health economy. Health and Wellbeing Boards are a forum for local commissioners across the NHS, public health and social care, elected representatives, and representatives of HealthWatch to discuss how to work together to improve the health and wellbeing outcomes of the people in their area. The Trust has been invited to be a non-voting member of the local Health and Wellbeing Board, chaired by the Chief Executive of Local Authority, where there is also representation from social services, the community trust, the mental health trust, the local GP commissioning consortium and commissioners; when necessary, this forum is used to discuss community issues pertaining to risks which may impact on other stakeholders.

The Trust actively seeks the view of public stakeholders by various means including patient surveys and public events. The results of this activity are compared with other quality indicators such as Patient Advice and Liaison Service (PALS) concerns and formal complaints to identify themes for specific action.

The Trust Objectives, Quality Account and Annual Governance Statement are presented to and discussed with the Board of Governors. Information gained from the governors, public, staff and stakeholders are used to form the basis of priorities set by the organisation.

The Trust continues to have an effective and transparent relationship with the Local Involvement Networks (LINks). LINKs undertook ‘Enter & View’ visits to the hospital in April 2011 and February 2012 to assist them with their work plan.

The Board also receives standardised key performance indicators relating to patient care and feedback on ward performance.

External partnerships

The Trust liaised closely with the North Mersey PCT Cluster and the Clinical Commissioning Groups (CCGs) encouraging two-way dialogue and transparency. Whenever possible and appropriate, the Trust works jointly with these partners to manage risk. Regular meetings with the PCT Cluster and the CCGs provide an opportunity for the Trust to identify financial and service risks and potential developments or changes in service which require investment and/or a system-wide response.

The Trust continued to work closely with John Hopkins Hospital, Baltimore, USA to explore ways of improving patient safety until September 2011. This led to the development and implementation programme across a wide range of issues, e.g. the Comprehensive Unit Safety Programme (CUSP).

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Performance Information

The data used in the Trust is regularly audited both internally and by external agencies. The Executive Directors regularly review operational performance and weekly performance discussions take place with the Divisional teams. Data quality is monitored on a regular basis using a range of real time data quality reports. The Trust Data Quality Manager produces monthly reports on system data quality; the aforementioned information is benchmarked against national standards and issues identified (e.g. readmissions, mortality etc) are formally investigated. Clinical performance data is reviewed by the Clinical Effectiveness Sub-Committee and other performance data is regularly reviewed by the Divisions and external agencies such as the Primary Care Trust and the Strategic Health Authority.

Care Quality Commission Registration

The Trust is required to register with the CQC and its current registration status is registered without conditions for the Health and Social Care Act 2008. The foundation trust is fully compliant with the registration requirements of the Care Quality Commission.

The CQC has undertaken one unannounced inspection of our Trust during 2011/12 covering five of the essential outcomes – care and welfare of people who use services, meeting nutritional needs, management of medicines, supporting staff and complaints. The report from CQC indicates they identified four moderate concerns and one minor concern (meeting nutritional needs) in the five outcomes they reviewed during their visit in March 2012. The Trust has submitted an action plan focussed on addressing these shortfalls to the CQC together with comments on the report. The actions will also be incorporated in the Quality Safety and Patient Experience Improvement Programme. It should be noted that the moderate and minor concerns will not impact on the governance rating for the Trust from Monitor.

The following internal assurance processes assist the Trust in monitoring compliance with the CQC Essential Standards and the quality of the information provided:

• Monthly review of essential standards by ward/department leads • Annual risk assessment against essential standards by all wards/departments • Supporting information against essential standards collected by all ward/department managers • Sub-committee structure that reflects the areas represented within the CQC essential standards • Review of adherence to ward and department processes at assistant director level • Supporting information provided to all wards/departments to raise awareness of CQC essential standards outcomes

This process is reviewed annually by the internal auditors, RSM Tenon, who provide a report to the Audit Committee. Following the CQC unannounced inspection, these Annual Report & Accounts 2011/12 190

Aintree University Hospital NHS Foundation Trust assurance processes are also being reviewed internally and additional guidance is being developed.

Data security

Risks relating to information governance are contained within the monitoring and reporting mechanisms. An Information Governance Committee facilitates the work programme that ensures the Trust maintains compliance with relevant information governance legislation and good practice. The Trust Information Governance Assessment report overall score for 2011/12 was 74% and was rated satisfactory in the grading scheme. The Trust has continued to review its data flows (both internal and external) during 2011/12 to ensure compliance with requests from the Department of Health ensuring bulk data is secure in transit.

Information risks, either reactive (following incidents) or proactive (following risk assessments), are managed in the same way as all other risks identified in the Trust. They are reviewed by the Information Governance Steering Group and the Information Governance Strategy Group.

The annual self-assessment of information security was undertaken utilising the Information Governance Toolkit (IGT). This assessment enables the Trust to provide assurance of the provision and support to the Information Governance agenda and also highlights areas of weakness. The results of this assessment are used by Monitor as part of the Compliance Framework and by the Care Quality Commission as part of the Quality Risk Profiles (QRP). In 2011/12, as in the previous year, the Trust achieved a green rating on the Toolkit.

Major Risks

The Trust has a culture of proactive risk management and assurances are required by the Board that the executive and management teams are actively mitigating risks and assessing outcomes. Controls and assurances which describe how the Trust will manage the risks to achievement of its strategic objectives are identified and managed through the Assurance Framework which is monitored by the Trust’s Assurance Committee and submitted to the Board for consideration on a quarterly basis. The detail of these risks is noted under the relevant headings within the Corporate Risk Register. The Assurance Framework and the Corporate Risk Register are also regularly monitored and reviewed by the Executive Directors through the assurance structures within divisions. The major risks, both in year and future, are highlighted below, identifying how they will be managed and mitigated and how outcomes will be assessed:

• Failure to provide consistently a high quality patient experience The Trust’s three year Quality Strategy focuses on the requirements to minimise avoidable deaths, reduce serious incidents and improve patient satisfaction levels. Additional outcome-based standards are being developed by clinical teams to Annual Report & Accounts 2011/12 191

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encompass medical and team quality standards in addition to nursing standards. Outcomes are assessed through the divisional governance structures, linking across to the Assurance Committee and the Board

• Non-delivery of our targets and obligations The Trust manages this risk through its internal systems and processes which include regular reviews of performance by Executive Directors and with divisional teams. The outcomes of these reviews are incorporated in the Corporate Performance Report and the Monitor Quarterly Report, both of which are submitted to the Board. In addition, real-time monitoring of targets is undertaken through the Aintree Business Intelligence System.

• Inability to develop effective external partnerships We have responded to this through successful liaison and joint planning with commissioners (including Clinical Commissioning Groups), other NHS trusts and private providers. The Board discusses these partnerships on a monthly basis to ensure they align with the strategic vision of the Trust.

• Failure to invest in and develop our staff The recent restructuring of our clinical divisions and corporate departments and the introduction of local governance arrangements to manage risks at the divisional level, has led to a risk that, during the transitional period, managers will fail to manage the performance of their staff through effective appraisal and performance management with the consequent risk that staff are not managed and developed effectively.

The Trust will mitigate against this risk through the rollout and monitoring of COMPASS 2, our enhanced electronic appraisal and performance management system. This will enable us to ensure all staff receive an effective appraisal in 2012/13. In addition, minimum managerial standards are being developed for all levels of managers. We have already introduced a leadership development programme for Band 6 and 7 managers which has been well received and are developing a programme for Band 8s and above which will form part of the essential training for all managers in the Trust.

As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments into the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations.

Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with.

The foundation trust has undertaken risk assessments and Carbon Reduction Delivery Plans are in place in accordance with emergency preparedness and civil Annual Report & Accounts 2011/12 192

Aintree University Hospital NHS Foundation Trust contingency requirements, as based on the UK Climate Projections 2009 weather projects, to ensure that this organisation’s obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with.

Review of Economy, Efficiency and Effectiveness of the Use of Resources

The mechanisms for ensuring the best use of resources are well established in the Trust. Longer term planning for the use of forecast revenue and capital resource is built into the Trust’s process. Forecasts are made of the impact of key drivers for income, particularly the activity related element, and expenditure, including the impact of inflation and assessment of efficiency requirements. For 2011/12, these were considered and approved by the Board and were discussed with the Board of Governors.

The 2012/13 budget was approved by the Board on the basis of the best use of resources. During the course of the year, reports are presented to the Board focusing on material exceptions.

With regard to efficiency, the key drivers are assessed and improvements, such as length of stay, are factored into the service & financial improvement programme (SFIP) approved by the Board. The quarterly workforce dashboard has key factors, such as sickness levels, built into it and if any factors become a concern to the Board they are added to the dashboard on a regular basis. On the basis of the Trust’s Annual Plan, a quarterly report is submitted to Monitor on its financial position including the key risk rating ratio. This review provides assurance to the Board.

Quality Governance

The Trust is committed to ensuring trust-wide quality performance by embedding quality in the Trust’s overall strategy. The delivery of high quality safe patient care is one of the Trust’s corporate objectives and the priorities supporting this are managed through robust structures and processes at and below Board level. Key elements of the Trust’s quality governance arrangements are:

• The Board and its committees take the senior leadership role on quality and actively engage in the delivery of quality improvement initiatives

• Monitoring of performance relative to quality goals through a quality scorecard

• Regular assessment and monitoring of risks to delivery of a quality service and ensuring steps are taken to address any issues that arise.

Work on our three year Quality Strategy continues with a focus on minimising avoidable deaths, reducing serious incidents and improving patient satisfaction levels. Clinical teams

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Aintree University Hospital NHS Foundation Trust are developing additional outcome-based standards to include more medical and team quality levels. Outcomes are assessed through the divisional governance structures, linking across to the Assurance Committee and the Board.

Annual Quality Report

The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended) to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual Quality Reports which incorporate the above legal requirements in the NHS Foundation Trust Annual Reporting Manual. The production of the Quality Account (also referred to as the Quality Report when integrated into the Trust Annual Report) is led by the Director of Nursing & Patient Safety. Throughout 2011/12 a quarterly summary reporting progress against the six priorities has been produced for consideration at a range of internal groups and shared with external stakeholders such as LINks. There are a number of relevant strategies and policies that govern how the data contained with the Quality Account is managed. These include a data quality strategy and policy, a risk management strategy, policy and associated procedures, an information governance strategy and related policies (Information Disclosure Policy, Records Management Policy, Safe Haven & Transfer of Confidential Information Policy, Clinical Coding Policy). There are also clinical policies to guide staff such as the Infection Control and Prevention Policy and the Slips, Trips and Falls Policy.

Key groups and committees co-ordinate the systems and processes that relate to the information contained within the Quality Account. For example the Infection Prevention & Control Sub-Group scrutinises and challenges the infection control data, ensures that the correct information is reported and where required agrees the actions to improve the quality of the service. This is overseen by the Director of Infection & Prevention Control. The Trust has a nominated Senior Information Risk Owner and Caldicott Guardian and individual leads identified to co-ordinate and ensure the priorities are delivered.

There are staffing resources and structures in place to co-ordinate and manage the risk agenda and ensure data quality. The Assurance Committee, which reports directly to the Board of Directors, plays an active role in reviewing the data related to the key priority areas.

During the year there have been both internal self assessments, such as completion of the Information Governance Toolkit, and external assessments of aspects of the data contained within the Quality Account.

The governors, staff and external organisations such as the Primary Care Trust, the Local Authority Overview and Scrutiny Committees and the three LINks have been consulted on the priorities for 2012/13 and the governors in determining which of the local indicators was to be reviewed by external audit. Annual Report & Accounts 2011/12 194

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Review of Effectiveness

As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, clinical audit and the executive managers and clinical leads within the Aintree University Hospital NHS Foundation Trust who have responsibility for the development and maintenance of the internal control framework. I have drawn on the content of the quality report attached to this Annual report and other performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Board, the Audit Committee and the Assurance Committee. Plans to address weaknesses and ensure continuous improvement of the system are in place.

Board of Directors - The Board receives a range of information, as described previously, which indicates whether the system of internal control is effective. The Corporate Performance report is received monthly with supporting information regarding areas where compliance with targets is not possible in month. This includes a quarterly update regarding compliance with the CQC Essential Standards. The Board Assurance Framework was presented four times during 2011/12.

Audit Committee - The Audit Committee consists of at least two of the Board’s Non Executive Directors and is the committee which provides to the Board of Directors an independent and objective review over the establishment and maintenance of effective systems of integrated governance, risk management and internal control across the organisation’s clinical and non-clinical activities. It received reports from both the internal and external auditors regarding progress against the annual plan and also commissioned a range of formal reports and representations from key managers in the Trust to gain assurance and scrutinise adherence to Trust policies and procedures. The Audit Committee reviews financial and clinical assurance on a regular basis and makes specific requests for supporting information in order to be able to provide assurance to the Board of Directors.

Assurance Committee - The Assurance Committee is responsible to the Board of Directors for providing assurance that mechanisms are in place to address, monitor and manage safety, quality, effectiveness, patient and staff experience and workforce issues within the organisation. It has a specific remit to provide assurance to the Board of Directors that the key organisational risks are being identified and managed appropriately and that the most efficient, effective and economic risk, control and governance processes are in place and assurance processes are optimal. The Chair of the Audit Committee attended the Assurance Committee on two occasions in 2011/12. This facilitated cross-reference between the two Committees.

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Leadership is exhibited at all levels in the Trust to ensure that progress is made with risk mitigation. Of particular importance are the roles of the triumvirate within the clinical Divisions; Clinical Head of Division, the Divisional Chief Operating Officers and the Lead Nurse/Allied Health Professional who are accountable for the management of risk in their Divisions.

Safety & Risk Sub-Committee - The Safety & Risk Sub-Committee has senior representation from across the Trust and provides an internal scrutiny role for risk management systems and processes and the mitigation of risk in the Trust. It is chaired by the Director of Nursing & Patient Safety. Risk management is co-ordinated at a corporate level via this Committee.

Clinical Audit - The Clinical Effectiveness Sub-Committee is accountable to the Assurance Committee and has delegated authority to ensure clinical governance issues are identified, managed or escalated to promote safe, high quality care. The audit process is facilitated and monitored at divisional level but overseen by the Clinical Effectiveness Sub-Committee. The clinical audit policy has been reviewed and updated, the forward clinical audit plan agreed and quarterly monitoring is in place.

Internal Audit - As part of its assurance function, the Trust internal auditors (RSM Tenon) are asked to raise at the Audit Committee any concerns they have, from their reviews, regarding use of resources. The Trust has a record of good financial discipline and this has been reinforced by its divisional management structure which focuses on local ownership of resource management.

The Audit Committee receives regular update reports from the Trust’s internal and external auditors on systems of internal control. The internal audit plan links to the Trust’s Board Assurance Framework. The internal audit reports, along with external audit reports and assessments, contribute to the overall assurance received. Based on the work undertaken in 2011/12, significant assurance can be given that there is a sound system of internal control which is designed to meet the organisation’s objectives, and that controls are being consistently applied in all the areas reviewed.

The internal audit programme reviewed the following themes during 2011/12 including:

• Data Quality • Capital Schemes • Budgetary Control and Treasury Management • Customer Services and Patient Experience

All the reports issued within the year resulted in positive opinions, with all but one resulting in a “green” or “amber / green” opinion. The one “amber / red” opinion (i.e. there are material concerns surrounding authorisation – see page 32 for a fuller explanation of the definition for governance risk ratings) was in relation to the CyberREN renal system, but

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Aintree University Hospital NHS Foundation Trust the tracking process has confirmed that the actions identified within this report have all been completed.

The Local Counter Fraud Specialist - works with key personnel in the Trust such as human resources, organisational development, security and risk management staff to ensure that the Trust has appropriate anti-fraud and anti-bribery measures in place. A programme of work is approved annually by the Audit Committee and at the end of each year a report is submitted to them detailing the work undertaken. The Trust has in place a Counter Fraud and Corruption Policy and a Bribery Policy and carries out regular awareness raising sessions with staff and other stakeholders. Consideration is given to anti-fraud and anti-bribery measures for all new policies.

Additional Assurance Mechanisms - The Trust is involved in the Advancing Quality standards in the North West, AQUA and QUEST. It commissions special reviews to take a deep dive and external and independent organisations provide external scrutiny on specific Serious Untoward Incidents.

The National Patient Survey and Staff Survey results provide feedback to the Trust of areas for improvement and assurance on a broad range of issues. Results of the NHS staff survey 2011 clearly evidence that there remains considerable work to do for this Trust and this is being taken forward in 2012/13.

Compliance with Terms of Authorisation – In accordance with its Authorisation, an NHS Foundation Trust must comply with all healthcare standards and targets (Condition 6). This requires Foundation Trusts to deliver on a wide range of standards (including cancer, infection control, waiting times for planned operations and for patients waiting in A&E, meeting CQC standards etc) while at the same time ensuring that financial plans are met. The Trust has successfully managed this risk in relation to a wide range of areas with two exceptions, the 62 Day classic cancer target and the 62 Day cancer screening standard which were not achieved in 2011-12.

It had been recognised that there were risks to the delivery of the 62 Day classic cancer target during the summer of 2011. A Task and Finish Group was put in place focussed on improving patient pathways and strengthening the administrative support for the Multi- Disciplinary Teams. To ensure that these were the appropriate actions, the Trust invited the National Cancer Intensive Support Team to visit the Trust in early 2012. The consequent report has confirmed that the approach and actions taken by the Trust are entirely in line with good practice. As evidence of the improvements, the Trust delivered the 62 Day classic cancer target in March and early indications are that this position will be maintained in April 2012.

The Trust achieved 87.5% compliance against the 90% target for 62-day screening over the year. As the locality hub for the Merseyside region, the Trust is being adversely affected by a reallocation of breaches from other provider organisations to Aintree. This is irrespective of whether Aintree has been involved in the treatment pathway. The impact of

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Aintree University Hospital NHS Foundation Trust this has been to reduce Aintree’s performance below the target level of 90%. The Trust is continuing to work with other provider organisations to improve performance.

Conclusion

My review confirms that Aintree University Hospital NHS Foundation Trust has a generally sound system of internal control that supports the achievement of its policies, aims and objectives.

There were some internal control issues during 2011/12 that are identified in the body of the Annual Governance Statement (for which the Trust developed and implemented robust action plans).

Signed

Catherine Beardshaw Chief Executive

30 May 2012

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Accounts 2011/12

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Foreword to the Accounts

Aintree University Hospital NHS Foundation Trust

These accounts, for the year ended 31 March 2012, have been prepared by the Aintree University Hospital NHS Foundation Trust in accordance with paragraphs 24 and 25 of Schedule 7 to the National Health Services Act 2006, in the form which Monitor (the Independent Regulator of NHS Foundation Trusts) has directed.

Signed

Catherine Beardshaw Date: 30 May 2012 Chief Executive

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Aintree University Hospital NHS Foundation Trust

STATEMENT OF COMPREHENSIVE INCOME FOR THE YEAR ENDED 31 MARCH 2012

Restated Note 2011/12 2010/11 £000 £000

Operating income 3.1 278,121 268,331

Operating expenditure 4.1 (280,769) (270,911)

OPERATING DEFICIT (2,648) (2,580)

FINANCE COSTS

Finance income 6.1 131 132

Finance expenditure 6.2 (1,002) (804)

PDC Dividends payable (4,141) (4,671)

NET FINANCE COSTS (5,012) (5,343)

DEFICIT FOR THE YEAR (7,660) (7,923)

Deficit after exceptional items (7,660) (7,923)

Exceptional income items 3.1 (4,175) 0 Exceptional expenditure items 4.1 15,237 10,108

Surplus before exceptional items 3,402 2,185

Other comprehensive income not affecting the deficit reported above:

Revaluations gains and impairment gains on purchased property, plant and equipment not charged to the Statement of Comprehensive Income 17 1,376 0

TOTAL COMPREHENSIVE EXPENSE FOR THE YEAR (6,284) (7,923)

The notes on pages 206 to 216 form part of these accounts.

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STATEMENT OF FINANCIAL POSITION AS AT 31 MARCH 2012 Restated * 31 March 31 March 1 April Note 2012 2011 2010 £000 £000 £000 NON-CURRENT ASSETS Intangible assets 7 1,477 1,480 0 Property, plant and equipment 8 167,593 176,967 171,382 Total non-current assets 169,070 178,447 171,382

CURRENT ASSETS Inventories 9 1,285 1,002 979 Trade and other receivables 11.1 11,165 12,892 10,031 Assets held for sale 10 900 0 0 Cash and cash equivalents 18 27,507 18,398 11,457 Total current assets 40,857 32,292 22,467

CURRENT LIABILITIES Trade and other payables 12.1 (24,302) (25,883) (22,625) Borrowings 13 (1,032) (1,052) (227) Provisions 16.1 (6,386) (2,312) (2,077) Other liabilities 12.2 (6,839) (8,644) (6,025) Total current liabilities (38,559) (37,891) (30,954)

TOTAL ASSETS LESS CURRENT LIABILITIES 171,368 172,848 162,895

NON-CURRENT LIABILITIES Borrowings 13 (26,656) (22,554) (5,943) Provisions 16.1 (624) (666) (725) Other liabilities 12.2 (3,877) (3,133) (901)

Total non-current liabilities (31,157) (26,353) (7,569)

TOTAL ASSETS EMPLOYED 140,211 146,495 155,326 FINANCED BY: Public Dividend Capital 112,526 112,526 113,434 Revaluation Reserve 17 26,863 25,490 25,490 Income and Expenditure Reserve 822 8,479 16,402

TOTAL TAXPAYERS' EQUITY 140,211 146,495 155,326 * Please see Note 1.

The financial statements on pages 199 to 203 were approved on 30 May 2012 by the Board of Directors and are signed on its behalf by:

Catherine Beardshaw Chief Executive

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STATEMENT OF CHANGES IN TAXPAYERS' EQUITY AS AT 31 MARCH 2012

Total Public Revaluation Donated Income and Dividend Reserve Assets expenditure Capital Reserve Reserve £000 £000 £000 £000 £000

Taxpayers' equity as at 1 146,324 112,526 25,479 1,816 6,503 April 2011

Prior Year Adjustment 171 0 11 (1,816) 1,976

Taxpayers' equity as at 1 April 2011 restated 146,495 112,526 25,490 0 8,479

Total deficit for the year (7,660) (7,660) ended 31 March 2012

Revaluation gains and 1,376 1,376 impairment losses property, plant and equipment

Transfers between 0 (3) 3 reserves

Taxpayers' equity as at 31 March 2012 140,211 112,526 26,863 0 822

£000 £000 £000 £000 £000

Taxpayers' equity as at 1 155,079 113,434 25,479 1,842 14,324 April 2010

* Prior Year Adjustment 247 0 11 (1,842) 2,078

Taxpayers' equity as at 1 April 2010 restated 155,326 113,434 25,490 0 16,402

Total deficit for the year (7,923) (7,923) ended 31 March 2011

Public Dividend Capital 742 742 received

Public Dividend Capital (1,650) (1,650) repaid

Taxpayers' equity as at 31 March 2011 146,495 112,526 25,490 0 8,479

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Description of each reserve

Public Dividend Capital This reserve represents the balance of central capital funding provided to acquire the plant, property and equipment held by the Trust. Revaluation Reserve This reserve represents the balance of plant, property and equipment revaluations undertaken by the Trust. Income and Expenditure This reserve represents the balance of historic surpluses and deficits Reserve since the Trust was established. Donated Asset Reserve In applying IAS 20 to the Trust Accounts, the balance held with the Donated Asset Reserve was transferred to the Income and Expenditure Reserve as described in Note 1 of the Trust's Accounting Policies.

* The prior year adjustment is detailed at Note 1.

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STATEMENT OF CASH FLOWS AS AT 31 MARCH 2012 Restated 2011/12 2010/11 Cash flows from operating activities

Operating deficit from continuing operations (2,648) (2,580)

Operating deficit (2,648) (2,580)

Non cash income and expenses

Depreciation & Amortisation 7,873 7,200 Impairments 9,781 7,377 Reversals of impairments (175) 0 Interest accrued but not received 44 44 Dividends accrued but not received 96 226 (Increase) / Decrease in Trade and Other Receivables 601 (3,704) (Increase) / Decrease in Inventories (283) (23) Increase / (Decrease) in Trade and Other Payables (1,126) 4,370 Increase / (Decrease) in Other Liabilities (1,061) 4,851 Increase / (Decrease) in Provisions 4,032 176

Net cash generated from operations 17,134 17,937

Cash flows from investing activities:

Interest received 131 132 Purchase of Property, Plant and Equipment (7,164) (24,559) Sales of Property, Plant and Equipment 0 1,650

Net cash used in investing activities (7,033) (22,777)

Cash flows from financing activities

Public Dividend Capital received 0 742 Public Dividend Capital repaid 0 (1,650) Loans received 5,000 18,000 Loans repaid (979) (490) Interest paid (996) (761) Interest element of finance leases (6) (6) Public Dividend Capital Dividend paid (4,011) (4,054)

Net cash generated from / (used in) financing activities (992) 11,781

Increase in cash and cash equivalents 9,109 6,941

Cash and cash equivalents at 1 April 17 18,398 11,457

Cash and cash equivalents at 31 March 17 27,507 18,398

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Notes to the Accounts

1. Accounting policies and other information

Monitor has directed that the financial statements of NHS foundation trusts shall meet the accounting requirements of the NHS Foundation Trust Annual Reporting Manual (FT ARM) which shall be agreed with HM Treasury. Consequently, the following financial statements have been prepared in accordance with the 2011/12 FT ARM issued by Monitor.

The accounting policies contained in that manual follow EU endorsed International Financial Reporting Standards (IFRS), IFRICs and HM Treasury’s Financial Reporting Manual to the extent that they are meaningful and appropriate to NHS foundation trusts. The accounting policies have been applied consistently in dealing with items considered material in relation to the accounts, except for donated asset and Government granted accounting which is referred to below. All relevant accounting policies contained within the ARM have been adopted.

Prior Period Adjustment

In applying IAS 20 to the Trust Accounts, balances relating to donated and Government granted assets were moved to the Income and Expenditure Reserve. The 2010/11 Accounts were restated with a prior year adjustment with the net effect of an increase in taxpayer's equity of £247,000, as a result of the reversal of deferred income relating to Government granted assets. In addition, the in-year 2010/11 deficit was restated to remove income received from the donation reserve and deferred income that had previously been used to match 2010/11 depreciation charges. The deficit was also restated to take account of the value of new donated assets brought into use by the Trust, as per the Trust's Accounting Policy referred to in Note 1.6. The net effect upon the Trust's 2010/11 Accounts was to worsen the deficit by £102,000 as follows:

Income from donation reserve (£97,000) Income from deferred income (£76,000) New donated assets £71,000 Net effect on 2010/11 deficit (£102,000)

Standards issued but not yet adopted

The following standards, amendments and interpretations to existing standards have been published and are mandatory for the Trust’s accounting periods beginning on or after 1 April 2012 or later periods, but the Trust has not early adopted them:

• IAS 1 Presentation of financial statements (Other Comprehensive Income) - this standard is applicable for periods beginning on or after 1 July 2012, the standard has not yet been EU endorsed • IAS 12 Income Taxes (amendment) - this standard is applicable for periods beginning on or after 1 January 2012 but the standard has not yet been EU endorsed • IAS 19 Post-employment benefits (pensions) - this standard is applicable for periods beginning on or after 1 January 2013, the standard has not yet been EU endorsed • IAS 27 Separate Financial Statements - this standard is applicable for periods beginning on or after 1 January 2013, the standard has not yet been EU endorsed • IAS 28 Investments in Associates and Joint Ventures - this standard is applicable for periods beginning on or after 1 January 2013, the standard has not yet been EU endorsed • IAS 32 Financial instruments: Presentation on Offsetting financial assets and financial liabilities – this standard is applicable for periods beginning on or after 1 January 2014 Annual Report & Accounts 2011/12 206

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• IFRS 9 Financial Instruments – this standard is applicable for periods beginning on or after 1 January 2015, the standard has not yet been EU endorsed • IFRS 10 Consolidated Financial Statements - this standard is applicable for periods beginning on or after 1 January 2013, the standard has not yet been EU endorsed • IFRS 11 Joint Arrangements - this standard is applicable for periods beginning on or after 1 January 2013, the standard has not yet been EU endorsed • IFRS 12 Disclosure of Interests in Other Entities - this standard is applicable for periods beginning on or after 1 January 2013, the standard has not yet been EU endorsed • IFRS 13 Fair Value Measurement - this standard is applicable for periods beginning on or after 1 January 2013, the standard has not yet been EU endorsed

Critical Accounting Estimates and Judgements

At 1st April 2011 the Trust's valuer carried out a revaluation of all land and buildings (except those valued within the last financial year). This has resulted in a downward valuation of these non-current assets of £8.2m (see note 8.1 for further details).

The Trust has estimated the month 12 patient related income based on an average cost for the activity delivered in the month for each speciality, as fully coded Healthcare Resource Group (HRG) data is not available in time for the closure of the annual accounts.

The Trust has made a judgement to defer some of the income received in 2011/12 where that income has been received to specifically fund an activity which will occur in a future financial year.

Accounting standards adopted early

The Trust has not adopted any accounting standards early in 2011/12.

Accounting Convention

These accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment, intangible assets and certain financial assets and certain financial liabilities.

1.1 Consolidation

NHS Charitable Funds considered to be subsidiaries are excluded from consolidation in accordance with the accounting direction issued by Monitor.

1.2 Income

Income in respect of services provided is recognised when, and to the extent that, performance occurs and is measured at the fair value of the consideration receivable.

The main source of income for the Trust is contracts with commissioners in respect of healthcare services. 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.

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1.3 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.

Pension costs - NHS Pension Scheme

Past and present employees are covered by the provisions of the NHS Pensions Scheme. The scheme is an unfunded, defined benefit scheme that covers NHS employers, general practices and other bodies, allowed under the direction of Secretary of State, in England and Wales.

It is not possible for the Trust to identify its share of the underlying scheme liabilities. Therefore, the scheme is accounted for as a defined contribution scheme.

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

1.4 Expenditure on other goods and services

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

1.5 Exceptional Items

Exceptional Items are those items that, in the Trust's view, are required to be disclosed separately in Notes 3.1 and 4.1 by virtue of their size or incidence to enable a full understanding of the Trust's financial performance.

1.6 Property, Plant and Equipment

Recognition

Property, Plant and Equipment is capitalised where: • the item is held for use in delivering services or for administrative purposes; it is probable that future economic benefits will flow to, or service potential be provided to, the • Trust; • the item is expected to be used for more than one financial year; • the cost of the item can be measured reliably; • the cost of the item is at least £5,000; or • the items for a group which collectively cost at least £5,000 and individually cost at least £250 and where the items form a single collective asset because they fulfil all of the following criteria: - the items are functionally interdependent; - the items have broadly simultaneous purchase dates and are anticipated to have Annual Report & Accounts 2011/12 208

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simultaneous disposal dates; - the items are under single managerial control; or - the items form part of the initial setting-up cost of a new building or refurbishment of a ward or unit, irrespective of their individual or collective cost (i.e. grouped assets).

Where a large asset, for example a building, includes a number of components with significantly different asset lives e.g. plant and equipment, then these components are treated as separate assets and depreciated over their own useful economic lives.

Measurement

Valuation All property, plant and equipment assets are measured initially at cost, representing the costs directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the ma nner intended by management. All assets are measured subsequently at fair value. Fair value is determined as the lower of replacement cost and recoverable amount.

All land and buildings are revalued using professionally qualified valuers (in accordance with IAS 16) at least every five years. The valuations are carried out primarily on the basis of depreciated replacement cost, under the modern equivalent asset methodology, for specialised operational property and existing use value for non-specialised operational property. The value of land for existing use purposes is assessed at existing use value. For non-operational properties including surplus land, the valuations are carried out at open market value. Assets in the course of construction are valued at cost and are valued by professional valuers when brought into operational use. All plant and machinery, transport equipment, information technology and furniture and fittings are treated as short-life assets with the depreciated historical cost deemed a proxy for fair value.

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 Trust and the cost of the item can be determined reliably.

Where a component of an asset is replaced, the cost of the replacement is capitalised if it meets the criteria for recognition above. The carrying amount of the part replaced is de- recognised. Other expenditure that does not generate additional future economic benefits or service potential, such as repairs and maintenance, is charged to the Statement of Comprehensive Income in the period in which it is incurred.

Depreciation Items of property, plant and equipment are depreciated over their remaining useful economic lives in a manner consistent with the consumption of economic or service delivery benefits. In order to ensure that each individual component of the asset is appropriately depreciated, each component is given an individual life which is then aggregated into a ‘weighted average life’ and applied to the value of the asset. This ensures that individual components are depreciated appropriately. Freehold land is considered to have an infinite life and is not depreciated. Property, plant and equipment which has been reclassified as ‘Held for Sale’ ceases to be depreciated upon the reclassification. Assets in the course of construction and residual interests in off-Statement of Financial Position PFI contract assets are not depreciated until the asset is brought into use or reverts to the Trust, respectively.

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Revaluation gains and losses Revaluation gains are recognised in the revaluation reserve, except where, and to the extent that, they reverse a revaluation decrease that has previously been recognised in operating expenses, in which case they are recognised in operating income.

Revaluation losses are charged to the revaluation reserve to the extent that there is an available balance for the asset concerned, and thereafter are charged to operating expenses.

Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income as an item of 'other comprehensive income'.

Impairments In accordance with the FT ARM, impairments that are due to a loss of economic benefit 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.

De-recognition Assets intended for disposal are reclassified as ‘Held for Sale’ once all of the following criteria are met: • the asset is available for immediate sale in its present condition subject only to terms which are usual and customary for such sales; • the sale must be highly probable i.e.: - management are committed to a plan to sell the asset; - an active programme has begun to find a buyer and complete the sale; - the asset is being actively marketed at a reasonable price; - the sale is expected to be completed within 12 months of the date of classification as ‘Held for Sale’; and - the actions needed to complete the plan indicate it is unlikely that the plan will be dropped or significant changes made to it.

Following reclassification, the assets are measured at the lower of their existing carrying amount and their ‘fair value less costs to sell’. Depreciation ceases to be charged 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.

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Donated assets Following the adoption of IAS 20, a revised treatment of donated assets is applied. Donated property, plant and equipment assets are now capitalised at their fair value on receipt. The donation is credited to income at the same time, unless the donor has imposed a condition that the future economic benefits embodied in the grant are to be consumed in a manner specified by the donor, in which case, the donation is deferred within liabilities and is carried forward to future financial years to the extent that the condition has not yet been met. This has resulted in the requirement for some prior year comparatives to be restated and a prior year adjustment, as described in Note 1, under "Prior Period Adjustments".

Donated assets are subsequently accounted for in the same manner as other items of property, plant and equipment. Previously, the balance within the Donated Reserve would have been released to match depreciation on donated assets.

Private Finance Initiative (PFI) transactions PFI transactions which meet the IFRIC 12 definition of a service concession, as interpreted in HM Treasury’s FReM, are accounted for as ‘on-Statement of Financial Position’ by the Trust. The underlying assets are recognised as property, plant and equipment at their fair value. An equivalent financial liability is recognised in accordance with IAS 17.

The annual contract payments are apportioned between the repayment of the liability, a finance cost and the charges for services. The finance cost is calculated using the implicit interest rate for the scheme. The service charge is recognised in operating expenses and the finance cost is charged to Finance Costs in the Statement of Comprehensive Income.

PFI transactions which do not meet the IFRIC 12 definition of a service concession, as interpreted in HM Treasury’s FReM, are accounted for as a service contract. The annual payments are expensed in full through the Statement of Comprehensive Income.

1.7 Intangible assets

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

Expenditure on research is not capitalised. Expenditure on development is capitalised only where all of the following can be demonstrated: - the project is technically feasible to the point of completion and will result in an intangible asset for sale or use; - the Trust intends to complete the asset and sell or use it; - the Trust has the ability to sell or use the asset; - how the intangible asset will generate probable future economic or service delivery benefits e.g. the presence of a market for it or its output, or where it is to be used for internal use, the usefulness of the asset; - adequate financial, technical and other resources are available to the Trust to complete the development and sell or use the asset, ,and - the Trust can measure reliably the expenses attributable to the asset during development.

Software Software which is integral to the operation of hardware e.g. an operating system, is capitalised as part of the relevant item of property, plant and equipment. Software which is not integral to Annual Report & Accounts 2011/12 211

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the operation of hardware, e.g. 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. Subsequent intangible assets are measured at fair value. Revaluations gains and losses and impairments are treated in the same manner as for property, plant and equipment. 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.

1.8 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 grant is used to fund revenue expenditure it is taken to the Statement of Comprehensive Income to match that expenditure.

1.9 Inventories

Inventories are valued at the lower of cost and net realisable value. The cost of inventories is measured using the First In, First Out (FIFO) method less any provisions deemed necessary.

1.10 Financial instruments and financial liabilities

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

Financial assets 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.

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

De-recognition All financial assets are de-recognised when the rights to receive cash flows from the assets have expired or the Trust has transferred substantially all of the risks and rewards of ownership. Financial liabilities are de-recognised when the obligation is discharged, cancelled or expires.

Classification and Measurement Financial assets are categorised as loans and receivables.

Loans and receivables Loans and receivables are non-derivative financial assets with fixed or determinable payments with are not quoted in an active market. They are included in current assets. The Trust’s loans and receivables comprise: cash and cash equivalents, NHS receivables, accrued income and ‘other receivables’.

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

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

They are included in current liabilities except for amounts payable more than 12 months after the Statement of Financial Position date, which are classified as non-current financial liabilities. Interest on financial liabilities carried at amortised cost is calculated using the effective interest method and charged to Finance Costs. Interest on financial liabilities taken out to finance property, plant and equipment or intangible assets is not capitalised as part of the cost of those assets.

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

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

1.11 Leases

Finance leases Where substantially all risks and rewards of ownership of a leased asset are borne by the 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 pa yments, discounted using the interest rate implicit in the lease. The implicit interest rate is that which produces a constant periodic rate of interest on the outstanding liability.

The asset and liability are recognised at the inception of the lease, and are de-recognised when the liability is discharged, cancelled or expires. The annual rental is split between the repayment of the liability and a finance cost. The annual finance cost is calculated by applying the implicit interest rate to the outstanding liability and is charged to Finance Costs in the Statement of Comprehensive Income.

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.

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Operating lease income is received for the lease of buildings or land where the risks and rewards of ownership of the leased asset are retained by the Trust.

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. Leased land is treated as an operating lease.

1.12 Provisions

The Trust recognises a provision where it has a present legal or constructive obligation of uncertain timing or amount; for which it is probable that there will be a future outflow of cash or other resources; and a reliable estimate can be made of the amount. The amount recognised in the Statement of Financial Position is the best estimate of the resources required to settle the obligation. Where the effect of the time value of money is significant, the estimated risk- adjusted cash flows are discounted.

Clinical negligence costs The NHS Litigation Authority (NHSLA) operates a risk pooling scheme under which the Trust pays an annual contribution to the NHSLA, which, in return, settles all clinical negligence claims. Although the NHSLA is administratively responsible for all clinical negligence cases, the legal liability remains with the Trust. The total value of clinical negligence provisions carried by the NHSLA on behalf of the Trust is disclosed at note 16.2 but is not recognised in the NHS foundation trust's accounts.

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

1.13 Contingencies

Contingent liabilities are not recognised, but are disclosed in Note 20, 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.

1.14 Public dividend capital

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

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A charge, reflecting the cost of capital utilised by the Trust, is payable as public dividend capital dividend. The charge is calculated at the rate set by HM Treasury (currently 3.5%) on the average relevant net assets of the Trust during the financial year. Relevant net assets are calculated as the value of all assets less the value of all liabilities, except for (i) donated assets, (ii) cash held with the Government Banking Service (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 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 amended should any adjustment to net assets occur as a result of the audit of the annual accounts.

1.15 Value Added Tax

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

1.16 Corporation Tax

Aintree University Hospital NHS Foundation Trust is a Health Service body within the meaning of s519A ICTA 1988 and accordingly is temporarily exempt from taxation in respect of income and capital gains within categories covered by this. There is a power for the Treasury to disapply the exemption in relation to the specified activities of a Foundation Trust (s519A (3) to (8) ICTA), accordingly, the Trust is potentially within the scope of Corporation Tax in respect of activities which are not related to, or ancillary to, the provision of healthcare and where the profits exceed £50,000 per annum. However, there is no tax liability in respect of the current financial year.

1.17 Third party assets

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

1.18 Losses and Special Payments

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

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

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1.19 Segmental Analysis

Operating segments are reported in a manner consistent with the internal reporting provided to the chief operating decision-maker. The Chief operating decision make, who is responsible for allocating resources and assessing performance of the operating segments, has been identified as the Board that makes strategic decisions. A segmental analysis is shown at Note 2.

2. Segmental Reporting

Medicine and Emergency Restated 2011/12 Care Surgery Total 2010/11

£000 £000 £000 £000

Income * 111,639 115,676 227,315 221,597

Expenditure * Pay (54,724) (59,584) (114,308) (112,240) Non-Pay (20,031) (22,489) (42,520) (39,322)

Total (74,755) (82,073) (156,828) (151,562)

Total Contribution 70,487 70,035

Other Services ** (78,147) (77,958)

Total Surplus / (Deficit) (7,660) (7,923)

* The expenditure figures for both Medicine and Surgery include income from non-clinical services of:

2011/12 2010/11 £000 £000 Surgery 1,044 1,374 Medicine 612 506 1,656 1,880

** "Other services" contains the following:

Income of £50,937,000 Comprises Training and Education Levies, Direct Access (2010/11, £46,866,000) Community Services, Service Level Agreements with other provider organisations, Research and Development and income generating activities (e.g. Catering, Injury Costs Recovery (ICR) income, etc).

Expenditure of £129,084,000 Comprises Clinical Support Services (e.g. Radiology, Pathology, (2010/11, £124,824,000) Physiotherapy, etc) and Central Support Departments (e.g. Estates & Maintenance, Hotel Services, Finance, HR, etc).

The Trust does not report total assets attributable to each operating segment to the Board. Consequently, total assets attributable to each operating segment are not disclosed.

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The Trust considers the Board to be the Chief Operating Decision Maker (CODM) because it regularly reviews operating results, makes decisions about where resources are allocated as a result and assesses performance.

Income and expenditure arising from both the medicine and surgery departments are what is reported to Board on a distinct and separate basis and therefore they have also been disclosed separately in the financial statements.

The majority of the Trust's revenue is generated from external customers in England.

The Trust has three external customers which generate income amounting to more than 10% of the Trust's total income. These customers generated income of £90m, £80m and £30m and are included in all of the segments reported above.

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Restated 3.1 Operating Income 2011/12 2010/11 £000 £000 Income from Activities (all relates to mandatory services apart from private patient income reported in Note 3.2)

Elective income 44,110 41,615 Non elective income 70,793 72,468 Outpatient income 41,204 40,116 A & E income 8,600 8,279 Other types of non-PBR NHS clinical income 77,549 71,530

Total Income from Activities 242,256 234,008

Other Operating Income

Research and development 1,164 611 Education and training 13,607 13,148 Charitable contributions to expenditure 77 71 SLAs for non patient care services to other bodies 8,087 8,584 Catering income 1,367 1,414 Car park income 2,106 1,626 Central funding for Consultant distinction awards 1,251 1,308 Reversal of impairments of property plant and equipment 175 0 Other income * 8,031 7,561

Total Other Operating Income 35,865 34,323

Total Operating Income 278,121 268,331

Total operating income after exceptional items 278,121 268,331 Income received to match restructuring costs (4,000) 0 Reversal of impairment of plant property and equipment (175) 0 Total operating expenditure before exceptional items 273,946 268,331

* Other income consists of a number of items (such as NHS Bank revenue support for capital items, charges to organisations using the Trust's facilities, income from various training courses, operating lease rentals, etc) that, individually, total less than £1m.

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3.2 Private Patient Income

Section 44 of the National Health Service Act 2006 requires that the proportion of income derived from private patient activity, to the total patient related income of NHS Foundation Trusts, should not exceed its proportion whilst the body was an NHS Trust in 2002/03 (the base year). The Private Patient Income Cap was not breached in 2011/12.

Base Year 2011/12 2010/11 £000 £000 £000

Private patient related income 712 553 540 Income from patient activities 111,823 242,256 234,008 Percentage of private patient activity 0.64% 0.23% 0.23%

3.3 Operating Lease Income 2011/12 2010/11 Operating lease income £000 £000

Rents recognised as income in the year 468 393

Total 468 393

Future minimum lease payments due 2011/12 2010/11 £000 £000

- not later than one year 38 39 - later than one year and not later than five years 97 129 - later than five years 0 0

Total 135 168

The majority of operating lease income relates to rent received for staff accommodation. These rental agreements are of an undetermined length and are not included in the above analysis by future minimum lease payments due.

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4.1 Operating Expenditure 2011/12 2010/11 £000 £000

Services from other foundation trusts 204 302 Services from other NHS trusts 492 57 Services from other NHS bodies 883 0 Purchases of healthcare from non-NHS bodies 1,685 1,551 Employee expenses - Executive Directors 812 901 Employee expenses - Non-Executive Directors 130 129 Employee expenses - Staff 173,524 176,153 Redundancy costs 4,932 349 Drug costs 17,911 16,590 Supplies and services - clinical (excluding drugs) 30,940 30,423 Supplies and services - general 4,776 4,540 Establishment costs 6,390 5,956 Transport costs 424 1,501 Premises costs 15,941 14,395 Bad debt costs 879 390 Depreciation on property, plant and equipment 7,522 7,200 Amortisation on intangible non-current assets 351 0 Impairments of property plant and equipment 9,781 7,377 Audit fees - statutory audit ** 66 64 Other audit fees 0 20 Clinical negligence 2,032 2,011 Other expenditure 1,094 1,002

Total operating expenditure (see table below) 280,769 270,911

Total operating expenditure after exceptional items 280,769 270,911 Impairment of plant property and equipment * (9,781) (7,377) Restructuring costs (5,456) (2,731) Total operating expenditure before exceptional items 265,532 260,803

* In 2011/12, a property, plant and equipment impairment charge of £9,781,000 resulted from a revaluation of the estate.

** The Auditors will accept liability to pay damages for losses arising as a direct result of breach of contract or negligence on its part in respect of services provided. The limitation on the Auditor's liability was set at £1m in the 2011/12 engagement letter (£1m in 2010/11).

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4.2 Arrangements containing an operating lease 2011/12 2010/11 £000 £000

Minimum lease payments 2,635 1,970

Total 2,635 1,970

Future minimum lease payments due 2011/12 2010/11 £000 £000

- not later than one year 2,493 2,482 - later than one year and not later than five years 4,948 5,474 - later than five years 471 1,343

Total 7,912 9,299

All operating leases refer to plant and equipment (the majority of which relates to medical equipment). A review (by an independent commercial consultancy) of leases held by the Trust confirmed the appropriateness of the leases being reported as "operating leases" under IAS 17.

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5.1 Employee Expenses 2011/12 2010/11 £000 £000

Salaries and wages 139,164 142,794 Social security costs 11,183 10,976 Employer's contribution to NHS Pensions 14,198 14,643 Termination benefits * 5,456 1,887 Agency / contract staff 9,267 7,103

Total 179,268 177,403

* Termination benefits include a £522,000 expenditure charge within salary costs (incurred as part of a Mutually Agreed Resignation Scheme) (2010/11, £1,538,000) and a £4,932,000 redundancy cost (2010/11, £349,000).

5.2 Average Number of Employees (WTE basis) 2011/12 2010/11

Medical and Dental 535 527 Administration and Estates 868 956 Healthcare Assistants and other Support staff 481 490 Nursing 1,328 1,391 Scientific, Therapeutic and Technical staff 806 868 Bank and Agency staff 262 195

Total 4,280 4,427

5.3 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, General 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.

In order that the defined benefit obligations recognised in the financial statements do not differ materially from those that would be determined at the reporting date by a formal actuarial valuation, the FReM requires that "the period between formal valuations shall be four years, with approximate assessments in intervening years". An outline of these follows:

a) 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

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The last formal actuarial valuation undertaken for the NHS Pension Scheme was completed for the year ending 31 March 2004. Consequently, a formal actuarial valuation would have been due for the year ending 31 March 2008. However, formal actuarial valuations for unfunded public service schemes have been suspended by HM Treasury on value for money grounds while consideration is given to public service pensions, and while future scheme terms are developed as part of the reforms to public service pension provision. Employer and employee contribution rates are currently being determined under the new scheme design.

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.

Actuarial assessments are undertaken in intervening years between formal valuations using updated membership data are accepted as providing suitably robust figures for financial reporting purposes. However, as the interval since the last formal valuation now exceeds four years, the valuation of the scheme liability as at 31 March 2012, is based on detailed membership data as at 31 March 2010 updated to 31 March 2012 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS19, relevant FReM interpretations and the discount rate prescribed by HM Treasury have also been used.

The latest assessment of the liabilities of the scheme is contained in the scheme actuary report, which forms part of the annual NHS Pension Scheme (England and Wales) Pension Accounts, 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 provides defined benefits which are summarised below. The 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 of the best of the last 3 years pensionable pay for each year of service for the 1995 section and 1/60th of reckonable pay per year of membership for the 2008 section. 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 by HMRC rules. This new provision is known as "pension commutation". A lump sum, normally equivalent to 3 years pension, is payable on retirement. 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 year. From 2011/12, the Consumer Prices Index (CPI) will be used to replace the Retail Prices Index (RPI).

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, less pension already paid 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 employer.

Members can purchase additional service in the NHS Scheme and contribute to money purchase AVCs run by the Scheme's approved providers or by other Free Standing Additional Voluntary Contributions (FSAVC) providers.

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Scheme members have the option to transfer their pension between the NHS Pension Scheme and another scheme when they move into or out of NHS employment. Where a scheme member ceases NHS employment with more than two years service, they can preserve their accrued NHS pension for payment when they reach retirement age.

5.4 Early Retirements due to Ill Health

This note discloses the number and additional pension costs for individuals who retired early on ill- health grounds during the year.

There were early 7 retirements on the grounds of ill health at a cost of £905,372 (3 at a cost of £93,400 in 2010/11). This information was supplied by NHS Pensions.

5.5 Directors' Remuneration and Other Benefits 2011/12 2010/11 £000 £000

Directors' Remuneration 1,202 1,191 Employer contributions to a pension scheme in respect of Directors 150 149

(The remuneration total excludes £6,000 (2010/11, £7,000) relating to salary sacrificed by Directors in order to receive benefits such as car parking, child care vouchers or a lease car.)

The highest paid Director received remuneration totalling £189,000 (2010/11 £188,000).

2011/12 2010/11 Number of Directors to whom benefits are accruing under: Number Number

Defined benefit scheme 10 11

(Full details of Directors' remuneration and other benefits are set out in the NHS Foundation Trust's Remuneration Report on pages 172 - 176 of the Annual Report.)

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5.6 Staff Exit Packages

Number of compulsory Number of other Total number of exit redundancies * departures agreed ** packages Exit package cost band 2011/12

Less than £10,000 8 21 29 £10,001 to £25,000 3 16 19 £25,001 to £50,000 3 9 12 £50,001 to £100,000 2 3 5 £100,001 to £150,000 0 1 1

Total number of exit packages 16 50 66

Total cash resource cost £296,000 £974,000 £1,270,000

* This relates to exit packages actually paid in cash in 2011/12. Note 5.1 records the 2011/12 expenditure charge for exit packages.

** This column relates to the cash costs of a local Mutually Agreed Resignation Scheme (MARS).

Number of compulsory Number of other Total number of exit redundancies * departures agreed ** packages Exit package cost band 2010/11

Less than £10,000 0 34 34 £10,001 to £25,000 0 26 26 £25,001 to £50,000 0 24 24 £50,001 to £100,000 2 2 4 £100,001 to £150,000 1 0 1

Total number of exit packages 3 86 89

Total resource cost £280,000 £1,538,000 £1,818,000

6.1 Finance Income 2011/12 2010/11 £000 £000

Interest on cash investments (none held as at 31 March) 39 50 Interest on bank deposits 92 82

Total 131 132

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6.2 Finance Expenditure 2011/12 2010/11 £000 £000

Interest on loans from the Foundation Trust Financing Facility 996 798 Interest on Finance Leases 6 6

Total 1,002 804

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7.1 Intangible Assets 2011/12 Total Software licences £000 £000

Cost or valuation at 1 April 2011 1,480 1,480 Additions - purchased 348 348

Cost or valuation at 31 March 2012 1,828 1,828

Accumulated amortisation at 1 April 2011 0 0 Provided during the year 351 351

Accumulated amortisation at 31 March 2012 351 351

Net book value total 31 March 2012 1,477 1,477

Net book value

NBV - Purchased at 31 March 2012 1,344 1,344 NBV - Finance Leased at 31 March 2012 133 133 NBV - Donated at 31 March 2012 0 0

Net book value total at 31 March 2012 1,477 1,477

7.2 Intangible Assets 2010/11

Cost or valuation at 1 April 2010 0 0 Additions - purchased 1,480 1,480

Cost or valuation at 31 March 2011 1,480 1,480

Accumulated amortisation at 1 April 2010 0 0 Provided during the year 0 0

Accumulated amortisation at 31 March 2011 0 0

Net book value total 31 March 2011 1,480 1,480

Net book value

NBV - Purchased at 31 March 2011 1,480 1,480 NBV - Finance Leased at 31 March 2011 0 0 NBV - Donated at 31 March 2011 0 0

Net book value total at 31 March 2011 1,480 1,480

The useful economic life for all reported intangible assets is 5 years (2010/11, 5 years).

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8.1 Property, Plant and Equipment 2011/12

Total Land Buildings Dwellings Assets Plant & Trans- Inform- Furniture excluding under machin- port ation & fittings dwellings construc- ery equip- techn- tion ment ology

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

Cost or valuation at 1 April 2011 243,330 8,981 159,484 6,069 3,747 48,512 83 12,930 3,524

Additions - purchased 7,201 0 5,682 0 0 1,341 0 161 17

Additions - donated 77 0 0 0 0 77 0 0 0

Impairments charged to revaluation reserve (2,971) (909) (1,760) (302) 0 0 0 0 0

Reclassifications 0 0 3,747 0 (3,747) 0 0 0 0

Revaluations 4,347 0 4,347 0 0 0 0 0 0

Transfer to disposal group as asset held for sale (900) (195) (705) 0 0 0 0 0 0

Transfer of depreciation to gross book value following revaluation (17,675) 0 (17,437) (238) 0 0 0 0 0

Transfer of depreciation to gross book value outside of revaluation (29,677) 0 0 0 0 (24,241) 0 (3,781) (1,655)

Cost or valuation at 31 March 2012 203,732 7,877 153,358 5,529 0 25,689 83 9,310 1,886

Accumulated depreciation at 1 April 2011 66,363 17,437 238 34,906 83 11,013 2,686

Provided during the year 7,522 3,423 135 2,743 0 991 230

Impairments recognised in operating expenses 9,781 9,781 0 0 0 0 0

Reversal of impairments (175) (175) 0 0 0 0 0

Transfer of depreciation to gross book value following revaluation (17,675) (17,437) (238) 0 0 0 0

Transfer of depreciation to gross book value outside of revaluation (29,677) 0 0 (24,241) 0 (3,781) (1,655)

Accumulated depreciation at 31 March 2012 36,139 13,029 135 13,408 83 8,223 1,261

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Net book value

NBV - Purchased at 31 March 2011 174,884 8,981 140,413 5,831 3,747 13,160 0 1,914 838

NBV - Finance Lease at 31 March 2011 96 0 0 0 0 93 0 3 0

NBV - Government Granted at 31 March 2011 171 0 0 0 0 171 0 0 0

NBV - Donated at 31 March 2011 1,816 0 1,634 0 0 182 0 0 0

Net book value total at 31 March 2011 176,967 8,981 142,047 5,831 3,747 13,606 0 1,917 838

Net book value

NBV - Purchased at 31 March 2012 165,679 7,877 138,425 5,696 0 11,969 0 1,087 625

NBV - Finance Lease at 31 March 2012 23 0 0 0 0 23 0 0 0

NBV - Government Granted at 31 March 2012 95 0 0 0 0 95 0 0 0

NBV - Donated at 31 March 2012 1,796 0 1,602 0 0 194 0 0 0

Net book value total at 31 March 2012 167,593 7,877 140,027 5,696 0 12,281 0 1,087 625

8.2 Analysis of Property, Plant and Equipment as at 31 March 2012

Total Land Buildings Dwellings Assets Plant & Trans- Inform- Furniture excluding under machin- port ation & fittings dwellings construc- ery equip- techn- tion ment ology

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

Net book value

NBV - Protected assets as at 31 March 2012 * 143,553 7,877 135,676 0 0 0 0 0 0

NBV - Unprotected assets as at 31 March 2012 24,040 0 4,351 5,696 0 12,281 0 1,087 625

Total as at 31 March 2012 167,593 7,877 140,027 5,696 0 12,281 0 1,087 625

* Protected assets are those that provide protected services as identified in Schedule 2 of the NHS Foundation Trust's Terms of Authorisation.

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8.3 Property, Plant and Equipment 2010/11

Total Land Buildings Dwellings Assets Plant & Trans- Informa- Furniture excluding under machin- port tion & fittings dwellings construc- ery equip- techno- tion ment logy

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

Cost or valuation at 1 April 2010 223,168 9,889 107,775 5,787 42,349 41,662 83 12,458 3,165

Additions - purchased 21,741 742 6,948 282 6,115 6,823 0 472 359

Additions - donated 71 0 44 0 0 27 0 0 0

Reclassifications 0 0 44,717 0 (44,717) 0 0 0 0

Disposals (1,650) (1,650) 0 0 0 0 0 0 0

Cost or valuation at 31 March 2011 243,330 8,981 159,484 6,069 3,747 48,512 83 12,930 3,524

Accumulated depreciation at 1 April 2010 51,786 6,947 117 32,648 83 9,564 2,427

Provided during the year 7,200 3,113 121 2,258 0 1,449 259

Impairments recognised in operating expenses 7,377 7,377 0 0 0 0 0

Accumulated depreciation at 31 March 2011 66,363 17,437 238 34,906 83 11,013 2,686

Net book value

NBV - Purchased at 31 March 2010 169,123 9,889 99,206 5,670 42,349 8,383 0 2,888 738

NBV - Finance Lease at 31 March 2010 170 0 0 0 0 164 0 6 0

NBV - Government Granted at 31 March 2010 247 0 0 0 0 247 0 0 0

NBV - Donated at 1,842 0 1,622 0 0 220 0 0 0 31 March 2010

Net book value total at 31 March 2011 171,382 9,889 100,828 5,670 42,349 9,014 0 2,894 738

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Net book value

NBV - Purchased at 31 March 2011 174,884 8,981 140,413 5,831 3,747 13,160 0 1,914 838

NBV - Finance Lease at 31 March 2011 96 0 0 0 0 93 0 3 0

NBV - Government Granted at 31 March 2011 171 0 0 0 0 171 0 0 0

NBV - Donated at 31 March 2011 1,816 0 1,634 0 0 182 0 0 0

Net book value total at 31 March 2011 176,967 8,981 142,047 5,831 3,747 13,606 0 1,917 838

8.4 Analysis of Property, Plant and Equipment as at 31 March 2011

Total Land Buildings Dwellings Assets Plant & Trans- Informa- Furniture excluding under machin- port tion & fittings dwellings construc- ery equip- techno- tion ment logy

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

Net book value

NBV - Protected assets as at 31 March 2011 * 146,455 8,981 137,474 0 0 0 0 0 0

NBV - Unprotected assets as at 31 March 2011 30,512 0 4,573 5,831 3,747 13,606 0 1,917 838

Total as at 31 March 2012 176,967 8,981 142,047 5,831 3,747 13,606 0 1,917 838

* Protected assets are those that provide protected services as identified in Schedule 2 of the NHS Foundation Trust's Terms of Authorisation.

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8.5 Econo mic Life of Property, Plant and Equipment

Min Life Max Life Min Life Max Life Years Years Years Years 31 March 2012 31 March 2011

Buildings excluding dwellings 35 80 35 80 Dwellings 75 80 75 80 Plant & machinery 5 10 5 10 Transport equipment 5 10 5 10 Information technology 5 5 5 5 Furniture & fittings 5 10 5 10

9. Inventories 31 March 31 March 2012 2011 £000 £000

Drugs 1,285 1,002

Total Inventories 1,285 1,002

Drug costs recognised in expenses in 2011/12 were £17,911,000 (£16,590,000 in 2010/11).

31 March 31 March 10. Assets Held for Sale 2012 2011 £000 £000 Property Plant and Equipment

Assets held for sale at the start of the year 0 0 Plus assets classified as held for sale in the year 900 0 Less assets sold in year 0 0

Net Book Value of Assets Held for Sale 900 0

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31 March 31 March 11.1 Trade and Other Receivables 2012 2011 £000 £000 Current

Trade receivables 6,984 8,391 Injury Costs Recovery Scheme (ICR) receivables 2,542 3,133 Provision for impaired receivables (813) (894) Prepayments 2,062 1,941 Accrued income 294 95 PDC dividend receivable 96 226

Total Current Trade and Other Receivables 11,165 12,892

11.2 Provision for Impairment of Receivables 2011/12 2010/11 £000 £000

As at 1 April 894 891

Increase in provision 879 390 Amounts utilised (960) (387) Unused amounts reversed 0 0

As at 31 March 813 894

11.3 Analysis of Impaired Receivables 2011/12 2010/11 (Receivables in this section only refer to outstanding invoices and Injury Cost Recovery claims) £000 £000

Ageing of impaired receivables

0 - 30 days 12 11 31 - 60 days 97 11 61 - 90 days 34 11 91 - 180 days 87 33 Over 180 days 583 828

Total 813 894

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Ageing of non-impaired receivables

0 - 30 days 2,710 2,483 31 - 60 days 706 1,066 61 - 90 days 585 705 91 - 180 days 1,000 996 Over 180 days 1,824 2,225

Total 6,825 7,475

31 March 31 March 12.1 Trade and Other Payables 2012 2011 £000 £000 Current

Trade payables - revenue * 10,461 11,954 Trade payables - capital 57 556 Accruals 10,150 9,786 Tax payable (income tax and national insurance) 3,634 3,587

Total Current Trade and Other Payables 24,302 25,883

* Trade payables include NHS payables and accruals

Restated 31 March 31 March 12.2 Other Liabilities 2012 2011 £000 £000 Current

Deferred income 6,839 8,644

Total Other Current Liabilities 6,839 8,644

Non Current

Deferred income falling due later than 1 year but less than 5 years 3,506 2,727 Deferred income falling due later than 5 years 371 406

Total Other Non Current Liabilities 3,877 3,133

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31 March 31 March 13. Borrowings 2012 2011 £000 £000 Current

Bank overdrafts 0 0 Drawdown in committed facility 0 0 Loans from the Foundation Trust Financing Facility (FTFF) * 979 979 Obligations under finance leases 53 73

Total Current Borrowing 1,032 1,052

Non Current

FTFF loans falling due later than 1 year but less than 5 years * 4,957 3,917 FTFF loans falling due later than 5 years * 21,595 18,614 Obligations under finance leases 104 23

Total Non Current Borrowing 26,656 22,554

Term * Analysis of FTFF loans Interest rate (years)

Loan 1 - (Limit of £24,000,000) Agreement Date 16 March 2010 4.27% 25

Loan 2 - (Limit of £20,000,000) Agreement Date 19 March 2012 2.92% 25

31 March 31 March 14. Annual Finance Lease Obligations 2012 2011 £000 £000

Gross annual lease obligations 181 99

Of which liabilities are due:

- not later than one year 58 73 - later than one year and not later than five years 123 26 Finance charges allocated to future years (24) (3)

Net annual lease liabilities 157 96

- not later than one year 53 73 - later than one year and not later than five years 104 23

157 96

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31 March 31 March 15. Prudential Borrowing Limit 2012 2011 £000 £000

Total long term borrowing limit set by Monitor 65,400 56,600 Working capital facility agreed by Monitor 19,600 19,600

Total Prudential Borrowing Limit 85,000 76,200

The Trust is required to comply and remain within a prudential borrowing limit. This is made up of two elements:

- the maximum cumulative amount of long term borrowing. This is set by reference to the four ratio tests set out in Monitor's Prudential Borrowing Code . The financial risk rating set under Monitor's Compliance Framework determines one of the ratios and therefore can impact on the long term borrowing limit; and

- the amount of any working capital facility approved by Monitor.

Further information on the Trust's Prudential Borrowing Code and Compliance Framework can be found on the website of Monitor, the Independent Regulator of foundation trusts.

The Trust had a prudential borrowing limit of £65,400,000 in 2011/12 (£56,600,000 in 2010/11). The Trust has actually borrowed £27,688,000 as at 31 March 2012 (£23,606,000 as at 31 March 2011). (Note: Total borrowings include finance lease obligations.)

Approved Actual Approved PBL Actual ratios PBL Financial Ratio ratios ratios 2011/12 2010/11 ratios 2011/12 2010/11 Minimum dividend cover 3.7 >1 3.0 >1 Minimum interest cover 14.0 >3 14.6 >3 Minimum debt service cover 7.0 >2 7.5 >2 Maximum debt service to revenue 0.8% <2.5% 0.7% <2.5%

The Trust has £19,600,000 of approved working capital facility (£19,600,000 in 2010/11). The Trust had not drawn down any of its working capital facility as at 31 March 2012 (nor at 31 March 2011).

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16.1 Provisions Other Total Pensions legal Other claims £000 £000 £000 £000

As at 1 April 2011 2,978 736 735 1,507

Arising during the year 5,180 29 614 4,537

Utilised during the year (502) (70) (405) (27)

Reversed unused (646) 0 (145) (501)

As at 31 March 2012 7,010 695 799 5,516

Expected timings of cash flows:

- not later than one year 6,386 71 799 5,516

- later than one year and not later than five years 284 284 0 0

- later than five years 340 340 0 0

TOTAL 7,010 695 799 5,516

"Pensions" include the certain cost of permanent injury and early retirement pension compensation settlements and the subsequent application of the appropriate value supplied by the Government's Actuary Department to assess the total provision required for the anticipated duration of the liability. It does not include any provision relating to former Directors.

"Other legal claims" comprises provisions in respect of the Trust's employer and public legal liabilities.

"Other" provisions arise from expected costs resulting from the introduction of the Consultants' Contract, Agenda for Change national pay scales, management restructuring, equal opportunity claims and the EU Emissions Trading Scheme.

16.2 Clinical Negligence liabilities Total £000

Amount included in provisions of the NHSLA at 31 March 2012 in respect of clinical negligence liabilities of Aintree University Hospital NHS Foundation Trust 9,442

Amount included in provisions of the NHSLA at 31 March 2011 in respect of clinical negligence liabilities of Aintree University Hospital NHS Foundation Trust 9,005

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31 March 31 March 17. Cash and Cash Equivalents 2012 2011 £000 £000

At 1 April 18,398 11,457

Net change in year 9,109 6,941

At 31 March 27,507 18,398

Cash at commercial banks and in hand 30 16

Cash with GBS (Government Banking Service) 27,477 18,382

Other current investments 0 0

Cash and cash equivalents as in the Statement of Financial Position 27,507 18,398

Bank overdraft 0 0

Cash and cash equivalents as in the Statement of Cash Flows 27,507 18,398

18. Contractual Capital Commitments

Commitments under property, plant and equipment capital expenditure contracts, as at 31 March 2012, were £2,032,000 (£2,589,000 as at 31 March 2011).

31 March 31 March 19. Contingent Liabilities 2012 2011 £000 £000

Contingent liabilities 95 94

95 94

The contingent liabilities recorded reflect amounts relating to employer liability legal cases not provided for in Note 16.1, as it is not probable that they will fall due. The amount recorded as a contingency is the difference between the amount provided in Note 16.1 and the agreed NHSLA excess level (i.e. the maximum which the Trust would be required to pay).

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20. Related Party Transactions

During the period reported in these accounts, none of the Board Members, Governors or key management staff have undertaken any material transactions with Aintree University Hospital NHS Foundation Trust. See note 5.5 for details of Directors' remuneration and other benefits.

Some staff and Governors of the Trust have an interest in the management of Woodlands Hospice Charitable Trust (a Hospice sit ed on the Trust grounds). However, the Trust does not enter into significant income and expenditure transactions with the Charity, although it does undertake some transaction processes on its behalf, such as salary payments and some procurement.

Members of the Board of Directors and Governors of the Trust hold positions at Universities but are not in a position to materially affect transactions between the two parties. The Trust has had a significant number of material transactions with the Universities of Liverpool and Edge Hill as follows:-

Receivable Receivable Payable Payable Expenditure Expenditure Income Income balance balance balance balance 31 March 31 March 31 March 31 March 2011/12 2010/11 2011/12 2010/11 2012 2011 2012 2011 £000 £000 £000 £000 £000 £000 £000 £000

University of Liverpool 2,196 1,908 177 155 24 54 243 183

Edge Hill University 229 7 259 276 31 35 2 1

Some Governors of the Trust are employed by Sefton, Liverpool and Knowsley PCTs and Mersey Care NHS Trust. Aintree University Hospital NHS Foundation Trust has had a significant number of material transactions with these bodies in 2011/12 and held receivable and payable balances with them as at 31 March 2012:-

Receivable Receivable Payable Payable Expenditure Expenditure Income Income balance balance balance balance 31 March 31 March 31 March 31 March 2011/12 2010/11 2011/12 2010/11 2012 2011 2012 2011 £000 £000 £000 £000 £000 £000 £000 £000

Sefton PCT 1 9 91,940 91,741 1,353 729 0 9

Liverpool PCT 179 78 83,490 82,692 526 647 8 16

Knowsley PCT 0 0 30,497 26,760 278 178 0 95

Mersey Care NHS Trust 478 60 1,638 1,694 35 3 4 11

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Aintree University Hospital NHS Foundation Trust has also had a significant number of transactions with other NHS or Government departments which are all classed as "related parties" to the Trust. Material transactions (and/or balances) in excess of £2m are detailed below:

Receivable Receivable Payable Payable Expenditure Expenditure Income Income balance balance balance balance 31 March 31 March 31 March 31 March 2011/12 2010/11 2011/12 2010/11 2012 2011 2012 2011 £000 £000 £000 £000 £000 £000 £000 £000

NHS North West 3 4 14,052 13,699 26 48 0 2

North West Specialist 0 0 9,218 9,245 0 0 2,356 2,167 Commissioning Group Western Cheshire PCT 0 0 1,977 2,016 19 266 0 0

Central Lancashire PCT 0 0 4,533 4,467 0 9 0 0

Central & Eastern Cheshire PCT 0 0 2,459 1,581 0 0 90 0

Halton & St Helens PCT 0 0 4,875 4,585 17 121 53 0

Wirral PCT 0 70 3,565 3,170 107 15 11 0

Liverpool Women's NHS FT 172 152 1,499 2,211 43 90 12 7

The Walton Centre NHS FT 97 18 5,732 5,397 956 1,081 30 72

Royal Liverpool & Broadgreen 2,450 2,300 1,166 518 38 29 432 550 University Hospitals NHS Trust NHS Litigation Authority 2,032 2,011 0 0 0 0 253 0

NHS Business Services 5,526 4,693 0 0 0 0 182 476 Authority National Insurance Fund 11,193 10,976 0 0 0 0 1,691 1,616

NHS Pension Scheme 14,198 14,643 0 0 0 0 1,781 1,838

All the transactions referred to in this note were on normal commercial terms. The Trust is the corporate trustee of The Aintree University Hospital Charitable Fund (Regn no: 1050542). The Charitable Fund Accounts have not been consolidated in accordance with IAS 27 as HM Treasury has given dispensation from this requirement for 2011/12.

An Annual Report and Audited Accounts of the Trust's Charity (covering the period reported in these Accounts) will be available from 31 January 2013 and may be accessed via the Charity Commission website at www.charity-commission.gov.uk.

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21.1 PFI Schemes deemed to be off-Statement of Financial Position (SoFP)

Sterile Services

The original contract commenced on 24th April 1998 and is contracted to end on 31st July 2013. That contract involved the provision of sterile services for theatre instrumentation from a facility on the Trust site which has been substantially refurbished by the private sector operator in order to comply with the latest standards for sterile instrument processing. However, in July 2011 the service was transferred by the Operator to an existing off-site facility whic h is used to provide services to a number of other contractors. The significant contractual and service changes resulting from this move have lead to a revision in how the contract is classified, consequently, the service is no longer classified as PFI.

21.2 PFI Schemes deemed to be on-Statement of Financial Position (SoFP)

Renal Dialysis

The original contract commenced on 13 April 2005 and was due to end on 12 April 2012, however, a 3-year extension (to 12 April 2015) has been agreed with the Contractor. The scheme involves the provision of a fully staffed and serviced renal dialysis unit which provides dialysis for NHS patients under the care of NHS Doctors. At the end of the contract period, if the service contract is not renewed or passed to another operator, the Trust is committed to acquiring the assets at the written down value from the private sector operator (estimated at £360,000). For the first seven years of this contract the equipment inherent in the service was valued, added to the SoFP and depreciated over the seven year life of the contract. As the contract has entered an extension period with all of the equipment risk falling to the service provider, the service is no longer classified as an on-SoFP PFI.

22. Financial Instruments

Although the NHS Foundation Trust does not hold or deal in complex financial instruments, it is required to comment upon its exposure to credit, liquidity and market risk and how those risks are managed.

22.1 Exposure to Risk

a) The majority of the NHS Foundation Trust's income is due from NHS commissioners and is subject to legally binding contracts which limits credit risk. Non-NHS customers form only a small proportion of total income and the majority of those customers are organisations that are unlikely to cease trading in the short term or default on payments (e.g. councils, universities, Woodlands Hospice, WRVS, etc).

b) The NHS Foundation Trust is exposed to liquidity risk in that it needs to maintain sufficient cash balances to meet creditor obligations in order to ensure continuity of service. However, that risk is mitigated by the regular monthly receipt of contractual cash from NHS commissioners.

c) As the NHS Foundation Trust does not deal in currencies, invest cash over the long term, borrow at variable rates or hold any equity investments in companies (other than its own subsidiary) its exposure to market risk (either interest rate, currency or price) is limited.

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22.2 Managing Risk

a) To manage credit risk, the NHS Foundation Trust has documented debt collection procedures which are regularly reviewed and ensures that its credit control staff are adequately trained and resourced. Potential payment defaulters are identified at an early stage and appropriate action is taken on a timely basis. (Also see measures to manage liquidity at (b)).

b) The NHS Foundation Trust has a working capital facility in place to help manage liquidity risk. It also ensures that daily cash flows are examined and the investment of surplus cash is restricted to a term of three months. Cash investments are also restricted to highly rated, UK domiciled financial, institutions and the levels of cash deposited in any individual institutions at any one time is restricted. Cash management is governed by a regularly reviewed Board Policy and departmental procedure notes.

c) Market risk is managed by limiting investments to fixed rate and fixed term with credit worthy institutions, based upon market knowledge as to the likely movements in interest rates.

22.3 Financial Assets by Category Loans and Loans and receivables receivables 31 March 2012 31 March 2011 Assets as per Statement of Financial Position £000 £000

Trade and other receivables (excluding non-financial assets) 6,008 8,424 Cash and cash equivalents 27,507 18,398 Total Financial Assets 33,515 26,822

Financial assets do not include receivables arising by statute (e.g. Injury Costs Recovery scheme receivables).

22.4 Financial Liabilities by Category Financial Financial liabilities liabilities 31 March 2012 31 March 2011 Liabilities as per Statement of Financial Position £000 £000

Borrowings (excluding finance leases) 27,531 23,510 Obligations under finance leases 157 96 Trade and other payables (excluding non-financial liabilities) 20,668 22,296 Total Financial Liabilities 48,356 45,902

22.5 Fair value of Financial Instruments

The Trust has 2 loans with the Foundation Trust Financing Facility which are categorised as non-current financial liabilities. The carrying value of the liability is considered to approximate to fair value as the arrangement is of a fixed interest and equal instalment repayment nature and the interest rate is not materially different to the discount rate.

The carrying values of short term financial assets and financial liabilities are considered to approximate to fair value.

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23. Third Party Assets

The Trust held £1,304 cash and cash equivalents as at 31 March 2012 (£207 as at 31 March 2011) which related to monies held by the Trust on behalf of patients. During the reporting year, the Trust received £22,982 and repaid £21,266 (£48,477 and £49,484 in 2010/11). These figures have been excluded from cash and cash equivalents reported in the Accounts.

24. Losses and Special Payments

There were 1,611 cases of losses and special payments (including individual bad debt charges) in 2011/12 (830 in 2010/11) totalling £1,515,000 (£870,000 in 2010/11). These are accounted for on an accruals basis and exclude provisions for future losses.

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