AIREDALE NHS FOUNDATION TRUST ANNUAL REPORT AND ACCOUNTS 2013/14
Airedale NHS Foundation Trust
Annual Report and Accounts 2013/14
Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006
CONTENTS PAGE
Section 1 – Annual Report and Quality Report
Chief Executive’s Overview 6 Who We Are and What We Do 8 Operating and Financial Review 10 Income 12 Expenditure 13 Business Review 16 Performance 19 Statement on Quality from Chief Executive 27 Quality Report 28 Review of Quality Performance 84 Statement of Directors’ responsibilities in respect of the Quality Report 90 Independent Auditor’s Limited Assurance Report to the Council of Governors of 93 Airedale NHS Foundation Trust on the Annual Quality Report Directors Report 95 Council of Governors 102 Membership 106 Governance 111 Remuneration Report 113 Public Interest Disclosures 120 Annual Governance Statement 133 Independent Auditor’s Report to the Council of Governors of Airedale NHS 141 Foundation Trust on the Financial Statements
Section 2 – Accounts
Forward to the Accounts 144 Statement of the Chief Executive’s Responsibilities as the Accounting Officer of 145 Airedale NHS Foundation Trust Consolidated Statement of Comprehensive Income 147 Consolidated Statement of Financial Position 148 Consolidated Statement of Changes in Taxpayers Equity 149 Consolidated Statement of Cash Flows 150
Section 3 – Contact Details
Glossary 179 Contact Details 181
CHIEF EXECUTIVE’S OVERVIEW
I am delighted to welcome you to this annual report and accounts for 2013/14.
Our continuing strategy to focus on patient safety and quality of service has delivered improved care for all our patients and we continue to expand and develop our services at Airedale Hospital, community hospitals at Ilkley, Settle and Skipton and other sites in the community.
Following the publication of the Francis report into Mid Staffordshire there were great repercussions throughout the NHS. The Foundation Trust, like all NHS organisations, has considered what this means for our patients and our staff and we are determined to ensure that we are never complacent and always think about the impact of what we do and say has on our patients.
During September we were one of the first hospitals to be reviewed by the new Care Quality Commission (CQC) inspectors. It was immensely rewarding that they not only found Airedale Hospital to be low risk and safe but that we were one of the only hospitals in the first stage of the new inspection process to be given no compulsory actions for improvement. I am immensely proud of everyone at Airedale for this significant achievement as the inspection team looked at what we do every day, not just when the team were here.
Our drive to deliver safe care was further recognised in December by the Dr Foster organisation naming Airedale as one of 12 trusts to receive a highly commended award for improving its performance at weekends including low re-admissions rates. In addition, the report named Airedale as one of only eight trusts with very low mortality rates for both weekdays and weekends and one of only six trusts with very low readmission rates for both weekdays and weekends – a fantastic achievement for the hospital and recognition of the professionalism and dedication of our staff throughout the year.
We have, as always, had a focus on making the experience for our patients the best it can be and during 2013/14 we have built on this and developed a strategy called ‘Right Care’ which brings together not only our own services but those providing by other health and social care partners as well as other voluntary and community organisations.
During the year, there have been a number of new developments. The completion of our new Endoscopy Unit and the upgrading of the Maternity Unit have been great highlights for staff and for patients. And in February 2014, our first dementia friendly ward opened at Airedale Hospital helping to create a calm and homely environment for some of our most vulnerable patients. In outpatients, we have improved our ophthalmology services and invested in new equipment to provide a new macular clinic and our enhanced recovery programme goes from strength to strength and is being extended from orthopaedic procedures to other areas such as breast care. Finally, another important development is the Gold Line service, managed by our digital hub, where patients and carers can call for help 24/7 when they or their loved ones are terminally ill.
I am also immensely proud of our infection prevention successes this year. Our work to improve our rates of Clostridium Difficile also continued with only 7 cases in 2013/14 against the previous year end of 17. Our tough target for this remains the same for the next year.
Despite these achievements, we are aware that the coming year and beyond will be challenging for the NHS, particularly in relation to the economic climate which will impact on the funding available at a local level. We are therefore looking at ways to become more efficient and effective to cut our costs and to secure a number of new services which will grow our income. In particular our work in the telemedicine field goes from strength to strength, as evidenced by the Foundation Trust agreeing contracts with the local CCG to provide a medical video conferencing solution to more local nursing homes.
WHO WE ARE AND WHAT WE DO
Airedale NHS Foundation Trust is an award winning NHS hospital and community services trust. We provide high quality, personalised, acute, elective, specialist and community care for a population of over 200,000 people from a widespread area covering West and North Yorkshire and East Lancashire.
We employ over 2,400 permanent staff and have around 370 committed volunteers. Last year, we cared for over 28,000 elective inpatients and day cases, more than 28,000 non-elective patients, over 156,000 outpatients and more than 71,000 patients in the community. Our Accident and Emergency department saw more than 53,000 patients and over 2,200 babies were born at the hospital last year. We have an annual budget of £147 million.
We provide services from our main hospital site, Airedale Hospital, and from community hospitals – such as Castleberg Hospital, near Settle, Coronation Hospital in Ilkley and Skipton Hospital – as well as health centres and general practices (GPs). Last year, 2013/14, our health services were commissioned by the newly formed Clinical Commissioning Groups (CCGs) for the patients within their GP practices and the three main CCGs referring patients to us were – Airedale, Wharfedale and Craven, Bradford Districts and East Lancashire – as well as regional specialist commissioners and NHS England (formerly the NHS National Commissioning Board).
Building on the development of the vision statement from the previous couple of years, the Foundation Trust Board of Directors decided to further strengthen the communication of the Foundation Trust’s key values through the use of the overarching message of ‘Right Care’ and by emphasising four key principles relating to patient experience:
• Nothing about me without me; • Making every contact count; • Through their eyes; and • At the heart of everything we do.
The key principles underpinning the delivery of the vision in the years ahead also remain similar to those outlined over the previous couple of years. These have been further updated to reflect the progress already made by the Foundation Trust against its key milestones and to respond to the key priorities outlined both nationally and locally.
• Safety, quality, patient experience and staff engagement are at the centre of everything the organisation does;
• The need to be serious about efficiency and business control in order to be viable in the future;
• Transforming care is critical to the delivery of our strategy, through developing our existing services whilst also designing and delivering new ways of working, using diversified models of care both in and out of a hospital setting;
• Ensuring the care of the vulnerable, elderly, patients with dementia and those with nutritional needs are given priority focus;
• Ensuring a greater focus on clinical leadership, engagement and outcomes;
• Partnerships form a significant part of the design and delivery of our services;
• Ensuring the value of the Airedale brand is retained within the community and beyond; and
• The requirement to adapt the size and shape of the workforce and estate in response to the updated service strategy.
Overall, the vision is about an approach focused on embedding the key principles of good experience, by continually assessing the impact and outcomes for patients of the way services are provided.
OPERATING AND FINANCIAL REVIEW
OUR FINANCES
The Foundation Trust has a slight deficit of £1,000 for 2013/14 which includes a technical impairment of £589,000 caused by the change to Modern Equivalent Assets valuation, when this is taken out of the balances the Trust has an underlying surplus of £588,000.
The accounts included in the annual report reflect both the financial position of the Foundation Trust and a group position which consolidates the Foundation Trust and Airedale NHS Foundation Trust Charitable Funds accounts.
These results arise from continuing to implement cost improvement plans and further increases in activity during the year, and will continue next year. Agency costs have prevented a more significant surplus.
INCOME AND EXPENDITURE
Total income from continuing activities for 2013/14 was £147 million. An analysis of this is shown on pages 12 and 13.
CASH
The Foundation Trust had a cash balance of £16.6 million at the close of the financial year.
BORROWING LIMIT
The Foundation Trust no longer uses the borrowing limit; it is regulated by the terms of the Licences agreement with Monitor which is subject to a detailed financial risk assessment.
MONITOR RISK RATING
Monitor, the independent regulator for NHS Foundation Trusts, assesses the financial risk of Foundation Trusts using a rating whereby 1 is significant and 5 is no financial risk.
The Foundation Trust achieved a financial risk rating of 3 at the end of 2013/14. The tables in the next column summarise the rating performance throughout the year and provide a comparison to the previous year.
Annual Q1 Q2 Q3 Q4 Plan 2013/14 2013/14 2013/14 2013/14 2013/14 Financial 3 3 3 3 3 risk rating Governance Amber/ Amber/ Green Green Green risk rating Red Green
Annual Q1 Q2 Q3 Q4 Plan 2012/13 2012/13 2012/13 2012/13 2012/13 Financial 3 3 4 3 3 risk rating Governance Amber/ Green Green Amber/ Amber/ risk rating Green Red Green
During the year Monitor changed its Risk Rating to a Continuity of Services Rating (CoSR) from Q3. This rating ranges from 1-4 with 1 being significant and 4 being no financial risk. At the end of the financial year the Foundation Trust is rated as 4 under this new rating.
The analysis below shows the Foundation Trust’s financial position against key performance indicators.
Details of any post balance sheet events are provided in note 24 of the accounts.
FINANCIAL OUTLOOK
In our long term financial planning we have considered a range of severe financial possibilities given the current economic climate, and we believe the Foundation Trust can withstand the impact of these possibilities.
The Foundation Trust will however be expected to improve overall efficiency by 5% in 2014/15 and 4% in the following year, which is in line with our strategic three year plan, set out last year. The Board remains determined to deliver efficiency improvements to ensure the long term sustainability of the Foundation Trust.
CAPITAL INVESTMENT ACTIVITY
The Foundation Trust’s capital programme has invested over £7 million in 2013/14 to improve its buildings and equipment.
The Foundation Trust has committed to significant investment in a new state-of-the-art Emergency Department at Airedale Hospital at a cost of £6.3 million. The new department, which will cost £1.9 million in 2013/14, will provide separate adult and children’s waiting areas, a quiet room for friends and families to use during stressful events and a separate screened entrance for ambulances. The work began in October 2013 and is expected to be completed by autumn 2014.
Our new Endoscopy Unit opened in July 2013, following an investment in 2013/14 of £1.3 million. It offers better facilities for patients, including greater privacy and an extra procedure room so that more people can be treated in the future and helps address previous capacity issues.
Airedale Hospital’s maternity facilities received a £748,000 upgrade following a successful bid to the Department of Health’s fund to improve and upgrade maternity units.
Airedale was one of the Health and Social Care partners across Bradford and Airedale to have been successful in a £4 million bid to NHS England’s Safer Hospitals, Safer Wards Technology Fund. The bid, which this year comes to £765,000, supports the delivery of the district’s Integrated Care for Adults Programme (ICAP) which focuses on the patient’s holistic needs and is designed to deliver ‘right care, in the right place, first time’, for local people.
The Foundation Trust was successful in its bid for capital development funding from the Department of Health to improve its environment for patients suffering from dementia. The Foundation Trust received £444,000 in July 2013 from the ‘Here to Care’ bid to provide a better level of care and experience of health services for patients suffering from dementia.
ACCOUNTING POLICY
There has been a change in accounting policy in respect of preparation of the Annual Accounts, as the charitable Funds accounts are now consolidated with the Foundation Trust accounts to produce Group accounts
INCOME
INCOME 2013/2014 £000 % A&E 5475 3.75 Elective 22299 15.27 Non Elective 37733 25.83 Outpatients 16724 11.45 Community Services 5042 3.45 Other Clinical Income 48103 32.93 Private Patients 361 0.25 R&D 1291 0.88 Education & Training 4445 3.04 Other Income 4596 3.15
Total 146069 100
EXPENDITURE
Expenditure 2013/2014 £000 % Medical Staff 28645 19.78 Nursing Staff 30337 20.95 Other staff 40407 27.90 Drugs 9158 6.32 Clinical Support & Services 13420 9.27 Other costs 17766 12.27 Depreciation/impairment 5085 3.51
Total 144818 100
INVESTMENTS
The Foundation Trust made no investments in 2013/14. The Charitable fund has a stockholding of £467,000
PRIVATE PATIENTS
Section 164(3) of the Health and Social Care act removes condition 10 (which restricts income from private charges), from the Foundation Trust Terms of Authorisation. The Foundation Trust is now required by the Act and constitution (rather than by the terms of Authorisation) to ensure that income derived from activities related to the Foundation Trusts principle purpose of delivering goods and services for the purpose of the NHS exceeds income derived from other activities. To increase this income in any financial year by 5% or more, the Foundation Trust is required to seek approval from the Council of Governors. In 2012/13 the Foundation Trust has not increased the percentage beyond the 5% threshold. The private patient income for 2013/14 was £361,000.
COST IMPROVEMENT PROGRAMME (CIP)
A formal cost improvement programme (CIP) was approved for 2013/14, which set targets and actions plans aimed at improving efficiency. The CIP was monitored monthly and achieved the target of £5.9 million within the financial year. Examples of higher value schemes are:
• Staffing and skills mix review £956,000; • Savings from procurement cost reductions £973,000; • New pathways £700,000; and • Growth and repatriation £700,000.
COUNTERING FRAUD AND CORRUPTION
The Foundation Trust complies with the Secretary of State’s directions on counter fraud measures issued in 2004. The Foundation Trust has a Reporting Concerns and Whistleblowing Policy which incorporates counter fraud measures. A specific Counter Fraud and Corruption Policy also exists which was updated during 2012/13 to take account of the provisions in the Bribery Act 2012.
The Foundation Trust has a dedicated section on counter fraud on the staff intranet. Presentations were given to staff during the year about tackling fraud in the NHS and who to contact if they suspected fraud has been committed. Articles are also published in the Foundation Trust’s weekly staff briefing. To support ongoing awareness among staff, the Local Counter Fraud Specialist also attends staff events to promote awareness.
CHARITABLE FUNDS
The Foundation Trust, which is directed by the Board, acts as Corporate Trustee of the Airedale NHS Foundation Trust Charitable Funds. The Foundation Trust’s charitable funds are operated for the benefit of the staff and patients in accordance with the objects of the charity. The funds are used for the purchase of equipment and the provision of amenities for both patients and staff, in accordance with the objects of the charity.
The Foundation Trust received a number of very generous donations throughout the year, from many parts of the community for which it is very grateful. The Friends of Airedale and Airedale New Venture charities were again very supportive in their fundraising efforts. During the year the Charitable Funds purchased a large number of items of equipment and enhancements to fixtures and fittings for the benefit of patients.
The appointment of a part time fundraiser has helped to support external fundraising activities for some of our larger capital projects, such as the new Endoscopy Unit and the A&E redevelopment. The Airedale NHS Foundation Trust Charitable Funds Annual Report and Accounts is available from the Company Secretary at the address shown on the final page of this report.
STATEMENT OF DIRECTORS’ RESPONSIBILITIES IN RESPECT OF THE AUDITORS
To the best of each Director’s knowledge and belief, there is no information relevant to the preparation of their report of which the Company’s Auditors are unaware.
Each of the Directors has taken all steps that a Director might reasonably be expected to have taken to be aware of all relevant audit information and to establish that the Foundation Trust’s Auditors are aware of that information.
AUDITORS AND AUDIT FEE
The Foundation Trust’s external auditor is PwC. Disclosure of the cost of work performed by the auditor in respect of the reporting period is shown right/below.
Audit Area Fee 2013/14 (£) Statutory Audit £43,628* Quality Report £8,268*
* All the above figures exclude VAT
ANNUAL REPORT AND ACCOUNTS
This annual report and accounts is available on our website at www.airedale-trust.nhs.uk
If you need a copy in a different format, such as large print, braille or in another language, then please contact our Interpreting Services on Tel: 01535 292811 or email [email protected]
BUSINESS REVIEW
SERVICE DELIVERY
Focus on access times has seen us deliver on a number of high profile requirements.
Almost all of our patients – over 92% – are being treated within 18 weeks of their referral to us and the majority (95%) of our patients are being admitted, treated or discharged within four hours of arriving in our Accident and Emergency (A&E) department.
The Foundation Trust’s performance on the national cancer standards has also met or exceeded the required levels with all (100%) cancer patients receiving their first treatment within 31 days of being diagnosed and all (100%) cancer patients receiving their second or subsequent treatment within 31 days. In addition, following significant work by our cancer team, the majority (96%) of patients with suspected cancer are seen within two weeks of their urgent GP referral.
Through contracts with our CCG Commissioners, the Foundation Trust has delivered an increased level of activity in 2013/14 across non-elective, elective and outpatient work. This work reflects dealing with both an increased level of demand whilst also delivering on key access waiting time targets.
Key requirements around performance and information have been met and the Foundation Trust has also delivered on the local clinical quality schedule and received the full incentive allocation associated with it.
Progress against all the business objectives set out in the Foundation Trust’s Business Plan, are reported to the Board on a quarterly basis. The year end position showed the majority of the objectives had been delivered and for the areas not yet completed, work is ongoing that will be carried forward for completion in 2013/14. Progress against each of the objectives will be monitored via the Board Assurance Framework.
DEVELOPING SERVICES
Investment in and development of a number of clinical services took place during 2013/14.
The new Patient Administration System (SystmOne) went live in late 2012. This implementation, delivered in partnership with technical partners TPP and Accenture, is an important step in delivering the Foundation Trust’s ambition to improve the patient experience. Through this development – one of the first in the country - we will be able to better integrate care for the local population as we now have the basis of an electronic shared record with primary care.
The next phase of the project was successfully introduced in 2013 enabling us to produce and save clinical letters onto the IT system and make them available to all staff who have rights of access.
During the year, our consultant leads and Clinical Directors have worked with the executive team to design and implement a different way of assessing and caring for urgent patients in both medicine and surgery. Our Surgical Assessment Unit, based on ward 14, is making a big difference for patients, meaning they are seen by a doctor more quickly and receive the right care so they can be admitted for further treatment or discharged home much sooner than before. The development of the Acute Medical Unit on ward 2 and the Ambulatory Care Unit on ward 3 has meant nearly a £1 million investment in doctors and nurses, meaning that GPs can call a consultant for advice about patients who otherwise would have been admitted. Patients are reviewed quickly and many more are getting their treatment in less time and discharged home.
Our new £2.4m state of the art Endoscopy Unit was opened in the summer of 2013 has met all of the requirements to be awarded JAG accreditation for 2014. The new unit supports the expansion of this service, with public health screening and awareness campaigns increasing demand.
The Telehealth Hub, which opened the in September 2011 as part of its key strategic approach to digital healthcare, continues to offer a range of Telehealth care across a range of specialties including:
• Remote consultant opinion to the HM Prison Service in England; • Supporting elderly patients with long term conditions in their own homes, nursing and residential care homes; • Supporting rural communities with community based remote outpatient consultations; and • Enhancing recovery for stroke patients through our telemedicine service.
Our telemedicine service into nursing homes is demonstrating significant change in patient experience, with patients getting access to expert consultation without having to leave their home. It is also resulting in reduced admissions both to A&E and our wards. We are rolling out the service across all nursing homes locally and further afield such as Birmingham and Lancashire.
Another significant development in the telemedicine field during 2013/14 was the establishment of a Limited Liability Partnership (joint venture) with a technical supplier – Immedicare - to support the further expansion of our innovative telemedicine service in nursing and residential homes.
In November 2013, we launched our telemedicine ‘Gold Line’ pilot service providing access 24 hours a day, 365 days a year to immediate clinical opinion and care for seriously and terminally ill patients. The Gold Line helps people who are being cared for on the Gold Standards Framework - people with a serious illness who may be in their last year of life – and aims to support them in their preferred place of care wherever possible.
Our lymphoedema service has been successful in renewing its contract to provide this valuable service to patients at Airedale and our pathology facilities continue to expand their services for local GP practices
Facilities within outpatients have been refurbished to host macular clinics at Airedale Hospital alongside clinics for other common eye conditions such as diabetic retinal screening (DRS), cataracts and glaucoma, so that patients with age related macular degeneration (AMD), which sometimes causes blindness, can now be treated on site without having to travel to Bradford or Leeds.
In February 2014, a new project, which provides personalised care to pregnant women, was launched across Bradford and Airedale. The My Airedale Midwife (MAM) scheme aims to provide personal one-on-one care to pregnant women -who want, for example, a home birth or have complex social needs - throughout their pregnancy, labour and immediately following the birth of their baby.
The Transform Programme drew to a close during 2013/14 as the work became part of the wider ‘Right Care’ programme. The infrastructure established as part of the programme’s work, the new ways of working and the eight integrated community teams will provide a strong foundation on which to improve the proactive care of patients around GP practice populations. The intermediate care and specialist locality level services will continue to be developed in order to provide services for preventing patients coming to hospital when they can be managed in community settings.
Community Services, which were successfully transferred to the Foundation Trust in 2011 and continue to cover Craven, Airedale and Wharfedale, are:
• Castleberg Hospital and Skipton Hospital; • Craven Virtual Ward; • Craven Collaborative Care Team; • Airedale Collaborative Care Team; • Airedale Specialist Nursing Team; • Airedale Community Therapy Services; and • Community Matrons and District Nurses.
Reablement funding continues to support transformation of care, which is central to the Foundation Trust’s strategy. This enabled the Foundation Trust to make additional beds available in the community, at Castleberg Hospital, near Settle and at local nursing and residential care homes.
PERFORMANCE
PUTTING PATIENTS FIRST
The past year has seen the Foundation Trust build on the previous year’s performance. Not only did we finish the year having achieved national targets we also met our CCGs local quality standards.
In April 2013, Airedale Hospital was shortlisted as one of the top five acute trusts for providing high quality of care to patients which is appropriate to their diagnosis in a national award for quality of care by CHKS - an independent provider of healthcare intelligence and quality improvement services. The awards are made on the basis of publicly available datasets and every NHS acute trust in the country is included in the analysis.
Employee health and wellbeing staff at Airedale Hospital passed a new national accreditation in June. The team were praised and given four commendations by external assessors, who visited the hospital as part of the Safe Effective Quality Occupational Standards (SEQOHS) award scheme, governed by the Royal College of Physicians of London. Assessors congratulated the team on achieving a ‘paper light’ system; its leadership and cohesion within the team, including how they use telemedicine to have consultations to provide a more efficient and convenient service, its written protocols, and its security checklist and the safety of its medicines audit.
The gardening team who are responsible for brightening up the hospital with beautiful flower displays were awarded a Silver Gilt award by a judging team from Yorkshire in Bloom in July as part of the public and private charitable establishments’ category for the 2013 event. They were nominated by the Friends of Airedale Hospital charity for their dedication in looking after the grounds and gardens of the hospital for the benefit of patients, visitors and staff.
In November, Bev Beaumont, a midwife who helps run the labour ward at Airedale Hospital got through to the regional finals of a prestigious leadership award - the NHS Leadership Recognition Awards 2013. Bev was nominated for the mentor or coach category.
One of the team of audiologists at Airedale Hospital received special recognition in a national competition for the fifth year in a row. Alan Walshaw, who cares for those with hearing difficulties, received another certificate of commendation in recognition of his achievement in the UK Audiologist of the Year award – the only person to be commended in the awards for five consecutive years.
The 2013 Hospital Guide was published by Dr Foster at the start of December. The Foundation Trust was one of 12 trusts to receive a highly commended award for improving its performance at weekends including low re-admissions rates from 2011/12 to 2012/13. Data gathered for the annual guide – which analyses information from all NHS health trusts – showed that Airedale NHS Foundation Trust was also named as one of only eight trusts with very low mortality rates for both weekdays and weekends and one of only six trusts with very low readmission rates for both weekdays and weekends. The report also noted that Airedale is one of just 20 hospital trusts where mortality rates were significantly lower than expected on at least two out of four (and not high on any) of the key mortality measures, including deaths in low-risk conditions and deaths after surgery.
In March 2014, a nurse who is part of Airedale Hospital community team received international recognition as a specialist for multiple sclerosis (MS). Jane Pearce was awarded a certificate from the Multiple Sclerosis Nurses International Certification Board (MSNICB) after passing a stringent examination for all nurses worldwide who provide MS care. There are just nine people each year who sit the exam, part-funded by The International Organisation of MS Nurses (IOMSN) and the UK Multiple Sclerosis Specialist Nurses Association (UKMSSNA).
HOW THE FOUNDATION TRUST IS MONITORED
Monitor requires each Foundation Trust board to submit an annual plan, quarterly and ad hoc reports. Performance is monitored against these plans to identify where potential and actual problems might arise. Monitor publishes quarterly and annual reports on these submissions and assigns each Foundation Trust with an annual and quarterly risk rating, which are designed to indicate the risk of a failure to comply with the terms of authorisation. Five risk ratings are published for each NHS Foundation Trust on:
• Governance (rated red, red/amber, amber/green or green); • Finance (rated 1-5 where one represents the highest risk and five the lowest); and • Mandatory services risk rating (services the Foundation Trust is contracted to supply to its commissioners).
Based on these risk ratings, the intensity of monitoring and the potential need for regulatory action is considered on a case-by-case basis. This also applies where a Foundation Trust is performing well, for example moving from the usual quarterly monitoring to six-monthly monitoring. Monitor’s analysis of our submissions and the Foundation Trust’s current ratings are:
REGULATORY RATINGS
The Foundation Trust achieved a green rating for governance in three of the four quarters and a financial risk rating of 3, for all four quarters in 2013/14.
NATIONAL SURVEYS
The Foundation Trust welcomes the opportunity to take part in a range of annual national patient surveys that are initiated by the Care Quality Commission. This is an ideal way of obtaining regular patient feedback as a means of seeking to improve our patient experience.
The results of National Cancer Patient Experience Programme were published in August 2013. A total of 116,525 patients nationwide, who has received treatment for cancer during September to November 2012, were asked to take part in the survey and this included 493 patients from Airedale Hospital.
Results revealed that the hospital was one of the best 20 percent in the country for the number of its patients who said their care was excellent or very good in results. Almost eight out of 10 patients (78 percent) said that this was the case, compared to seven out of 10 in the previous survey.
The aim of the survey is to monitor progress being made around cancer care by trusts throughout the country in a bid to make sure that patients experience safe, effective and quality care.
The survey highlighted a number of positive findings, including, patients being involved in decisions about their care; being seen as soon as necessary; having hospital and community teams which always worked well together; providing a complete explanation of what operation would be carried out and how it had gone; getting written and verbal information about side effects from treatment and how they could be affected in the future and providing understandable answers from hospital doctors to all of their questions most or all of the time
In December 2013, the latest national survey about maternity service at Airedale Hospital was published. More than 23,000 women who used maternity services around the country took part in the survey involving 137 NHS acute trusts. Women were invited to take part if they were over 16 years old and gave birth in February 2013 in hospital or at home. Participants were also asked about their experiences of antenatal and postnatal care to cover their entire experience of being pregnant.
They survey covered labour and the birth, how patients were treated by staff, care in hospital after birth, feeding the baby, and care at home after the birth. Airedale NHS Foundation Trust compared as about the same as other trusts in almost every question asked.
In two areas, Airedale was amongst the best performing trusts – women said they were given the help they needed if they contacted a midwife, and they had confidence and trust in the midwives they saw at home after leaving the hospital. Significantly more women said they were treated with kindness and understanding after the birth of the baby this year, compared with previous surveys. There were no areas where Airedale was judged as one of the worst performing trusts.
The results of the eleventh survey of adult inpatients, which was conducted in August 2013, were published by the Care Quality Commission in April 2014.
It involved 156 acute and specialist NHS trusts and looked at the experiences of over 62,400 people who were admitted to hospital with at least one overnight stay.
The Foundation Trust scored well for privacy and dignity and infection prevention practices and Airedale scored highest in the section relating to waiting lists for those referred to the hospital and planned admissions (9.2). The Foundation Trust also had fewer respondents who had their admission date changed (patient satisfaction rose from 9.3 last year to 9.6).
FRIENDS AND FAMILY TEST
In July, the first results of the NHS Friends and Family Test (FFT) for all acute hospitals inpatient and accident and emergency departments were published.
The data included results for every NHS trust in England and provided new and unique insights into the experiences of patients and how they view their local hospital services. Every inpatient ward and hospital A&E department is now given a monthly score based on the responses to one simple question: ‘How likely are you to recommend our ward/A&E department to friends and family if they needed similar care or treatment?’ Patients are surveyed at, or within 48 hours of discharge.
Each trust achieves a score based on the satisfaction levels of patients surveyed. This is calculated in the same way by every hospital using a ‘proportion of patients who would strongly recommend minus those who would not recommend, or who are indifferent’. The range of scores that are possible using this method are -100 to +100. The score is not a percentage.
The first results for Airedale Hospital were:
• The FFT score for June 2013 for inpatients (wards) at Airedale Hospital is 74 • The FFT score for June 2013 for A&E at Airedale Hospital is 56
These scores compare favourably with the national scores for England for June 2013, which were 71 for inpatients (wards) and 54 for Accident and Emergency (A&E) departments. Patients taking part in the survey are able to make comments in addition to the descriptive six-point response scale which determines the NHS trust score. For Airedale Hospital, these included:
• “Well looked after by the nurses. Food has been OK. Helpful staff in every way” • “Very good care, patient staff, helpful, empathetic, obviously well trained” • “Staff were very polite and compassionate”
The first results of the NHS Friends and Family Test for maternity services were published in January 2014. New and expectant mums are given a Friends and Family questionnaire at various stages of their maternity care, for example, after their 36 week antenatal
appointment, following the birth of their baby and also after their final postnatal appointment with a midwife.
Each element of that care is given a monthly score based on the responses to one simple question: “How likely are you to recommend our service, ward and maternity care to friends and family if they needed similar care or treatment?” The first results for Airedale Hospital maternity services were:
• The FFT score for December 2013 for antenatal services for Airedale Hospital is 74. • The FFT score for December 2013 for the labour ward / birthing unit at Airedale Hospital is 82. • The FFT score for December 2013 for the post natal ward at Airedale Hospital is 82. • The FFT score for December 2013 for post natal community services for Airedale Hospital is 89.
These scores compared favourably with the national scores for England for December 2013, which were 63 for antenatal services, 75 for the labour ward / birthing unit, 66 for the post natal ward and 74 for post natal community services.
Mums taking part in the survey were also able to make comments in addition to the descriptive six point response scale which determines the NHS trust score. For Airedale Hospital, these included:
• “Friendly service providing lots of information” • “Excellent care from very supportive staff” • “Fantastic care from all the midwives, take their time with you to explain things”
In April 2014, to improve the uptake of the Friends and Family Test, the Foundation Trust introduced questionnaire cards in five different languages and Easy Read (for patients with mental capacity issues) to help patients complete test. They are produced in Polish, Slovakian, Urdu, Bengali and Mandarin as part of our work with a new contractor Direct Data Analysis and if patients need help with other languages this will be looked into to ensure we continue to meet their needs.
REAL TIME INPATIENT SURVEY
The Foundation Trust continued to implement its own real time inpatient survey in 2013/14 as a means of helping staff make improvements to the care and services that are provided to patients. The survey is undertaken on a daily basis, Monday to Saturday, supported by the Foundation Trust’s volunteers who assist patients being discharged that day to complete the survey.
The project is overseen by a steering group whose members continually monitors progress and include volunteer representatives. During 2013/14, the survey was expanded into other areas and now also covers the endoscopy unit as well as maternity services, physiotherapy and paediatrics.
PATIENT LED ASSESSMENTS OF THE CARE ENVIRONMENT (PLACE)
April 2013 saw the introduction of patient-led assessments of the care environment (PLACE), which is the new system for assessing the quality of the patient environment, replacing the old Patient Environment Action Team (PEAT) inspections. The assessments apply to hospitals, hospices and day treatment centres providing NHS funded care. The assessments see local people go into hospitals as part of teams to assess how the environment supports patient’s privacy and dignity, food, cleanliness and general building maintenance. It focuses entirely on the care environment and does not cover clinical care provision or how well staff are doing their job.
The assessments take place every year, and results will be reported publicly to help drive improvements in the care environment. The results aim to show how hospitals are performing nationally and locally.
The Foundation Trust’s first PLACE inspection took place at Airedale Hospital on 17 and 18 June 2013. The assessment team included seven staff and five patient assessors represented by two volunteers, one Foundation Trust elected governor and two patient carer panel members. Validation was provided by the facilities manager for Bradford Teaching Hospitals NHS Foundation Trust, whose role was to ensure the audits were carried out as required according to the guidance provided.
PLACE requires the inspection to cover a minimum of 10 wards and 10% of departments plus external and internal public areas. The areas visited were established on the day in agreement with the patient assessors as follows:
• Wards 1, 5, 6, 7, 9, 13, 14, 15, 21 and the Children’s Unit; • A&E, HODU, Pre-Op Assessment, Main Outpatients; • Internal Areas; • External Areas; and • Food on wards 7, 15 and 21.
The results are provided in the domains of cleanliness (including hand hygiene); condition, appearance and maintenance; privacy, dignity and wellbeing and food. In all cases results are expressed as a simple percentage – which is calculated by reference to points scored as a percentage of the maximum available – the maximum available in every question x 2 the maximum score. There is no weighting and no further definition of results - the former ‘rating’ of excellent/good/acceptable/poor no longer applies.
Airedale’s PLACE results for 2013/14 were:
• Cleanliness – 93.13%; • Condition, Appearance and Maintenance – 82.58%; • Privacy, Dignity and Wellbeing – 81.19%; and • Food – 82.96%.
CLEANER AND SAFER
The Foundation Trust has continued to make improvements in reducing healthcare acquired infections.
During 2013/14, the Foundation Trust had 2 cases of hospital acquired MRSA bacteraemia. This compares to 12 MRSA cases in 2008/09 and 21 in 2003/04. For Clostridium Difficile, the number of people affected was 7 hospital acquired cases in 2013/14 compared to 17 in the previous year, which is a significant achievement.
Our Matron for Infection Prevention works closely with all staff, the Director of Nursing and the Director of Infection Prevention and Control in order to ensure that we provide best practice in infection prevention and control. Important patient safety initiatives aimed at achieving even further reductions in the number of healthcare acquired infections have been introduced. These include enhancing staff training to improve hand hygiene; developing up to date information for both patients and staff; and training and assessing our staff in asepsis practice and techniques.
STATEMENT IN RESPECT OF INFORMATION GOVERNANCE SERIOUS INCIDENTS REQUIRING INVESTIGATION
The Foundation Trust manages the reporting of personal data related incidents through the Incident Reporting System. All incidents are classified in terms of severity on a scale of 0-5 in terms of either/both risk to reputation and risk to individuals in accordance with the Department of Health Gateway Reference 13177 dated January 2010.
The Foundation Trust had no incidents classified at a severity rating of 3-5 that met the criteria for inclusion in the annual governance statement. The Foundation Trust recorded one incident classified at a severity rating of 2 which is shown below. All incidents are investigated and actions plans put in place to mitigate risks.
Category Nature Total I Loss/theft of 0 inadequately protected electronic equipment, devices or paper documents from secured NHS premises II Loss/theft of 1 inadequately protected electronic equipment, devices or paper documents from outside secured NHS premises III Insecure disposal of 0 inadequately protected electronic equipment, devices or paper documents IV Unauthorised disclosure 0
V Other 0
During 2013/14 the role of Senior Information Risk Owner (SIRO) was the responsibility of the Medical Director. Since 1 March 2014, the SIRO has transferred to the Director of Finance.
SUPPORTING SAFE, QUALITY CARE
The following departments continue to work with the Director of Nursing, the Medical Director and their teams to help support the delivery of high quality, safe care.
• Quality and Safety • Complaints Management and PALS • Nursing Practice Development Team • Patient and Public Engagement and Experience • Infection Prevention • Safeguarding
SAFER PATIENT INITIATIVE
Following completion of The Safer Patient Initiative 2 (SPI2), we have continued using the methodology learnt in SPI2. As agreed with the Institute of Health Improvement and Health Foundation we are continuing to report our safety and quality data on a monthly basis. The
organisation continues to be an active member of the Safer Patients Network run by the Health Foundation, ensuring greater learning and understanding is applied around safe patient care.
EMERGENCY PLANNING
The Foundation Trust has continued to develop its plans to deal with emergencies in line with national regulations and guidance.
PRIVACY AND DIGNITY
The Foundation Trust’s Dignity Room, an initiative set up by a group of staff at the hospital in 2009, continues to go from strength to strength. Their passion for dignity, together with the help of the Friends of Airedale and Airedale New Venture charities, has ensured that the initiative not only continues but grows each year.
The Dignity Room has been successful because of its potential to touch every patient within the hospital and to treat patients with compassion, kindness, dignity and respect, thereby enhancing the patient experience.
The Dignity Room, located close to ward 4 in the hospital, stocks a range of essential items which are all provided free of charge, including slippers, warm clothing, underwear and toiletries such as soap, shaving foam, razors, toothpaste, toothbrushes, shampoo and combs. It enables vulnerable, older patients who have been admitted to hospital in their nightwear and without toiletries to access day to day essential items. This allows them to go home or be transferred to other places of care wearing day clothes.
During 2013/14 the Dignity Room expanded to cover other areas of the hospital, such as the children’s unit, to support younger patients.
A patient’s relative, who was helped by the Dignity Room, says: “On his discharge, he was sent home with these articles which belong to the Dignity Room. It gave him pleasure to wear them whilst on the ward as they were so much more suitable than his own clothes.”
SAME-SEX ACCOMMODATION
The hospital provides same-sex accommodation by having separate male and female wings on all wards and doors which have been added to all of the four-bedded bays on all our inpatient wards. Toilet and shower facilities in some wards/departments have also been upgraded. This means the Foundation Trust continues to be compliant with the Department of Health’s requirements to provide same-sex accommodation.
LEARNING FROM COMPLAINTS
The Foundation Trust continues to deal with complaints in accordance with the legislation for complaints handling, which came into effect in April 2009. The Patient Liaison Service (PALS) and complaints team respond to individual concerns at the point of contact which results in the early intervention by clinical staff and managers. As a result, the Foundation Trust has seen a slight increase in the number of formal complaints during the year, from 67 in 2012/13 to 73 in 2013/14. However, 73 reflects the amount of complaints received during 2011/12. We have worked hard to learn from formal complaints. Examples are:
Your concern … “there was a lack of communication between various members of the community team.” Our response … this was identified and in response new handover methods and documentation has been implemented. The team leader has undertaken observational audit of the new process and provides constructive feedback to the team.
Your concern … “there was a significant delay in the reporting of a blood result.” Our response … A review of systems and processes has taken place, including auditing of the auditing of the changes within the pathology department.
CLINICAL GOVERNANCE
Clinical governance is the framework through which NHS organisations deliver and continually improve the quality of their services and safeguard high standards of care, by creating an environment in which excellence in clinical care will flourish.
This means being able to produce and maintain effective change so that high quality care is delivered.
The Foundation Trust has a committee structure designed to monitor and take forward the improvements to the clinical quality and safety of the services it offers patients. The Board of Directors is the accountable committee for quality. It is supported by a Board sub-committee and a number of other specialist groups and committees.
The Board of Directors receives a regular detailed report documenting progress and assurances from these various groups and committees that quality is improving. We have a corporate risk register that sets out potential risks to us meeting our targets and objectives. Our committee structure incorporates regular reviews of the corporate risk register and the Board Assurance Framework. The principal risks and uncertainties facing the Foundation Trust known at this time are:
• Influencing the wider health economy to ensure the health needs of the local population are sustained; • Delivering patient safety, quality, productivity and efficiencies; • Diversifying sufficiently to attract new income; and • Achieving widespread change in clinical practice.
STATEMENT ON QUALITY FROM THE CHIEF EXECUTIVE
We continue to focus on patient safety, compassion and quality to deliver the “Right Care” and treatment to our patients and their families. In September 2013 the Trust became the second hospital in England to be scrutinized under the Care Quality Commission’s [CQC] new rigorous inspection regime. Over two days a large team of inspectors, including clinical experts and lay representatives, evaluated whether we are safe, effective, caring responsive and well-led. Inspectors visited departments and wards, including at night, observing standards, speaking at length to staff, patients and carers as well as analysing an extensive range of quality measures. An unannounced inspection then followed.
The inspectors found safe and clinically effective care, but particularly praised the professionalism and compassion of our staff and dedication of volunteers. I would like to take this opportunity to express my thanks for their ongoing commitment to quality improvement. Areas where performance can be developed were identified and we have acted on recommendations. We are proud that we can feedback on this new process and maximise safety for patients not only at Airedale, but elsewhere.
Recent years have seen significant changes in the NHS and, in the present economy, challenges for all public services. We continue to work to maximise efficiency without compromising the clinical quality of care. To sustain and develop the quality of services, it is important that we listen to local people and those representing our wider community - commissioners, local authorities and Healthwatch. I am heartened that so many wish to be involved in our work and future plans.
Our goal of transforming local services to integrate around the needs of individual patients is progressing. The telemedicine service has been recognised at national level and is helping reduce inappropriate hospital admissions, whilst supporting patients with long-term conditions and those at the end of life whether at home or in residential care. This innovative approach offers the opportunity to enhance quality of care, release time and better utilize resources. The Trust now has direct access to electronic GP held information. This means we can access information about patients, for example medication, reducing risks, particularly for the most vulnerable. We continue to develop the delivery of dementia care having been successful in our “Here to Care” funding bid to the Department of Health to improve the wards and hospital at Airedale.
Delivering modern healthcare from a hospital over 40 years old can be a challenge. This year saw the completion of a number of dynamic infrastructure projects, including the Endoscopy Unit’s upgrade and the Labour Ward refurbishment. We are currently embarking on a £6 million “state of the art” Emergency Department project. These developments will support the delivery of safe and dignified standards of care whilst ensuring a sustainable future for Airedale NHS Foundation Trust.
It is not enough to say we deliver quality; we must be able to evidence it. In doing so, it is essential to present an open and honest picture of our care. All the information used and published in the Quality Account is, to the best of my knowledge, accurate and complete. In describing our quality improvements, I hope you recognise our genuine commitment to our community and that you will continue to make us your hospital of choice.
Bridget Fletcher Chief Executive 29 May 2014
Current view of Airedale NHS Foundation Trust’s position & status on quality
Introduction
“Right Care”: our vision is to be the hospital chosen by our community for putting patients’ needs first, providing excellent, innovative and diverse services and delivering safe, evidence-based standards of care. Whether it is in the community or as a hospital inpatient, ensuring our patients have a positive experience of care and services is central to what we do. 1 Our quality improvement programme focuses on three domains: patient experience, patient safety and the clinical effectiveness of care and treatment. The Quality Account seeks to provide accurate, timely, meaningful and comparable measures to allow you to assess our success in delivering this vision.
In 2013, for the second year in succession, Airedale NHS Foundation Trust was named as one of the 40 Top Hospitals by CHKS, the independent provider of healthcare intelligence and quality improvement. The 40 Top Hospitals award is based on the evaluation of 22 key performance indicators covering data quality, safety, quality of care and, new in 2013, the delivery of care of patients with dementia. Airedale also featured as one of 12 highly commended trusts in The Good Hospital Guide (Dr Foster Intelligence 2013) for our low mortality rates. We recognise, however, that there is always opportunity for improvement and that quality programmes must be progressed in collaboration with others.
Our partners: we need to understand what matters to our patients and we continue to listen, understand and respond to the views of our partners: patients and carers, staff, volunteers, governors, commissioners and the local authority, as well as, foundation trust members, community, patient and voluntary groups. A well-attended Quality Account public engagement event was held in October 2013 with a varied programme of presentations and workshops based on feedback from the previous year’s report. Our objective was to share and seek information on some of the challenges facing us, especially those relating to care of patients with dementia as well as discussing the opportunities in areas such as telemedicine care.
“This was my first time at a Quality Account Event. I have been enlightened on so many aspects of the hospital.”
“I am going home suffering an overload of information. It makes a welcome change! Many exciting strategies ahead – keep up the good work.”
“A very informative event and a clear demonstration that AGH is forward looking and is concentrating on the patient experience.”
Source: Quality Account Engagement Event 17th October 2013.
We are aware that people who are socially isolated and hard to reach, such as the elderly, those with learning and physical disabilities, and black and minority groups are often the most vulnerable and least likely to attend this kind of event. To help understand their experience and to meet their individual healthcare needs, a series of monthly health events have been planned in the community over the last year. The Patient and Carer Panel continues to be an invaluable independent source of “expertise by experience” and an important representation of the “patient voice”.
We have a close working relationship with the three Healthwatch organisations which cover Bradford, North Yorkshire and Lancashire. A Quality Health Summit, co-ordinated by our
1 Airedale NHS Foundation Trust (2013), Forward Plan Strategy 2013-14 to 2015-16.
commissioners with, amongst others, local GPs, patient groups and social care providers, was held in September 2013. It is increasingly recognised that quality improvement requires a “whole system” response across health, social care and the voluntary sector and we look forward to developing this collaborative ethos. The combined intelligence guides and informs the Trust’s strategic vision of quality improvement whilst supporting the work of the Quality Account Steering Group.
Domain 1: The patient experience
The implementation of the Patient and Public Engagement and Experience Strategy continues apace with its key principle of “no decision about me, without me.” To assess progress, we asked independent auditors to review patient experience initiatives. Their findings gave significant assurance:
“It is apparent that Airedale [Foundation Trust] has actively strived to promote positive patient experiences throughout the organisation through the enactment of excellent and clear monitoring systems, reporting processes, information collation and communication plans. A number of excellent, forward thinking and innovative engagement and patient experience initiatives have also been noted”.2
A particularly powerful tool is the patient story. Each month the Trust Board listens to a unique patient perspective: known as “through your eyes”. The following is based on a qualitative interview and is used with permission.
David’s Story
In December 2009, David’s partner, Roy, suffered a stroke and was admitted to Ward 5. David described the ward staff, from the orderlies to the doctors, as “fantastic”. Their affection for Roy and compassion for David was evident:
“When I was feeling down, they’d give me a hug.”
David was able to visit at any time, during the day or at night. When Roy developed pneumonia, David was fully involved in the care decisions. In January 2010, Roy, died. He was 84. David and Roy had been together for 42 years.
Whilst David could not fault the care received, he believes that there are aspects of bereavement that deserve greater consideration. He feels that it is difficult for men in our society to openly grieve, whilst there is a lack of specialist support in respect of homosexual bereavement. He cautions against insensitive stereotyping and presumptuous questions. If greater support across the health and social care had been available, David feels he would have been better able to address the anguish and the emotional isolation he felt after Roy’s death.
Source: Trust Board Meeting June 2013.
The attitude and behaviours towards dying and the care and treatment needs of vulnerable groups have been the subject of local and national reassessment in the last year. David’s experience reinforces the need for continual reflection.
We strive to provide a dignified death for patients at the end of their life and appropriate support to their relatives and carers. Following an independent national review, the Liverpool Care Pathway is being phased out to be replaced with an end of life care plan. Nationally, it transpired that poor training in the use of the pathway had led to the guidance being misinterpreted. In the absence of a countrywide pathway, the Medical Director, in consultation with fellow professionals and following assessment against the NICE quality standard (QS13), issued guidance to clinical staff in caring for those approaching the end of life. Our palliative care team continues to support staff, patients and relatives with the necessary information, including the principles of the Gold Standard Framework. Decisions
2 Mersey Internal Audit Agency Report (2013), Review of Patient Experience Final Report. p.7.
regarding resuscitation are currently under review as recommended by the findings of clinical audit. This includes improving documentation of conversations with the patient and family.
“We saw actions had been developed to improve end of life care for people who used the service. Systems were in place to ensure these plans were reviewed and monitored by the Trust.”
Source: Care Quality Commission (2013) Airedale NHS Foundation Trust Airedale General Hospital Quality Report. p.34. 8
The Patient and Carer Panel has identified end of life care as a priority work stream in its 2014/15 work programme.
The ageing population and the growing prevalence of dementia make caring for this group of patients a core priority. Staff continue to undertake additional training to recognise and deliver more effective care for those with dementia and support carers who live with its affects. The environment can have an impact on how a patient with dementia functions and often simple alterations can improve cognition. This year the Trust made a successful “Here to care” bid to the Department of Health to upgrade four wards and a garden area at Airedale General Hospital to make these settings dementia-friendly. A refurbishment of the orthopaedic suite includes dementia environmental improvements.
Behaviours and values: a series of high profile reports – Mid Staffordshire, Winterbourne View, and the Patients’ Association – serve to remind us all of the significance of a culture of compassionate care. Good care is not only about technical skills and knowledge; it is also about demonstrating genuine concern, empathy and respect for people’s individuality. The way our staff deal with people in their everyday work has a considerable impact on the quality of their care and experience. How we care at a time of vulnerability will always be remembered; “we must make every contact count”.1 Building on the 2012 project Dignity and Respect in Care, a set of essential standards has been developed and apply to all staff. The nursing directorate has set out its strategic vision for nursing in “Right Care” Nursing and Midwifery 2013-2015, aligning with the national nursing strategy of care, compassion, competence, communication, courage and commitment (“The 6 Cs”).
Each year the Trust takes part in national patient surveys to find out about the experience of people who use our services. Findings are used to help us understand how to improve the quality of service provision. In February 2013, 300 women who used our Maternity Services to give birth were sent a questionnaire from the CQC focusing on the care, treatment and support provided; 48 per cent responded. Compared to 137 other trusts, patients told us we were better at postnatal care at home: they had confidence and trust in the midwives and were given the help needed. There were no areas where we were judged to be performing below the expected range. Valuable feedback has provided insight into where improvements can be made, including more support for breastfeeding mothers.3 A similar survey was undertaken in 2010. There is a limit to how accurately the data can be compared across years and evaluation can only be reliably made within labour and birth; a statistically significant improvement in kindness and understanding after birth is reported.
Friends and Family Test: since April 2013, patients have been asked whether they would recommend hospital wards and the Emergency Department to their friends and family if they needed similar care or treatment. This provides an understanding of the needs of our
3 Care Quality Commission (2013) Survey of women’s experience of maternity services 2013. Available from:- http://www.nhssurveys.org/Filestore/MAT13/Benchmark_LB/Labour%20and%20Birth%20Reports/MAT13_LB_RCF.pdf [Accessed 23/12/13].
patients and enables improvement. The Trust performs at or above the national average in this survey.8 (For more analysis see section 2.3.6 Friends and Family Test – Patient.)
Adult Inpatient survey 2013:4 during August 2013, 808 people aged 16 or over, who had spent at least one night in hospital, were asked a range of questions about their care and treatment; 50 per cent responded compared to 49 per cent nationally. Generally, the scores reflect similar responses to the survey undertaken in 2012. We have made a significant improvement in: seeking patient views on the quality of care during a hospital stay and in the provision of printed information about what to do and not do after leaving hospital. Compared to 2012, we scored significantly worse for hospital staff discussing whether additional equipment or adaptations are needed in patient homes. In last year’s survey, there was one area where our score was significantly lower: waiting for a bed from the time of arrival at the hospital to getting a bed on a ward. Although there continues to be high numbers of patients coming through our ED, we have looked at a range of measures to speed up this process and we can report an improved score in the 2013 inpatient survey. For the majority of questions, the Trust is performing about the same as other providers but is better than most others for one question: Was your admission date changed by the hospital? The Patient and Public Engagement and Experience Operational Group is currently determining ways to ensure improvement measures are in place and carried out in those areas of identified shortfall.
The 2013 National Cancer Patient Experience Survey places the Trust in the top 20 per cent in England for the number of patients who reported our care as “excellent” or “very good”. Of 493 eligible Trust patients, 304 questionnaires were returned. Overall the feedback showed hospital and community staff always worked well together and patients did not feel they were treated as a “set of cancer symptoms”. There was one area where we were rated in the lowest 20 per cent: staff failing to inform patients about free prescriptions. The Trust is working to ensure this information is given to all eligible patients.
The Inquiry into Mid Staffordshire NHS Foundation Trust highlights the role of complaints as a warning sign of underlying issues. An independent review of how complaints are handled in the NHS was published in 2013.5 The Trust has sought to learn from the recommendations set out in this Review and is presently revising its complaints management procedures. Independent and external auditors report that there are adequate systems in place within our Trust for the management of complaints and these are operating effectively.6 They also note good levels of customer care when dealing with complaints.
The Trust takes complaints extremely seriously and is committed to learning how we can improve. Whilst a summary of complaints activity is included in the Quality Account, more detailed quantitative and qualitative analysis is provided in the Trust’s statutory annual Complaints and Concerns Report 2013/14.7
In 2013/14 there were 2566 issues raised, from 1910 contacts with the Patient Advice and Liaison Service (PALS), of which 2408 were specifically related to Airedale General Hospital: 490 were compliments, 384 were requests for information and 1534 were expressions of concern, dissatisfaction and requests for action to be taken. The remaining 158 issues were related to other organisations. Evaluation focuses on recurring themes and on specialities or wards with a persistent profile of concern. Nine of the PALS contacts became a formal
4 CQC (2013) Survey of Adult Inpatients.Available at: http://www.nhssurveys.org/Filestore/documents/IP13_RCF.pdf [Accessed 08/04/14]
5 Clwyd A. and Hart T. (2013), A Review of the NHS Hospitals Complaints System: Putting Patients Back in the Picture. London: Crown copyright.
6 Mersey Internal Audit Agency Report (2013), Complaints Review – Final Report.
7 The annual Airedale NHS Foundation Trust Complaints and Concerns Report 2013/14 will be available in June 2014 at: http://www.airedale-trust.nhs.uk/About/corporateinfo/complaints.html
complaint during 2013/14. This is often due to the complexity of the concern which requires a formal investigation, undertaken on the instruction of the complainant. Whilst the number of PALS contacts continues to increase year on year, the number of formal complaints has stabilised in the last three years.
In 2013/14 a total of 73 formal complaints were received, compared to 67 in the previous year and 72 in 2011/12. The Trust has no outstanding complaints that are undergoing an initial review by the Parliamentary Health Service Ombudsman (PHSO). In this period one complaint was partially upheld by the PHSO; the key area was the lack of evidence relating to multi-disciplinary team discussions. An action plan will be implemented once the final report has been received.
Your concern… “There appeared to be a lack of understanding of the requirements of a patient who has dementia.”
Our response… 70 per cent of staff have received the Butterfly Scheme training with a programme in place for the outstanding staff to complete by October 2013.
Your concern… “The speech and language therapist did not follow the statutory assessment guidelines, failing to include us as parents, leading to a poor assessment.”
Our response …We reviewed the statutory speech and language report writing guidelines, highlighting the importance of involving parents.
Source: Airedale NHS Foundation Trust Complaints Team 2013.
Domain 2: Patient safety
In July 2013 the Care Quality Commission (CQC) announced a new hospital inspection scheme for acute hospitals under the leadership of Professor Sir Mike Richards. Airedale was selected for inspection in the first wave of 18 NHS trusts. The 18 NHS trusts were chosen as collectively they represented the variation in NHS hospital care in England. Airedale was included due to our low risk associated with mortality ratios, re-admission rates, patient safety incidents, avoidable infection rates and qualitative patient intelligence and survey information.
The inspection took place over two days and included an “out of hours” visit. It involved a significantly large inspection team comprised of doctors, nurses, trained members of the public, managers, regulators and health intelligence analysts. Drawing on clinical data and information provided by patients, the public and other organisations, the inspection focused on eight key service areas: Emergency Department, medical care (including the frail and elderly), surgery, intensive/critical care, maternity, paediatrics and children’s care, end of life care and outpatients. A further unannounced follow-up inspection occurred.
A Quality Summit with the CQC inspection panel and the Trust Chairman, Chief Executive, Medical Director and Director of Nursing was held in November 2013 to present the review findings. The CQC found that care is safe, effective, well-led and responsive to the needs of patients. Patients are positive about the care they receive. The sense of community, staff pride and the ethos of volunteering was highlighted. Although there are no actions identified that we must take, the CQC made a series of recommendations to improve record keeping and staff uptake of mandatory training; review nurse staffing levels and skill mix
(particularly on wards caring for older more dependent patients); reassess the additional duties of maternity healthcare support workers (HSW); and reconsider our Critical Care Unit service strategy to ensure it is organised around the needs of patients.
“In one medical ward and one surgical ward we were concerned that the current level and mix of staffing could present a risk of patients not receiving safe care…it needs to be addressed to reduce risk.
We also had some concerns about the way the hospital’s critical care unit is managed…the unit appears to work in isolation from the rest of the hospital …it lacks a clear direction and strategy.”
Source: Care Quality Commission (2013) Airedale NHS Foundation Trust Airedale General Hospital Quality Report. p.1. 8
We take our duty to learn from the advice of our regulators seriously: an action plan is in place, monitored by executive directors and task and finish groups have been established to review the issues relating to staff. Staffing levels, skill mix and continued professional development are all paramount to the delivery of safe and responsive care. From January 2014, the Safer Nursing Care Tool has been utilised to calculate nursing establishment levels; the training programme was reviewed in 2013 to ensure clinical practice is based on current available evidence. To view the CQC summative report of our standard of care, follow the link at the foot of the page.8
The CQC did not formally rate the hospital; this process is being piloted at present and we will therefore be subject to a further inspection before the end of 2014. In support of this new regulatory regime, the CQC publishes a quarterly Intelligent Monitoring Report on each acute provider. The CQC categorises trusts into one of six bands, with band 1 representing the highest risk and band six the lowest. These bands are based on the proportion of 118 indicators identified as at “risk” or “elevated risk”. Airedale is in the lowest category, band six. Despite this, we remain focused on areas where we can learn and improve.
Incident monitoring: the first step towards improving patient safety is to understand where problems are occurring. Regrettably this year the Trust recorded its first Never Event under the wrong site surgery classification. The incident relates to a day case dental procedure, which has been thoroughly investigated to ensure we learn lessons from the events surrounding it. In accordance with our Being Open Policy the patient was informed, an immediate review of practice was undertaken and a root cause analysis meeting convened and chaired by the Chief Executive. We have made changes to our processes by including an additional verbal check prior to all dental procedures.
We reported a serious incident in 2012 which sadly resulted in the death of a patient awaiting emergency surgery. A preliminary investigation revealed that this was due to a number of complex factors. Surgery was initially delayed to ensure the patient was well enough to undergo the procedure. Clinicians subsequently failed to recognise the severity of the patient’s condition, whilst a busy theatre schedule added to the delay in response. In consequence, the Trust referred itself to the Royal College of Surgeons. Action plans focussing on what happens once a patient is admitted for emergency surgery are currently being implemented to mitigate future risk.
Reporting Concerns and Whistle blowing Policy: whilst nothing prevents our staff from raising patient care and safety concerns, CQC feedback indicates that the Trust must continue to reflect on its behaviours. A positive and transparent culture that supports staff to do “the right thing” for patients depends on listening to staff and understanding that reaching targets and achieving financial balance can never be at the expense of acceptable standards of care. Whilst the Trust awaits national guidance on the duty of candour, we
8 Care Quality Commission (2013) Airedale NHS Foundation Trust Airedale General Hospital Quality Report . Available from:- http://www.cqc.org.uk/sites/default/files/media/reports/20131115_airedale_general_hospital_-_cqc_quality_report_final.pdf [Accessed 25/11/13].
recognise the necessity to listen to staff willing to challenge decisions or actions they perceive to be wrong or harmful. Staff need to feel supported to do their job well.
An open reporting and learning culture is important to enable us to identify trends in incidents and implement preventative action. We continue to review incident reporting systems to promote an effective safety culture. The 2012 NHS National Staff Survey indicated that this is an area we could improve upon: 88 per cent of our staff reported errors and near misses against a national average of 90 per cent. The 2013 issue shows 91 per cent of staff reporting errors, near misses or incidents witnessed against a 2013 national average of 90 per cent. Staff scored the fairness and effectiveness or incident reporting procedures in the highest 20 per cent of all acute trusts surveyed.9 Low and no harm incidents account for 98.6 per cent of all incidents that occur.8 (See section 2.3.9 Reported patient safety incidents for more analysis.)
The annual National NHS Staff Survey9 helps us to improve the working lives of all our staff. Previous surveys have revealed issues around work pressure; work related stress; satisfaction with the quality of work and patient care; and staff motivation at work. In the 2013 survey, Airedale showed improvement in the score for “staff job satisfaction”. Airedale staff also scored the hospital highly in terms of “recommendation of the Trust as a place to work or receive treatment”, “the care of service users as a top priority” and “acting on concerns raised by patients”. Compared to other trusts, the results of the survey indicated that we are better at: infection control and hygiene; provision of support and opportunity for staff to maintain their health, wellbeing and safety; and equality and diversity. Areas where we need to make improvements compared to other trusts are: in the number of staff appraisals undertaken, staff “feeling pressure to attend work when feeling unwell”; staff “agreeing that their role makes a difference to patients” and being “satisfied with the quality of work and patient care they are able to deliver”. The latter two issues feature highly amongst staff with corporate functions. The Trust is currently considering how best to respond to these findings and will develop Trust-wide and service level action plans. (Also see section 2.3.5 Family and Friends Test-Staff recommendation.)
Building and strengthening leadership: we know that there is a relationship between strong leadership, a caring and compassionate culture and high quality care. Valuing and nurturing our staff is crucial to staff engagement and organisational development. Leadership potential and talent spotting continue to be actively promoted, with appropriate access to leadership development programmes, including the Rising Stars initiative. Emphasis has been given to coaching individuals and teams to support innovation, problem solving and programme delivery through effective change management. Projects on discharge, outpatients and maternity are underway with executive team sponsorship. A number of quality improvement projects have been initiated by our junior doctors, supervised by the Medical Director’s Unit.
As the care landscape evolves through integration, opportunities for nursing staff and allied health professionals will become available. The staff appraisal scheme is being reviewed to ensure our workforce is adaptable and flexible and that staff are supported through the transition and re-design. Human Resources is currently working with Bradford University School of Management to understand how this can be achieved.
Infections that are acquired as a result of healthcare interventions (healthcare associated infections) remain a high priority for the Trust. Across England there has been a 72 per cent reduction in MRSA bacteraemia rates in the period 2008/09 to 2012/13 and a 67 per cent decrease in the rate of C. difficile.10 According to the CQC’s analysis, our C. difficile infection rate is better than expected, whilst the MRSA bacteraemia rate is within the expected
9 NHS Staff Survey 2013 available from: http://www.nhsstaffsurveys.com/Page/1010/Home/Staff-Survey-2013/ [Accessed 04/03/14].
10 CQC (2013), The state of healthcare and adult social care in England 2012/13. London: The Stationery Office.
range.11 In October 2013 we reported our first MRSA bacteraemia case after 434 days; a further case occurred in February 2014. Despite our best efforts, we breached the Department of Health target for all trusts of zero cases for the 2013/14 fiscal year. (See sections 3.2.1 Infection prevention and 2.3.8 Rate of C. difficile for further review.)
Safeguarding: in the light of the Jimmy Saville allegations, all NHS providers were required to review arrangements and practices relating to vulnerable people, particularly in regard to access to patients including that afforded to volunteers. In response we have developed an action plan, monitored via the Trust’s Safeguarding Group. We continue to focus on ensuring that lessons are learned from local, regional, and national safeguarding incidents.
In the face of rising demand and reduced budgets, it is important that the focus on efficiency savings is not at the expense of patient safety. The “Right Care” Programme to Safely Reduce Costs proposes to move away from cost savings associated with individual services and departments where efficiencies have already been made, to focus on new ways of working between teams and departments. The aim is to improve effectiveness whilst minimising any risks to quality and safety by recognising inter-dependence of services.
Domain 3: Clinical effectiveness
Mortality rates: The Good Hospital Guide (Dr Foster Intelligence 2013) analysed weekend care across trusts in England: emergency admission mortality; re-admissions of those discharged at weekends; waits for tests and scans; timeliness of emergency operations; and survival of patients where their operation was scheduled earlier in the week. Airedale is one of eight trusts with low mortality rates for both weekdays and weekends and one of six trusts with low re-admission rates for both weekdays and weekends. In the key mortality measures – Hospital Standardised Mortality Ratio (HSMR), Summary Hospital-level Mortality Indicator (SHMI), deaths in low-risk conditions and deaths after surgery – Airedale is one of 20 trusts where rates are lower than expected or within the expected range.12 (See section 2.3.1 Summary hospital-level mortality indictor for more analysis.) In 2013 individual surgeon’s death rates in a number of surgical specialties were published.13 The data derives from national clinical audits which the Trust participates in. Consultants had to agree to have results from their operations published; no Airedale consultant refused consent to participate although one consultant’s data could not be located. The Medical Director reviewed all specialties (including visiting consultants); all are “operating” within the expected range.
We want our services to be organised around the interests of patients. In order that the patient is treated in “the right place, at the right time, the first time, in all care settings”1, we continue to collaborate with our partners across social, voluntary and health care sectors to transform clinical services. This ambition requires new evidence-based clinical care pathways which integrate primary, intermediate and acute care.
Eight multi-disciplinary community team meetings, focused around GP practice populations and comprised of district nurses
11 CQC (2013), Airedale NHS Foundation Trust Inspection Data Pack. p. 37.
12 Dr Foster Intelligence (2013), Dr Foster Hospital Guide 2013: Strengthen Your “Weakend”. Available from:- http://myhospitalguide.drfosterintelligence.co.uk/#/weekend-care [Accessed 12/12/13].
13 Surgeons’ outcome data is available from: http://www.nhs.uk/choiceinthenhs/yourchoices/consultant-choice/pages/consultant- data.aspx. [Accessed 02/12/13].
and matrons, social workers, mental health practitioners and voluntary groups, have been developed to improve the care of patients. Frontline staff work cohesively to deliver services, whilst a predictive risk (stratification) tool helps teams to identify and prioritise the needs of those patients at greatest immediate risk. A Directory of Services has been compiled of health, social and voluntary provision to support referral to the right services. Staff and patient evaluations continue to inform learning and direct progress. A group has recently been established to ensure that intermediate specialist locality services are fully co-ordinated with community services. Evaluation of progress indicates a high level of staff engagement and suggests that this model can avoid patients coming into hospital when they can be more effectively cared for in community settings.
“It is only when I attended the multi-disciplinary team [meetings] that I started realising the benefits or certainly the potential…By having partners around the table to discuss the patient’s wider needs it means we can come up with integrated solutions. For example…we have been able to access mental health outreach services for patients at high risk of admission…
We are able to access a wider spectrum of care providers who we may not otherwise have had access to, including voluntary sector organisations…The biggest problem is tackling generalised health anxiety, loneliness and isolation. The medical approach is not always the best option for dealing with these issues and this is one of the biggest reasons for getting repeat visits to the surgery and unscheduled admission. …
The multi-disciplinary team approach is a good start but we need to have a better service offer, including community based services …”
Source: Dr Graeme Summers, GP Ilkley Moor Medical Practice.
The Trust is now able to access SystmOne, the computer system used by GPs, meaning patient information can be shared amongst the professionals involved in care. This can be particularly important for patients with a cognitive impairment who may have difficulty remembering prescribed medication on admission to hospital. Patient information can be exchanged with greater efficiency; the technology supports electronic reporting of GP radiology results with 48 hours. SystmOne has enhanced cohesion with partners and, with its ability to send instant messages internally between professionals, improved in-hospital communication. Work has begun to scope the next phase of our plans for a shared and integrated electronic patient record across primary, secondary and social care communities.
The Emergency Department continues to experience high demand. Sustaining the required level of performance (patients receiving treatment within the four hour standard) is challenging, particularly in winter months. We recognise that for our local community long waits for treatment and admission to wards causes inconvenience, frustration and anxiety. This pattern is repeated across the country and, in the last year, the Trust has participated in a round table discussion with the Secretary of State for Health to discuss a national framework for urgent care. In the interim, clinical directors have worked with hospital managers to design and implement a different way of assessing and caring for urgent medical and surgical patients. A Surgical Assessment Unit has been established and increased investment in the development of the Acute Medical Unit and the Ambulatory Care Unit means GPs can access consultant expertise and avoid unnecessary admissions. Patients are reviewed quickly and can receive the required treatment. Although we are better able to manage increased numbers of patients, the Trust, in conjunction with our commissioners, continues to advocate for improvements across the health and social care economy to improve patient flow, primarily, via the re-design of the medical admission pathway.
In 2011 we established a Telehealth Hub on the Airedale General Hospital site. This technology continues to support patients with long-term conditions in their own homes, nursing and residential care homes and to rural communities with community based remote outpatient consultations. Telemedicine and other assistive technologies offer the opportunity for personalised and responsive treatment and support.
“…there is no expensive journey to and from hospital. No re-organising of work commitments to then spend time sitting around in waiting rooms… …simply a live link up where I can talk freely and we can swap ideas as to how to improve my life…”
Gillian, diabetes patient, talking about her home based telemedicine service.14
The last year has seen increased uptake of this technology in nursing homes and GP surgeries. We continue to work with Manorlands and specialist palliative consultants in supporting those at the end of their life who wish to die in their own home. The Telehealth Hub has been designated as a three star reference site in the European Union Active and Healthy Ageing Innovation Programme. With a focus on older people, this pilot scheme aims to increase the average healthy lifespan of Europeans by two years by 2020. We are the only site in England to receive the maximum star award.
Complementing innovation is Airedale’s strong research culture, designed to promote the best use of available evidence and to increase knowledge and expertise in the support of clinical effectiveness. The Trust participates in a broad portfolio of clinical trials, including long-term conditions (diabetes, dementia), cardiology, stroke and oncology. We continue to meet the national approval target with recruitment to trials steadily increasing.
Research in Action: P-I-E
The Trust is taking part in the “PIE” programme, a three year observational research project funded by the National Institute of Health Research, to improve the quality of communication with older and more vulnerable patients. An observational tool is used to look at the “Person” receiving care, their “Interactions” with staff and the immediate “Environment”. Staff sit alongside patients at planned intervals to view and experience care at first hand. Observations of staff routines and ward practice are made. Source: Airedale NHS Foundation Trust (November 2013) Research Newsletter.
In conclusion
Delivering high quality evidence-based care depends on measuring outcomes in order to understand and drive improvement. Alongside clinical outcomes, measurement should focus on the experience of those using our service. It is important that our Quality Account is accurate, transparent and presents an unbiased view of the quality delivered by Airedale NHS Foundation Trust. There is always opportunity for improvement and we are committed to working with and listening to staff, expert bodies, including royal colleges, and other partner organisations to identify, monitor and improve services and ensure that all our patients and carers receive high quality, compassionate and responsive care.
Dr Andrew Catto, Dr Harold Hosker Rob Dearden, Medical Director 2013/14 Interim Medical Director 2014 Director of Nursing 29 May 2014
14 Link to this interview and others: http://www.airedaledigitalhealthcarecentre.nhs.uk/Videos/ [accessed 19/11/13].
2. Priorities for improvement and statements of assurance from the Board
2.1 Priorities for improvement
In last year’s Quality Account, we identified our three key local quality priorities for the coming year:
Domain 1: Patient experience: improving nutritional care for patients with dementia; Domain 2: Patient Safety: reduction of slips, trips and falls sustained by patients admitted to our hospital wards; and Domain 3: Clinical Effectiveness: the use of telemedicine to improve the overall quality of healthcare for people with long-term conditions.
We report on our progress against these in section 2 of this report and also present a core set of national quality statements and metrics to allow comparative understanding of performance.
Our progress and performance during 2013/14 in other local quality improvement work is reported in section 3 of this Account and within the three domains of quality:
Section 3.1: privacy and dignity; creating a customer service culture; Section 3.2: infection prevention; management of pressure area care; and Section 3.3: management of the number of Caesarean sections; enhanced recovery programme; fractured neck of femur improvement project.
In the last year, the Medical Director and Director of Nursing have commenced work on developing a Trust-wide quality improvement strategy, underpinned by the Trust’s Forward Plan Strategy 2013-14 to 2015-16,1 as approved by the Board of Directors.
The quality improvement priorities for 2014/15 are as follows:
Domain 1: Patient experience: improving nutritional care for patients with dementia; Domain 2: Patient Safety: reduction of slips, trips and falls sustained by patients admitted to our hospital wards; and Domain 3: Clinical Effectiveness: the use of telemedicine to improve the overall quality of healthcare for people with long-term conditions.
As previously described in section 1, the views of staff and governors as well as the external health economy stakeholders have been considered in the work described.
2.1.1 Priority 1 patient experience: improving nutritional care for patients with dementia Lead Executive Director Rob Dearden, Director of Nursing Clinical Lead and Implementation Lead Elaine Andrews, Assistant Director Patient Safety Fiona Throp, Senior Nurse for Older People Jane McSharry, Senior Nurse Practice Development Sharon Robinson, Senior Nurse Older People
Rationale and aim
Of people accessing acute hospital services, 25 per cent are liable to have dementia and the number of people with dementia is expected to double in the next 30 years. Hospital stays are recognised to have detrimental effects on people with dementia.15 Refusal to eat, loss of appetite, forgetting to chew and swallow and being distracted are all frequently observed in this vulnerable group.16 The Patient and Carer Panel continues to regard dementia care as a key work stream and dementia services are part of our wider integration work across local health and social care sectors. Through focusing on developing the skills and expertise of our workforce in the care of patients with dementia, the Trust seeks to meet the complex needs of those living with dementia, including improved nutrition.
The Butterfly Scheme was developed by a carer, Barbara Hodkinson, from observations of her mother’s dementia care whilst she was in hospital recovering from a knee operation. The scheme is designed to:
. Highlight the unique needs of patients whose memory is permanently affected by dementia by displaying (with appropriate consent) a butterfly symbol. . Provide staff with simple, practical guidance towards meeting the needs of these patients such as the REACH response: Remind, Explain, Arrange, Check, History. . Alert staff to the use of carer information via the “All about Me” form which offers helpful information to enable staff to better engage and create a more positive experience for the patient. In completing the form, input from relatives and carers is encouraged to ensure a patient’s care plan reflects preferences and dislikes, including food and drink. This can improve nutrition, hydration and the mealtime experience.
Current status
The Trust has adopted the Butterfly Scheme with mandatory training for nurses, health care support workers, phlebotomists, physiotherapists, doctors, and dietitians. This provision also includes volunteers and bank staff. By the end of March 2014 over 77 per cent of the workforce had achieved competency in privacy and dignity training which incorporates the Butterfly Scheme. Staff are also encouraged to undertake the Social Care Institute for Excellence dementia e-learning programme. Communication has been consolidated with primary care via SystmOne, the patient administration system, and now includes a butterfly alert alongside access to the GP record.
Generally, there is a low level of knowledge about what makes a positive therapeutic environment for a person with dementia. Changes in the physical surroundings can encourage greater independence, lessen anxiety, improve nutrition and reduce the number of falls. The King’s Fund has developed a toolkit for the acute setting, with the purpose of enhancing the healing environment. The Patient and Carer Panel has used the toolkit to audit friendliness, atmosphere, colours, surfaces and identifiable areas for dementia patients across the Trust. This work informs the ongoing refurbishment work.
15The Kings Fund (2012), Enhancing the Healing Environment. Available from:- http://www.kingsfund.org.uk/projects/enhancing-healing-environment/ehe-design-dementia [accessed 26/11/13].
16 Watts, V.et al., (2007) Feeding Problems in dementia Geriatric Medicine 37:8 –pp.15-19.
Supported by the successful “Here to Care” bid of £450,000, work has commenced to improve four wards and a garden area at Airedale General Hospital. Planned changes include: . Dining and social areas: research suggests that access to safe social spaces and improved dining areas reduces distress and has a positive impact on dietary intake. Scoping work on how aroma can stimulate appetite is being undertaken. Colour selection is designed to promote relaxation and minimise visuo-spatial problems; . New matt flooring: shiny surface are perceived as slippery resulting in changes in gait and increased risk of slips, trips and falls; . Eye-catching, colour contrasting schemes and signage to help patients find their way around, whilst highlighting key facilities such as toilets and handrails; . Artwork to make bed areas identifiable and less clinical; and . Accommodation for carers to stay with distressed relatives. These principles have been also been adopted within other units and departments in their refurbishment such as the Endoscopy Unit, and incorporated in the Emergency Department plans. A task group of clinical experts, the Alzheimer Society, patient and carer representatives and estate personnel is overseeing this work.
In line with NICE recommendations, a formal Malnutrition Universal Screening Tool (MUST) is used for all inpatient admissions to establish nutritional risks. Completion of this tool is audited on a monthly basis using nursing key performance record keeping indicators and scrutinised by the Trust’s Nursing and Midwifery Leadership Group. A recent audit of completion of the MUST tool has identified that further training for nurses is required to ensure that all sections are completed properly and that any malnourished patients are identified correctly.
It is important that we are able to monitor the effectiveness of these measures. Complaints provide valuable quantitative and qualitative information. . In 2011/12, the Trust received five formal complaints on matters relating to nutrition; one of these concerned a patient with dementia. . In 2012/13, three formal complaints were made, raising concerns to do with nutrition; two of these concerned patients with dementia. . In 2013/14, there were four formal complaints regarding nutrition, of which two patients had dementia. Actions arising from the above were dealt with in accordance with our complaints processes in order to seek early resolution, change practice and ensure that lessons are learned.
Healthwatch Bradford and District, Enter and View Report
Healthwatch was created to represent the views of those that sometimes struggle to be represented. Comprised of members of the public, trained to deal with sensitive situations and confidential information, it is authorised to carry out visits to health and social care providers to evaluate how a service is being run and make recommendations for improvement.
After concerns were raised locally in relation to the care of older people with cognitive impairment on Ward 1 (Elderly Care), Healthwatch conducted an “enter and view visit” in August 2013 with a particular focus on communication between staff, patients and family members, predominantly for those for whom English is not their first language.
Healthwatch was impressed by the commitment of staff, the general conditions and the care of patients: eight members of staff have become “Dementia Champions”, which equates to 25 per cent of ward staff; visiting times are flexible; the ward environment is part of the wider [described] upgrade. A number of recommendations were made, including improving: the visibility of the butterfly logo and communication at discharge.
Healthwatch attended the December 2013 Trust Board meeting to present its findings.17
17 The full report is available from Healthwatch at the following link:- http://www.healthwatchbradford.co.uk/sites/default/files/ev_visit_19th_aug_final_report.pdf [Accessed 08/01/14].
The Trust continues to reflect on how to promote more active links with various community and voluntary services, particularly those that provide social support for elderly from ethnic minorities. This initiative is supported by Healthwatch which plans to gather more views from carers and patients with dementia.
Initiatives and progress in 2013/14
. A dementia “Rapid Improvement Event” was held in 2013. Using LEAN methodology lasting over five days and involving key local stakeholders, its aim was to look at how to improve the care and treatment of patients attending Airedale with dementia. The current pathway was mapped and information on good practice and areas for development gathered. One aspect under consideration is the improved access to and provision of drinks in the Emergency Department. . A one-to-one nursing project is being implemented for those patients with dementia who are distressed and/or may have more challenging behaviours. Staff have been identified and trained to support this patient group and work with carers and families. . The development of our multi-disciplinary “Dementia Champions” continues. . A monthly Dementia Carers Audit is being undertaken to monitor the effectiveness of our current care provision. . The “feeding buddy” scheme continues to enhance the patient experience with 23 volunteers (including staff members) on the rota. . Daily monitoring reports to matrons of the number of patients who require assistance to eat allows support staff, including “feeding buddies”, to be assigned to those wards requiring greater assistance to help patients to eat and drink.
The Trust is involved in a number of regional and national dementia networks, notably the Bradford and District Dementia-Friendly Communities Project led by the Alzheimer’s Society. This ensures that we are at the forefront of current research and innovation.
Initiatives in 2014/15 to achieve progress:
. Work to develop the environment for people with dementia is due to be completed by September 2014. . The social spaces, particularly on the elderly care wards, will include regular “coffee and cake” afternoons facilitated by volunteers. . Alongside the Person Interaction Environment (PIE) research previously described, the University of Bradford’s Dementia Group has invited the Trust to participate in its Person Centred Care Programme. Twelve staff members will be selected to receive intensive training with a cascade of learning to colleagues. . Our dementia focus extends beyond our elderly care wards and we are currently reviewing the patient pathway for dementia patients to ensure admission, assessment and allocation to the relevant ward is timely, with stress for the patient minimised. Work streams include: admission avoidance, patient flow (a system is in place to allow patients with dementia to bypass queues at outpatient reception), the elective pathway and discharge planning.
Process for monitoring progress
The multi-disciplinary and agency Transform Dementia Services Group co-ordinates the key dementia priorities: environment, training, admission avoidance, patient flow and elective pathway. Membership includes patient and carer representatives. The Nutrition and Hydration Group meets regularly to agree what is best practice in all aspects of nutrition and hydration and provides quarterly update on progress to the Quality and Safety Operational Group. Complaints are one of a series of quality markers used to provide measurement of
the effectiveness of initiatives. Complaints feedback is received on a monthly, quarterly and annual basis at ward level and through to Board. The annual Airedale NHS Foundation Trust Complaints and Concerns Report provides a summary of the Trust’s mechanisms for measurement and learning.
2.1.2 Priority 2 patient safety: reduction of slips, trips and falls sustained by patients admitted to our hospital wards Lead Executive Director Rob Dearden, Director of Nursing Clinical Lead and Implementation Leads Debra Fairley, Deputy Director of Nursing Elaine Andrews, Assistant Director Patient Safety Noel McEvoy, Senior Nurse Safeguarding Adults
Rationale and aim
Whilst patients of all ages fall, the occurrence is greater in older people: one in three people over the age of 65, and half of those over 80 will fall each year.18 For hospital inpatients the risk is compounded by factors such as delirium and cognitive impairment; medical diagnosis/condition which could be multi-factorial; disabilities for example, poor eyesight, hearing and mobility; and other problems associated with continence. Slips, trips and falls are collectively our most reported patient safety related incident, a finding consistent across England. With inpatient falls being a common cause of injury, pain, distress, delay in discharge and loss of independent living, the effective management to reduce their number is an important priority. The Trust aims to demonstrate a year on year reduction in the number of falls sustained by inpatients. This is not without challenges: staff must continually balance duty of care with patient independence and rehabilitation.
The Patient and Carer Panel continues to regard this area as a priority, with representation on the Trust’s Falls Management Steering Group. This group has been in place since June 2010 and is responsible for implementing robust systems and processes to reduce the risk of falls and the resultant harm and injury. This group is accountable to the Strategic Safeguarding Adult and Children Group.
Current status
Table 1: Airedale NHS Foundation Trust rate of inpatient falls per 1000 bed days
Fiscal year Bed days Reported Reported *Reported Reported falls [Y] Falls falls per falls resulting in resulting in [X] 1000 bed fracture fracture per 1000 days bed days 2013/14 112289 1254 11.2 25 0.2 2012/13 113315 1287 11.4 15 0.1 2011/12 101078 1100 10.9 32 0.3 2010/11 123529 1197 9.7 25 0.2 2009/10 127983 1089 8.5 26 Not available 2008/09 128740 777 6.0 15 Not available
A bed day is a day during which a person is confined to a bed and in which the patient stays overnight in a hospital (OECD Health Data 2013. June 2013). Data source: bed days – Airedale NHS Foundation Trust Information Services; patient safety incidents – Airedale Quality and Safety Team [Ulysses database].
*Methodology:
18 Department of Health [DH] (2009), Falls and fractures: effective interventions in health and social care. Crown copyright: COI for DH.
Bed occupancy is calculated from data from wards 1,2,3,4,5,6,7,9,10,13,14,15,17,18,19,21, High Dependency, Intensive Care and Coronary Care. Supplied by the Trust’s Information Services Department. Falls comparable with National Reporting and Learning System [NRLS] calculations are calculated as follows: X= the total number of all patient falls reported in your hospital/unit in the most recent year for which data are available. Include falls in day units and outpatients. Y= the total number of occupied bed days in your hospital/unit in the most recent year for which data are available, divided by 1000. X divided by Y gives the number of falls per 1000 occupied bed days. Taken from: The Third Report from the Patient Safety Observatory, Slips, Trips and Falls in Hospital (NPSA, 2007).
In evaluating our performance, it should be noted that the data is not adjusted for age or case-mix. The proportion of Airedale’s population aged 75 and over is nine per cent of our admitted patients.19 As explained, this is a vulnerable group with an increased likelihood of falling. With age comes an increased risk of developing osteoporosis, which in the event of a fall, increases the risk of sustaining a fracture.
All slips, trips and falls (including those that might be deemed a minor incident such as a graze) are included in the dataset. A sign of a strong safety culture is that whilst the rate of reported incidents should increase, the number of incidents resulting in severe harm should reduce. Of the 2013/14 inpatient falls: 13 resulted in a fractured neck of femur, 12 in other factures and 13 in significant harm.
Based on incident reporting, in 2013/14 the overall proportion of Airedale General Hospital inpatient falls, against inpatient admissions was 2.1 per cent of which falls resulting in fracture was 0.04 per cent. (This compares to 2.5 per cent in 2012/13 with 0.03 of these resulting in fracture.) 20
Falling is not an inevitable part of ageing and we remain committed to safeguarding patients from this occurrence. All falls that result in significant injury (fracture, head injury) are considered as a serious incident. A two day information gathering process is instigated with a report then presented to the Medical Director and the Director of Nursing for consideration so remedial measures to prevent similar incidents. For those cases not deemed a serious incident, a root cause analysis is carried out; developmental work has commenced to use a standardised tool to support this process. Patients and relatives are kept fully informed of ongoing findings. Information is aggregated with other similar episodes to maximise potential learning. The Trust’s Safeguarding Adults Team is pivotal in supporting this process.
Initiatives and progress in 2013/14:
. Feedback from our 2012/13 participation in the national Training and Action for Patient Safety (TAPS) Programme, informed an inter-agency falls “Rapid Improvement Event” held in June 2013. Participants included colleagues from Bradford District Care Trust. . The occult hip fracture pathway has been reviewed by the Missed Fracture Working Group. . The Trust’s Policy for the Prevention and Management of Slips, Trips and Falls for Patients is subject to annual review and is now a fully integrated policy encompassing community services. . Thirteen floor-level beds for patients at high risk of falling out of bed are being successfully utilized, two more than previously reported in 2012/13. An electronic hospital tracking system supports their timely location. . We have purchased a “patient safety system” for use in conjunction with the low level beds for severely agitated patients which provides a protective area around the bed and is secured using the mattress and bed rails. . Monitoring reports are now requested to ensure bed and chair alarms for those patients at high risk of falling are available and functional. . The Trust continues to contribute to the district wide Bradford and Airedale integrated Falls and Bones Health Strategy Group.
19 Yorkshire and Humber Public Health Observatory (2012) Calculating catchments. Available at: http://www.yhpho.org.uk/ [Accessed 20/01/14]. 20 Based on the inpatient admissions of 59,867 in 2013/14 and 51,863 in 2012/13.
Initiatives in 2014/15 to achieve progress:
. We will continue to develop education and training in falls management and prevention for registered nurses, allied health professionals and health care support workers, drawing upon the use of e-learning packages such as that developed by the Royal College of Physicians. . We will undertake further audit to evaluate the recent ward refurbishments and the impact on falls reduction. This will involve analysis of the number of falls before and after change as well as seeking to continually evaluate the risks to patients. . We will continue to develop closer links with health, social care and voluntary providers to encourage continuity of care and services for patients who have fallen. For example, the Trust is working with the Yorkshire Ambulance Service to ensure that mobility aids used at home are transferred with the patient to hospital. . We will seek to continually review our falls prevention and management guidance in line with NICE clinical guidelines to ensure that practice is evidence-based. . We will continue to explore the use of different mobility aids aimed at reducing the risk of falling. For example, we now supply patients who are at a high risk of falling with anti-skid socks.
Process for monitoring progress
The multi-disciplinary Trust’s Falls Management Steering Group co-ordinates the work to deliver a sustained reduction in falls. An overarching action plan is in place detailing key areas of focus: falls risk assessment, care and management of patients following a fall, discharge, patient and family information, equipment and training and education. Incident monitoring systems support measurement and learning; occurrences of slips, trips and fall events and the level of harm are reported and reviewed on a monthly, quarterly and annual basis at ward level through to Board. A Missed Fracture Working Group has been established to focus on learning from incidents and near misses, education, national guidance and current pathways. The annual report – Falls with Airedale NHS Foundation Trust - provides a summary of progress against this priority.
2.1.3 Priority 3 clinical effectiveness: quality of healthcare for people with long-term conditions – telemedicine technology Lead Executive Director Stacey Hunter, Director of Operations Implementation Lead Marie Buchan, Telemedicine Manager
Rationale and aim
There is evidence to suggest that people, particularly those with long-term conditions, want to have control over decisions about their care, desire to live a normal life and do not wish to spend time in hospital unnecessarily.21 Feedback from our Quality Account engagement event in October 2013, which included a demonstration of telemedicine technology, and satisfaction surveys of patients and staff endorse this finding. According to Dr Foster (2013), people with chronic illness can avoid emergency treatment and admission if their condition is well-managed.22 Assistive technologies, such as telemedicine, can allow patients to manage their conditions and avoid time-consuming and costly trips either to hospital or outpatient clinics. An approach integrated around the needs of individual patients offers the potential for greater collaboration and efficiency across health and social care. Airedale’s Telehealth Hub aims to care for patients closer to home whenever it is safe to do so.
21 Department of Health (2011) Whole System Demonstrator Programme. Available from:- https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215264/dh_131689.pdf [Accessed 06/12/13].
22 Dr Foster Intelligence (2013), Dr Foster Hospital Guide 2013. Dr Foster Limited. p.10.
Current status
Currently across Airedale, Wharfedale and Craven, there are six patients with chronic heart failure, 40 patients living with chronic obstructive pulmonary disease (COPD) and 25 patients with diabetes who have access, via a set top box, to the Telehealth Hub at Airedale General Hospital. The Hub is staffed 24 hours a day, seven days a week (24/7), by highly skilled nurses who specialise in acute care and with a consultant on hand if required.
“The experience of clinical staff is that the consultation appears ‘natural’ in that people seem very comfortable consulting with their clinical carers; it is possible to detect changes in a person’s tone of speech, body language and general demeanor in a similar way to that which happens in face to face meetings.”23
Via the Hub, we are able to offer medication advice and we can review ongoing clinical observations. If a patient needs to come to hospital, we can communicate with the ambulance service to ensure a direct admission to the Medical Assessment Unit.
In the period November 2012 to October 2013, the Hub received 1063 calls and the volume of calls continues to increase. Findings from a recent evaluation of the Hub were presented to The King’s Fund in July 2013 in support of its ongoing review of the impact of technologies on long-term condition management. Results for 26 patients with COPD revealed that:
. Emergency Department attendance was reduced by 69 per cent; . Hospital admissions were reduced by 45 per cent; . Average length of stay reduced by nine per cent; and . Overall bed days fell by 50 per cent.
The provision of the service was also evaluated in 17 nursing and residential homes across the locality. Results demonstrated:
. Emergency Department attendance reduced by 69 per cent; . Hospital admissions reduced by 45 per cent; . Average length of stay reduced by 30 per cent; and . Overall bed days reduced by 60 per cent.
Data source: Airedale NHS Foundation Trust Information Services
These are small samples and we must be cautious of generalising findings to larger populations. Across England, Dr Foster Intelligence indicates a relative rise in emergency diabetes admissions of 74 per cent and a 15 per cent rise in emergency COPD admissions. In Airedale, Craven and Wharfedale there are decreasing rates of avoidable emergency admissions.24
23 Cruickshank J. and Paxman J. (2013) Yorkshire and Humber Telehealth Hub: 2020health Evaluation.2020 health.org.:London.
24 Dr.Foster Intelligence (2013), Dr Foster Hospital Guide 2013: Commissioning.
. The percentage of diabetics in the area who have an emergency admission = 2.4; as expected. . The percentage of people with respiratory problems in the area who have an emergency admission = 11; better than expected.
Available from:- http://myhospitalguide.drfosterintelligence.co.uk/#/commissionin [Accessed 12/12/13].
Initiatives and progress up to 2013/14:
. Over 2000 patients are linked to the Telehealth hub; this compares to 1000 in 2012/13. . There are now 26 nursing and residential homes across the Bradford, Wharfedale and Craven district using this technology and we are currently working with five further homes to implement this service; this compares to a total of 17 in 2012/13. . Access to the SystmOne GP record has made available care plans and patient medication information in support of clinical decision-making. It also means a patient’s GP is kept appraised of consultations. . Calderdale and Huddersfield Foundation Trust is funding work to provide 18 nursing homes across it locality with Hub access. Seven local authority residential homes in East Lancashire are “live” with an expansion into 50 more planned during 2014. A further 50 nursing and residential homes across Bradford are also expected to go “live” in the coming year. . In 2010, Airedale NHS Foundation Trust successfully secured funding from the European Commission to participate in a three year project spanning four European countries. The RICHARD project – Research ICT based Clusters for Healthcare Applications Research and Development Integration – aimed to provide opportunities to use technology to manage chronic conditions. Our taskforce has visited Sweden, Italy and Poland. A detailed action plan was drawn up to support the Polish team to initiate its programme. The project is now complete. More details about this project can be found in previous editions of our Quality Account.
Initiatives in 2014/15 to achieve progress:
. Continue to review and monitor patient feedback and satisfaction regarding the telemedicine service. . Evaluation of acute hospital activity from nursing and residential homes. . Installation of telemedicine and telemonitoring into the homes of patients with heart failure across Bradford and Airedale.
End of Life Care – Health Foundation Shared Purpose Programme
In 2012/13 we reported that the Trust secured a three year grant from the Health Foundation Shared Purpose Programme to enhance the experience of end of life patients through the use of assistive technologies.
Work has included an End of Life Register, accessible on SystmOne and shared with partners across primary, community and secondary care in Airedale, Wharfedale and Craven. All patients on the Register can access clinical support from the Telehealth Hub team 24/7 via telephone. From January 2014 a cohort of 30 patients, identified using a risk model, have access to a video link to the Hub.
Collaborative work continues with Sue Ryder Manorlands Hospice. The Hub nurse can now contact the Palliative Care Consultant at the hospice for advice during weekdays. Where a video consultation is needed, the hospice can link directly to nursing and residential homes across Airedale, Wharfedale and Craven which have the telemedicine facility.
Process for monitoring progress
The multi-disciplinary and agency Telemedicine Operational Group is responsible for the delivery of the priority of improved quality of care for those with long-term conditions. Meeting monthly, the group monitors activity levels, the roll out of telehealth technology and reviews avoided admissions in those cohorts previously described. To provide a more complete understanding of quality, qualitative feedback is also considered. Monitoring is ongoing both internally and to commissioners to support assessment of the impact of the innovation and inform future initiatives and strategy.
2.2 Statements of assurance from the Board
The following statements serve to offer assurance that the Trust is measuring clinical outcomes and performance, is involved in national projects aimed at improving quality and is performing to essential standards.
2.2.1 Review of services
During 2013/14 Airedale NHS Foundation Trust provided and sub-contracted 66 NHS services [as per Monitor’s Provider License].
Airedale NHS Foundation Trust has reviewed all the data available to them on the quality of care in 66 of these NHS services.
The income generated by the NHS services reviewed in 2013/14 represents 92.4 percent of the total income generated from the provision of NHS services by Airedale NHS Foundation Trust for 2013/14.
2.2.2 Participation in clinical audits and national confidential enquiries
Clinical audit measures the quality of care and services against agreed national and local standards and recommends improvements where necessary. National confidential enquiries into patient outcomes and death are conducted by specialists with the aim of improving patient care and safety.
During 2013/14, 32 national clinical audits and 5 national confidential enquiries covered relevant health services that Airedale NHS Foundation Trust provides.
During that period Airedale NHS Foundation Trust participated in 86 per cent of national clinical audits and 100 per cent of national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Airedale NHS Foundation Trust was eligible to participate in during 2013/ 14 are as follows: see table 2 and 3.
The national clinical audits and national confidential enquiries that Airedale NHS Foundation Trust participated in during 2013/14 are as follows: see table 2 and 3.
The national clinical audits and national confidential enquiries that Airedale NHS Foundation Trust participated in, and for which data collection was completed during 2013/14, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.
Table 2: National clinical audits undertaken by Airedale NHS Foundation Trust
Per cent Applicable ANHSFT eligible Ref. Title to ANHSFT participation patients submitted Elective surgery – knee replacement (Patient Reported Outcome 1 116.9 Measures [PROMs]) Elective surgery – varicose veins (Patient Reported Outcome Measures 2 112.4 [PROMs]) Elective surgery – hip replacement (Patient Reported Outcome 3 110 Measures [PROMs]) 4 Acute coronary syndrome or acute myocardial infarction (MINAP) 100 5 Bowel cancer (NBOCAP) 100 6 Cardiac rhythm management (CRM) 100 7 Case mix programme (CMP) (care provided in intensive care) 100 8 Emergency use of oxygen 100 9 Epilepsy 12 audit (childhood epilepsy) 100
Per cent Applicable ANHSFT eligible Ref. Title to ANHSFT participation patients submitted Falls and fragility fractures audit programme (FFFAP) (now 10 100 incorporates National Hip Fracture Database [NHFD]) 11 Lung cancer (NLCA) 100 12 National diabetes inpatient audit (NADIA) 100 13 National joint registry (NJR) 100 14 Neonatal intensive and special care (NNAP) 100 15 Oesophago-gastric cancer (NAOGC) 100 16 Paediatric asthma 100 17 Red cell use survey (National Comparative Audit) 100 18 Sentinel stroke national audit programme (SSNAP) 100 19 Use of anti D (National Comparative Audit) 100 20 National heart failure audit 100 Use of blood in adult medical patients – part 2 (National Comparative 21 100 Audit) Elective surgery – hernia (Patient Reported Outcome Measures 22 97.8 [PROMs]) 23 Diabetes (Paediatric) (NPDA) 90 24 Severe trauma (TARN) 73.4 25 Diabetes (Adult) (NDA) 0 Moderate or severe asthma in children (care provided in emergency 26 Underway departments) National chronic obstructive pulmonary disease audit programme 27 Underway (COPD) 28 National diabetes in pregnancy audit (NPID) Underway 29 National emergency laparotomy audit (NELA) Underway 30 Paracetamol overdose (care provided in emergency departments) Underway 31 Patient information and consent (National Comparative Audit) Underway 32 Rheumatoid and early inflammatory arthritis Underway Severe sepsis and septic shock (care provided in emergency 33 Underway departments) 34 Inflammatory bowel disease (IBD) * 35 National audit of seizures in hospitals (NASH) * 36 National cardiac arrest audit (NCAA) * 37 Paediatric bronchiectasis * Adherence to British Society for Clinical Neurophysiology (BSCN) and 38 Association of Neurophysiological Scientists (ANS) Standards for Ulnar Not applicable Neuropathy at Elbow (UNE) testing 39 Congenital heart disease(CHD) (Paediatric cardiac surgery) Not applicable 40 Coronary angioplasty Not applicable 41 Head and neck oncology (DAHNO) Not applicable 42 National adult cardiac surgery audit Not applicable 43 National audit of schizophrenia (NAS) Not applicable 44 National vascular registry Not applicable 45 Paediatric intensive care (PICANet) Not applicable 46 Prescribing observatory for mental health (POMH) Not applicable 47 Pulmonary hypertension (specialist centres) Not applicable 48 Renal replacement therapy (renal registry) Not applicable
Data source: Airedale NHS Foundation Trust Clinical Audit Department.
* Not adopted by the Trust for 2013/14
Explanation for variation from 100 per cent submission rate:
. Ref. 1, 2, 3, & 22. There are known issues regarding participation rates for PROM data including: patients getting better, patients refusing surgery, cancelled operations (in these cases the pre-operative questionnaire may be counted but not mapped to an episode), coding issues, sub-contracting activity and the timing of questionnaires. . Ref. 24: published data is based on the “anticipated” number of patients. This is not the final figure. . Ref. 25: on-going data extraction difficulties (primary/secondary care interface) which the Trust is working to resolve for the next data submission. . Ref 23: the current participation rate has been estimated by the lead clinician.
Table 3: National Confidential Enquiries (NCEPOD) undertaken 2013/14
Per cent Applicable to ANHSFT eligible Ref. Title ANHSFT participation patients submitted 1 Alcohol Related Liver Disease - NCEPOD report 100 2 Lower Limb Amputation - NCEPOD report 100 Maternal, Newborn and Infant Clinical Outcome Review 3 100 Programme - MBRRACE-UK 4 Subarachnoid Haemorrhage - NCEPOD report 100 5 Tracheostomy Care - NCEPOD report 100 6 Child Health Outcome Review programme - CHR-UK ** Mental health clinical outcome review programme: National 7 Confidential Inquiry into Suicide and Homicide for people with Not Applicable Mental Illness - NCISH report
** Currently undergoing procurement; contract award due winter 2014.
Data source: Airedale NHS Foundation Trust Clinical Audit Department.
The reports of 21 national clinical audits were reviewed by the provider in 2013/14 and Airedale NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided.
This is a sample.
National Neonatal Audit Programme (NNAP) i. Monitoring of breast feeding on the Special Care Baby Unit; and, ii. Further staff training to encourage breast feeding.
Diabetes – Paediatric (NPDA) i. Aim for all newly diagnosed children to have their HbA1C (marker of average blood glucose levels) at less than 58mmol/mol by one year. ii. Increase the use of insulin pumps. iii. Continue clinical review meetings for all children with HbA1C greater than 90 mmol/mol. iv. Increase the usage of “Diasend” software to standardise reports and further engage with parents and families to support self-management.
Falls and Fragility Fractures Audit Programme (FFFAP) – includes the National Hip Fracture Database Continue to delivery of high quality healthcare for patients with neck of femur fractures; this has been recognised at national level.
Improving care and achieving Best Practice Tariff: Airedale NHS Foundation Trust
“In May of 2011 Airedale NHS Foundation Trust started an orthogeriatrics service. The specific aims of the service were to achieve Best Practice for patients with fracture neck of femurs based on the Blue Book indicators. The service started from a zero starting point, where no patients were submitted by Airedale NHS Foundation Trust to the National Hip Fracture Database. The overall aim is to provide optimal medical, surgical and anaesthetic care to patients who have been part of the service. The service is based on a small team, all located within the same site. This service has been implemented and grown considerably within the last 24 months, based on a strong multi-disciplinary team ethic and close working between Geriatrics, Orthopaedics, Anaesthetics and Emergency Department. The Nurse specialist has been key to coordinating the links between the specialities. The key to the success has been a neck of fracture trauma board and a neck of fracture spreadsheet being kept to highlight all the key indicators to be achieved. Other initiatives have included close collaboration with the Emergency Department to ensure femoral nerve blocks are done to reduce opiate anaesthesia, nursing care pathways assist in the management of the patient and a neck of femur patient and relative information booklet. This service has grown to achieve 70 per cent; Best Practice in the first year .The subsequent year
2012–13 has shown a further improvement in the service to 79%. The length of stay in hospital for these patients has fallen significantly. In recognition of these achievements, the service was shortlisted for a Healthcare Innovations award in 2012.”
Source: National Hip Fracture Database National report 2013 p22.
National joint registry (NJR) Maintain excellent outcomes and performance within the expected range for 90-day mortality and for revision rates for hips and knees.
Emergency use of Oxygen (BTS) Analysis of local data and review of trends since 2010 has been received at the Medical Gas Group for action planning as follows: i. Pre-printed oxygen prescription on drug charts. ii. Re-introduction of oxygen administration in nurse training. iii. Trial of adjuvants (pharmacological agents) to improve oxygen utilisation in ward areas.
Lung Cancer (NLCA) i. Sustain improvement in delivery by the multi-disciplinary care team (MDT); and ii. Maintain the “patient seen by a Clinical Nurse Specialist (CNS)” and “CNS present at diagnosis” at green. iii. Review of radiotherapy utilisation.
The reports of 157 local clinical audits were reviewed by the provider in 2013/14 and Airedale NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided.
This is a sample.
Audit ID 13/6054: Urinary Catheter Audit Aim: To monitor compliance against urinary catheter guidelines. Conclusions: The audit highlighted areas of good practice and identified where improvement could be made.
Actions: Outcome i. Prioritise training sessions Complete ii. Collaborate with supplier to improve packaging Complete iii. Undertake unannounced audits over the next 12 month period Planned Q1 2014/15
Audit ID 13/6062: Comparison of Extended Interval Gentamicin with Multiple Daily Dosing Aim: To determine whether the current method of pharmacokinetic dosing is better than the newly proposed method of extended interval dosing. Conclusions: Based on the results of the audit, the extended daily dose regime is a safe and effective alternative to dosing patients with the pharmacokinetic method. The approach offers a clear way for prescribers to monitor and dose gentamicin, is more patient friendly with fewer blood tests and potentially allows a reduction in workload for nurses, doctors, pharmacists and laboratory staff. The new regime is a cost-effective alternative to pharmacokinetic management, promotes maximum efficacy and reduces the risk of toxicity.
Actions: Outcome i. Redesign the prescription form to better differentiate clinical details Complete ii. Monthly training of pharmacy staff Complete iii. Training programme for doctors, with particular focus on junior medics In progress
Audit ID 6115: Rapid Access Transient Ischemic Attack (TIA) Clinic Aim: To evaluate and improve compliance with TIA NICE Guidance Conclusions: Review of the first two quarters of 2013/14 indicates that the Trust is out performing the contractual 60 per cent target for the review, investigation and treatment of high risk TIA referrals within 24 hours of the onset of symptoms. Where areas of shortfall were identified, instances were documented and divided into themes to target actions. (No data was collected on low risk referrals seen and treated within 7 days.)
Actions: Outcome i. All consultants to record clearly whether patient high or low risk at time of In progress referral ii. Collect data for low risk 7 day breaches Complete iii. Collaborate with Cardiorespiratory specialty (scanning of ward patients over In progress weekend)
Audit ID 5053: Lymphoedema Service Patient Satisfaction Survey Aim: To establish how effectively the service meets patients’ needs. Conclusion: The 12 patients surveyed were satisfied with the service they received. Statements made by the patients were mainly positive, including comments that the team was “excellent”, “friendly”, “helpful”, and that patients felt supported and informed. However, patients reported confusion about the discharge process.
Actions: Outcome i. Establish a clear timeline for care and treatment Complete ii. Enhance training programme to include communication and leadership Complete iii. Improve utilisation of SystmOne for recording of patient information, generation of Complete GP letters, prescription requests and associated tasks
Audit ID 6016: Speech and Language Therapy Record Keeping Audit Aim: To review the quality of Speech and Language Therapy team record keeping. Conclusion: Whilst generally of a good standard, areas of record keeping which could be improved were identified.
Actions: Outcome i. Present clinical audit findings at governance meeting Complete ii. Agree a list of acceptable abbreviations Ongoing iii. Develop a standard letter proforma for the paediatric team Complete iv. Monitor record keeping in primary and secondary settings Complete v. Re-audit record team with a revised audit tool reflective of implemented actions Complete
Audit ID 13/6027: Anaesthetic Information for Women with a High Body Mass Index (BMI) in Pregnancy Aim: To evaluate the quality of information currently available to women and assess whether this can be improved upon. Conclusion: For those women with a BMI over 40, the anaesthetic information is good. The audit highlighted that women with a BMI between 30 and 40 would only be seen by an anaesthetist if they presented in labour. To ensure that this group is aware of the risks for both mother and baby associated with a high BMI, a series of actions have been identified.
Actions: Outcome i. Devise an information leaflet with multi-disciplinary and lay input Complete ii. Implement a clear dissemination plan to include community midwives Complete iii. Re-audit within three months to appraise the effectiveness of the information Ongoing
2.2.3 Participation in clinical research
Clinical research and clinical trials are an everyday part of the NHS. The people who do research are mostly the same doctors and other health professionals who treat people. A clinical trial is a particular type of research that tests one treatment against another. Airedale NHS Foundation Trust is committed to research as a driver for improving the quality of care and patient experience. Research is a core part of the NHS, enabling it to improve the current and future health of the people it serves.
The number of patients receiving relevant health services provided or sub-contracted by Airedale NHS Foundation Trust in 2013/14 that were recruited during that period to participate in research approved by a research ethics committee was 360.
Participation in clinical research demonstrates the commitment of Airedale NHS Foundation Trust to improving the quality of care we offer and to making our contribution to wider health improvement. Our clinical staff stay abreast of the latest possible treatment possibilities and active participation in research leads to successful patient outcomes. National systems are being used to manage the studies in proportion to risk and the Trust is participating fully in the central sign-off process (CSP) for National Portfolio studies and has fully signed up to the Research Passport system.
Airedale NHS Foundation Trust was involved in conducting 106 clinical research studies across all specialties during 2013/14 of which 65 were on the National Portfolio.
There were 45 [senior] clinical staff participating in research approved by a research ethics committee at Airedale NHS Foundation Trust during 2013/14. These staff participated in research across 16 different medical specialties. The Trust is committed to expanding research into new specialties to improve the quality of care for our patients. The primary motivation for conducting research within the Trust is for the advancement of knowledge and promotion of evidence-based practice within clinical care. This is reflected in the number of non-commercial studies undertaken during 2013/14 which represent 94 per cent of the total.
As well, in the last three years, 16 publications have resulted from our involvement in National Institute for Health Research, which shows our commitment to transparency and desire to improve patient outcomes and experience across the NHS.
Our engagement with clinical research also demonstrates the commitment of Airedale NHS Foundation Trust to testing and offering the latest medical treatments and techniques.
Research in action: IBIS II Prevention Trial
The Trust was proud to have been involved in the IBIS II breast cancer prevention trial. The study looked at whether the drug anastrozole could reduce the risk of breast cancer in post menopausal women at high risk of getting the disease.
The trial recruited nearly 4,000 women nationally who had been through menopause and were considered high risk generally because of a strong family history of breast and ovarian cancer. The results were published in the Lancet Online in December 2013 with the contribution of Dr Ali Nejim and the research team at Airedale acknowledged.
2.2.4 Use of Commissioning for Quality and Innovation framework
Commissioners are responsible for ensuring that adequate services are available for their local population by assessing needs and purchasing services. A proportion of a provider’s income is conditional on the achievement of quality and innovation as set out in the Commissioning for Quality and Innovation (CQUINS) payment framework.
Use of CQUINS payment framework
A proportion of Airedale NHS Foundation Trust’s income in 2013/14 was conditional on achieving quality improvement and innovation goals agreed between Airedale NHS Foundation Trust, and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework.
Further details of the agreed goals for 2013/14 and for the following 12 month period are available electronically at: http://www.england.nhs.uk/wp-content/uploads/2013/02/cquin- guidance.pdf
As part of the drive to improve quality, an amount of funding to be paid to the Trust during 2013/14 for the delivery of services to our patients was dependent upon achieving a range of quality markers. This scheme (CQUIN) linked £2,931,750.00 of our funding to the delivery of the agreed quality indicators. [This is based on the indicative outturn value for 2013/14.]
During 2013/14 Airedale NHS Foundation Trust delivered CQUINs to the value of £2,785,162.00 to the satisfaction of our commissioners.
The monetary total of funding conditional to the delivery of agreed quality indicators in 2012/13 was £2,457,886.
2.2.5 Registration with the Care Quality Commission
The Care Quality Commission (CQC) is the independent regulator of health and social care in England.
Statements from the Care Quality Commission
Airedale NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is without conditions. Airedale NHS Foundation Trust has no conditions on registration.
The Care Quality Commission has not taken enforcement action against Airedale NHS Foundation Trust during 2013/14.
Airedale NHS Foundation Trust has not participated in any special reviews or investigations by the Care Quality Commission during the reporting period.
In 2013/14, the following inspections by the Care Quality Commission have occurred:
In September 2013, the following services were inspected in line with the new inspection regime: Emergency Department, medical care (including older people’s care), surgery, intensive/critical care, maternity and family planning, children’s care, end of life care, and outpatients.
All CQC inspection reports are publically available at: http://www.cqc.org.uk/directory/RCF
2.2.6 Information on the quality of data
The Secondary Uses Service (SUS) is designed to provide anonymous patient-based data for purposes other than direct clinical care such as healthcare planning, commissioning, public health, clinical audit and governance, benchmarking, performance improvement, medical research and national policy development.
NHS Number and General Medical Practice Code Validity
Airedale NHS Foundation Trust submitted records during 2013/14 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data – which included the patient’s valid NHS number was: 99.93 per cent for admitted patient care; 99.97 per cent for out patient care; and 99.28 per cent for accident and emergency care. – which included the patient’s valid General Practitioner Registration Code was: 99.83 per cent for admitted patient care; 99.35 per cent for out patient care; and 98.85 per cent for accident and emergency care.
Information governance toolkit attainment levels
Information governance (IG) ensures necessary safeguards for, and appropriate use of patient and personal information; the IG toolkit is a system which allows NHS organisations and partners to assess themselves against Department of Health information governance policies and standards. The attainment levels provide an overall measure of the quality data systems, standards and processes within an organisation.
Airedale Foundation Trust Information Governance Assessment Report overall score for 2013/14 was 72 per cent, graded as satisfactory.
Clinical Coding error rate
Airedale NHS Foundation Trust was not subject to the Payment by Results clinical coding audit during the reporting period by the Audit Commission.
However, Airedale NHS Foundation Trust was subject to an independent Information Governance (IG) Clinical Coding Audit Report conducted during the reporting period. The error rates reported in this audit are of the same format as the Payment by Results audit.
The diagnoses and treatment coding error rates were as follows (Levels range from 0 to 3 with Level indicating the highest achievement): . Primary Diagnoses Incorrect 6.00 per cent; this equates to Level 2 performance (Level 3 is less than 5 per cent error rate); . Secondary Diagnoses Incorrect 3.39 per cent; this equates to Level 3 performance (Level 3 is less than 10 per cent error rate); . Primary Procedures Incorrect 0.93 per cent; this equates to Level 3 performance (Level 3 is less than 5 per cent error rate), and . Secondary Procedures Incorrect 3.55 per cent; this equate to Level 3 performance (Level 3 is less than 10 per cent error rate).
This was a random sample of 200 fully coded episodes taken from across all specialties within the Trust between the period April and November 2013. The results overall were within the recommended IG Level 2 requirements. To achieve a Level 3 standard overall, all four indicators must be at Level 3.
Airedale NHS Foundation Trust will be taking the following actions to improve data quality:
. Address recommendations in the Information Governance Clinical Coding Audit Report. . Ensure coding staff skills are current and in line with national recommendations; monthly meetings are held to review changes to practice, the updating of coding books and to address data quality issues. . Encourage and support staff to achieve national clinical coding accreditation qualification. . Maintain the electronic encoding system with the latest codes and guidance. . Continue to implement a robust planned and responsive audit programme to safeguard the quality and completeness of data items. . Where there is ambiguity in the documentation, advice is sought from the relevant consultant.
2.3 National quality indicators
To provide a better understanding of comparative performance, the Quality Account includes a core set of statutory national quality indicators aligned with the Department of Health’s NHS Outcomes Framework for 2013/14 and reflects data that the Trust reports nationally. The information underpinning the measures is robust and conforms to specified data quality standards and prescribed standard national definitions and is subject to appropriate scrutiny and review.25
To understand whether a particular number represents good or poor performance, the national average, outlier intelligence and a supporting performance commentary is included where available. Unless indicated, the data source for the following indicators is the NHS Health and Social Care Information Centre (HSCIC). In line with national guidance, information for at least the last two reporting periods is provided.26
Domain 1 – Preventing people from dying prematurely Domain 2 – Enhancing the quality of life for people with long-term conditions
2.3.1. Summary hospital-level mortality indicator (SHMI)
Rationale
The SHMI is not an absolute measure of quality but is a useful indicator for supporting organisations to ensure they properly understand their mortality rates across services.
The SHMI is based on all primary diagnoses, with deaths measured which take place in or out of hospital for 30 days following discharge. The SHMI value is the ratio of observed deaths in the Trust over a period of time divided by the expected number given the characteristics of patients treated (where 1.0 represents the national average). Depending on the SHMI risk adjusted value, trusts are banded between 1 and 3 dependent on whether their SHMI is low (3), as expected (2) or high (1) compared to other trusts. Banding uses a 95 percent control limit; there is a one in 20 chance that an organisation is an outlier.
The SHMI takes account of underlying illnesses such as diabetes and heart disease. By including a measurement of the potential impact of providing palliative care on hospital mortality, additional context to the SHMI value and banding is offered.
Oct 11 - Jan 12- Apr 12- Jul 12- Table 4: SHMI Sep 12 Dec 12 Mar 13 Jun 2013
Pub: Pub: Pub: Pub: Apr 13 Jul 13 Oct 13 Jan 14 Airedale NHS Foundation Trust SHMI value 0.92 0.94 0.97 0.93 National average 1.00 1.00 1.00 1.00 The highest value for any acute trust 1.21 1.19 1.17 1.16 The lowest value for any acute trust 0.68 0.70 0.65 0.63 Airedale NHS Foundation Trust SHMI banding 2 2 2 2 [2 = as expected]
25 Definitions are based on Department of Health guidance, including the NHS Outcomes Framework 2013/14 Technical Appendix.
26 To ensure consistency in understanding of these indicators, NHS England will be publishing a “data dictionary” for the quality accounts (see the Quality Accounts area of the NHS Choices website). The data dictionary will include a definition for each indicator.
Percentage of patient deaths with palliative care coded at either diagnosis or speciality level for Airedale NHS 20.84 22.73 22.58 22.78 Foundation Trust Percentage of patient deaths with palliative care coded at either diagnosis or speciality level average for 18.9 19.1 19.9 20.3 England The highest value for any acute trust 43.3 42.7 44.0 44.1 The lowest value for any acute trust 0.2 0.1 0.1 0.0
Statement
Airedale NHS Foundation Trust considers that this data is as described for the following reasons:
. Trust mortality data is submitted in accordance with established information reporting procedures. . To date, the SHMI for the Trust has remained constant and not subject to significant variation (which might indicate a data quality issue). . To assure the quality of information submitted, the Trust undertakes periodic audits of data quality including audits of the use of the palliative care code on discharge and when patients are deemed to have died with a palliative care code. The palliative care code indicates that the patient has had access to specialist palliative care services. . SHMI data is provided through NHS Indicators and is formally signed off by the Medical Director.
Airedale NHS Foundation Trust intends to take /has taken the following actions to improve this rate, and so the quality of its services, by:
. Exhibiting notable practice: all mortality cases are routinely reviewed by a well- established, consultant-led Trust Mortality Group, chaired by the Consultant Microbiologist. Themes and trends are highlighted and have led to demonstrable service quality improvements, including a focus on pressure ulcers, fluid balance and antibiotic prescribing and the development of a specialist Falls subgroup to improve the care of frail susceptible older people. . Examining excess mortality risk in COPD by means of a comprehensive review of corroborative data, discussion at the Clinical Safety Assurance Committee and the specialty governance meeting, and participation in the 2014 national COPD audit. . Holding periodic multi-disciplinary mortality meetings where all clinicians can learn from mortality events. . Receiving SHMI performance at the Board and publishing trends in the quarterly public quality improvement account.
Domain 3 – Helping people recover from episodes of ill health or following injury
2.3.2 Patient Reported Outcome Measures (PROMS)
Rationale
PROMs indicate patients’ health status or health-related quality of life from their perspective, based on information gathered from a questionnaire that they complete before and after surgery. PROMs offer an important means of capturing the extent of patients’ improvement in health following ill health or injury.
Airedale’s adjusted average health gain is presented alongside the national average and control limits. An average adjusted health gain allows fair comparison as the demographics of the patient and level of complexity is accounted for. It is a measure of outcomes in the sense of how much a patient has improved as a result of the surgery. A high health gain score is good.
Datasets for 2012/13 are provisional and will not be finalised until August 2014. The 2013/14 dataset is not included in this Quality Account as there is limited response data at this stage, particularly for hip and knee procedures as the post-operative questionnaires are not sent to orthopaedic patients until six months after the procedure is carried out. The standardised EQ-5D measure is given as this applies to all elective conditions. However, this is less sensitive than condition specific measures and for a more complete analysis, the Oxford Score is provided for hip and knee replacement and the Aberdeen score for varicose vein surgery. Control limits are set at 95 per cent. A high health gain score is good.
Statement
Airedale NHS Foundation Trust considers that this data is as described for the following reasons:
Airedale NHS Foundation Trust considers that this data is as described and an accurate position statement for the health gains that patients have experienced since their elective surgery. Patients who have undergone surgery may still be experiencing pain six months afterwards. However, a follow up questionnaire 12 months after their surgery should reflect increased health gains in the upper quartiles.
Airedale NHS Foundation Trust intends to take /has taken the following actions to improve the score and so the quality of its services, by:
. Continuing to monitor its rate of participation for each procedure and, although it has less direct influence, response rates are similarly reviewed. The Trust continues to raise awareness of the importance of returning the questionnaires at pre-operative assessment and in the ward environment at discharge. . Reviewing special interest topic features issued by the HSCIC, at local level to inform discussion: Complications after Surgery 2010/11 (May 2013), Aberdeen Varicose Vein Questionnaire (November 2013) and Guide to PROMS.
. Evaluating its own data extracted from the HSCIC. Preliminary review has been conducted of hip and knee replacement with feedback from the HSCIC on how this can be most effectively reviewed.
2.3.3 Percentage emergency re-admissions to Airedale NHS Foundation Trust within 28 days of discharge
Rationale
Whilst some emergency re-admissions following discharge from hospital are an unavoidable consequence of the original treatment, others could potentially be avoided through ensuring the delivery of optimal treatment according to each patient’s needs, careful planning and support for self-care. A low percentage score is good.
2010/11 2011/12 Table 5: Emergency re-admissions Pub: Dec 13 Airedale NHS Foundation Trust percentage 0 to 15 years 11.70 11.32
National percentage average [England] 0 to 15 years 10.01 10.01
The highest* percentage return by small acute trust 0 to 15 years 12.61 14.87
The lowest* percentage return by small acute trust: 0 to 15 years 6.19 5.74
Airedale NHS Foundation Trust percentage 16 years or over 10.30 10.04
National percentage average [England] 16 years or over 11.43 11.45
The highest* percentage return by small acute trust 16 years or over 12.69 12.69
The lowest* percentage return by small acute trust 16 years or over 7.14 8.73
* The highest and lowest rates are taken from comparable trusts [small acute]. Indirectly age, sex, method of admission, diagnosis and procedure standardised per cent.
Statement
Airedale NHS Foundation Trust considers that this data is as described for the following reasons:
The figures presented are from the Health and Social Care Information Centre website and are derived from information provided by Airedale and other trusts. Elements of this information are subject to commissioner scrutiny and a variety of external audits.
0 to 15 years: the re-admission rate is above average, but has fallen in the last year. As part of Trust strategy to get patients home as soon as possible, we frequently discharge them and then offer “open access”. This allows the patient to be readmitted directly to the ward if the parents or carers feel there is any deterioration in the patient or if they are struggling with caring for the patient for any other reason. Clearly this will impact on the re-admission rate.
16 years or over: the re-admission rate is below average and has fallen in the last year. A number of actions have had an impact, including a target for urgent referrals to community of 95 per cent of patients being seen within 24 hours of discharge from hospital.
Airedale NHS Foundation Trust intends to take /has taken the following actions to improve this percentage, and so the quality of its services, by:
0 to 15 years:
. Consider the integration of “open access” into our ambulatory paediatric service, which we are currently developing so that patients can be allowed home without being formally discharged.
16 years or over:
. Medical re-admissions by consultant are incorporated into performance metrics, circulated to colleagues and discussed at the monthly General Internal Medicine meeting. A similar process is in place within Surgical Services and provides the opportunity to discuss, understand the rationale and accuracy of clinical coding and ensure re-admissions are correctly captured on the Trust’s patient administrations system.
. As part of the 2014/15 CQUIN scheme, reducing re-admissions within 28 days has been identified with the overarching goal to improve integrated discharge co-ordination.
Domain 4 – Ensuring that people have a positive experience of care
2.3.4 Responsiveness of Airedale NHS Foundation Trust to the personal needs of patients
Rationale
Patient experience is a key measure of the quality of care. The NHS Outcomes Framework for 2012/13 includes an organisation’s responsiveness to patients’ needs as a key indication of the quality of patient experience. This measure is based on the average percentage score of answers to five questions in the CQC National Inpatient Survey (published April 2014): i. Were you involved as much as you wanted to be in decisions about your care and treatment? ii. Did you find someone on the hospital staff to talk to about your worries and fears? iii. Were you given enough privacy when discussing your condition or treatment? iv. Did a member of staff tell you about medication side effects to watch for when you went home? v. Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital?
The scores are presented out of 100 with a high score indicating good performance.
2012 2013 Table 6: Responsiveness to patient needs 443 replies; 403 replies; 850 surveyed 808 surveyed Airedale NHS Foundation Trust overall percentage score 67.3 67.3
National percentage score 68.1 68.7
The highest value for any acute trust 84.4 84.2
The lowest value for any acute trust 57.4 54.4
Statement
Airedale NHS Foundation Trust considers that this data is as described for the following reasons:
The Trust score has remained static. The number of patients surveyed was fewer and the response rate lower when compared to 2012. The Trust sample varies from year to year unlike the national score which is, by definition, adjusted data. These factors should be considered when making comparison.
Improvements or deterioration of patient experience, reflected in the scores over the course of the year, continue to be monitored via our real-time inpatient survey and Friends and Family Test so that remedial actions can be introduced in a timely way.
Airedale NHS Foundation Trust intends to take /has taken the following actions to improve this score and so the quality of its services, by:
. Monitoring of local and national patient survey results by the Trust’s Patient and Public Engagement and Experience Steering Group. . Establishment of a task and finish group to ensure improvement measures are in place and carried out in those areas of identified shortfall. . Continued implementation of the Patient and Public Engagement and Experience Strategy with key focus areas of: access points to the organisation, “Right Care” training for staff and the experience of patients with dementia and families and carers. . Listening and learning from patient experiences via the Friends and Family Test and the real- time inpatient survey and take action where necessary.
2.3.5 Friends and Family Test – Staff: percentage of staff employed by, or under contract to the Trust during the reporting period, who would recommend Airedale NHS Foundation Trust as a provider of care to their family or friends
Rationale
How members of staff rate the care that their employer organisation provides can be a meaningful indication of the quality of care and a helpful measure of improvement over time.
The following is the percentage of staff who agree or strongly agree with the statement “If a friend or relative needed treatment, I would be happy with the standard of care provided by this Trust” and is based on the annual NHS Staff Survey.
The scores are presented out of 100 with a high score indicating good performance.
2012 2013 Table 7: Friends and Family Test – Staff 341 replies; 1146 replies; 775 surveyed 2480 surveyed Pub: Feb 2013 Pub: Feb 2014 Airedale NHS Foundation Trust percentage 67 73
National median percentage acute trusts [England] 60 64
Statement
Airedale NHS Foundation Trust considers that this data is as described for the following reasons:
The Trust’s response rate in 2013 is 46 per cent which is below average for acute trusts in England, and compares with a response rate of 44 per cent in this trust in the 2012 survey. It should be noted that all staff were included in the 2013 survey compared to a third in previous years. This makes this year’s return more robust than previous issues.
Airedale NHS Foundation Trust considers that this data is consistent with our local Staff Pulse Survey, conducted quarterly amongst our workforce to obtain feedback. The national and local surveys provide information which supports improved care and treatment for our patients. Improving patient experience and staff engagement are key priorities for the Trust.
Overall staff engagement was 3.77 in the 2013 NHS Staff Survey, compared to 3.73 in 2012 and is above the average for acute trusts. Possible scores range from one to five, with one indicating that staff are poorly engaged (with their work, team and Trust) and five indicating staff are highly engaged. In 2013 the Trust has seen an improvement in the number of staff recommending the Trust as a place to work or receive treatment; the Trust is above average for acute trusts.
Airedale NHS Foundation Trust intends to take /has taken the following actions to improve this score and so the quality of its services, by:
Engaging with staff to understand their thoughts and ideas about how patient experience can be improved further; what can be learned from the Mid Staffordshire public inquiry; and how to address those areas of shortfall highlighted in the NHS Staff Survey 2013. These themes relate, principally, to:
. Work pressure; . Feeling pressure to attend work when feeling unwell; . Feeling their roles make a difference to patients; and . Feeling satisfied with the quality of work and patient care they can deliver.
In the last year we have put in place a number of initiatives to ensure that patients, service users, their families, friends and carers are treated with kindness, compassion, courtesy and respect. (Please see sections 3.1.1 Privacy and Dignity and 3.1.2 Creating a Customer Service Culture.)
2.3.6 Friends and Family Test – Patient: score of patients who would recommend Airedale NHS Foundation Trust hospital wards or Emergency Department [A&E] as a provider of care to their family or friends
Rationale
Since April 2013, patients have been asked whether they would recommend hospital wards and Emergency Departments to friends and family if they needed similar care or treatment. This means every patient in these wards and departments is able to give feedback on the quality of the care they receive and provides hospitals with a better understanding of the needs of their patients, enabling improvement. 27 Although there is no statutory requirement to report on the patient element of the Friends and Family Test (FFT), we have included this information to support transparency.
The following is the average score of who agree or strongly agree with the statement, “How likely are you to recommend our ward/ED department to friends and family if they needed similar care or treatment?” Each Trust receives a score based on the satisfaction levels of patients surveyed, calculated using a proportion of patients who would strongly recommend the ward/department at Airedale minus those who would not recommend or who are indifferent. The range of scores that are possible using this method are -100 to +100. The score is therefore not a percentage.
27 NHS Choices Friends and Family Test: http://www.nhs.uk/NHSEngland/AboutNHSservices/Pages/nhs-friends-and-family- test.aspx [Accessed 31/01/14].
December January Table 8: Friends and Family Test – Patient 2013 2014 Airedale NHS Foundation Trust score* 62 68
National score acute NHS trusts [England]* 64 64
The highest value for any provider 100 100
The lowest value for any acute provider 2 10
* Based on inpatient and ED combined score. Source: NHS England.
Statement
Airedale NHS Foundation Trust considers that this data is as described for the following reasons:
. The Trust-wide average score between April 2013 and January 2014 is 65. The national NHS average score between April 2013 and January 2014 is 64. . Findings are consistent with the results of national inpatient and staff surveys and those seen in our local real-time inpatient survey, conducted monthly since 2009/10. . The average FFT – Patient response rate (inpatients and ED combined) for the period April 2013 and January 2014 is 18 per cent compared to a national NHS response rate of 17.3 per cent. The response rate for the Emergency Department has been poor. This is thought to be largely due to the move to temporary accommodation, but much work is being done with the department to ensure this improves and is sustained.
Airedale NHS Foundation Trust intends to take /has taken the following actions to improve this score and so the quality of its services, by:
. The Trust has met its CQUIN 2013/14 targets: meeting the national roll out programme; achieving a baseline response rate of 15 per cent in the first quarter and 20 per cent by quarter four; and increasing its score in the 2013/14 NHS Staff Survey (as reported in section 2.3.5 Friends and Family Test – Staff). . From October 2013 the FFT – Patient was made available to women who use Maternity Services covering: antenatal care, birth, postnatal care in hospital and in community. In line with national guidance, the test is to be introduced into Community Services, Day Case and Outpatients by October 2014 and all remaining NHS funded services by March 2015. . Providing information which supports improved patient care and treatment, for example: i. Creating a customer service culture (see section 3.1.2), selected as a key quality priority for the Trust in 2013/14. ii. Developing the FFT questionnaire to include more demographic information to better understand the experiences of people with protected characteristics as described in the Equality Act 2010.
Domain 5 – Treating and caring for people in a safe environment and protecting them from avoidable harm
2.3.7 Percentage of patients admitted to hospital and were risk assessed for venous thromboembolism (VTE)
Rationale
VTE can cause death and long-term morbidity. Many cases of VTE acquired in healthcare settings are preventable through effective risk assessment and prophylaxis. A high percentage score is good.
Apr-Jun Jul-Sep Oct-Dec Table 9: Risk assessment for VTE 2013 2013 2013
Pub: Sep 2013 Pub: Dec 2013 Pub: Mar 2014 Airedale NHS Foundation Trust percentage 95.71 96.77 97.9
National percentage average [England] 95.45 95.74 95.8
The highest percentage return for any acute trust 100.00 100.00 100.0
The lowest percentage return for any acute trust 78.78 81.70 77.7
Source: NHS England.
Statement
Airedale NHS Foundation Trust considers that this data is as described for the following reasons:
. The Trust has maintained a consistently high standard of compliance with the national VTE risk assessment priority. . Data is provided weekly to all managers and lead clinicians. Broken down by clinical area, this allows those which are under reporting to be identified and supported with improvement and restorative actions. . The VTE risk assessment tool is embedded in the clinical areas and features prominently in clinical decision making, ensuring vigilance in completing risk assessments. . By way of a cross check, thromboprophylaxis prescription rates are benchmarked against other NHS providers, using data from the NHS Safety Thermometer. These compare favourably and indicate that clinicians are completing VTE risk assessments with appropriate VTE prophylactic measures.
Airedale NHS Foundation Trust intends to take /has taken the following actions to improve this percentage, and so the quality of its services, by:
. Benchmarking Airedale’s performance against other providers in England. . Through the multi-professional VTE group, which includes consultant, nurse and pharmacy representation, the Trust is seeking further ways of improving VTE care: for example training of junior medical staff in VTE and revising the Trust VTE policy. . Regular discussion of VTE assessment data with clinical directors to educate and improve rates in all directorates. . The Trust has changed its processes to include a root cause analysis for reported VTE with the dissemination of results within the Trust to learn lessons and improve overall VTE care.
2.3.8 Rate of Clostridium difficile infection per 100,000 bed days in Airedale NHS Foundation Trust patients aged 2 or over
Rationale
Hospital associated C. difficile can be preventable. There are issues around reporting cases of C. difficile, resulting from differences in the tests and algorithms used in the NHS for determining whether patients have a C. difficile infection. In March 2012, the Department of Health issued revised guidance on a new clinical testing protocol; this aims to bring about more consistent testing and reporting of cases of C. difficile infection.
The rate provides a helpful measure for the purpose of making comparisons between organisations and tracking improvements over time. A low rate is good.
Table 10: Rate of Clostridium difficile 2011/12 2012/13
Airedale NHS Foundation Trust rate per 100,000 bed days 18.7 15.0
National average rate [England] rate per 100,000 bed days 22.2 17.3
The highest rate for any acute trust rate per 100,000 bed days 58.2 30.8
The lowest rate for any acute trust rate per 100,000 bed days 0.0 0.0
Figures based on Trust apportioned cases for specimens taken for patients aged 2 or over. Source: Public Health England
Statement (please read in conjunction with section 3.2.1)
Airedale NHS Foundation Trust considers that this data is as described for the following reasons:
. The Trust has a rigorous diagnostic testing protocol to identify cases. All confirmed cases are monitored through internal processes and reported to Public Health England, Monitor and commissioners. . Performance is reflective of: a robust antibiotic policy closely scrutinised by Pharmacy staff, high standards of staff and patient hand hygiene, environmental cleanliness and the continued vigilance and awareness of staff. . Root cause analysis on all hospital acquired cases is undertaken to ensure opportunities to improve practice are identified and enacted.
Airedale NHS Foundation Trust intends to take /has taken the following actions to improve this rate, and so the quality of its services, by:
Implementing further strategies during the forthcoming year, including: . Early detection of all cases; . Environmental monitoring and sampling; . The use of different antibiotic agents for patients with penicillin allergy; and, . Working with community colleagues through the Joint Infection Prevention and Control Strategy Group and the execution of NHS England guidance.
Domain 5 - Treating and caring for people in a safe environment and protecting them from avoidable harm
2.3.9 Reported number and rate of patient safety incidents per 100 admissions reported within the Airedale NHS Foundation Trust and the number and percentage that resulted in severe harm or death
Rationale
Patient safety incidents are adverse events where either unintended or unexpected incidents could have led or did lead to harm for those receiving NHS healthcare. Based on national evidence about the frequency of adverse events in hospitals, it is likely that there is significant under reporting. An open, transparent culture is important to readily identify trends and take timely, preventative action.
This indicator is designed to measure the willingness of an organisation to report incidents and learn from them and thereby reduce incidents that cause serious harm. The expectation is that the number of incidents reported should rise as a sign of a strong safety culture, whilst the number of incidents resulting in severe harm or death should reduce. (“Severe” denotes when a patient has been permanently harmed as a result of the incident.) The National Reporting and Learning System (NRLS) categorises NHS organisations for the purpose of indexing data reports. Airedale is categorised as a “small acute trust”.
Table 11: Patient safety incidents
Apr-Sep 2013 All reported patient safety incidents Severe harm Death
Rate [per 100 Number admissions] Number Percentage Number Percentage
Airedale NHS Foundation Trust 2556 9.6 3 0.1 3 0.1
National position [small acute trust] 57463 8.1 348 0.6 69 0.1
The highest value [small acute trust] 4301 17.1 41 1.0 5 0.1
The lowest value [small acute trust] 908 3.9 17 1.9 1 0.1
Oct 2012- Mar 2013 All reported patient safety incidents Severe harm Death
Rate [per 100 Number admissions] Number Percentage Number Percentage
Airedale NHS Foundation Trust 2,404 8.9 1 0.04 2 0.08
National position [small acute trust] 54,983 7.3 332 0.6 103 0.2
The highest value [small acute trust] 4517 17.5 45 3.1 28 1.4
The lowest value [small acute trust] 924 4.1 0 0.0 0 0.0
Apr-Sep 2012 All reported patient safety incidents Severe harm Death
Rate [per 100 Number admissions] Number Percentage Number Percentage
Airedale NHS Foundation Trust 2,159 8.0 1 0.04 2 0.09
National position [small acute trust] 50,741 6.5 361 0.7 100 0.2
The highest value [small acute trust] 4545 17.64 67 1.8 0 0.0
The lowest value [small acute trust] 815 3.48 0 0.0 15 0.6
Statement
Airedale NHS Foundation Trust considers that this data is as described for the following reasons. The Trust has in place:
. An open and engaged culture of reporting and investigating patient safety incidents is reflected in the rate of reported incidents which is above the national rate for “small acute trusts”. . An open and engaged culture to learn from incidents and improve the quality and safety of services, hence the lower than average number of cases for severe harm or death. . A systematic and timely approach for the reporting, management and uploading of all patient safety incidents. . Consistent reporting of all patient safety incidents to the NRLS against each of the required six month periods. . A rate of reported patient safety incidents per 100 admissions that is above the average “small acute trusts” (see tables above), which indicates that we are unlikely to be under- reporting patient safety incidents. . Systems to review the incidence of severe harm and death. It is important to note that whilst this presents as low, the incidence of no and low harm is highly suggestive of a positive reporting culture.
Airedale NHS Foundation Trust intends to take /has taken the following actions to improve this rate, and so the quality of its services, by:
. Maintaining and improving an open and transparent reporting culture, one which encourages all healthcare staff to report all incidents. . Recent review of the incident reporting documentation. This will enable staff to provide more accurate information and further streamline the process to continue to report all incidents including near misses. . Continuing to provide training and education programmes that seek to raise awareness and promote the reporting of incidents from across all staff groups. . Identifying trends and themes that can be triangulated with other measures of quality and safety, to ensure that immediate actions and shared learning takes place for quality improvement. . Acting on areas of concern, aimed at improving patient outcomes and shared learning across the Trust.
3 Other information
As well as the selected improvement projects detailed in section 2.1, the Quality Account takes the opportunity to outline other local priority work in the three areas of quality: patient experience, safety and clinical effectiveness. Metrics or measures are included and where possible, historical and benchmarking data is provided to support interpretation.
3.1 Patient experience
The Trust is committed to the principle that all patients and the public are treated as individuals with dignity and respect, that cultural and ethnic diversity are valued, and that vulnerable and “hard to reach” people have equal opportunity to be fully involved in all aspects of their care.
3.1.1 Privacy and dignity Lead Executive Director Rob Dearden, Director of Nursing Clinical Lead and Implementation Lead Debra Fairley, Deputy Director of Nursing Noel McEvoy, Senior Nurse Safeguarding Adults Fiona Throp, Senior Nurse for Older People Sharon Robinson, Senior Nurse for Older People
In recent years the media has highlighted a lack of care, compassion and dignity in NHS care. High profile inquiries have shown a failure at individual and organisational level to safeguard people’s basic human rights. We are entrusted to care for people, often when they are at their most vulnerable, and it is therefore important that we continually reflect on and challenge the way in which we, as a hospital and community, treat and care for our patients, their relatives, friends and carers.
Building on the 2012 project Dignity and Respect in Care, along with feedback from patients about dignity, the last year has seen an extensive consultation with our staff on how they give dignified care and how essential standards can be embedded into practice in a meaningful way. This involved talking with a large cross section of staff including portering and ancillary staff, interpreters, managers, engineers, HSW, pharmacy staff, midwives, ward hostesses, technicians, IT staff, dieticians, medical records personnel, electricians, therapists, doctors and nurses. Identifying what dignified care should look like and where it falls short, Essential Standards of Caring for People with Dignity and Respect (2013) embodies this work and applies to all staff.
We encouraged our staff to share their experiences of how they provide dignified care. The following examples are drawn from their comments about what constitutes dignified care:
. Seeking to speak with a patient in a private space about their care and treatment, “Curtains aren’t sound proofed.” . Maintaining eye contact with patients and not talking “over them” or “about them” as if they are not there. . The use of an interpreter when English is not a first language to support decisions about treatment.
And what is not dignified care:
. Ignoring patients and visitors: “Many staff can be around the nurses’ station and no one lifts their head.” “Not my patient.” . Staff using a mobile phone, including texting, in the presence of patients and their families. . Not addressing a patient by their preferred name.
Source: Airedale NHS Foundation Trust (2013) Essential Standards of Caring for People with Dignity and Respect. p5.
A number of initiatives are underway that will serve to ensure that people are cared for in a modern hospital environment and with privacy and dignity. For example, a long-term programme of refurbishment of the patient infrastructure is underway. A self-contained bereavement suite is a key feature of the upgraded midwifery-led unit. At a time of great vulnerability, families can be treated with the upmost privacy and dignity. Facilities include a lounge area, a bedroom with en suite wet room and a private remembrance garden.
A new endoscopy unit opened in 2013 to address increased demands since the introduction of the National Bowel Screening Programme. Facilities are designed to deliver high quality care and address privacy and dignity issues. Following inspection, full accreditation for the next five years has been granted. The following is a first hand account of a patient with experience of both the old and new endoscopy facilities.
Paul was diagnosed with bowel cancer in 2010.
“The old endoscopy unit was well organised but dated. Whilst staff did their utmost to maintain privacy, it was not always possible and necessary to speak in whispers. In the new unit, there is more room, less congestion which is more supportive of privacy. The ambience is friendly with warm relaxing colours, reducing the clinical and ‘fear factor’ for what is a difficult procedure.”
Paul’s treatment and surgery have been successful.
Source: Patient Story Trust Board Meeting July 2013.
The following metrics have been selected to measure improvement in our patients’ experience. We know that there is some work for us to do to improve the quality of information provided for patients and their relatives, particularly around discharge planning. The metrics have been selected with this in mind.
Table 12: Patient experience – performance against selected metrics at Airedale NHS Foundation Trust
2011/12 2012/13 2013/14
Did you feel you were treated with respect and dignity while you were in hospital? 8.8 8.8 8.8
Did you feel you were involved in decisions about your discharge from hospital? 7.2 7.1 7.0
Did hospital staff give your family or someone close to you all the information they needed? 6.2 5.9 5.8
Overall, how would you rate the care you received? 7.9 7.8 7.9
Data source: Care Quality Commission National NHS In-Patient Survey 2013.
People are asked by the CQC about different aspects of their care and treatment. Based on these responses, trusts receive scores out of ten. A higher score is better.
GREEN = best performing trusts. AMBER = trusts about the same. RED = worst performing trusts.
“Are services caring?”
“The vast majority of people told us about their positive experiences of care. The Trust’s patient survey scores match the national averages. Patients said that they were satisfied with how they had been treated, and the doctors, nurses and other staff were caring and professional. Staff respected patients’ dignity and privacy.”
Source: Care Quality Commission (2013) Airedale NHS Foundation Trust Airedale General Hospital Quality Report. p.11. 8
In 2013 a Patient-Led Assessment of the Care Environment (PLACE) was undertaken, which replaced previous Patient Environment Action Team (PEAT) inspections. This assessment looked at cleanliness, condition of the buildings, food and drink, privacy and dignity, signage, car parking and dementia-friendly environment. Its primary purpose is to obtain patients’ views, with patient assessors comprising at least half of the inspection team.
Table 13: Airedale General Hospital’s PLACE results compared to the national average
Domain Airedale percentage score National percentage average
Cleanliness 93.13 95.74 Condition, appearance & maintenance 82.58 88.75 Privacy, dignity & wellbeing 81.19 88.87 Food 82.96 84.98
Source: Health and Social Care Information Centre.
To ensure the needs and expectations of patients are met, an action plan detailing how we expect to improve our services before the next assessment is being implemented.
3.1.2 Creating a customer service culture Lead Executive Director Rob Dearden, Director of Nursing Clinical Lead and Implementation Leads Debra Fairley, Deputy Director of Nursing Karen Dunwoodie, Patient Experience Lead
The quality of care is as important as the excellence of treatment; patients and their carers must feel welcome and safe when receiving our care and services. A series of initiatives to reinforce a culture of kindness, compassion, courtesy and respect have been implemented in recent years. These include:
. Dignity and Respect in Care project (described above in section 3.1.1); . The Patient and Public Engagement and Experience Strategy; . “Right Care” - Nursing and Midwifery Strategy 2013 – 2015; . Monitoring via the real-time inpatient survey (a previous Quality Account priority); and . Customer care training – “Right Care”.
Research suggests that compassion declines the more staff are exposed to clinical practice.28 Innovative staff training is ongoing to inculcate core values and challenge adverse attitudes and behaviours. Training is aligned with line management standards, the NICE patient experience standard (QS15) and the NHS Constitution.29 As of September 2013, 1,756 staff, including community staff, had received an element of “Right Care” training, including community service teams. The Trust employs approximately 2,400 staff. Elements of this training are now part of the Trust’s induction and mandatory training for clinical and non-clinical staff. The package refreshes key messages of who our customers are and the importance of treating people as individuals. Drawing on the real experiences of patients, the training is co-delivered by members of the Patient and Carers Panel. Examples of good and inadequate customer care form its basis and,
28 Department of Health and National Commissioning Board (2012), Developing the Culture of Compassionate Care. London: Crown Copyright.
29 Department of Health (2013) The NHS Constitution. Available from:- http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Documents/2013/the-nhs-constitution-for-england- 2013.pdf [Accessed 20/01/14].
although it is acknowledged that the term “customer” is not necessarily the best language to use, its use reinforces the four principles of patient experience:
1. “Through your eyes.” 2. “Making every contact count.” 3. “No decision about me without me.” 4. “The patient at the heart of everything we do.”
As well as the number of staff who have received “Right Care” training, the following are useful metrics to measure progress: . In 2013/14 the number of times patients have had cause to formally complain about the attitude and behaviour of staff during the course of their experience of care and services was 11 times: seven complaints were raised regarding nursing staff, two medical staff and two healthcare professions. . The number of complaints that were upheld concerning attitude and behaviours of staff was three: The remaining eight concerns were partially upheld. An apology was offered in all instances and individuals have reflected on their behaviour.
3.2 Patient safety
Together with the reduction of inpatient falls, infection prevention and the reduction in unavoidable pressure ulcers have been selected as specific areas of focus for the Trust for 2013/14.
3.2.1 Infection prevention Lead Executive Director Rob Dearden, Director of Nursing Clinical Lead and Implementation Lead Debra Fairley, Deputy Director of Nursing Allison Charlesworth, Matron Infection Prevention
Healthcare associated infections (HCAI) are infections that are acquired as a result of healthcare interventions. There are a number of factors that can increase a patient’s risk of acquiring an infection, but high standards of infection control practice minimise the risk of occurrence (Health Protection Agency [HPA] 2013). This fiscal year the Trust reported its first hospital acquired MRSA bacteraemia case since August 2012. A further case occurred in February 2014. Although this is disappointing, the risk of a patient acquiring a MRSA infection while in Airedale still remains low. C. difficile cases developing in hospital and after admission continue to fall year on year. (Please also see section 2.3.2 Rate of C. difficile which provides a national comparator.)
Figure 1: MRSA bacteraemia and C. difficile cases at Airedale General Hospital in the last six years
70 68 60 50 40 30 27 21 20 16 18 Count of cases 12 7 10 6 3 2 2 0 0 2008/09 2009/10 2010/11 2011/12 2012/13 2012/13
1st April to 31st March C. difficile MRSA
Data source: Airedale NHS Foundation Trust Infection Prevention.
To prevent HCAI, we continue to monitor closely the rates of infection; strengthen infection control measures; and learn from best practice. Key measures include:
. Senior sisters/charge nurses provide updates and assurance on measures implemented to reduce HCAI through the Infection Prevention Implementation Group. . All hospital acquired MRSA, MSSA and Ecoli bacteraemia and C. difficile infections are subject to root cause analysis with learning points cascaded immediately to clinical teams. . Anti-microbial selection and usage is reviewed by the Antibiotic Pharmacist and Director of Infection Prevention; treatment choice is closely monitored as part of analysis of C. difficile infection prevention. . Environmental sampling has been carried out to establish if C. difficile can be detected in the immediate environment of patients with C. difficile infection. Further work to refine this process is ongoing. . The district wide Infection Prevention Team and the Joint Infection Prevention Control Strategy Group continues to support an integrated approach to C. difficile prevention work. . A teleconference was held with colleagues from North Yorkshire and Humber on Carbapenemase producing Enterobacteriaceae, a new and emerging multi-resistant organism and is ongoing. . Executive hand hygiene walk rounds, led by the Matron for Infection Prevention, continue to promote compliance with “bare below the elbows” and hand hygiene guidelines. . The monthly hand hygiene audit continues to report compliance of 94 per cent and above. This is part of a robust and ongoing infection prevention clinical audit programme. . Hospital acquired pneumonia cases and urinary tract infections continue to be closely monitored. . Quarterly newsletters are issued to maintain the profile of infection prevention. Topics have included: C. difficile, flu, and Norovirus. . Domestic Services undertake routine cleanliness audits whilst the Enhanced Cleanliness Team maintains its work programme.
Rigorous efforts including hand washing, screening cultures to detect patients (and in some cases staff) colonised with MRSA and the use of contact precautions and alerts for colonised patients who are re-admitted all seek to help reduce the transmission of MRSA within hospitals. The Trust’s inpatient MRSA carriage rate remains low (reported as 0.89 in December 2013) and, as illustrated below, demonstrates a sustained downward shift in the last six years.
Figure 2: Special process control chart of the relative frequency of Airedale General Hospital inpatients carrying MRSA 1996–2013
15
UCL=12.09
10
mean=6.167 5
Percentage carriage rate of inpatients 0 LCL=0.2489
1996 2006 2013
Data source: Airedale NHS Foundation Trust Infection Prevention.
3.2.2 Management of pressure area care Lead Executive Director Rob Dearden, Director of Nursing Clinical Lead and Implementation Lead Elaine Andrews, Assistant Director Patient Safety Janine Ashton, Tissue Viability Nurse
The prevention of hospital acquired pressure ulcers and improved treatment and management of acquired ulcers (both community and hospital) reduces the risk of associated complications such as infection, pain and disability, as well as reducing the length of hospital stay. Improved nursing care and management of pressure ulcers have resulted in a reduction in the prevalence of hospital acquired pressure ulcers from 8.9 per cent reported in 2008 to 3.1 per cent in 2013 as measured in the annual pressure ulcer audit conducted over two days in October. Of an overall sample of 291, nine patients were recorded as having Trust acquired pressure ulcers: one was category 1, eight were category 2 (superficial injury) and none had the most severe form of pressure ulcer (category 3, 4 or suspected deep tissue injury).
Figure 3: Airedale NHS Foundation Trust pressure ulcer point prevalence 2008–2013
14% 12.8% 12.3% 12% 10.0% 9.0% 10.1% 9.6% 10% 8.9% 9.6% 8% 6.5% 6%
4%
Percentage of Patients 3.1% 3.4% 2% 2.7%
0% 2008 2009 2010 2011 2012 2013
Overall prevalence [hospital acquired plus community acquired]
Patients with hospital acquired ulcers
Patients within our community catchment area [care may not necessarily be provided by Airedale e.g. residential nursing homes]
Data source: Airedale NHS Foundation Trust Tissue Viability/Nursing Practice Development.
At a national level, methodological differences in studies and differing patient populations limit meaningful comparisons between healthcare providers. ArjoHuntleigh assist with annual prevalence audits across many hospitals in the UK, allowing it to compile the ArjoHuntleigh National Audit Database with a patient population of 26,083 nationally.30 ArjoHuntleigh’s hospital acquired prevalence for 2008/09 (excluding category 1 pressure ulcers) was reported as 6.18 per cent (these are the latest available figures). The Trust’s 2013 prevalence, excluding category 1 pressure ulcers, is 2.8 per cent.
The NHS Safety Thermometer, a national improvement tool used to monitor and analyse patient harm including that relating to pressure ulcers, has been embedded within the organisation over the last 18 months. A point prevalence tool surveys 100 per cent of in hospital patients and a sample of community patients one day per month but, unlike incident reporting, records only the most serious category rather than each single incident. This can result in under reporting of prevalence. There is variation within the Safety Thermometer data which makes it unsuitable for like for like comparison. This is due partly to case mix and local interpretation of the measures which can vary from one collector to the next. (An independent evaluation of local data collection methods is underway and is expected to report back in 2014.) The Safety Thermometer information is reviewed internally on a monthly basis to identify where prevalence is high and the possible reasons for this in support of quality improvement work.
The Trust has a robust incident investigation process to determine the root causes of significant pressure ulcers (category 3 and 4) acquired in hospital. All key issues are investigated with learning and actions for improvement set out in an action plan which is monitored via the Trust’s governance systems. Part of this process determines whether the pressure ulcer is preventable (avoidable) or inevitable in development (unavoidable). To date the following figure illustrates the outcome of root cause analysis of category 3 and 4 pressure ulcers since June 2013; this is an ongoing process. C/S refers to Airedale NHS Foundation Trust services within the community. Moisture associated skin damage or
30 It is unpublished data and does not provide a case mix adjustment and so cannot provide a true benchmark; however, due to the absence of any other available measure and the fact that our prevalence audit follows the same format, our results can be compared with ArjoHuntleigh’s national prevalence.
moisture lesions are defined as inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine, perspiration and wound exudate.
Figure 4: Breakdown of ANHSFT Pressure Ulcers (Category 3 & 4) by avoidable, unavoidable harm and moisture lesion from 1st June 2013
8 7 6 5 4 3 2 1 0 C/S PU C3 C/S PU C4 Hosp. PU C3 Hosp. PU C4
Avoidable Unavoidable Moisture lesion
Data source: Ulysses database
A number of initiatives have been introduced in the past twelve months including work to reduce pressure ulcers that occur beneath cervical collars; the introduction of pressure reducing trolley toppers in the Emergency Department; review of the risk assessment tool used in the Craven community service; re-evaluation of the pressure care equipment provision across the Craven community teams; additional training on pressure ulcer grading; and the introduction of interventions to specifically reduce the incidence of pressure ulcers to the heel. The Trust’s Pressure Ulcer Prevention and Management Policy has been integrated with Craven community services. The next year will see a review of the wound care formulary guidelines and the development of a more comprehensive wound assessment record.
The Trust sees and treats a significant number of patients who are admitted from nursing homes, residential care or their own homes that are not within the care domain of Airedale General Hospital or its community services. The Airedale, Wharfedale and Craven Clinical Commissioning Group have funded an interim Tissue Viability Service across the Craven area, whilst a service review is undertaken by the West Yorkshire and South Yorkshire and Bassetlaw Commissioning Support Unit. This provision includes the introduction of Pressure Ulcer Co-ordinators across the locality. It is recognised that patients are living longer with increased frailty. The Trust is establishing a task and finish group to explore the opportunities to introduce proactive initiatives to prevent pressure damage in residential care homes in the Craven area.
3.3 Clinical effectiveness
The following projects focus on the delivery of clinical excellence in care and treatment.
3.3.1 Management of the number of caesarean sections Lead Executive Director Dr. Andrew Catto, Medical Director Clinical Lead and Implementation Lead Mr Naren Samtaney, Clinical Director Obstetrics and Gynaecology Julie Hinchliffe, Senior Matron Midwifery
Work has continued within Maternity Services to reduce the number of caesarean sections during 2013/14 as there are a number of risks associated with caesarean section, both for the mother and the baby, in the immediate and longer term.
Figure 5: Caesarean section rate for Airedale NHS Foundation Trust against the national average for England since 2005/06
50 45 40 35 27.6 30 26.9 25.8 25.0 25.4 25.5 25 24.5 20 24.1 24.6 24.8 23.9 23.1 21.8 15 10
Percentage confinements of all 5 0 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 1st April to 31st March National Average ANHST Percentage of all confinements
Data Source: Evolution Maternity System. National average data source: Health Episode Statistics (not available as yet for 2013/14).
The national incremental trend in caesarean birth has continued, with a 0.5 per cent increase in 2012/13. Although the Trust’s overall caesarean section rate is below the national mean, detailed analysis has identified that the elective section rate is above the national mean. The unit is currently utilising the NHS Institute for Innovation and Improvement’s “Pathways to success: resource pack: optimising opportunities for normal birth and reducing intervention rates” (2011) to address this issue. In order to ensure that there is no preventable loss or morbidity, a balance must be drawn between reducing the number of caesarean sections and ensuring safety for the mother and newborn.
Initiatives and progress up to 2013/14:
. A new bespoke midwifery unit opened in July 2013. Its goal is to make the environment less clinical and more homely, to provide a relaxing place to give birth. Evidence suggests that this can reduce clinical intervention and promote a more positive patient outcome. The upgrade followed feedback from those using our maternity service, as well as from the National Childbirth Trust and local voluntary group, Airedale Mums.
The unit’s primary focus is on normality, active birth from the onset of labour and midwifery-led care. The aim is to promote normal birth and a reduction in the number of interventions, including caesarean section. Both medical and midwifery staff are fully committed to this philosophy of care. At the time of this report, total hospital births have increased by 50 per cent with “water labours” increasing by 33 per cent in 2013/14.
. Women who have had one previous caesarean section for a non-recurring reason and who are not at increased risk of uterine rupture in labour are actively encouraged to aim for vaginal birth in the subsequent pregnancy. . The introduction of a midwife-led vaginal birth after caesarean (VBAC) clinic in 2014 has replaced previous plans for a midwife-led high risk clinic. It is anticipated that women who are undecided or decline VBAC following discussion with an obstetrician, will have further opportunity to discuss all options, ensuring they are fully informed prior to making a final decision. For those women with tocophobia or extreme anxiety, they can be referred to
the Healthcare Psychology Service. We plan to evaluate the potential learning from this information in 2014/15. . External Cephalic Version (ECV) is offered to women with a baby in the breech position and for whom it is safe. At the time of this report, 27 women had attended for ECV in 2013/14, 16 of these had elective caesarean for breech presentation because ECV was unsuccessful or not attempted. . “My Airedale Midwife” (MAM) community team launched in January 2014. The team focuses on delivering services and continuity of care-giver for vulnerable women, those requesting home birth and women who have had a previous caesarean.
3.3.2 Enhanced Recovery Programme Lead Executive Director Dr Andrew Catto, Medical Director Implementation Leads Mr Alex Acornley, Consultant Mr Basit Khan, Consultant Mr Naren Samtaney, Clinical Director Obstetrics and Gynaecology Denise Todd, Matron Surgical Services Nona Toothill, Clinical Nurse Specialist Urology Denise Parker, Clinical Nurse Specialist Breast Care Julie Livesey, General Manager, Surgical Services
Enhanced recovery is an effective way of improving the experience and wellbeing of patients who need planned elective surgery. Funded by the Department of Health and endorsed by the National Cancer Action Team, the principles of the Trust’s Enhanced Recovery Programme are to ensure that patients are in a favourable clinical condition prior to surgery; they have optimal management during their operation; and have the best post-operative rehabilitation.
The programme focuses on delivering key principles of care:
. Pre-surgery education diminishes anxiety and increases the knowledge and understanding of the patient. . Admission on the day of surgery reduces length of stay. . A standardised anaesthetic protocol helps pain management and recovery. . Multi-professional patient records support the sharing of information and reduce risk of complications. . Orthopaedic physiotherapy and occupational therapy is promoted to ensure effective rehabilitation. . Criteria-based discharge: a checklist that helps to reduce error in the discharge process, reducing the risk to the patient. . A telephone call to the patient in the 48 hours following discharge helps to reduce risk to the patient and re-admission to hospital.
The Trust initially selected orthopaedic and colorectal clinical specialties to implement the programme. All colorectal specialty patients are now entered onto the enhanced recovery pathway. Orthopaedic services have built on their successful implementation of the Enhanced Recovery Programme and have recently opened a dedicated elective orthopaedic ward. This comprises dementia-friendly modifications; a treatment room; physiotherapy area; and education facilities. An integrated service pathway is aimed at reducing infection and early supported discharge from hospital. Most patients can now expect to go home on average four days after their operation.
In 2011/12 the Enhanced Recovery Programme was successfully extended to gynaecology whilst, more recently, the principles have been adopted in urology and breast surgery. In urology more detailed information is now given to patients undergoing specific procedures. Ward staff have undertaken enhanced training to improve post-operative recovery and minimise complications. The urology pathway has been reviewed and earlier removal of the urinary catheter is undertaken. In most instances urology patients are now being discharged a half to one day earlier.
Within breast surgery, joint working with community teams and improved training has been spearheaded by the Clinical Nurse Specialist for Breast Care and underpinned by a revised integrated care pathway. In most circumstances and with the support of community staff, breast care patients are now discharged half a day to one day after surgery, with a surgical drain in place.
Overall a third of the patients going through the enhanced recovery programme are discharged on the first day after their operation with the vast majority being home within three days. Figures 6 to 8 present the mean length of stay for joint replacement and abdominal hysterectomy at Airedale in the last four fiscal years. The success of the programme with its demonstrable improvement in patient experience, has led to its adoption within the Medical Division, specifically within the cardiac pacemaker programme and endoscopic retrograde cholangiopancreatography (ERCP).
Please note that the hip and knee data was transposed in the 2012/13 Quality Account and has been rectified in this year’s report. Control limits are set at 95 per cent, meaning there is a one in 20 chance that the true value lays outside this range. Not all 2013/14 episodes are coded; the return covers the period April 2013 to February 2014.
Figure 6: Airedale NHS Foundation Trust hip replacement mean length of stay over the last four fiscal years
8.00
7.00
6.00
5.00
4.00
Length stay: days of 3.00
2.00
1.00
0.00 2010/11 2011/12 2012/13 2013/14
Airedale NHS FT Upper Control Limit Lower Control Limit
Figure 7: Airedale NHS Foundation Trust knee replacement mean length of stay over the last four fiscal years
8.00
7.00
6.00
5.00
4.00
Length stay: days of 3.00
2.00
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Airedale NHS FT Upper Control Limit Lower Control Limit
Figure 8: Airedale NHS Foundation Trust abdominal hysterectomies mean length of stay over the last four fiscal years
8.00
7.00
6.00
5.00
4.00
Length stay: days of 3.00
2.00
1.00
0.00 2010/11 2011/12 2012/13 2013/14
Airedale NHS FT Upper Control Limit Lower Control Limit
Data source: Airedale NHS Foundation Trust Information Services.
3.3.3 Fractured neck of femur improvement project Lead Executive Director Dr Andrew Catto, Medical Director Implementation Lead Mr Gethin Thomas, Consultant Ian Segovia, Orthopaedic Nurse Practitioner Denise Todd, Matron Surgery John Logue, Matron Critical Care Unit Julie Livesey, General Manager, Surgical Services
A broken hip, also known as a fractured neck of femur, is the most serious consequence of a fall, with the risk of occurrence increasing with age. According to NICE, the majority of fractured neck of femurs occur in elderly patients with osteoporosis; mortality is high although most deaths are from associated conditions and not the fracture itself.31 For those who recover, there is a possibility of a loss in mobility and independence. Hip fracture is attributable to a number of factors (age, underlying conditions, sex and ethnicity), but research suggests that organisational factors in a patient’s treatment can affect outcomes.
In the last year the trauma and orthopaedic ward has relocated, becoming the first ward to benefit from the “Here to Care” dementia-friendly upgrade. Routine orthopaedic-geriatric ward rounds are fully established to ensure that at least 95 per cent of our patients with a fractured neck of femur are reviewed within 72 hours of admission. The Trust is currently recruiting an Orthogeriatric Registrar to work alongside the Orthopaedic Nurse Practitioner. An assessment protocol has been agreed with anaesthesia and the orthopaedic and geriatric specialities work collaboratively on falls prevention and bone health. The wider multi- professional team continues to support patients with the appropriate advice, rehabilitation services and aids and adaptations to promote mobility and independence. Further enhancement of recovery for neck of femur fracture patients involving fascia iliaca nerve blocks is proposed.
Dr Foster Intelligence (2013), in its review of NHS care at weekends,22 has undertaken analyses of fractured neck of femur and offers some useful national performance benchmarks. For the quality measure of “not repairing broken hips within two days”, the Trust rate is 9.8 per cent; with the England rate between 14.2 and 29.5 per cent, this makes our performance better than expected. This measure is further broken down:
. For “not repairing broken hips within two days: Friday to Saturday” the Trust rate is 11.4 per cent against a rate for England of between 11.4 and 40.5 per cent. This places our performance within the expected range. . For “not repairing broken hips within two days: Sunday to Thursday” the Trust rate is 9.2 per cent against a rate for England of between 11.7 and 29.6 per cent. This places our performance as better than expected.
An alternative marker of the quality of care that patients receive is the total length of NHS care following a fractured neck of femur with a shorter length of stay associated with less risk.
31 NICE (2011) Hip Fracture. The management of hip fracture in adults. NICE clinical guideline 124. NICE: Manchester.
Figure 9: Fractured neck of femur mean length of stay [day] for Airedale NHS Foundation Trust patients in the last six years
25.0 23.3
20.0 19.3 19.4 20.5 16.0 17.2 15.0
10.0
Length of stay: days 5.0
0.0 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14
1st April to 31st March
Length of Stay Airedale General Hospital mean AGH upper control limit AGH low er control limit"
Please note that not all March 2014 episodes are fully coded as yet.
Data source: Airedale NHS Foundation Trust Information Services.
The figure above describes our performance in the last six years in the reporting period 1st April to 31st March: mean length of stay is 19 days with upper and lower control levels (of 95 per cent) ranging from 17 to 22 days. These levels help to identify positive and negative special cause variation which falls outside the limits (an outlier) and support understanding of performance. The return for 2009/10 is classed as a negative outlier, meaning that the length of stay is worse than expected, falling outside the expected variation. The subsequent performance in the last four years demonstrates a sustained fall in length of stay, with the returns either around or below the mean. Between 1st April 2011 and 31st March 2012, the overall mean length of stay for England was 20 days with trusts’ performance varying from as little as ten days to as much as 40 days. 32
32 The Information Centre (2012), The National Hip Fracture Database National Report.
3.4 Performance against key national priorities
The following indicators support the national priorities as set out in the Department of Health’s NHS Operating Framework 2013/14 and includes performance against relevant indicators and performance thresholds set out in Appendix B of Monitor’s Compliance Framework 2013/14. The return conforms to specified data quality standards and prescribed standard national definitions25 and is subject to third party scrutiny and review.
Indicator Threshold 2012/2013 2013/2014 Clostridium difficile – meeting the Clostridium difficile objective 9 18 7 All cancers: 31-day wait for second or subsequent treatment, comprising either: surgery 94% 100% 100% anti cancer drug treatments 98% 100% 100% radiotherapy 94% N/A N/A All cancers: 62-day wait for first treatment, comprising either: from urgent GP referral to treatment 85% 93.9% 89.8% from Cancer screening service referral 90% 95.8% 94.1% Maximum 18 week waits from referral to treatment in aggregate – admitted 90% 93.1% 91.8% Maximum 18 week waits from referral to treatment in aggregate – non-admitted 95% 97.3% 95.9% Maximum 18 week waits from referral to treatment in aggregate – patients on an incomplete pathway 92% 92.5% 92.6% All cancers: 31-day wait from diagnosis to first treatment 96% 100% 100% Cancer: two week wait from referral to date first seen, comprising either: all cancers 93% 96.5% 97.8% for symptomatic breast patients (cancer not initially suspected) 93% 98.9% 98.4% A&E maximum waiting time of four hours from arrival to admission/ transfer/ discharge 95% 95.9% 95.8% Data Completeness: Community Services comprising: Referral to treatment information 50% 100% 100% Referral information 50% 71.7% 99.9% Treatment activity information 50% 89.6% 92.6%
Green = achievement against the target.
Data source: Airedale NHS Foundation Trust Information Service
Annex
4.1 Airedale, Wharfedale and Craven Clinical Commissioning Group (CCG)
The draft Quality Account 2013/14 was circulated to the Airedale, Wharfedale and Craven Clinical Commissioning Group and the following feedback received in May 2014:
Millennium Business Park Station Road Steeton West Yorkshire BD20 6RB
23rd May 2014 Dear Bridget,
Airedale NHS Foundation Trust Quality Accounts 2013/14 Feedback from Airedale, Wharfedale and Craven CCG (AWC CCG)
Thank you for sending through the Airedale NHS Foundation Trust (ANHSFT) 2013/14 Quality Accounts for review. AWC CCG has also shared this with our associate commissioning colleagues from East Lancashire, Bradford City and Bradford Districts CCGs and this letter reflects our collective thoughts.
Overall, the ANHSFT Quality Account provides a detailed, open and honest reflection on the activities undertaken throughout 2013/14. It shows clear evidence of continuous improvement in the quality of services delivered. The Account is comprehensive and clear to the reader and the design layout successfully links the quality agenda to the NHS Outcomes Framework. This provides an assurance to the reader that the national drive to improve quality is deeply embedded in the culture and overall direction of travel of ANHSFT.
Throughout the report, the use of statements and action plans provides in depth quality detail, resulting in an informative document. It may have been beneficial to include timescales and recommendations from the action plans, to provide the reader with a complete picture. There are numerous examples of good practice within the account and it would be unfair to highlight a few and lengthy to reference all, as such, the CCGs acknowledge the many examples of good practice and congratulate the Trust on these.
Currently, the national agenda is extremely demanding and challenging and it is acknowledged that ANHSFT has continued to sustain and provide a safe, effective and high quality environment to our patients. It is encouraging that the hospital’s reputation precedes itself and is nationally recognised; hence its selection in the Clinical Quality Commission (CQC) first wave inspection visits due to its perceived low risk rating which was confirmed during the inspection.
The CQC visit in September 2013, which comprised announced and unannounced inspections, both in and out of hours, resulted in high praise and inspectors highlighted
several areas of good practice. These included the use of volunteers, the Telehealth Hub and the use of a shared electronic patient record with access to primary care information. All staff must be acknowledged and congratulated for the hard work and dedication they have shown and continue to show.
The CCGs recognise the commitment of ANHSFT to improving quality and ensuring a safe environment for patients and congratulate the Trust on its achievement on the award from CHKS - The 40 Top Hospitals. It is also recognised that the Trust has invested time in its staff with developments of particular note being the Rising Stars initiative and Directory of Services. It is identified that this year’s staff survey results have not been as good as previous years in certain areas, but the CCGs feel confident that these areas will be addressed in the coming months.
The account also successfully demonstrates the Trust’s energies to focus on the interests of patients, as explained articulately within the transformation section, however, the account would have benefitted from more mention of the Trust’s community services who are playing a pivotal role in this agenda.
The Trust has evidenced its commitment to compliance with national standards and guidelines, demonstrating 86% participation levels in national clinical audits and 100% national confidential inquires, with many actions completed. This is extremely positive and shows once again the Trust’s commitment to ongoing development.
Continuing with learning and development, the 106 clinical research studies ANHSFT are involved in is extremely impressive and demonstrates again the Trust’s commitment to new developments. One particular example is The Research in Action project which reflects a healthy allegiance to innovation and progress. The Research ICT based Clusters for Healthcare Application Research and Development Integration is reported as being complete and has involved a local taskforce visiting European countries; however the report does not provide detail of the project, its success, outcomes and patient benefits. A more detailed synopsis would enhance the readers’ knowledge and recognition.
As we are all aware, the Government’s agenda currently is extremely demanding and challenging. The Friends and Family Test has been a particular challenge for acute providers. ANHSFT has had difficulties at times with this over the last year; however, due to the commitment and dedication of staff the scores from both patients and staff are above national average.
Patient experience features highly in the current agenda for health services. ANHSFT’s in- patient Survey results reported that although experience is good, there has been little improvement over time, compared to better performing Trusts. The CCGs would expect this to be given a high priority during the coming months to ensure an improved experience for our patients.
When looking at the priorities from previous years’ Quality Accounts and comparing to the future identified areas for 2014/15, it is apparent that focus continues on dementia, slips, trips, falls and telemedicine. It is acknowledged that this is the Trust’s three year plan and this will be the final year for this focus.
In view of the above focus the CCG has identified that the report documents a number of in- patient falls resulting in fractures since 2008, although there is fluctuation and a significant dip in numbers in 2012/13, it appears that in the last year there has been an increase in the numbers of falls resulting in fracture. Whilst the CCGs acknowledge that it is impossible to prevent all falls, given the focus of the last three years this trend is of concern. The CCGs
look forward to seeing a reduction in falls resulting in fractures over the coming weeks and months given the continued focus in this area.
In the 2012/13 Quality Account there was reference to the introduction of internal professional standards in relation to pressures faced within the organisation and work around discharge flow and speeding things up to improve the experience for patients. The CCG asked for a synopsis of the implementation and comparative outcome last year and the response from the Trust was that as this was a whole systems issue across health and social care, it was judged too early for an evaluation of outcomes and an update would be included in 2013/14 account. Disappointingly, the account does not include an evaluation of this work which the CCGs were expecting to see.
Overall, the Trust has had a very positive twelve months and there is very clear evidence of the continued commitment to improved quality of care for patients. We hope that you agree that this summary provides an objective review and is accepted in the spirit intended.
Kind regards
Dr Phil Pue Steph Lawrence Chief Clinical officer Head of Clinical Quality and Governance/Executive Nurse
4.2 Healthwatch
The draft Quality Account 2013/4 was circulated to HealthWatch Bradford and District HealthWatch North Yorkshire and HealthWatch Lancashire. The following feedback was received in May 2014:
Airedale NHS Foundation Trust (ANHSFT) Quality Accounts 2013- 2014 Statement by Healthwatch Bradford and District Care Quality Working Group (CQWG)
Healthwatch Bradford and District thanks the ANHSFT staff for their helpfulness and readiness to discuss drafts of this Quality Account and we would like to congratulate the Trust for the clarity of the report.
We were pleased to see:
• The very impressive achievements in the continuing TeleHeath programme and the reduction in Emergency Department attendance resulting
• the positive results following a visit under the new CQC scrutiny regime
• the high ranking awarded by CHKS
• the achievement of low weekend mortality rates shown on the Dr Foster Good Hospital Guide
• the continuing high quality work on dementia
• the developments in maternity services
• the continuing good work with patients with cancer
• the new endoscopy unit
• the awareness of safeguarding issues
• the continuing feeding buddy scheme
• additional information provided about local learning from participation in national audits and enquiries for example we were impressed with the speed of response to TIA referrals
We congratulate the Trust on their public and patient engagement work
We welcome the openness demonstrated and detail given on responses to patient complaints and action taken following serious incidents. We are particularity pleased that the Trust incorporates learning from these in staff training. We are slightly worried to see an increase in the number of formal complaints
We are very interested in the P-I-E research aiming to improve interaction with elderly and vulnerable patients
We note that staff surveys continue to show the need to reduce staff work pressures.
We find the small increases in readmission of up to 15 year olds a little worrying.
We are pleased to see the phasing out of the Liverpool Care Plan and will take an interest in the development of the Gold Standard Framework – we are particularly concerned to see that relatives and patients are kept fully informed and continually consulted. We are aware of Airedale’s previous good practice on this and that there were cases where patients have been taken off the end-of-life care pathway as a result. We urge that patients and relatives are given good information so that they have a proper understanding of the implications and that they give clear consent to patients being placed in end-of-life care. We would like to know more about the Shared Purpose Programme and about the coding of patients receiving palliative care
We are pleased that continued efforts are made to reduce the number and severity of falls and to hear about the new safety system purchased for use with low level beds for agitated patients. Also we think the Trust is doing well, in tackling infection.
Ideally we would like to see the PROMS data provided in a more accessible form
Overall we are pleased with the quality of care delivered by the Trust and we think this is shared by patients and therefore reflected in the responses to the Family and Friends question. However we are disappointed at the ratings given by PLACE inspections and feel the Trust must urgently address issues raised.
4.3 Overview and Scrutiny Committee
The Trust attended Bradford Metropolitan District Council Health Overview and Scrutiny Committee in April 2014 to outline quality priorities. The draft Quality Account 2013/14 was circulated to Bradford Metropolitan District Council Health Overview and Scrutiny Committee and North Yorkshire County Council Overview and Scrutiny Committee for comment. Both acknowledged receipt; the following feedback was received in May 2014:
4.4 How to provide feedback on the Account
We welcome your views on our Quality Account, specifically:
. Where you think the biggest improvements on our quality priorities can be made? . How to engage our partners in our work to improve the quality of services? . Do you have any comments or suggestions on the format of our Quality Account? . Your suggestions for quality priorities in 2013/14?
The Annual report and Quality Account will be available on our website at: www.airedale-trust.nhs.uk
A summary of the Quality Account is available in The Airedale Annual Record 2013/14. If you need a copy in a different format, such as large print or in another language, then please contact our Interpreting Services on telephone: 01535 292811 or email interpreting at [email protected]
4.6 Monitor guidance for data quality assurance on Quality Reports
Monitor requires foundation trusts to obtain external assurance on its quality reports. Set out below is the detailed 2013/14 guidance for auditors to enable review and testing of data quality.
4.6.1 C. difficile33
Detailed descriptor
Number of C. difficile infections, as defined below, for patients aged two or over on the date the specimen was taken.
Data definition
A C. difficile infection is defined as a case where the patient shows clinical symptoms of C. difficile infection, and using the local trust C. difficile infections diagnostic algorithm (in line with Department of Health guidance), is assessed as a positive case. Positive diagnosis on the same patient more than 28 days apart should be reported as separate infections, irrespective of the number of specimens taken in the intervening period, or where they were taken.
In constructing the C. difficile objectives, use was made of rates based both on population sizes and numbers of occupied bed days. Sources and definitions used are:
For acute trusts: The sum of episode durations for episodes finishing in 2010/11 where the patient was aged two or over at the end of the episode from Hospital Episode Statistics (HES).
Basis for accountability
Acute provider trusts are accountable for all C. difficile infection cases for which the trust is deemed responsible. This is defined as a case where the sample was taken on the fourth day or later of an admission to that trust (where the day of admission is day one).
To illustrate: • Admission day; • Admission day + 1; • Admission day + 2; and • Admission day + 3 – specimens taken on this day or later are trust apportioned.
Accountability
The approach used to calculate the C. difficile objectives requires organisations with higher baseline rates (acute trusts and primary care organisations) to make the greatest improvements in order to reduce variation in performance between organisations. It also seeks to maintain standards in the best performing organisations.
Appropriate objective figures have been calculated centrally for each primary care organisation and each acute trust based on a formula which, if the objectives are met, will collectively result in a further national reduction in cases of 26% for acute trusts and 18% for primary care organisations, whilst also reducing the variation in population and bed day rates between organisations.
Timeframe/baseline
The baseline period is the 12 months, from October 2010 to September 2011. This means that objectives have been set according to performance in this period.
33 The Quality Accounts Regulations requires the C. difficile indicator to be expressed as a rate per 100,000 bed days. The Trust must also disclose the number of cases in the quality report, as it is only this element of the indicator that we intend auditors to subject to testing.
4.6.2 Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers
Detailed descriptor34
PHQ03: Percentage of patients receiving first definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer.
Data definition
All cancer two month urgent referral to treatment wait.
Denominator
Total number of patients receiving first definitive treatment for cancer following an urgent GP (GDP or GMP) referral for suspected cancer within a given period for all cancers (ICD-10 C00 to C97 and D05).
Numerator
Number of patients receiving first definitive treatment for cancer within 62 days following an urgent GP (GDP or GMP) referral for suspected cancer within a given period for all cancers (ICD-10 C00 to C97 and D05).
Accountability
Performance is to be sustained at or above the published operational standard. Details of current operational standards are available at: http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/ prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_103431.pdf
4.6.3 Fractured neck of femur improvement project
Detailed descriptor
The mean length of stay for patients aged 16 and over with fracture of the neck of femur, 1st April 2013 to 31st March 2014.
Data definition
. A fracture of the neck of femur is defined as a case where the patient shows clinical symptoms and is assessed as a positive case. Standard coding definitions apply.
. Based on admission and discharge information, length of stay conforms to standard definitions for Hospital Episode Statistics (HES).
Methodology
Numerator Length of stay of patients receiving first definitive treatment for fracture neck of femur (ICD-10 S72) within the reporting period April 2013 to March 2014.
Denominator The number of patients receiving first definitive treatment for fracture of the neck of femur (ICD-10 S72) within the reporting period April 2013 to March 2014.
Indicator format: mean days
Timeframe: 1st April 2013 to 31st March 2014
34 Cancer referral to treatment period start date is the date the acute provider receives an urgent (two week wait priority) referral for suspected cancer from a GP and treatment start date is the date first definitive treatment commences if the patient is subsequently diagnosed. For further detail refer to technical guidance at www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131880
DIRECTORS’ REPORT
The Board of Directors is responsible for exercising all the powers of the Foundation Trust and is the body that sets the strategic direction, allocates the Foundation Trust’s resources and monitors its performance.
Its role is to:
• Set the organisation’s values; • Note advice from, and consider the views of, the Council of Governors; • Set the strategic direction and leadership of the Foundation Trust; • Ensure the terms of the Provider Licence are met; • Set organisational and operational targets; • Assess, manage and minimise risk; • Assess achievement against the above objectives; • Ensure that action is taken to eliminate or minimise, as appropriate, adverse deviations from objectives; and • Ensure that the highest standards of corporate governance are applied throughout the organisation.
The full Board of Directors has met formally with the Council of Governors during the year, to seek and consider the views of the Governors in considering the Foundation Trust’s Annual Plan for the coming year. As Airedale entered its third full year as a Foundation Trust, the emphasis was again placed on ensuring Governors were engaged fully in planning for the 2014/15 Annual Plan. Regular meetings are held with Governors, attended by Directors, in which specific topics chosen by Governors are discussed. The Chairman, who chairs both the Board of Directors and the Council of Governors, ensures synergy between the two Boards through regular meetings and updates.
In addition, Governors and Directors, including the Chairman attend members’ events that are held regularly at the hospital on subjects requested by members. Past topics have focused on end of life care, breast cancer and applying for medical school.
The Directors (both Executive and Non Executive) meet regularly with Governors during their day to day working through meetings, network sessions, Chairman’s briefings, consultations and information sessions. Examples include participation in Foundation Trust committees and working groups, and consultations about the Annual Plan and Quality Account. The Foundation Trust has also established a buddying system in which each of the Executive and Non Executive Directors meet informally with a number of Governors to provide briefings and up to date information about the Foundation Trust.
The Board is made up of five Executive Directors and six Non Executive Directors including the Chairman. It also has an Associate Director – the Director of Operations.
Responsibility for the appointment of the Chairman and Non Executive Directors resides with the Council of Governors. The Appointments and Remuneration Committee, which comprises five members of the Council of Governors and two Non Executive Directors plus the Chairman, is responsible for bringing recommendations for non executive appointments to the Council. The Committee also has the option to commission an independent adviser if appropriate.
A separate committee, the Board Appointments, Remuneration and Terms of Service Committee, comprising Non Executive Directors and the Chief Executive has been established with responsibility for the recruitment and selection of Executive Directors including the remuneration and terms of service of executive directors.
The composition of the Board for the year of the report is set out on the following pages, which also includes details of background, committee membership and attendance at meetings. The Board may delegate any of its powers to a Committee of Directors or to an Executive Director and these matters are set out in the Scheme of Decisions Reserved to the Board and the Scheme of Delegation. Decision making for the operational running of the Foundation Trust is delegated to the Executive Directors Group, which comprises all of the Executive Directors, Associate Director, Head of HR and the Company Secretary.
The Board has an annual schedule of business which ensures it focuses on its responsibilities and the long-term strategic direction of the Foundation Trust. It meets ten times a year to conduct its business and periodically to discuss matters requiring strategic debate. Board members also attend seminars and training and development events throughout the year.
Since becoming a Foundation Trust, the Board has undertaken a rigorous evaluation of its own performance and of individual Directors. The aim is to conduct a full performance evaluation every three years supplemented by more frequent baseline assessment of skills, experiences and competencies. Prior to the year end, the Foundation Trust was invited by Monitor to participate in the new Governance and Capability Review pilot. The review undertaken by an external evaluation company, Foresight Partnership/Capita concluded in March 2014 and the report findings shared with the Board. The company has no other connection with the Foundation Trust.
An annual appraisal process for Non Executive Directors is in place. The Chairman appraises the performance of the Non Executive Directors and provides a detailed report to the Appointments and Remuneration Committee, while the Senior Independent Director leads the Chairman’s appraisal and provides a summary report also to the Appointments and Remuneration Committee. In preparing the appraisals, both the Chairman and Senior Independent Director consult with the Lead Governor and take in to account the views of Governors in their appraisal reports. Individual Directors have also had detailed appraisals of their performance and an annual appraisal process is in place with regular reviews of objectives set by the Chief Executive for Executive Directors.
Non Executive Directors are involved in regular development activities including Board workshops, and attendance at seminars and conferences. We consider we have the appropriate balance and completeness in the Board’s membership to meet the ongoing requirements of an NHS Foundation Trust.
Disclosures of the remuneration paid to the Chairman, Non Executive Directors and senior managers are given in the Remuneration Report on page 113. The Board of Directors who served during the year comprised the following Executive and Non Executive Directors:
NON EXECUTIVE DIRECTORS
Colin Millar, Chairman (retired 30 April 2014) Colin was appointed Chairman in 2005 and retired after serving a second term of four years. His early career was in marketing with an international consumer goods company, principally in the UK. Subsequently he held senior marketing appointments in the financial services sector. Latterly, he owned and ran a market research company supplying information to companies and trade organisations throughout the world. Up to his retirement he was also a Non Executive Director of a regional building society and a Trustee of a hospice in Leeds.
Michael Luger, Chairman (appointed 1 May 2014) Michael was appointed Chairman in May 2014 following the retirement of Colin Millar. Michael formerly served as Dean of Manchester Business School for seven years, retiring from that post in December 2013. Prior to that he was a professor of public policy, business and planning at the University of North Carolina and taught economics at Duke University and the University of Maryland. In addition to university leadership roles, Michael has served on numerous public sector and not-for-profit boards, commissions, and task forces. He has worked as a professional planning officer in the USA and for the Greater London Council, as a consultant and advisor to national,
state, regional and local governments throughout the world, and to major multi-national corporations. His expertise in public finance, infrastructure, and economic development has been used in the health care sector in both the USA and UK.
As well as being chairman of the Board of Directors and Council of Governors, Michael chairs the Appointments and Remuneration Committee.
David Adam, Non Executive Director and Senior Independent Director David was appointed a Non Executive Director in February 2007. His current term of office is due to complete in September 2014. David is a chartered accountant with almost 40 years financial management experience, including 13 years as a PLC Finance Director with two publicly listed companies. He previously worked as Finance Director in a number of large UK plc subsidiaries and has also held the post of Chief Executive of a large educational supply company. He has also held Non Executive Director roles in three UK companies as well as being a Pension Fund Trustee for over 20 years. David is chair of the Board Appointments and Remuneration and Terms of Service Committee and is a member of the Audit Committee and Appointments and Remuneration Committee.
Ronald Drake, Non Executive Director and Deputy Chairman Ronald was appointed a Non Executive Director in February 2007 and is serving his second term of office. Ronald has over 30 years as a qualified solicitor since being admitted to the Roll in 1978. He retired as partner with a national legal practice in 2012 and is currently acting as a freelance consultant specialising in employment law. He has also been a part-time employment tribunal Judge since 1997. Ronald is a member of the Board Appointments, Remuneration and Terms of Service Committee and the Appointments and Remuneration Committee.
Professor Anne Gregory, Non Executive Director Anne was appointed a Non Executive Director in June 2012. Anne has 30 years of experience in public relations and is currently employed at Leeds Metropolitan University, where she also served a term as pro-vice chancellor, until 2010. For eight years Anne was a Non Executive Director of South West Yorkshire Partnership NHS Foundation Trust and previously served eight years on the board of Bradford Community NHS Trust. Ann is a member of the Board Appointments and Remuneration Committee and the Clinical Specialty and Assurance Committee.
Sally Houghton, Non Executive Director Sally was appointed a Non Executive Director in February 2006 and is currently serving a third term, which is due to end in 2015. Sally is a qualified accountant and has over twenty years experience in multi-national manufacturing and engineering companies, some of which was at Finance Director level. Sally chairs the Audit Committee and Airedale NHS Foundation Trust Charitable Funds Committee.
Dr Michael Toop, Non Executive Director Michael was appointed a Non Executive Director in February 2013 and is a retired consultant in chemical pathology. He previously managed the chemical pathology department at Harrogate Hospital for 25 years until his retirement in 2011. Michael also worked in various specialties at Leicester Royal Infirmary and then as registrar in Birmingham. Throughout his career Michael has held a number of formal positions including with the Royal College of Pathologists and Association for Clinical Biochemistry. Michael is chair of the Clinical Specialty and Assurance Committee.
The Board considers all the Non Executive Directors to be independent.
EXECUTIVE DIRECTORS
Bridget Fletcher, Chief Executive Bridget was appointed Chief Executive in November 2010. Bridget was previously Chief Operating Officer/Chief Nurse and prior to this Director of Nursing for 5 years having joined Airedale in 2005. Before joining Airedale, Bridget was Assistant Director, Quality Assurance at The Royal Marsden
NHS Foundation Trust. Prior to this she was at West Middlesex University Hospital NHS Trust and Salford Royal NHS Trust where she held a number of senior management roles with responsibility for acute health services and professional nursing services.
Rob Dearden, Director of Nursing Rob joined Airedale NHS Foundation Trust as Interim Director of Nursing in August 2011 and was appointed to the substantive role of Director of Nursing on 1 August 2012. Prior to this, he was Deputy Director of Nursing at Calderdale and Huddersfield NHS Foundation Trust. He qualified as a Registered General Nurse in 1987 at Manchester Royal Infirmary and then as a Registered Mental Nurse at Wigan Infirmary in 1990. He later specialised in Care of Older People and Rehabilitation Medicine in Manchester, Wirral and Halifax. Rob has a significant background in Practice Development.
Andrew Copley, Director of Finance Andrew was appointed Director of Finance in January 2013, having previously been Deputy Director of Finance. Andrew is a Fellow of the Association of Chartered Certified Accountants with nearly 20 years of financial management experience. He joined the Foundation Trust from Calderdale and Huddersfield NHS Foundation Trust in 2008. Andrew initially trained as a radiographer at Pinderfields and Pontefract hospitals and later joined St Luke’s hospital, Bradford.
Dr Harold Hosker, Interim Medical Director Harold was appointed Interim Medical Director on 1 March 2014, having previously been Deputy Medical Director with the Foundation Trust. Harold joined Airedale in 2007 as Consultant in General and Respiratory Medicine having previously held the same position at Burnley NHS Trust. His early career was spent at Newcastle as a medical SHO/Registrar before going on to research lung cancer. Harold has also worked as a Specialist Registrar in Leeds and Hull.
Ann Wagner, Director of Strategy and Business Development Ann joined the Airedale NHS Foundation Trust in 2006 originally as Director or Corporate Development taking on responsibility for securing Foundation Trust status – this was achieved in 2010. Since then she has taken the lead for strategy and business development. Prior to joining Airedale, Ann held a number of senior strategic roles including Executive Director of Service Improvement at West Yorkshire SHA, National Programme Director for the Department of Health Integrated Service Improvement Programme, Programme Director for the West Yorkshire Choice Pilot and Director of Performance Management at Bradford Health Authority. Prior to joining the NHS, Ann worked in the private sector as a PR consultant managing a range of business to business accounts and before that worked in Local Authorities and the North of England in a number of marketing related posts.
During the year, Dr Andrew Catto, Medical Director resigned with effect from 28 February 2014.
REGISTER OF INTERESTS
A register of interests for all members of the Board of Directors is held within the Foundation Trust and is continually updated. There are no company Directorships or other significant interests held by Directors that are considered to conflict with their Board responsibilities. The Register of Interests is available on request from the Company Secretary.
STATEMENT OF DISCLOSURE TO AUDITORS
For each individual who is a director at the time that the Annual Report is approved, so far as each director is aware, there is no relevant audit information of which the NHS Foundation Trust’s auditor is unaware, and the directors have taken all the steps they ought to have taken as a director in order to make themselves aware of any relevant audit information and to establish that the NHS Foundation Trust’s auditor is aware of that information.
BOARD OF DIRECTORS Attendance at meetings 2013/14
Charitable Funds Members Board of Directors Audit Committee BART CSAC Sub Committee Colin Millar 09/10 5/5
David Adam 8/10 4/5 6/7
Ronald Drake 10/10 7/7 5/5
Professor Anne Gregory 10/10 5/7 3/5
Sally Houghton 10/10 5/5 5/5
Dr Mike Toop 10/10 5/5 4/5
Bridget Fletcher 10/10 7/7
Andrew Catto (up to February 2014) 8/9 4/5
Harold Hosker (from March 2014) 1/1
Andrew Copley 10/10 5/5 5/5
Rob Dearden 10/10 5/5
Ann Wagner 10/10
NOTE: Mr Adam’s absence from the Board and sub-committee meetings was due to extenuating personal circumstances
COUNCIL OF GOVERNORS
The Council of Governors consists of 32 Governors – the majority, elected – who play a vital role in the governance of the Foundation Trust, working closely with the Board of Directors. They represent the interests of the Foundation Trust’s public and staff constituencies as well as its members and partner organisations in the local community including healthcare, universities, voluntary organisations and local authorities under the terms of the Foundation Trust’s Constitution. The Council has a number of statutory duties as defined in the Constitution which include:
• The appointment (and removal) of the Chairman and Non Executive Directors of the Foundation Trust and approval of the appointment of the Chief Executive; • Deciding on the pay and allowances, and other terms and conditions of office, of the Chairman and Non Executive Directors; • Appointing the Foundation Trust’s auditors; • Holding the Non Executive Directors, to account, individually and collectively, for the performance of the Board of Directors; • Approving changes to the Constitution of the Foundation Trust; • Being consulted on future plans of the Foundation Trust and having the opportunity to contribute to the planning cycle; • Scrutinising the Annual Plan and receiving the Annual Report and Accounts; and • Developing the membership of the Foundation Trust.
We have 26 Governors elected by our members (including staff members) who represent the following constituencies (groups):
• Bradford Metropolitan District Council (five Governors) • Craven District Council (five Governors) • Pendle Borough Council (five Governors) • Leeds City Council (one Governor) • Rest of England (one Governor) • Staff and Volunteers (six Governors)
Of the remaining six nominated Governors, these represent the interests of partner organisations in the local community including universities, voluntary organisations and local authorities.
During the year, the Council of Governors reviewed the Foundation Trust Constitution and approved a change to the requirement for the Volunteers constituency to have to opt-in for membership of the Foundation Trust. The effect of this change has resulted in an increase in membership of the volunteers’ constituency from 127 to 332.
The annual ballot of Governors for the appointment of a Lead Governor and Deputy Lead Governor was held during the year. Mrs Anne Medley, Governor for Keighley West, was duly elected as Lead Governor, and Mr John Roberts, Governor for Worth Valley was elected as Deputy Lead Governor.
A joint meeting with the Board of Directors is held twice yearly to review progress on the Foundation Trust’s Annual Plan and to consider priorities for the forthcoming year. In preparation for the Annual Planning process, the Council of Governors canvassed the opinion of its members and the public by attending local shows and member events, holding drop-in sessions at the hospital, meeting the public and members at GP surgeries, having a dedicated exhibition stand at the hospital open day as well as informal networking. During the year our Governors were fully engaged in different activities and working groups and continued to familiarise themselves with the complexities of such a large organisation. To help support newly elected Governors, the Foundation Trust has developed a bespoke induction programme which existing Governors are also invited to attend. Other training sessions are organised on a monthly basis to provide further
development opportunities for Governors utilising our in-house staff as well as extending invitations to external organisations to speak at Governor network meetings. The Foundation Trust has also funding for several of its Governors to attend national training events organised by the Foundation Trust Network.
We value the contribution our Governors make and the different perspectives they bring to the development of services
In consultation with the Council of Governors, the Board re-appointed Non Executive Director, Mr David Adam, as the Senior Independent Director. Mr Adam is available to Governors if they have concerns, which contact through the normal channels of Chairman, Chief Executive or Director of Finance have failed to resolve or for which contact is inappropriate.
Elections are held each year for those seats either vacated due to resignations or because Governors have reached the end of their three year term of office. Governors can serve no more than three consecutive terms of office (resulting in a maximum of nine years’ tenure). The overall make-up of the Council of Governors, together with their attendance at Council of Governors meetings in 2013/14 is shown below.
During 2013/14, nine Governors claimed travelling expenses totaling £1,593 as reimbursement for attending Governor related meetings and training and development courses both at the hospital and at external venues.
COUNCIL OF GOVERNORS MEETINGS
Attendance at Council of Governors meetings 2013/14
Elected Governors Constituency Name Tenure Meetings attended Bingley David Child 3 years from June 2013 3/4 Bingley Rural Pat Thorpe 3 years from June 2013 4/4 Craven Alan Davies 3 years from June 2012 4/4 Ilkley Nick Beeson Resigned 31 May 2013 1/1 Bryan Thompson 3 years from June 2013 2/3 Keighley East Jean Hepworth 3 years from June 2013 4/4 Keighley Central Adrian Mornin 3 years from June 2012 1/4 Vacant n/a - Keighley West Anne Medley 3 years from June 2011 3/4 Lower Wharfe Valley Vacant n/a - Pendle East & Colne Steve Coakley 3 years from June 2013 2/4 Rest of England John Osborn Resigned 31 May 2013 0/1 Janet Robinson Resigned 25 October 2013 1/2 Settle and Mid Craven Pat Taylor 3 years from June 2013 2/3 Skipton Catherine Bourgeois 3 years from June 2012 2/4 Peter Allen 3 years from June 2013 3/4 South Craven Janet Ackroyd 3 years from June 2011 4/4 Alan Pick 3 years from June 2012 4/4 West Craven Valerie Kimberley 3 years from June 2011 4/4 Chris Nolan 3 years from June 2012 3/4 Wharfedale Peter Beaumont 3 years from June 2013 4/4 Worth Valley John Roberts 3 years from June 2013 3/4
Stakeholder Governors Constituency Name Tenure Meetings attended Craven District Council Marcia Turner Appointed from June 2013 4/4 Bradford Metropolitan District Council Pauline Sharp Appointed from June 2013 4/4 Pendle Borough Council Dorothy Lord Resigned 16 May 2013 0/1 Ken Hartley Appointed from June 2013 2/3
North Yorkshire County 3/4 Council Robert Heseltine Appointed from June 2013 Voluntary Sector Naz Kazmi Appointed from June 2013 1/4 Anne Forster University of Leeds Appointed from June 2013 2/4
Staff Governors Constituency Name Tenure Meetings attended 3 years from June 2013 All Other Staff Shujahat Shah Resigned 24 January 2014 1/2 Doctors and Dentists Naren Samtaney 3 years from June 2012 4/4 Nurses and Midwives Val Henson 3 years from June 2012 2/4 Stephanie Lawrence Resigned 26 April 2013 1/1 3 years from June 2013 Karen Swann Resigned 26 November 2013 0/2 Registered Volunteers David Petyt Resigned 31 May 2013 1/1 3 years from June 2013 John Neale Resigned 29 January 2014 2/2
In addition, the Council of Governors meetings were attended by the following Directors: Non Executive Directors Job Title Meetings attended Colin Millar Chairman 3/4 David Adam Senior Independent Director 4/4 Ronald Drake Non Executive Director 3/4 Anne Gregory Non Executive Director 4/4 Sally Houghton Non Executive Director 4/4 Mike Toop Non Executive Director 2/4 Executive Directors Bridget Fletcher Chief Executive 4/4 Andrew Catto Medical Director 3/4 Andrew Copley Director of Finance 4/4 Robert Dearden Director of Nursing 4/4 Ann Wagner Director of Strategy and Business Development 4/4
MEMBERSHIP
The Foundation Trust has two membership constituencies:
• a public constituency; and • a staff constituency.
PUBLIC CONSTITUENCY
An individual who lives in one of the following public constituencies may become a member of the Foundation Trust by making an application for membership to the Foundation Trust.
As of 31 March 2014 the Foundation Trust had over 10,600 public members.
Constituencies within the public Local Authority electoral areas/or local constituency authority electoral areas falling within the following Electoral Wards Bingley Bingley Bingley Rural Bingley Rural Craven Craven Ilkley Ilkley Keighley East Keighley East Keighley Central Keighley Central Keighley West Keighley West Wharfedale Wharfedale Worth Valley Worth Valley Skipton Skipton East Skipton North Skipton South Skipton West Embsay with Eastby Grassington Upper Wharfedale Barden Fell Settle and Mid-Craven Settle and Ribblebanks Gargrave and Malhamdale Hellifield and Long Preston Penyghent Bentham Ingleton and Clapham South Craven West Craven Aire Valley with Lothersdale Cowling Glusburn Sutton in Craven West Craven Coates Craven Earby Pendle East and Colne Barrowford Boulsworth Foulridge Horsfield Vivary Bridge Waterside
Lower Wharfe Valley Rawdon & Guiseley Otley & Yeadon Rest of England Rest of England
STAFF CONSTITUENCY
An individual who is employed by the Foundation Trust under a contract of employment (which includes full and part time contracts of employment) may become a member of the Foundation Trust provided:
• he or she is employed by the Foundation Trust under a contract of employment which has no fixed term or has a fixed term of at least 12 months; or • he or she has been continuously employed by the Foundation Trust under a contract of employment for at least 12 months.
Individuals who exercise functions for the purposes of the Foundation Trust, otherwise than under a contract of employment with the Foundation Trust, may become members of the staff constituency provided such individuals have exercised these functions continuously for a period of at least 12 months.
The staff constituency also includes registered trust volunteers with at least one year’s service.
The staff constituency is divided into the following constituencies:
Doctors and dentists who are registered with their regulatory body to practice Nurses and midwives who are registered with their regulatory body to practice Allied health professionals and scientists who are registered with their regulatory body to practice All registered volunteers (with a minimum of 12 months service) All other staff
AUTOMATIC MEMBERSHIP FOR STAFF
All eligible staff and volunteer are automatically made members in the staff constituency unless they inform the Foundation Trust they do not wish to do so.
As at 31 March 2014, 10 members of staff had chosen to opt out of membership. All other staff and volunteers are registered as members.
The Foundation Trust had over 2,800 staff members, as of 31 March 2014.
SUMMARY OF MEMBERSHIP STRATEGY
The Membership Development Strategy covering the period 2013/14 is reviewed by the Membership Development Group and approved by the Council of Governors.
The strategy, along with the communications plan and patient and public involvement strategy, will ensure that the membership and the public are:
• fully represented at all levels; • clearly informed; and • used appropriately in decision making around service provision.
The strategy aims to:
• ensure public membership is representative of the community it serves (in terms of nationality, gender, disability, ethnic origin, age, social background, geographical spread and social deprivation); • ensure that all staff groups are given equal opportunity to become involved; • identify levels of involvement and participation within the membership according to the wishes and needs of individuals; and • ensure a continuous approach to the development of the membership in terms of both numbers and level of engagement.
The 2013/14 strategy achieved its aim of increasing the total membership by 5%. In 2014/15 the strategy is to maintain current membership levels and focus on engagement with members and the public, by continuing our programme of regular focus events and in particular continuing our work of collecting member and public views so that these inform the planning process.
THE MEMBERSHIP DEVELOPMENT GROUP
This group is responsible for developing the membership by recruitment, retention, communication and engagement. The group which meets monthly was involved in the following membership activities during 2013/14:
• assisting in planning the public open event; • contributing ideas to the member newsletters • contributing to the involvement of members and the public in the annual plan; • raising the profile of Governors and membership at hospital events and other recruitment activities; and • promoting Foundation Trust membership and the role of Governors through neighbourhood forums, patient participation groups and other local community groups.
RECRUITMENT ACTIVITY DURING 2013/14
Recruitment of new members is an ongoing activity to ensure the membership is representative of the local community. In 2013/2014 we achieved our aim of increasing our membership by 5% and to increase representation in the working age membership by recruitment drives with local employers and by targeted recruitment in the Pendle and Bingley Rural constituencies.
MEMBERSHIP ACTIVITY 2013/14
This year has also seen a number of key developments with regard to membership engagement, development and communications:
Open Events
In August 2013, we delivered our most successful annual open event to date, which attracted over 500 visitors to the hospital. The open event provided interactive displays of equipment and behind the scenes tours from a wide variety of departments and clinical areas within the Foundation Trust. The event was also supported from other health and emergency care organisations such as Sight Airedale, Healthwatch, guide dogs, cave rescue and the police.
The annual general meeting was held on 25 July 2013 and was attended by governors, directors, members of staff and the public.
The theatres open day was held in September and the endoscopy open day was held in October. Both gave our patients and the public the opportunity to tour the departments and meet staff.
‘Focus on’ ... Events
Our ‘Focus on’ events are presentations and demonstrations in response to a number of different health topics, and tailored to the interests expressed by our members. They provide all members with opportunities to gain more of an insight into how our services operate. The programme ran throughout 2013/14 and included talks on:
• Caring for your feet; • Irritable bowel syndrome; • Fundraising; • Applying for medical school; • Stammering; • Organ donation; • Anticoagulation; and • Breast cancer.
Each member attending is asked to complete a feedback form and to make suggestions for future events. Of the responses received over 90% rated the events as ‘excellent’.
We also continue to hold drop in sessions before each ‘Focus on’ event where members can meet their Governors and find out more about their role and have the opportunity to ask questions or give feedback about our services. We also advertise the Governor email addresses on our Foundation Trust website and bi-annually with the newsletter and encourage members to contact their Governor with any feedback.
‘Interested in Becoming a Governor Events’
Our ‘Interested in becoming a Governor?’ events are an opportunity for members to meet the Chairman and find out about the role of a Governor in more detail. We held two of these events during 2013/14 with featured talks from the chairman, membership manager and governors on the role and responsibilities of a Governor, the election process and what happens once you are elected.
MEMBERSHIP COMMUNICATIONS
This year we have sent our regular quarterly communications newsletter to all our membership households. These communications, sent by post and email, are exclusive to our members and they provide updates on new developments at the Foundation Trust, information on membership activities, useful patient information, and health advice.
All this information is also available on the ‘Join us as a member’ section of our Foundation Trust website.
All new members receive a welcome letter which includes a special interest form and membership card containing membership contact information and details for the Foundation Trust website.
YOUNG PEOPLE’S MEMBERSHIP DEVELOPMENT
This year we have continued our recruitment drive of young people via local colleges and by holding events for young people such as:
. Applying for medical school; . Theatres and endoscopy open day; and . Annual open day.
We have continued to produce our Young Members newsletter, specifically aimed at our members aged 16-21 years, giving them health information and invites to our events.
INCREASING REPRESENTATION
This year we have continued our aim to have an increasingly representative membership by targeted recruitment in specific areas and with specific groups in the community.
MEMBERSHIP INTERESTS AND INVOLVEMENT
The ‘Welcome’ mailing members receive, also includes a form for members to record their areas of special interest. This is returned to the Foundation Trust and allows us to create a database of interests where members would be interested in contributing, for example by completing a survey or participating in a focus group. Members have also been invited to events specific to their interests.
In 2013/14 we also focused our work on collecting member and public feedback and ensuring those views were included in the preparation of the Foundation Trust annual plan 2014/15 – 2015/16. Feedback and views were collected via governor drop in sessions, governor attendance at community events, member events, the annual hospital open day, staff events hosted by governors and via direct contact with governors. These views were collated and presented to the Board of Directors by the governors in December 2013 to ensure their consideration. The Board of Directors responded to the views of governors, members and the public at a board to council meeting in February 2014. Governors will feedback to members and the public to explain how those views have been incorporated into future plans.
THE FOUNDATION TRUST OFFICE
The Foundation Trust office continues to be a central point of contact for all members to make contact with the Foundation Trust and the Council of Governors. It can be contacted during office hours, Monday to Friday on 01535 294540 (24 hour answerphone also available) or by email to [email protected]
A list of Governor contact email addresses is published on the Foundation Trust website in the Council of Governors section.
Members are also sent, by email or post according to their preference, a bi-annual Governor update with their Foundation Trust newsletter, which details the work the Governor has been involved in along with an update on hospital news and developments and contact details for their own Governor, should a member have any concerns or issues they want to raise.
Members are also invited, via their newsletter and the website, to meet Governors at drop in sessions before every member talk, held throughout the year.
Governors also take part in the annual public open day, staff event and theatres open day, giving members an opportunity to meet with them and discuss any issues or questions.
GOVERNANCE
The Foundation Trust Board of Directors and Council of Governors have discharged their functions throughout the year through a number of sub-committees as outlined below. The Board receives regular reports from the Committee Chairperson as well as the minutes in order to evaluate the performance and effectiveness of its sub-committees.
AUDIT COMMITTEE
The Audit Committee is chaired by a Non Executive Director – Mrs Houghton, and has a further two Non Executive Directors, Mr Adam and Dr Toop as members. The Director of Finance and other senior managers including the Company Secretary and the Assistant Director Healthcare Governance, attend each committee meeting. Also in attendance is a Governor representative.
Its terms of reference are approved by the Board of Directors. The Committee has an annual work plan which shows how it plans to discharge its responsibilities under its terms of reference. Minutes of each meeting are reported to the Board along with any recommendations by the Chairman of the Audit Committee. Committee members carry out a self assessment each year. The Committee reports to the Board of Directors through its annual report on its work in support of the Annual Governance Statement, specifically commenting on the fitness for purpose of the Board Assurance Framework, the completeness and embeddedness of risk management in the Foundation Trust, the integration of governance arrangements and the appropriateness of the self- assessment against the Care Quality Commission outcomes.
Its main duties throughout the year were:
• Financial reporting – The Audit Committee monitors the integrity of the financial statements of the Foundation Trust, including scrutinising the quarterly corporate governance statement to Monitor, and any formal announcements relating to the Foundation Trust’s financial performance, reviewing significant financial reporting judgements contained in them. The Committee received and approved the Foundation Trust accounts and the Annual Governance Statement for 2013/14.
• Governance, risk management and internal control – The Committee reviews the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the Foundation Trust’s activities (both clinical and non-clinical) that support the achievement of the Foundation Trust’s objectives. The Audit Committee ensures that the review of the effectiveness of the system of internal control is undertaken and its findings reported to the Board. The Committee received the Foundation Trust’s Board Assurance Framework and various audit reports concerning these matters, during this period. The Committee received reports outlining the progress made in planned counter fraud work and general issues concerning the NHS Counter Fraud Service (CFS). The Committee also reviewed as appropriate the findings of other relevant significant assurance functions, both internal and external to the Foundation Trust and considered the implications to the governance of the Foundation Trust.
• Internal audit – The Committee ensures that there is an effective internal audit function established by management that meets mandatory internal audit standards and provides appropriate independent assurance to the Audit Committee, Chief Executive and the Board of Directors. The Committee received the internal audit plan, internal audit annual report and progress reports in this period and also received the review of the internal audit function by external audit and the Director of Finance.
• External audit – The Audit Committee reviews and monitors the external auditor’s independence and objectivity and the effectiveness of the audit process. The Committee received and reviewed external audit plans and regular routine reports, along with holding
regular private discussions with the external auditors and internal audit. The external auditor attends each Audit Committee meeting. In 2012/13, the Foundation Trust conducted a tendering exercise to appoint a new external auditor following the disestablishment of the Audit Commission. The process involving a panel comprising of three Governors, appointed PriceWaterhouseCoopers for a term of three years.
The Company Secretary was the formal secretary for the Committee and ensured that coordination of papers and minutes were produced in accordance with the Chair of the Committee. The Foundation Trust has a process agreed by Governors for the agreement of non-audit services provided by external audit; however other than a specific piece of VAT advice relating to a business arrangement, no additional non-audit services were required during the period.
CLINICAL SPECIALTY ASSURANCE COMMITTEE
The Clinical Specialty Assurance Committee, chaired by Dr Toop, Non Executive Director, provides the Board of Directors with assurance that high standards of care are provided by the Foundation Trust by reviewing clinical specialties, focussing on the following service quality areas:
• Patient experience; • Quality; • Safety; • Medicines Management • Staffing • Activity; and • SLR performance.
It also provides support to the Board of Directors in developing an integrated approach to governance by ensuring clinical effectiveness and compliance with best practice in each of the clinical specialties areas reviewed
CHARITABLE FUNDS SUB COMMITTEE
The Charitable Funds Sub Committee, chaired by Mrs Houghton, Non Executive Director, acts on behalf of the Foundation Trust in its capacity as Corporate Trustee of the Airedale NHSFT Charitable Funds.
The purpose of the committee is to give additional assurance to the Board of Directors that its charitable activities are within the law and regulations set by the Charity Commission for England and Wales and to ensure compliance with the charity’s own governing document.
The annual report and accounts of the Airedale NHSFT Charitable Funds are available from either contacting the Company Secretary or via the Foundation Trust’s or Charities Commission website.
REMUNERATION REPORT
The Foundation Trust has established two committees responsible for the appointment and nomination of Board directors: the Appointment and Remuneration Committee and the Board Appointments, Remuneration and Terms of Service Committee. Through these two committees, the Board ensures that that a robust and thorough process of performance evaluation of Executive and Non Executive Directors is undertaken. The process in which the Non Executive Directors are evaluated is managed by the Appointments and Remuneration Committee and involves Governors and Board members. The Chairman conducts the appraisals, whilst the Senior Independent Director conducts the appraisal of the Chairman. The Council of Governors receives a report each year outlining the process undertaken. The Executive Directors appraisals are conducted by the Chief Executive and in the case of the Chief Executive by the Chairman. The evaluation process involves input from other Executive Directors as well as Non Executive Directors. The process is reported to the Board of Directors and includes the reporting of the Chief Executive’s annual objectives.
APPOINTMENTS AND REMUNERATION COMMITTEE
The Appointments and Remuneration Committee is established for the purpose of overseeing the recruitment and selection processes to secure the appointments of Non Executive Directors (including the Chairman) being cognisant of the Board of Directors knowledge, skills and experience. The Committee also oversees the review of remuneration levels of the Chairman and Non Executive Directors. The Committee makes recommendations to the Council of Governors on the appointment of Non Executive Directors (including the Chairman) of the Foundation Trust and the Chairman and Non Executive Directors remuneration levels.
The standing membership of the Committee comprises:
• Chairman of the Foundation Trust • Deputy Chairman of the Foundation Trust • Senior Independent Director of the Foundation Trust • Two elected Governors • One stakeholder Governor • One staff Governor • Lead Governor
The Head of Human Resources also attended in an advisory capacity.
During 2013/14, the Committee met to consider the process for the replacement of Mr Colin Millar as Non Executive Director and Chairman and Mr David Adam as Non Executive Director. The Committee also considered the Board succession plan for Non Executive Directors and conducted a remuneration review of Non Executive Directors
The process of appointing a successor Chair commenced prior to the 2013/14 financial year. Following a rigorous selection process in which a preferred candidate had been selected, the candidate decided to withdraw from the process due to other external work commitments. The Committee re-commenced the appointment process during the year and commissioned a different external recruitment consultant to source suitable candidates in which a strong field of candidates came forward. The Committee involved the remaining Governors in reviewing the person specification and role description as well the recruitment process – all of which were approved by the Council of Governors. The Committee as part of a robust selection process undertook a series of long listing and short listing meetings prior to conducting interviews. The interview process involved the assistance of an independent assessor who conducted one to one interview with each of the candidates. In addition to this the Chief Executive and together the Lead Governor and Deputy Chairman also conducted one to one interviews. The Council of Governors was also invited to take part in a discussion forum with each of the candidates – of which a number of
Governors took part in. Also contributing to the selection process was the Board of Directors who also took part in a discussion forum with the candidates of which a number of Executive and Non Executive Directors participated in. Finally, the selection panel comprising the Senior Independent Director, Deputy Chairman, Lead Governor, Stakeholder Governor, Staff Governor and a Public Governor conducted a series of interviews with each of the candidates. Each element of the selection process then fed back their comments to the Committee and a preferred candidate nominated for approval by the Council of Governors. An Extraordinary Council of Governors meeting was convened on 2 April 2014 for the purpose of approving the recommendation by the Committee. The recommendation was approved and the successor Chairman – Mr Michael Luger appointed with effect from1 May 2014.
The Chairman did not take an active role in the recruitment and selection process but provided advice and guidance on the role of the Chairman in order to assist the Committee in its deliberations.
As a consequence of the delay in appointing a successor Chair to take office from November 2013; that is when Mr Colin Millar was due to retire, the Committee considered and recommended the extension of Mr Millar’s term of office to May 2014. This was duly considered and approved by the Council of Governors. In order to stagger the refreshing of the Board, the succession plan was reviewed and it was considered by the Committee appropriate to extend the term of office of Mr David Adam, Non Executive Director and Senior Independent Director to September 2014. This was duly considered and approved by the Council of Governors.
BOARD APPOINTMENTS AND REMUNERATION AND TERMS OF SERVICE COMMITTEE
The committee is established for the purpose of overseeing the recruitment and selection process for Executive Directors and the appointment of formal Board positions, for example the Senior Independent Director. It also reviews current and future requirements applicable to the performance and setting of salaries for the posts covered by the committees remit and in addition the Foundation Trust’s Senior Management Succession Planning arrangements and talent management process. The members of the Committee comprises the Deputy Chairman, Senior Independent Director, Chief Executive (or another Executive Director when considering the appointment of the Chief Executive) and one other Non Executive Director. The Company Secretary and Head of HR were in attendance to provide specialist advice.
The Committee met on five occasions, with the Chief Executive attending all meetings. During 2013/14, the Committee met to consider the selection process for the appointment of a Medical Director to replace Dr Andrew Catto who left the organisation at the end of February 2014. Following a rigorous selection process, the Foundation Trust successfully appointed Mr Karl Mainprize as Medical Director to take office with effect from 3 June 2014. The Committee also met to consider the interim arrangements for Medical Director and allocated responsibilities accordingly, including the appointment of Dr Harold Hosker as Interim Medial Director to cover the period from March to June 2014. The Committee considers the interim arrangements to have been appropriate and robust.
The Committee’s second purpose is to determine the remuneration terms of service of Executive Directors and Associate Directors as well other senior managers covered by NHS Agenda for Change or the Consultant Contract.
The Committee met during the 2013/14 period to consider the latest independent benchmarking information for Director’s remuneration and to agree the appropriate level of remuneration. The Committee considered and agreed a formal Executive Pay Framework, the purpose of which is to provide a level of remuneration linked to performance, role weight, and pay of other staff in the Foundation Trust and in the context of wider public sector considerations.
No performance related pay scheme (for example, pay progression or bonuses) was in operation within the Foundation Trust during the year for Executive Directors. All other senior managers are
subject to Agenda for Change pay rates, terms and conditions of service, which are determined nationally.
Each year, the Committee considers a report from the Chief Executive which summarises the performance of individual Directors (including the Company Secretary), against their agreed objectives. The Committee then makes a decision about each director’s salary review, linked to their performance.
For Executive Directors, appointments are not time limited and the period for serving notice, whilst historically has been six months, is now three months for new appointees. Executive Director contracts will reflect this change as new directors are appointed. Contractual provision for early termination is not appropriate as the contracts are not fixed term. Liability for early termination is therefore not calculated. No significant termination payments have been made since the organisation became a Foundation Trust. The Foundation Trust’s remuneration reports are subject to a full external audit.
Details of person information and remuneration are detailed on pages 97, 98 and 99 and page 116, respectively.
MEDIAN REMUNERATION NOTE
The HM Treasury FReM requires the disclosure of the median remuneration of the Foundation Trust’s staff and the ratio between this and the mid-point of the banded remuneration of the highest paid Director. The calculation is based on full-time equivalent staff of the Foundation Trust at the end of 2013/14 on an annualised basis.
Median remuneration of staff £23,825 Mid-point of highest paid Director £167,500 Ratio 7.1
OFF–PAYROLL ENGAGEMENTS
The Foundation Trust is required under the reporting requirements published by the HM Treasury in relation to PES (2012)17, to report that it has no engagements which meets the disclosure requirements.
PES (2012)17 requires the Foundation Trust to seek assurance from off–payroll engagements, that all their tax obligations are being met. This is required for existing engagements who at the 31 January 2012 cost in excess of £58,000 per annum or for new engagements during the period between the 23 August 2012 and 31 March 2014 cost more than £220 per day and were engaged for more than six months.
The Foundation Trust has received the required assurance for the engagement that the tax obligations are being met as per the terms of their contract.
The Foundation Trust has a number of Doctors who meet the Financial Criteria but have no financial responsibility and therefore fall outside the scope of the reporting requirement.
ASSESSMENT AGAINST THE MONITOR CODE OF GOVERNANCE
In considering the provisions of the Monitor Code of Governance for Foundation Trusts, the Board is satisfied that all the requirements have been complied with and consequently there are no departures from the Code of Governance requiring disclosure.
REMUNERATION OF SENIOR MANAGERS
Salary and Allowances (For period 1 April 2013 to 31 March 2014)
2013/14 (12 months) 2012/13 (12 months)
Salary Taxable Annual Long All Total Salary Taxable Annual Long All Total benefits perform term pension benefits perform term pension ance perform related ance perform related related ance benefits related ance benefits Name and Title bonuses related bonuses related bonuses bonuses (bands (total to (bands (bands (bands (bands (bands (total to (bands (bands (bands (bands of of nearest of of of of of nearest of of of £5000) £5000) £100) £5000) £5000) £5000) £5000) £5000) £100) £5000) £5000) £5000) £000 £000 £000 £000 £000 £000 £000 £000 £000 £000
Mr David Adam, Non Executive Director 10-15 2 0 0 0 10-15 10-15 3 0 0 0 10-15
Dr Andrew Catto, Medical Director (1) 20-25 0 0 0 0 20-25 25-30 0 0 0 0 25-30
Dr Harold Hosker, Interim Medical Director (2) 0-5 0 0 0 0 0-5 n/a 0 0 0 0 n/a
Mr Ronald Drake, Non Executive Director 10-15 0 0 0 0 10-15 15-20 0 0 0 0 15-20
Miss Bridget Fletcher, Chief Executive 165-170 2 0 0 22.5-25 190-195 140-145 4 0 0 22.5-25 165-170
Mrs Sally Houghton, Non Executive Director 15-20 1 0 0 0 15-20 15-20 1 0 0 0 15-20
Dr Mike Toop, Non Executive Director (3) 10-15 10 0 0 0 10-15 0-5 0 0 0 0 0-5
Mr Colin Millar, Chairman 40-45 5 0 0 0 40-45 40-45 4 0 0 0 40-45 Mrs Ann Wagner, Director of Strategy & 110-115 14 0 0 10-12.5 125-130 110-115 0 0 0 10-12.5 125-130 Business Development
Mr Rob Dearden, Director of Nursing 100-105 3 0 0 12.5-15 115-120 95-100 1 0 0 10-12.5 110-115
Mr Andrew Copley, Director of Finance (4) 100-105 0 0 0 10-12.5 115-120 25-30 0 0 0 0-2.5 25-30
Prof Anne Gregory, Non Executive Director 10-15 0 0 0 0 10-15 10-15 0 0 0 0 15-20
Notes: (1) Dr Andrew Catto – Medical Director pay only included, left 28 February 2014 (2) Dr Harold Hosker – Medical Director pay only included, from 1 March 2014 (3) Dr Mike Toop – Non Executive Director from 1 February 2013 (4) Mr Andrew Copley – Director of Finance from 1 January 2013
The chair of the audit committee and the clinical specialty assurance committee receive an additional remuneration fee of £2.5k per annum. Mrs Sally Houghton was chair of the audit committee during 2013/14 and the chair of the clinical specialty assurance committee transferred from Mr Ronald Drake to Dr Mike Toop part way through the year.
During the year, Miss Bridget Fletcher voluntarily withdrew from the NHS Pension Scheme. The equivalent sum of the Foundation Trust’s contribution to Miss Fletcher’s pension was paid to her as part of her annual salary. The financial effect for the Foundation Trust was cost neutral.
During 2013/14, five Board Directors claimed expenses totaling £6,121 as reimbursement for attending Foundation Trust related external business meetings.
No Executive Directors are Non Executive Directors of any other organisation.
No former senior managers received compensation in the period 1 April 2013 to 31 March 2014.
PENSION ENTITLEMENTS OF SENIOR MANAGERS
The definition of senior managers is those persons in senior positions having authority or responsibility for directing or controlling the major activities of the NHS body. This means those who influence the decisions of the entity as a whole rather than the decisions of individual directorates or departments. The Foundation Trust has decided that this refers to just Executive and Non Executive Directors of the organisation.
Pension Benefits
Real Real Total Lump Cash Cash Real Employers Increase Increase accrued Sum at Equivalent Equivalent Increase Contribution in Pension in Pension pension at Age 60 Transfer Transfer in Cash to at Age 60 Lump age 60 at Related to Value at Value at Equivalent Stakeholder Sum at 31 March Accrued 31 March 31 March Transfer Pension Age 60 2014 Pension at 2014 2013 Value Name and title 31 March 2014 (bands (bands (bands of (bands of of of £5000) £5000) £2500) £2500) £000 £000 To nearest £000 £000 £000 £000 £000 £100 Miss Bridget Fletcher, Chief Executive 0-2.5 2.5-5.0 65-70 195-200 1322 1296 26 0 Dr Andrew Catto, Medical Director 0-2.5 7.5-10.0 40-45 120-125 704 653 51 0 Dr Harold Hosker, Interim Medical Director 7.5-10.0 17.5-20.0 55-60 165-170 1108 963 145 0 Mr Andrew Copley, Director of Finance 2.5-5.0 12.5-15.0 35-40 110-115 619 528 90 0 Mr Rob Dearden, Director of Nursing 5.0-7.5 20-22.5 30-35 100-105 570 444 126 0 Mrs Ann Wagner, Director of Strategy & Business Development 0-2.5 5.0-7.5 30-35 95-99 630 582 48 0
As Non Executive Directors do not receive pensionable remuneration, there are no entries in respect of pensions for Non Executive Directors.
Dr Andrew Catto left the Foundation Trust on the 28 February 2014 Dr Harold Hosker is Interim Medical Director from the 1 March 2014
PUBLIC INTEREST DISCLOSURES
INNOVATION AND DEVELOPMENT
In 2013/14, Airedale continued to build on its already significant technological innovation in the development of telemedicine – a system whereby patients can receive medical consultations in their home via a TV link - when a regional Telehealth Hub, funded by the Yorkshire and Humber Strategic Health Authority, was opened in September 2011.
Benefits are already being seen by our patients’ with long term conditions as well as those in nursing homes, where a number of hospital admissions have been avoided by the online intervention of clinical staff working round the clock in the Hub.
In November 2013, an NHS Futures Summit was held, hosted by NHS England, Monitor and the NHS trust Development Authority, to spark debate about how the landscape of health and care providers could evolve over the next decade to better meet the challenges ahead. Over 100 senior health leaders took part including commissioners, providers (including GPs), health policy experts, and patient and charity representatives. As part of one of the presentations, Bridget Fletcher, chief executive, spoke about Airedale’s use of secure video conferencing between clinicians and prisons, care homes and patients at home.
Bridget Fletcher and Dr Richard Pope took part in a pop-up NHS university at this year's Health and Care Innovation Expo, hosted by NHS England in March 2014 and also ran two workshops. The first focused on exploring how technology and the way services are provided can allow people to play a greater role in shaping their own care and get help when they need it in the most appropriate place and the second on how primary and secondary care clinicians can work more closely together and use technology to provide a better experience and seamless care for the benefit of patients and their families.
The Foundation Trust’s bid to the Health Foundation Shared Purpose programme – an independent charity working to improve healthcare in the UK – was successful. The Foundation Trust secured one of eight places on the programme which included a grant of £420k over three years. Our bid aimed to enhance the experience of end of life patients through the use of assistive technologies and in November 2013, a new helpline for patients, and their carers, who have a serious illness and may be in the last year of their lives was launched across Airedale, Wharfedale and Craven. It was extended in early 2014 for the benefit of hundreds of patients in Bradford and the trial runs until March 2015. The dedicated ‘Gold Line’ telephone number aims to provide one point of contact for patients and their carers for help and advice, 24-hours-a- day, seven-days-a- week, to support them in their preferred place of care wherever possible. Calls are answered by the team of experienced nurses based in Airedale’s Telehealth Hub linked up to community-based teams, who can visit patients if necessary. The pilot scheme is not expected to replace patients’ use of their GP and other community health care services during normal working hours but aims to provide care when daytime services have closed. A formal evaluation of the service is also underway and the results will be available in 2014/15.
As part of our commitment to enhancing the care of end of life patients, nurses and consultants at Manorlands Hospice re using telemedicine to extend the specialist advice service they provide for staff and their patients. The charity, based in Oxenhope, now has a senior doctor or specialist nurse available between 9am and 5pm, Mondays to Fridays, to have telemedicine consultations with care home staff in over 30 care homes in Airedale and Craven. Outside these times, the care homes can get advice from Airedale’s Telehealth Hub. There are currently around 150 patients who receive palliative care in their own home from Manorlands and the specialists nurses also provide advice to the GPs, district nurses and practice staff who help look after them.
The Yorkshire and the Humber (Y&H) Telehealth Hub partnership (which includes Airedale NHS Foundation Trust, NHS Barnsley and the University of Hull) became a top rated European reference site in England for good practice and innovation in the field of telehealth. It is now one of
32 reference sites, under the European Innovation Partnership Active and Healthy Ageing Programme, which will share its learning throughout Europe to help improve the health of our aging population. The bid, on behalf of the Yorkshire and Humber region, to become a reference site was awarded three stars – and was the only site in England to receive this maximum star rating.
The development of an Electronic Patient Record (ePR) is gathering momentum and we have taken the next steps, working our technical provider TPP, towards adapting SystmOne for secondary care. Our work towards becoming a digital hospital to improve patient care and experience continues and electronic prescribing and drugs administration (EPMA) as well as electronic discharge (eDischarge) due to come on line during 2014/15.
Work to replace the conventional patient discharge letter with a much slicker e discharge system is also underway. This will integrate with electronic prescribing and administration project reducing duplication and removing the risk of transcription errors. Alongside this is an ‘order-comms’ project which initially will allow pathology requests to be made and results to be delivered electronically within SystmOne. Later this will be extended to other diagnostic and support functions within the Foundation Trust.
RESEARCH AND DEVELOPMENT
During 2013/14 research has broadened across specialty groups. Traditionally researchers have been very active in cancer and stroke and the activity in Airedale reflected this with the bulk of the clinical trials being in these specialties. However, there are now more trials opening across the board and the past 12 months have seen new research in fields such as dementia, surgery, rheumatology and maternity.
Half of all the clinical trials open in 2013/14 were in oncology and haematology, as compared with 2009/10 where almost 80% were in this specialty. This reflects the broader research portfolio of the Foundation Trust and illustrates our ability to offer more of our patients the opportunity to participate in clinical research. It is also an indication of the growing research culture and the number of clinicians who are research active.
Academic research forms part of the Foundation Trust portfolio and is regarded as an important part of the work of the Department. Over the year, a total of 22 academic studies were open and a number of staff members have been advised and guided through the research process leading to successful completion of academic degrees, predominantly at Masters level.
The Foundation Trust’s research and development team took part in 128 research studies during 2013/14. Over 2013/14 a total of seven commercial trials were open, of which four are on the National Portfolio. Research is actively being conducted in the following areas and includes studies with commercial sponsors:
. Oncology and Haematology . Surgery . Stroke . Paediatrics . Diabetes . Neonatal and Maternity . Gastroenterology . Obstetrics and Gynaecology . Critical Care . Rheumatology . Cardiology
OUR STAFF
The Foundation Trust has an ethos of diversity and using talents to best effect regardless of age, disability, ethnicity, gender, religion and belief or sexual orientation. We aim to give full and fair consideration to all applicants who apply for jobs at the Foundation Trust.
We have Foundation Trust Guidelines on recruitment and selection, which take into account the need for reasonable adjustment for disabled employees. We also have a policy on managing attendance, which contains specific provision for dealing with employees who have become disabled. The development of all staff has a high priority and is based on a Knowledge and Skills Framework and individual’s personal development plans.
During the year, we ensured we communicated with staff on matters that concern them as employees. Staff had access to information through the Foundation Trust’s intranet, weekly staff bulletins, and monthly team briefings which are cascaded throughout the organisation within 24 hours after the Board of Directors meeting via email. Individual directorates also have their own management and clinical team meetings where core messages are delivered. These systems have been used throughout the year to communicate the financial and economic factors affecting the performance of the Foundation Trust.
ANNUAL STAFF SURVEY
The 2013 annual survey of NHS staff was conducted in October 2013.
The four key findings for which Airedale NHS Foundation Trust compares most favourably with other acute trusts in England are:
• Percentage of staff saying hand washing materials are always available. • Percentage of staff believing the trust provides equal opportunities for career progression or promotion; • Percentage of staff suffering work-related stress in the last 12 months; and • Percentage of staff having equality and diversity training in last 12 months.
The four key findings for which Airedale NHS Foundation Trust compares least favourably with other acute trusts in England are:
• Percentage of staff appraised in last 12 months; • Percentage of staff feeling pressure in last 3 months to attend work when feeling unwell; • Percentage of staff agreeing that their role makes a difference to patients; and • Percentage of staff reporting god communication between senior management and staff.
Each trust is given an overall indicator of staff engagement, as part of the staff survey, using the responses to the following key findings:
• staff members’ perceived ability to contribute to improvements at work; • their willingness to recommend the trust as a place to work or receive treatment; and • the extent to which they feel motivated and engaged with their work.
The Foundation Trust's score of 3.77 was a slight improvement on last year and better than average when compared with trusts of a similar type. Possible scores range from 1 to 5, with 1 indicating that staff are poorly engaged (with their work, their team and their trust) and 5 indicating that staff are highly engaged.
STAFF SURVEY
2013 2012 Trust Improvement/Deterioration Response rate Trust National Average Trust National Average 46% 49% 44% 52% Increase in 2% points
2013 2012 Trust Improvement/Deterioration Top four ranking scores Trust National Trust National Average Average % of staff believing the trust provides equal 93% 88% 93% 88% Maintained 2012 response opportunities for career progression or promotion % of staff suffering work-related stress in 32% 37% 34% 37% 2% decrease in percentage points the last 12 months % of staff having equality and diversity 74% 60% 72% 55% 2% increase in percentage points training in the last 12 months % of staff saying hand washing materials 69% 60% 67% 60% 2% increase in percentage points are always available
2013 2012 Trust Improvement/Deterioration Bottom four ranking scores Trust National Trust National Average Average % of staff feeling pressure in last 3 months 30% 28% 34% 29% 4% increase in percentage points to attend work when feeling unwell % of staff agreeing that their role makes a 89% 91% 87% 89% 2% increase in percentage points difference to patients % of staff appraised in last 12 months 80% 84% 85% 84% 5% decrease in percentage points % of staff reporting good communication 26% 29% 30% 27% 4% decrease in percentage points between senior management and staff
HUMAN RESOURCES MANAGEMENT
Research tells us that effective line management and leadership is critical to effective service delivery.
During 2013/14 we continued with our locally commissioned staff pulse survey. The pulse survey, which forms part of our staff engagement programme, is conducted quarterly and will support the national staff survey.
Based on the advice of the NHS emergency care intensive support team, Airedale has been developing core internal professional standards. The aim of the standards are to ensure that clinical teams across the Foundation Trust work together systematically and predictably so that patient experience is enhanced and flow improved, for example, time of discharge. Clinical behaviour is an important element of patient flow through the hospital system and directors and lead clinicians recognise that patient flow is also a patient safety issue. In partnership with clinical directors, the standards for the emergency department (A&E), MAU, wards and community settings have been developed and went live during 2012.
During 2013/14, the Foundation Trust consulted with colleagues on a reward and recognition scheme for staff to follow on from previous national recognition schemes such as NHS Heroes. Final plans and proposals are being drawn up and a staff event is planned for August 2014, which will take forward some of the key themes and suggestions.
A number of new Clinical Directors were appointed during 2013/14 due to staff retirements and they and their teams will be supported and developed to reach their maximum potential, so together we achieve the ambition we aspire to for our patients in terms of excellent service and experience.
The Medical Director and Chief Executive held a series of clinician engagement sessions, meeting groups of clinicians in each specialty to discuss their views on their services and ideas for improvement and innovation to enhance the patient experience.
The second phase of our new Rising Stars development programme was launched in 2013. The programme has been expanded and two cohorts are now available – one for mid grade staff and one for those in lower grades. Developing and valuing our staff and nurturing future leadership potential is key to our approach to staff engagement and organisational development
The Human Resource Management service has also been re-designed to ensure the most effective business contribution. For example the Human Resources Team have a led a programme which has reduced the Foundation Trust’s sickness absence.
The staff sickness absence for 2013 is shown below:
Average sickness absence 2013 3.7% Average FTE 2013 2,210 FTE days available 497,166 FTE days lost to sickness absence 18,580 Average sick days per FTE 8.4
WORKING IN PARTNERSHIP
We have continued to develop our strategic and other partnerships from a clinical, business and financial perspective. During 2013/14 we continued to work with our partners to ensure that as an organisation we are outward looking and connected to our local community, enabling and supporting health, independence and the well being of our patients.
STRATEGIC AND BUSINESS PARTNERSHIP ARRANGEMENTS
In addition to partnerships with its commissioners, the Foundation Trust has also developed a range of strategic and business partnerships, including:
• A strategic clinical partnership with its neighbouring Trust, Bradford Teaching Hospitals NHS Foundation Trust, who support us in providing sustainable services in our single handed specialties and hub and spoke arrangements for Ear Nose Throat, ophthalmology, dental specialties and plastic surgery. • A strategic clinical partnership with tertiary centre, Leeds Teaching Hospitals NHS Trust, which provides support in a number paediatric services. Additionally they provide a wide range of diagnostics in Pathology and X-ray which, by and large, is highly specialist and not available at Airedale NHS Foundation Trust. • A Private Finance Initiative (PFI) with SIEMENS Medical Systems for a managed technology service to supply and maintain diagnostic x-ray equipment to the Foundation Trust. • A Public Private Partnership (PPP) with Frontis Homes for the provision of staff residential accommodation on site. • Liaison with Airedale, Wharfedale and Craven Clinical Commissioning Group and Local Care Direct – an independent primary care out of hours provider – to provide out of hours services in accommodation adjoining the Foundation Trust’s Accident and Emergency department. • The Foundation Trust worked in partnership with Airedale Wharfedale and Craven Clinical Commissioning Group, Bradford City and Districts Clinical Commissioning Groups and Calderdale and Huddersfield NHS Foundation Trust to provide telemedicine pilot services delivering round the clock care from specialist nurses directly into nursing and residential care homes.
In addition to the above partnerships, alliances and developments, during 2013/14 the Foundation Trust also had a number of partnerships with contractors for outsourced services including car parking and security with CPP, transport with Ryder and catering with Sodexo.
LINKS WITH OUR COMMISSIONERS
Our population’s healthcare is commissioned in the main by three Clinical Commissioning Groups (CCGs) – Airedale, Wharfedale and Craven, which in 2013/14 accounted for 60.3% of the Foundation Trust’s revenue; Bradford Districts which last year accounted for 11.6% of revenue and East Lancashire, which accounted for 8.8% of revenue, NHS England which accounted for 8.2%, all from patient care activity respectively.
Our annual plan and five year plan have been developed in line with the Clinical Commissioning Groups (CCGs), NHS England and specialist commissioners to enable us to support delivery of our commissioners’ intentions.
TRAINING AND DEVELOPMENT
The Foundation Trust has continued to invest in the development of managers and leaders over the last year, to enable us to achieve business goals. Based on learning and evaluation for 2013/14 these programmes are being updated regularly to meet business needs.
AIREDALE STAFF PARTNERSHIP
We have a strong staff side/management partnership, the Airedale Staff Partnership (APG), which is a joint negotiating and consultation body to promote joint working in the interests of patient care.
CHILDCARE SUPPORT
Our onsite ‘Nightingales Nursery’ continues to provide high quality childcare at competitive rates for the Foundation Trust and other NHS employees. Open from 7.00am until 7.00pm, five days a week, 52 weeks of the year, it caters for babies and children up to the age of five.
This high quality service is regulated and approved by OFSTED and an inspection in September 2013 gave it an overall rating of ‘good’. The nursery was praised for its capacity for continuous improvement, effective leadership and management, its ability to evaluate its success, and successful working relationships with parents, carers and other agencies.
Financial support is also offered to Foundation Trust staff, either through a full salary sacrifice scheme for staff who use the onsite nursery, or childcare vouchers for staff choosing alternative childcare. The manager of this service provides a wide range of support and training for parents and parents to be, including maternity workshops for parents to find out about rights and benefits and baby massage and yoga classes.
HEALTH AND WELLBEING
Research shows that looking after the health and well being of the workforce pays significant dividends in relation to attendance, performance, productivity and motivation. Airedale is at the leading edge of the innovative work. It is led by our Employee Health and Wellbeing team, and works to assist management and staff to protect health, promote well being and prevent ill health.
In September 2011, a new service started for staff offering free, confidential help and support with any work, personal or family issue to all employees and their families. The new Employee Assistance Programme (EAP) introduced by Employee Health and Wellbeing services is provided by Workplace Options, an expert provider of employee support services and which is completely independent of Airedale Hospital. It operates 24 hours a day, 365 days a year.
The EAP replaces the previous staff counselling service and provides specialist support including a telephone helpline, information packs, and short-term counselling. Its employee support staff will have access to a wealth of up-to-date practical information and resources.
Airedale staff are able to get help on a wide range of problems including: work-life balance, relationships, child care, health and well-being, debt, disability and illness, careers, bereavement and loss, stress, caring for the elderly, life events, immigration, anxiety and depression, family issues, bullying and harassment, education, consumer rights and workplace pressure.
MANAGING RISK
All wards and departments continue to work with the Quality and Safety team in the identification of risk and analysis of incidents. This work is important to the improvement of patient safety and the delivery of clinical services. Systems are in place whereby all risks and reported incidents are assessed and monitored.
A Committee, whose members include all the Executive Directors, consider the risks carried by the Foundation Trust on a monthly basis, and the Board of Directors receives a regular report about the management of those risks documented in the risk register.
The Foundation Trust has achieved compliance with the NHS Litigation Authority Risk Management standards at Level 1 for both Acute Trust services and for Maternity Services. These standards recognise the Foundation Trust’s commitment to safe practice and effective risk management.
HEALTH AND SAFETY
The key group in the management of health and safety at Airedale NHS Foundation Trust is the Joint Health and Safety Committee. This comprises management, staff side representatives and reports into the Executive Strategic Risk Management Group (ESRMG), and can be escalated to the Board where indicated by magnitude of risk.
The Committee ensures that the Foundation Trust meets its legal requirements to consult with staff on matters that affect their health and safety, and has the responsibility of promoting and developing health and safety arrangements across the Foundation Trust, and ensuring compliance with the Health and Safety at Work Act 1974 (and related regulations).
The Committee is chaired by the Director of Operations, whose role includes being the designated lead Director for health and safety for both the Foundation Trust’s Executive Directors Group and the Board. They are supported in this role by the Health, Safety and Emergency Planning Manager who works in the Quality and Safety Team.
POLITICAL AND CHARITABLE DONATIONS
Airedale NHS Foundation Trust made no political or charitable donations during the year.
PATIENT AND PUBLIC ENGAGEMENT AND EXPERIENCE
Engagement with patients and the public is a top priority for the Foundation Trust as a means of improving patient experience.
The Patient and Public Engagement and Experience (PPEE) Steering Group and PPEE Operational Group closely monitor information about engagement and experience activity in a way that will enable the Foundation Trust to ensure it meets the five commissioner requirements.
The PPEE policy was reviewed in 2013 with a great deal of involvement with local community groups, staff and patients and we are now in our second year of our three year PPEE strategy and implementation plan. The whole ethos within the strategy is to ensure that patient involvement activities are embedded into all aspects of the Foundation Trust’s business.
The following outlines some of the Foundation Trust’s patient and public engagement activities.
VOLUNTEERING
Airedale NHS Foundation Trust is supported by two very active volunteer groups, the Friends of Airedale and Airedale New Venture. There are around 370 active volunteers who undertake vital and diverse activities across the hospital. Whether it’s acting as guides for patients attending appointments, assisting our patients to eat and drink during meal times; staffing the volunteer shops, taking the shop or library trolley to patients on the ward; or helping patients to attend our religious services, our volunteers are an invaluable resource for our staff and patients.
In the Care Quality Commissions (CQC) hospital inspection report published in November 2013, it comments on the good sense of community and high levels of volunteering at Airedale Hospital and recommend the Foundation Trust’s volunteering programme as one that others could learn from.
The two charities Friends of Airedale and Airedale New Venture contributed over £200,000 last year to the hospital. The funds were raised through the two shops, the car boot sales that are held in the grounds of the hospital during the summer months and through public donations. The money was used to buy a range of new equipment for the hospital, including:
• £10,500 on an resuscitation trolleys for A&E • £8,700 on a tutela remote temperature monitor • £10,600 on an endoscopy light processor kit • £8,500 on a pair of bariatric leg supports for theatres • £10,000 on three carbon dioxide (CO2) insufflators for endoscopy • £50,000 on two flexible ureterorenoscopes and a laser lithotripter machine for urology
As highlighted by the CQC report ‘Dignity and Nutrition for Older People’, published in October 2011, it is important to make sure that people have enough to eat and drink when they are in hospital. A lot of work has been done at Airedale Hospital to ensure that patients do get the right nutritional care and our volunteers provide crucial support to our nurses and ward hostesses to help patients eat and drink.
We continue to receive support from our volunteer feeding buddies, following a successful trial in 2010 to train volunteers so that they could help ward staff assist patients to eat and drink at meal times, an increased number of volunteers have also become involved in the scheme. These volunteer feeding buddies are an invaluable support to our ward staff in this key area of patient experience.
Another key element of patient experience is the feedback we receive from our real time patient survey, which a number of volunteers help the hospital with six days a week.
PATIENT AND CARER PANEL
As part of the Foundation Trust’s commitment to engage service users in the development of services, and to gain a range of different perspectives and views, a Patient and Carer Panel was set up in 2007 and is now well established. It meets monthly and is consulted about various aspects of the Foundation Trust’s business, including service developments and new initiatives.
During 2013/14, the Panel has continued working in task groups focusing on communication; recruitment; patient information at point of discharge; services for dementia patients; medication issues; and review of Foundation Trust policies.
Our overall aim is to ensure that work undertaken by our task groups’ influences real and sustained improvement in a range of services from a patient perspective.
YOUTH PANEL
During 2013/14, work has continued to link with younger people to develop a Youth Panel to help us better understand how we can improve the healthcare we provide for young people in our local community. A group of young people have been influential in producing a ‘young person’s Patient Liaison and Advice Service (PALS) leaflet and a relationship is developing with Barnardos.
ENGAGEMENT ACTIVITIES
The following are examples of some of the engagement work staff have undertaken during the year:
• Dietetics patient survey • Multiple Sclerosis education programme • Diabetes education programme • Focus groups with end of life patients • Healthy heart badge project • Long term conditions workshop (done jointly with Bradford Local Involvement Network (LINk) • Improvements to reception areas in community buildings
• Regular involvement sessions with diabetes patients • Parent survey for children attending therapy groups at the child development centre • Improvements to pharmacy services • Speech and language therapy surveys • Neonatal and children’s units feedback • Project improving dignity and respect for people with dementia and cognitive impairment in general ward settings
PATIENT INFORMATION
The NHS Constitution makes it clear that people have the right to reliable information to help them make choices and that good quality information will help people make confident, informed decisions about their health care. This is endorsed by the Foundation Trust and work is underway to improve how we provide patient information.
In June 2011, a new information pod was set up in Airedale Hospital’s health information centre to help patients and visitors to find out more about their health, condition or medication. People can use video, audio and interactive websites through the computer in the enclosed area to discover more about staying healthy and managing long term conditions. The service is a drop-in service, but patients can also pre-arrange a specific time to use the pod between 9am and 5pm, Monday to Friday. Information is available about:
• conditions and interventions • self care and management advice • other patients personal experiences • advice on benefits and social care • details of local or national support groups.
During 2013, staff from the health information centre worked with our local Healthwatch services to hold informal information events at local libraries to boost awareness of the service and in November 2013 the service launched a ‘health blog’ on the Foundation Trust’s website to highlight local news and events, signpost local services and encourage discussions among local people about health issues.
The Foundation Trust has a Readers’ Panel which consists of members of the public who have volunteered their time to read patient information produced by the Foundation Trust whilst it is in its draft stages. The panel is asked for its views on the type of language used, the structure of sentences and paragraphs, the style of presentation, and whether the information will be readily understood by its target audience. By asking for opinions from a sample audience, the Readers’ Panel ensures publications are easily understood and resources are not wasted by producing leaflets that patients do not understand.
The Readers’ Panel whilst being popular always needs to recruit new members. Contact details for the Readers’ Panel are shown on the final page of this Annual Report.
LEARNING FROM THOSE WITH A DISABILITY
A strong emphasis has been placed on involving people with learning disabilities to help us introduce guidelines for our staff in order to assist in planning and identifying the care needs of patients with learning disabilities and ensure care plans take account of individual patient’s needs.
We work with the regional Learning Disabilities Group, Access to Acute, for Yorkshire and Humberside, as well as the local Craven Health Task Force, to benchmark the care we provide. We are using an audit tool to help us review each episode of care and identify any aspects that are
missing. The findings and any shortfalls are shared with the regional group to enhance learning and development of the service.
The group has also worked with us on improving signage around the hospital site and helped our Patient Advice and Liaison Services (PALS) team develop an easy read version of our PALS leaflet.
PATIENT ADVICE AND LIAISON SERVICES (PALS)
As well as providing information, advice and support to help patients, families and their carers, the emphasis within the Foundation Trust is for PALS to work closely with front-line staff, particularly our matrons, in order to help resolve issues and queries as quickly as possible for patients.
The work undertaken by PALS is a ‘real time’ and continuous way of being able to respond positively to patient feedback in terms of both concerns and compliments in order to improve the delivery of our services and clinical care.
During 2013/14 there were 2,566 issues raised, from 1,910 contacts with the Patient Advice and Liaison Service (PALS), of which 2,408 issues were specifically related to Airedale NHS Foundation Trust. Of these, 490 were compliments, 384 were requests for information and 1,534 were expressions of concern, dissatisfaction and requests for action to be taken. The remaining 158 issues were related to other organisations.
PALS also received 4,040 compliments about the Foundation Trust’s care and services via the clinical areas and departments. Therefore, a total of 4,530 compliments were received during 2013/14, which is a significant increase from the total of 2,814 received last year.
Examples of learning from PALS issues include:
Your concern … “There appeared to be a lack of understanding of the requirements of a patient who has dementia.” Our response … “Over 75% of staff have received the Butterfly scheme training.”
Your concern … “The actions of the resuscitation team did not reflect the actions taken when attending my father in the OPD setting. Our response … “Resuscitation Policy has been reviewed.”
The PALS office is located at the entrance to Ward 18. Contact with the PALS office can also be made by telephoning 01535 294019 or via email: [email protected]
COMMUNITY ENGAGEMENT
Foundation Trust staff support many health related groups in both a business and voluntary capacity. We also support our staff to play a full part in the community, for example, by acting as Governors for schools.
Our now well established Patient and Carer Panel and more recent Youth Panel ensure we involve our community in monitoring standards and in the development of services.
During the year we continued to build on our links with schools and colleges. As a result, we have successfully recruited many young people to join our Foundation Trust membership. We also developed links with local BME groups and improved membership representation from different communities.
We continued to support Sue Ryder Care, who runs our local hospice Manorlands, as the charity that the Foundation Trust staff support through a salary deduction scheme.
CORPORATE SOCIAL RESPONSIBILITY
The Foundation Trust works to be environmentally responsible and aware of its social impact on the community it serves. During the year we have worked to ensure that we make purchases not just from big corporations but from a mix of small, medium and large businesses and social enterprises, in order to ensure we invest more in the local economy and community and contribute to regeneration.
The Foundation Trust is committed to reducing its carbon footprint with a Foundation Trust endorsed Carbon Management Strategy. Our staff have continued to work closely with external consultants, such as the Carbon Trust, to monitor energy usage to enable the consumption to be reduced and thereby reduce our carbon footprint as well as reduce costs.
As part of our travel plans we continue to promote the use of public transport to staff for journeys to work. We also take part in the Cycle2Work scheme, which enables staff to buy bicycles for work using a monthly salary sacrifice scheme to encourage staff to reduce car use.
REDUCING OUR CARBON FOOTPRINT
The CRC Energy Efficiency Scheme (formerly known as the Carbon Reduction Commitment) is the UK's mandatory climate change and energy saving scheme. It is central to the UK's strategy for improving energy efficiency and reducing CO2 emissions as set out in the Climate Change Act 2008.
The scheme is mandatory for all organisations whose electricity consumption is equivalent to an annual electricity bill of approximately £500k, so therefore applies to Airedale NHS Foundation Trust.
The Climate Change Act 2008 requires carbon dioxide and greenhouse gas emission reductions of 34% by 2020 and 80% by 2050 against 1990 performance. The same Act establishes that from 2010 all Government departments, including the NHS, will receive annual carbon budgets which they must adhere to.
The Foundation Trust has developed a Carbon Management Plan (CMP) which commits it to reducing CO2 by 15% by 2015 from a 2007 baseline figure. Potential savings to the Foundation Trust could be around £1 million by that date. By following the CMP and delivering its objectives, the Foundation Trust will achieve a reduction of 15% on its 2007 carbon footprint (estate only figures) by 2015. This will mean that we will have not only reduced our carbon output but also reduced expenditure on utilities and the maintenance and operation of our estate.
The CMP will mean an improved environment for our local population, patients, visitors and staff.
Following its set up in 2012, the EcoawAire group continued to meet regularly throughout the year to assess sustainability as part of the Trust’s external contracts or capital investments, look at potential energy efficiencies and other environmental savings. It aims to engage with and involve staff in energy and environmental issues and make them more aware of the impact their actions at work can have on the local environment and how everyone can work together to reduce that impact.
Campaigns during 2013/14 included a focus on PC usage and computers that were left on unnecessarily, particularly overnight and at weekends, wasting both energy and resources and support for the waste paper recycling scheme.
During the year, the Foundation Trust continued to roll out its paper waste recycling scheme across Airedale Hospital. This enhances the current recycling scheme where all black bag waste is sorted for recyclables before it is sent to landfill.
Moves to make Airedale Hospital more eco-aware and sustainable include entering a contract with Carbon Energy Fund to have a CHP (Combined Heat and Power unit) to generate our electricity and heating, instead of the current less efficient steam boilers.
As part of the Foundation Trusts energy efficiency drive it replaced 2,200 of Airedale Hospital’s inefficient light fittings during 2013/14 and will replace a further 600 to save approximately £6,000 a month on its electricity bill. The lighting upgrade consisted of a combination of LED and linear light fittings, which are dimmable in conjunction with daylight levels and also controlled by presence sensors. Work started in September 2013 with ward areas being the main priority.
Intelligent controls are also being incorporated to the theatres’ ventilation system so it will only run when the area is occupied. The aim is to save 34% of energy costs by 2020, and 80 percent by 2050 – these are reductions from a 1990 baseline.
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 Airedale 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 Airedale NHS Foundation Trust for the year ended 31 March 2014 and up to the date of approval of the Annual Report and Accounts.
CAPACITY TO HANDLE RISK
As Accounting Officer, I have overall responsibility for ensuring that there are effective risk management and integrated governance systems in place within the Foundation Trust and for meeting all statutory requirements and adhering to guidance issued by Monitor in respect of governance and risk management.
The Foundation Trust has a risk management strategy, which is reviewed and endorsed by the Board of Directors annually; there is a clearly defined structure for the management and ownership of risk through the development of the risk register and assurance framework. The ‘high level’ risks and board assurance framework are monitored at Executive level and in the Board’s sub committees and by the Board of Directors.
Some aspects of risk are delegated to the Foundation Trust’s Executive Directors:
• The Medical Director is responsible for clinical governance, and has overall lead for risk management and patient safety with support from the Assistant Director of Healthcare Governance. Responsibility for information governance risks transferred from the Medical Director to the Director of Finance on 1 March 2014. The Medical Director is, with support from the Assistant Director of Healthcare Governance, also responsible for reporting to the Board of Directors on the development and progress of the quality and patient safety strategy and for ensuring that the strategy is implemented and evaluated effectively;
• The Medical Director is also the executive lead (with management support provided from the Assistant Director of Healthcare Governance) to ensure a fully integrated and joined up system of risk and control management is in place on behalf of the Board;
• The Director of Nursing is responsible for infection prevention and control;
• The Director of Operations is responsible for health and safety;
• The Director of Finance provides the strategic lead for financial and performance risk and the effective coordination of financial controls throughout the Foundation Trust;
• The Head of HR is responsible for workforce planning, staffing issues, education and training. Responsibility for organisational development is incorporated in to Executive Directors combined objectives both on an individual basis and collectively as the executive team; and
• All heads of service, Clinical Directors and managers have delegated responsibility for the management of risk and patient safety in their areas. Risk is integral to their day-to-day management responsibilities. It is also a requirement that each individual division produces a divisional/directorate patient safety and risk register, which is consistent and mirrors the Foundation Trust’s patient safety and risk register requirements and is in line with the risk management strategy.
All members of staff have responsibility for participation in the risk/patient safety management system through:
• Awareness of risk assessments which have been carried out in their place of work and to compliance with any control measures introduced by these risk assessments;
• Compliance with all legislation relevant to their role, including information governance requirements set locally by the Foundation Trust;
• Following all Foundation Trust policies and procedures;
• Reporting all adverse incidents and near misses via the Foundation Trust incident reporting system;
• Attending regular training as required ensuring safe working practices;
• Awareness of the Foundation Trust patient safety and risk management strategy and their own Group patient safety and risk management strategy; and
• Knowing their limitations and seeking advice and assistance in a timely manner when relevant.
The Foundation Trust recognises the importance of supporting staff. The risk management team act as a support and mentors to Foundation Trust staff who are undertaking risk assessments and managing risk as part of their role. Risk assessment training is available to all members of staff and includes:
• Corporate induction training when staff join the Foundation Trust; • Mandatory update training for all staff every two years; and • Targeted training on specific areas including risk assessment, incident reporting and incident investigation.
The Foundation Trust seeks to learn from good practice and will investigate any serious incidents, complaints and SIRI’s (Serious Incidents Requiring Investigation) using Root Cause Analysis methodology. The findings are reviewed by the Foundation Trust’s Assurance Panel to ensure learning points are implemented. Assurance is gained by presenting reports to the Foundation Trust’s Executive Assurance Group and summary reports to the Board of Directors. Any learning points for staff are published via staff briefings.
In addition to the Foundation Trust reviewing all internally driven reports, the Foundation Trust adopts an open approach to the learning derived from third party investigations and audits, and/or external
reports. The Foundation Trust actively seeks to share learning points with other health organisations, and pays regard to external guidance issued. This learning approach is supported by implementing a ‘true for us’ test which seeks to test the Foundation Trust’s systems and processes against the findings and recommendations of external reports and reviews. Accordingly, the Foundation Trust will undertake gap analyses and adjust systems and processes as appropriate in line with best practice. The Foundation Trust has also adopted a pro-active approach to seeking independent reviews as evidenced by the commissioning of Royal College reviews to examine surgical services following concerns raised. During 2013/14, the Foundation Trust one was of the first Foundation Trusts to be inspected by the CQC under its new hospital inspection regime. The Hospital Inspection Report was considered by the Board and the areas identified as requiring strengthening were reviewed. The Board has taken on board the CQC’s recommendations and is monitoring progress accordingly. A number of external reports including the Final Report of the Independent Inquiry Report in to Care Provided by Mid Staffordshire NHS Trust (Francis Report), and the Clywd Hart Report in to hospital complaints, have also been considered and the recommendations arising from those reports reviewed and acted upon.
THE RISK AND CONTROL FRAMEWORK
The Board approved risk management strategy has defined the Foundation Trust’s approach to risk throughout the year. The strategy determines the requirements for the identification and assessments of risks and for control measures to be identified and how risks should be managed and the responsibilities of key staff in this process. As an organisation seeking to develop its innovative work in the field of telemedicine, the Foundation Trust is risk aware, and adopts a risk management approach.
The risk management strategy assigns responsibility for the ownership and management of risks to all levels and individuals to ensure that risks which cannot be managed locally are escalated through the organisation. The process populates the risk register and board assurance framework, to form a systematic record of all identified risks. All risks are evaluated against a common grading matrix, based on the Australia/New Zealand risk management standard to ensure that all risks are considered alike. The control measures, designed to mitigate and minimise identified risks, are recorded within the risk register and board assurance framework.
The board assurance framework sets out:
• What the organisation aims to deliver (corporate/strategic objectives);
• Factors which could prevent those objectives being achieved (principal risks);
• Processes in place to manage those risks (controls);
• The extent to which the controls will reduce the likelihood of a risk occurring (likelihood); and
• The evidence that appropriate controls are in place and operating effectively (assurance).
The board assurance framework provides assurance, through ongoing review, to the Board, that these risks are being adequately controlled and informs the preparation of the Statement on Internal Effectiveness and the Annual Governance Statement. The board assurance framework and risk register have identified no significant gaps in control/assurance.
The Board reviews performance data each month against Monitor and CQC standards and outcomes via a series of integrated dashboards focusing on quality, safety, patient experience and clinical outcomes; staff engagement and workforce development; finance and performance; service developments and transformation and business development. A quality account report has been
developed and designed specifically to support the triangulation of data across the organisation, and is reviewed by the Board in conjunction with the integrated dashboards.
The Foundation Trust’s risk management processes have identified a number of risks. The most significant are outlined below along with how they have been/are being managed and mitigated and how outcomes are being assessed.
The Foundation Trust’s financial position is subject to a number of risks. Its position is dependent on delivering productivity and efficiency improvements. This is set against a difficult national economic background and changing NHS landscape. The strategy of focusing on partnership working to deliver system change at pace is therefore continuing and will continue in to 2014/15 and beyond. This change is also dependent upon the Foundation Trust’s ability to secure and retain the right workforce at clinician level as well as being able to influence widespread change in clinical practice. The clinical management structure has undergone significant changes during the current and previous year in order to equip clinicians with the skills and resilience to meet the challenges of the changing NHS landscape. The further development of the clinician workforce and structure remains key to the success of the Foundation Trust and therefore this work will also continue in to the coming year.
The Foundation Trust is mitigating these risks through rigorous budgetary control and management of significant productivity and efficiency improvements. Outcomes are being measured by monthly review of financial performance information by the Board, in addition to scrutiny of the impact of efficiency savings on patient safety and quality of service.
The Board has delegated scrutiny of the quarterly Corporate Governance Statement Monitor return to the Audit Committee prior to review by the Board. In conjunction, the Board receives the quarterly quality account, integrated governance dashboards and the quarterly finance and performance report. This process provides assurance to the Board that the Corporate Governance Statement is a valid reflection of the Foundation Trust’s performance over the previous quarter(s), whilst allowing the Board opportunity for scrutiny of compliance.
In addition to the standard reporting and assurance process, the Foundation Trust undertook an external independently evaluated Board Governance and Capability Review during the year as part of the Monitor pilot scheme. The Review examined the effectiveness of governance structures; the responsibilities of Directors and subcommittees; the capability at Board level to provide organisational leadership; reporting lines and accountabilities between the Board, its subcommittees and the executive team; the assessment of risks and the risk management process; and the degree and rigour of oversight the Board has over the Foundation Trust’s performance. The outcome of the evaluation assessed the Foundation Trust’s governance arrangements to be strong with no major areas of weakness identified. I the spirit of learning the Board has considered the Review and formed a response to the findings which will be taken forward though its governance processes.
Maintaining the security of the information that the Foundation Trust holds provides confidence to patients and employees of the Foundation Trust. To ensure that its security is maintained an Executive Director has been identified – the Foundation Trust’s Medical Director – to undertake the role of Senior Information Risk Owner (SIRO). The SIRO has overseen the implementation of a wide range of measures to protect the data held and a review of information flows to underpin the Foundation Trust’s information governance assurance statements and its assessment against the information governance toolkit. As part of the Foundation Trust’s assurance mechanism, the internal audit work plan includes an annual review of the Information Governance Toolkit submission. Following the identification of a number of areas of weakness in the 2012/13 submission, a rigorous and robust review of the information governance toolkit process took place and a number of improvements were implemented. I can report that for 2013/14, the information governance toolkit submission process was given a ‘significant assurance’ opinion by the Foundation Trust’s internal
auditors. During 2013/14, the Foundation Trust had no incidents classified at a severity rating of 3 to 5 that met the criteria for inclusion in the Annual Governance Statement.
Control measures are in place to ensure all organisations’ obligations under equality, diversity and human rights legislation are complied with. This is evidenced by the response to the Equality Act 2010 in which the Foundation Trust built on the work undertaken in reviewing the Single Equality Scheme at Board level and the inclusion and completion of equality impact assessments on all the Foundation Trust’s policies. Accordingly, the Board has approved the proposed approach and action plan for delivering the Equality Delivery System, approved the objectives of the System for publication and nominated a Non Executive Lead.
Discussion has been ongoing throughout the year with Commissioner colleagues to ensure all key access targets are being met from within available resource. There have been regular contract management meetings with the Foundation Trust’s lead commissioning cluster – Airedale, Wharfedale and Craven Clinical Commissioning Group (CCG) and other reviews with Bradford Districts and East Lancashire Clinical Commissioning Groups.
The Foundation Trust successfully registered, without conditions, with the Care Quality Commission in 2010, and continues to be fully compliant with the registration requirements of the Care Quality Commission. Assurance against the requirements of the CQC registrations is monitored on an ongoing basis throughout the year by the Executive Lead responsible for ensuring compliance for each of the CQC outcomes.
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.
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 contingency requirements as based on UKCIP 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 Foundation Trust has a comprehensive system that sets strategic and annual objectives. The Board of Directors sets these objectives with regard to the economic, efficient and effective use of resources.
The objectives set reflect national and local performance targets for standards of patient care and financial targets to deliver this care within available resources. Within these targets, the Foundation Trust includes specific productivity and efficiency improvements. These are identified from a range of sources including internal review such as internal audit, external audit and external organisations including benchmarking agencies.
The Foundation Trust has a robust monitoring system to ensure that it delivers the objectives it identifies. Ultimate responsibility lies with the Board which monitors performance through reports to its meetings of the Board of Directors. Underpinning this is a system of monthly reports on quality and safety, financial and operational information to the Foundation Trust’s executive management group, and clinical management groups. The information received by the Board is supplemented
with integrated governance dashboards and a summary dashboard mapping movements during the previous quarter. The reporting at all levels includes detail on the achievement against productivity and efficiency targets and is derived through a bottom-up approach to management reporting.
The Foundation Trust operates within a governance framework of Standing Orders, Standing Financial Instructions and other processes. This framework includes explicit arrangements for:
• Setting and monitoring financial budgets; • Delegation of authority; • Performance management; and • Achieving value for money in procurement.
The governance framework is subject to scrutiny by the Foundation Trust’s Audit Committee and internal and external audit.
ANNUAL QUALITY ACCOUNT
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 Foundation Trust has continued to build on the extensive work undertaken to develop the Quality Account during the last three years and has drawn on the various guidance published in-year in relation to the Quality Account.
The Foundation Trust has developed its vision, values and priorities through wide involvement and in consultation with patients, carers, staff, external stakeholders and Governors. The consultation process for the Quality Account included presentations to the Board of Directors, Council of Governors and informally to Governors at their network meetings, a workshop session with representatives from the Council of Governors, Healthwatch and Patient and Carer Panel as well as members of the public. In addition, Foundation Trust members were canvassed for their opinions on the Foundation Trust’s quality improvement plans via a number of member events as well as the hospital’s open day.
Through this engagement the Foundation Trust has been able to ensure the areas chosen provide a balanced view of the organisations priorities for 2013/2014. In preparing the Quality Account, the Foundation Trust had a Quality Account project lead to develop the Quality Account, reporting direct to the Medical Director, and the Quality Account Steering Group established the previous year with Governor membership continued. A formal review process was established, involving a presentation of the Foundation Trust’s initial draft account to its external stakeholders (Overview and Scrutiny Committee’s, Healthwatch and Commissioners). The Quality Account drafts were formally reviewed through the Foundation Trust’s governance arrangements (formal management group, Board sub- committee and Board of Directors). The Foundation Trust set priorities for 2013/14 were patient safety, patient experience and clinical effectiveness. Priorities were then developed to embed and monitor quality improvement processes, set against the needs of patients in the delivery of the Foundation Trust’s services.
The Foundation Trust has utilised Group performance reports, governance and quality reports, clinical outcome measures, mortality reports, Dr Foster and CHKS benchmarking data and a range of key national targets to govern the work associated with these priorities. The data used to report the Foundation Trust’s quality performance in 2013/2014 was taken from national data submissions, CHKS and national patient surveys. The quality and safety metrics were reported on a monthly basis
to the Board through the performance and governance reports including the Quality Account Report. The process by which the quality of care is monitored at management and executive level is achieved through the triangulation of data from patient and staff surveys as well as internal and external data sources. Assurance was gained by sharing the Quality Account with the Foundation Trust’s Commissioners, Healthwatch and OSCs as required by national regulation. The Foundation Trust’s external auditor, PwC, have undertaken a review of the arrangements in place at the Foundation Trust to secure the data quality of information included in the Quality Account. The report prepared by PwC will be submitted to Monitor by the end of May 2014.
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, the executive managers and clinical leads within the 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 Executive Assurance Group, and a plan to address weaknesses and ensure continuous improvement of the system is in place.
The board assurance framework itself provides me with evidence that the effectiveness of controls that manage the risks to the organisation achieving its principal objectives have been reviewed. My review is also informed by the major sources of assurance on which reliance has been placed during the year. These sources included reviews carried out by PwC, Care Quality Commission, Internal Audit, NHS Litigation Authority and the Health and Safety Executive.
The following groups and committees are involved in maintaining and reviewing the effectiveness of the system of internal control:
• The Board of Directors has overall accountability for delivery of patient care, statutory functions and Department of Health requirements;
• The Audit Committee oversees the maintenance of an effective system of internal control and reviews the statement on internal effectiveness and Annual Governance Statement;
• The Executive Assurance Group oversees the risk management process at operational level, ensuring that risks are managed and/or escalated in line with the Risk Management Strategy;
• The Assistant Director of Healthcare Governance through the Executive Assurance Group ensures that a fully integrated approach is taken when considering whether the Foundation Trust has in place systems and processes to support individuals, teams and corporate accountability for the delivery of safe patient centered, high quality care.
• The Assistant Director of Healthcare Governance also manages the clinical audit programme through a dedicated audit team. The Audit work programme is reviewed by the Executive Assurance Group and is overseen by the Audit Committee;
• The Clinical Specialty Assurance Committee provide the Board of Directors with assurances of clinical effectiveness and compliance with best practice in the specialties reviewed, through scrutiny of patient quality and safety, patient experience, medicines management, staffing, activity and service line reporting; and
INDEPENDENT AUDITOR’S REPORT TO THE COUNCIL OF GOVERNORS OF AIREDALE NHS FOUNDATION TRUST
REPORT ON THE FINANCIAL STATEMENTS
Our opinion
In our opinion the financial statements, defined below:
• give a true and fair view, of the state of the group’s and of the parent NHS Foundation Trust’s affairs as at 31 March 2014 and of the group’s income and expenditure and the group’s and parent NHS Foundation Trust’s cash flows for the year then ended; and
• have been prepared in accordance with the NHS Foundation Trust Annual Reporting Manual 2013/14.
This opinion is to be read in the context of what we say in the remainder of this report.
What we have audited
The group financial statements and parent NHS Foundation Trust financial statements (the “financial statements”), which are prepared by Airedale NHS Foundation Trust, comprise:
• the group and parent NHS Foundation Trust Statement of Financial Position as at 31 March 2014;
• the group Statement of Comprehensive Income for the year then ended;
• the group and parent NHS Foundation Trust Statement of Cash Flows for the year then ended;
• the group and parent NHS Foundation Trust Statement of Changes in Taxpayers’ Equity for the year then ended; and
• the notes to the financial statements, which include a summary of significant accounting policies and other explanatory information.
The financial reporting framework that has been applied in their preparation is the NHS Foundation Trust Annual Reporting Manual 2013/14 issued by the Independent Regulator of NHS Foundation Trusts (“Monitor”).
In applying the financial reporting framework, the directors have made a number of subjective judgements, for example in respect of significant accounting estimates. In making such estimates, they have made assumptions and considered future events.
What an audit of financial statements involves
We conducted our audit in accordance with International Standards on Auditing (UK and Ireland) (“ISAs (UK & Ireland)”). 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 group’s and the parent NHS Foundation Trust’s circumstances and have been consistently applied and adequately disclosed;
• the reasonableness of significant accounting estimates made by the directors; and
• the overall presentation of the financial statements.
In addition, we read all the financial and non-financial information in the Annual Report to identify material inconsistencies with the audited financial statements and to identify any information that is apparently materially incorrect based on, or materially inconsistent with, the knowledge acquired by us in the course of performing the audit. If we become aware of any apparent material misstatements or inconsistencies we consider the implications for our report.
Opinion on other matters prescribed by the Audit Code for NHS Foundation Trusts
In our opinion:
• the information given in the Strategic Report and the Directors’ Report for the financial year for which the financial statements are prepared is consistent with the financial statements; and
• the part of the Directors’ Remuneration Report to be audited has been properly prepared in accordance with the NHS Foundation Trust Annual Reporting Manual 2013/14.
Other 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 2013/14 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 whether 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, on any aspect, our opinion on the Quality Report.
Responsibilities for the financial statements and the audit
Our responsibilities and those of the directors
As explained more fully in the Directors’ Responsibilities Statement 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 2013/14.
Our responsibility is to audit and express an opinion on the financial statements in accordance with the National Health Service Act 2006, the Audit Code for NHS Foundation Trusts issued by Monitor and ISAs (UK & Ireland). Those standards require us to comply with the Auditing Practices Board’s Ethical Standards for Auditors.
This report, including the opinions, has been prepared for and only for the Council of Governors of Airedale 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.
GLOSSARY
Acute trust An acute trust provides hospital services; mental health hospital services are provided by a mental health trust.
Board of Directors The Board of Directors is responsible for the effective governance of the organisation by setting the corporate strategy, supervising the work of the executive directors, setting the organisation’s culture, taking those decisions that the Board reserves to itself and being accountable to its stakeholders. Executive directors are responsible for the management of the foundation trust and are accountable to the Board of Directors, of which they are part, for the performance of the foundation trust. The Board of Directors is accountable to the Council of Governors via the non executive directors.
Care Quality Commission (CQC) The independent regulator of health and social care in England.
CHKS A provider of healthcare improvement services, including analytic tools. It is part of the Capita plc group.
Commissioning for Quality and Innovation (CQUIN scheme) A proportion of a healthcare provider’s income is conditional on quality and innovation through the CQUIN payment framework.
Clinical Commissioning Groups (CCG) From April 1st 2013, a CCG is the local NHS organisation responsible for making sure that appropriate health services are in place to meet local people’s needs.
Dr Foster The Dr Foster Unit at Imperial College London has developed methodologies to support organisations to improve quality and efficiency through the use of data. It adheres to a code of conduct that prohibits political bias and requires it to act in the public interest.
Foundation Trust A type of NHS trust in England created to devolve decision-making from central government control to local organisations and communities to ensure they are responsive to the needs and wishes of their local people. NHS foundation trusts members are drawn from patients, the public and staff and are governed by a Board of Governors comprising people elected from and by the membership base.
Gold Standard Framework A nationally recognised systematic, evidence-based approach to improve the quality of care for people considered to have a life expectancy of less than 12 months. The framework is widely used in primary care and nursing homes.
Health Foundation An independent, charitable foundation working to improve the quality of healthcare in the UK and beyond.
Healthwatch England An independent consumer champion for health and social care in England. Working with a network of 152 local Healthwatch, it ensures that the voices of consumers reach the ears of the decision makers.
Institute for Innovation and Improvement The Institute supports the NHS to transform healthcare for patients and the public by rapidly developing and spreading new ways of working, new technology and world class leadership.
Monitor The independent regulator responsible for authorising, monitoring and regulating NHS Foundation Trusts.
NHS Constitution The Constitution sets out the rights of NHS patients and staff. These rights cover how patients access health services, the quality of care, confidentiality, information and the right to complain if things go wrong.
NHS England is empowered to make informed decisions, spend taxpayers’ money wisely and provide high quality services through the mechanism of the clinical commissioning groups (CCGs).
The National Institute for Health and Clinical Excellence (NICE) An independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health.
NHS Outcomes Framework 2013/14 Sets out the national outcome goals and indicators that the Secretary of State uses to monitor progress of the NHS.
Overview and Scrutiny Committees (OSC) These are committees made up of locally elected lay members which provide a mechanism by which the local authority or population can scrutinise the NHS.
Patient Advice and Liaison Service (PALS) PALS ensures that the NHS listens to patients, carers and friends, answers their questions and resolves concerns as quickly as possible.
Parliamentary Health Service Ombudsman (PHSO) The role of the PHSO is to provide a service to the public by undertaking independent investigations into complaints where the NHS in England has not acted properly or fairly or has provided a poor service.
Patient Safety Thermometer A tool developed to check basic levels of care In order to identify where things are going wrong and take action. It is being used by frontline healthcare workers to measure and track the proportion of patients in their care with pressure ulcers, urinary tract infections, venous thromboembolisms and falls.
Patient safety walk rounds are scheduled visit by an Executive Director and Non-Executive Director to a ward or department to meet with staff and discuss good practice and safety issues. Where issues are highlighted, corrective actions are suggested and the individuals concerned are assigned responsibility to act upon them.
Primary Care The first point of contact for most people, for example, services provided by local GPs and their teams.
Providers The organisations that provide NHS services, for example NHS trusts and their private or voluntary sector equivalents.
Rapid Improvement Event Part of the Lean System (as developed in the Japanese car industry to promote quality and efficiency), providing a mechanism for making radical changes to current processes and activities within very short timescales.
Registration From April 2009, every NHS trust that provides healthcare directly to patients has to be registered with the Care Quality Commission (CQC).
Secondary Care A service provided by medical specialists who generally do not have first contact with patients.
Special Review A review carried out by the CQC to look at themes in health and social care. Reviews focus on services, pathways of care or groups of people.
The King's Fund An independent charity working to improve health and health care in England. It shapes policy and practice through research and analysis; development of individuals, teams and organisations; and promoting understanding of the health and social care system.
Training and Action for Patient Safety (TAPS) A new training programme to improve safety in the NHS in Yorkshire, developed by experts in the fields of patient safety.
CONTACT DETAILS
AIREDALE NHS FOUNDATION TRUST AIREDALE GENERAL HOSPITAL SKIPTON ROAD STEETON KEIGHLEY WEST YORKSHIRE BD20 6TD
Tel: 01535 652511 www.airedale-trust.nhs.uk
Patient Advice and Liaison Service (PALS) The PALS team at Airedale NHS Foundation Trust offer support, information and advice to patients, relatives and visitors. The PALS office is located at the entrance to Ward 18 and is open weekdays from 8.00 am to 4.00 pm. Tel: 01535 294019. Email: [email protected]
READERS PANEL The Readers Panel, whilst being popular, always needs to recruit new members. If you would be interested in joining this group, please contact Karen Dunwoodie, patient experience lead. Tel: 01535 294027. Email: [email protected].
VOLUNTEERS New volunteers are always welcome and if you are interested in becoming a volunteer at Airedale NHS Foundation Trust, please contact Gurmit Jauhal, voluntary services manager. Tel: 01535 295316. Email: [email protected].
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