Annual Report and Accounts 2012-13 2 York Teaching Hospital NHS Foundation Trust Annual Report and Accounts 2012-13 Presented to Parliament pursuant to Schedule 7, paragraph 25(4) of the National Health Service Act 2006 3 4 Contents Introduction ................................................................................................................... 7 Introduction.................................................................................................................. 8 Chairman’s Statement ................................................................................................. 8 Chief Executive’s Statement...................................................................................... 10 Strategy........................................................................................................................ 13 2012/13...................................................................................................................... 14 Strategic approach..................................................................................................... 14 Performance against corporate objectives................................................................. 14 Improve quality and safety......................................................................................... 14 Create a culture of continuous improvement ............................................................. 20 Develop and enable stronger partnerships ................................................................ 24 Improve our facilities and protect the environment .................................................... 27 Integration of Scarborough and North East Yorkshire Healthcare NHS Trust into York Teaching Hospital NHS Foundation Trust ................................................................. 30 Strategy for 2013/14 .................................................................................................. 32 Quality Report ............................................................................................................. 34 Part 1 – Overview ...................................................................................................... 35 Letter from the Chief Executive ................................................................................. 35 Statement of Directors’ Responsibilities in Respect of the Quality Report................. 37 Quality and Safety ..................................................................................................... 39 National Awards......................................................................................................... 42 Local Awards ............................................................................................................. 43 Part 2 – In More Detail............................................................................................... 44 Performance for the last 12 months........................................................................... 44 York Teaching Hospital Priorities from 2011-12 ........................................................ 44 Scarborough Hospital Priorities from 2012-13 ........................................................... 48 Priorities for the Trust’s Quality & Safety for 2013/14 ................................................ 52 Part 3 – Regulatory Requirements and Assurance from the Board ........................... 54 The Regulations......................................................................................................... 54 Assurance from the Board ......................................................................................... 54 Commissioning for Quality and Innovation Payment Framework (CQUIN)................ 54 Care Quality Commission .......................................................................................... 55 Data Quality............................................................................................................... 55 Monitor Quality Governance Framework ................................................................... 56 Part 4 – Clinical Audit ................................................................................................ 57 National Clinical Audits and National Confidential Enquiries ..................................... 57 Financial Year 2012/13 – York Hospital..................................................................... 57 Financial Year 2012/13 – Scarborough Hospital ....................................................... 57 Research and Development ...................................................................................... 61 Part 5 – New Initiatives, Targets and Trajectories ..................................................... 62 Trust Performance against National Quality Indicators.............................................. 64 Part 6 – Statements from Key Stakeholders.............................................................. 70 Statement on behalf of the Council of Governors (CoG) ........................................... 70 Statement on behalf of Healthwatch York.................................................................. 70 Statement from Healthwatch East Riding of Yorkshire .............................................. 71 Statement from Vale of York Clinical Commissioning Group..................................... 71 Statement from Healthwatch North Yorkshire............................................................ 73 Independent Auditors' Limited Assurance Report to the Council of Governors of York 5 Teaching Hospital NHS Foundation Trust on the Quality Report............................... 75 Glossary .................................................................................................................... 78 Performance Report.................................................................................................... 87 Performance Report .................................................................................................. 88 Key facts.................................................................................................................... 88 Principal activities of the Trust ................................................................................... 88 Patient care ............................................................................................................... 88 Community services .................................................................................................. 97 Our staff................................................................................................................... 100 Operational HR........................................................................................................ 102 Research and Development .................................................................................... 102 Corporate Learning and Development..................................................................... 104 Review of Financial performance............................................................................. 105 Fair view of the Trust ............................................................................................... 105 Regulators ............................................................................................................... 109 Governance Report................................................................................................... 111 Governance Report ................................................................................................. 112 NHS Foundation Trust Code of Governance ........................................................... 112 Board of Directors.................................................................................................... 116 Council of Governors............................................................................................... 136 Foundation Trust membership................................................................................. 147 Statutory information................................................................................................ 157 Statutory information................................................................................................ 158 Directors .................................................................................................................. 158 Brief history of the Trust........................................................................................... 158 Environmental matters............................................................................................. 159 Financial information................................................................................................ 159 Remuneration Report .............................................................................................. 160 Sustainability ........................................................................................................... 166 Equality Report ........................................................................................................ 167 Workforce profile...................................................................................................... 168 Staff Survey ............................................................................................................. 170 Regulatory ratings...................................................................................................