and Accounts 1 Central Manchester University Hospitals NHS Foundation Trust Annual Report and Accounts – 2010/11. Presented to parliament pursuant to Schedule 7, Paragraph 25 (4) of the National Health Service Act 2006. 2 3 Message from the Chairman and Chief Executive ............... 4 Message from the Medical Director .......................... 6 All about the organisation ................................. 8 Quality Accounts ....................................... 10 A Year of Quality ....................................... 11 Carbon Reduction ...................................... 46 Equality, Diversity & Human Rights ..........................48 Council of Governors .................................... 50 Membership ........................................... 62 Working with our staff. 66 Infection Prevention and Control ........................... 74 Performance against Trust business objectives 2010/11 .......... 76 Monitor’s Regulatory Ratings ...................................80 Working with our patients & visitors ........................ 82 Research and Innovation ................................. 86 Highlights and Developments .............................. 90 Contents Activity and Performance ................................. 98 Board of Directors ..................................... 100 Emergency Preparedness ................................ 107 Statement of Internal Control ............................. 108 Statement of Compliance with the NHS Foundation Trust Code of Governance ................................116 Audit Committee Report .................................117 The Remuneration and Nominations Committee Report ........ 121 Statement of Chief Executive’s Responsibilities ................ 122 Report of the Executive Director of Finance .................. 123 Independent Auditor’s Report ............................ 124 Foreword to the accounts ............................... 126 Financial Statements .................................... 127 Mission Statement The Trust aims to become the leading integrated health, teaching, research and innovation campus in the NHS and to position itself on an international basis alongside the major biomedical research centres, as part of the thriving city region of Manchester – with its strong emphasis on economic regeneration, science and enterprise. We have three main organisational objectives, all of which we are committed to and working to improve: 1) Patient safety and clinical quality. 2) Patient and staff experience. 3) Productivity and efficiency. 4 elcome to our third Wannual report as a Foundation Trust. We would like to begin this report by thanking our staff for all their hard work and dedication over the year. One major event for our organisation was the transfer of around 1,400 staff members working in community services. The transfer took place on 1st April 2011 as part of the Government’s Transforming Community Services (TCS) programme. The aim of the national TCS programme is to secure greater effectiveness and efficiencies in community services so that they can provide modern personalised and responsive care of a consistently high standard. In Manchester, community health services transferred from NHS Manchester (Manchester Primary Care Trust) and split across and merged into four main NHS organisations including our own. The community services transferred to us included Adult Services (eg District Nursing) for the central Manchester area, along with Children’s Services, Contraception and Sexual Health, Community Dentistry, and Learning Disabilities services for the whole of the city. Our Quality Campaign, which was launched on 12th May 2009, goes from strength to strength with each of our divisions working hard to improve quality for patients within their wards and departments. The campaign focuses on many areas such as implementing, measuring, recognising and rewarding high quality standards thereby supporting one of our key objectives of improving patient safety and patient experience. Following an inspection by the Care Quality Commission, we were pleased with their report which confirmed we are meeting all essential standards. Their report highlighted each Message from the Chairman and Chief Executive standard and how we are performing against it. The following quote was detailed in the report: “Every person we spoke to said that they felt involved in their care and that they had no 5 complaints at all about any of the staff. People used and informed about the organisation. Staff words like “excellent” and “brilliant” to describe the engagement sessions are held regularly staff and people were particularly complimentary whereby the Chief Executive and his about the nursing staff. One patient said that Executive Director colleagues hold open “nothing was too much trouble”. briefings in each division providing up-dates on the national, regional and organisational We are proud to be a member of the Manchester direction. Additional sessions are also held Academic Health Science Centre (MAHSC), which with our consultant colleagues to ensure together with our Biomedical Research Centre status that the doctors at the forefront of our means that we are one of the leaders of medical patient services are fully briefed and research. Our vision is to be a leading global centre informed. It is not only an opportunity for the delivery of innovative applied health research for staff to be up-dated but also and education into healthcare. a forum where they can raise any On 5th May 2011 the new £19 million Manchester matters of concerns directly with the Health Academy building was officially opened by directors. Olympian Jonathan Edwards. This was the first NHS There have been many more sponsored Health Academy. We are also pleased to developments and achievements report that a recent OFSTED assessment categorised which are highlighted throughout this Academy School as ‘good’, an amazing the report. achievement in such a short space of time. News and up-dates throughout Together with our co-sponsors Manchester City the year can be found on our Council and The Manchester College, the Health website (www.cmft.nhs.uk) and Academy provides 600 places for 11-16 year we are excited that we have olds with an additional 120 post 16 places. The just launched a new improved Academy is also supported by the Manchester United version of our website which Foundation who provide on site coaching for pupils. is easier to navigate and The Trust, in partnership with Manchester City provides more information Council, The University of Manchester and for our patients and visitors. Manchester Metropolitan University, are founders of We are indebted to our ‘The Corridor, Manchester’. The Corridor partnership staff, without whom our based around Oxford Road has been formed to drive achievements would not future economic growth and investment. The former have been possible. Royal Eye Hospital is now under development to establish a state-of-the-art facility providing research, laboratory and business space. Work continues in relation to our Carbon Reduction Management Plan. As a large organisation we are committed to reducing our emissions and ensuring that we use energy appropriately and efficiently Peter W Mount CBE thereby reducing our carbon footprint. Chairman In the first part of 2011 our second series of ‘Children’s Hospital’ was broadcast for 12 weeks on ITV1. This is a prime-time series, which achieves over 3 million viewers each week and features the work and staff of Royal Manchester Children’s Hospital. In these current challenging times with the impact of the financial and economic climate it is more Mike Deegan important than ever to ensure that staff are engaged Chief Executive 6 ollowing the move into our Fnew hospitals during 2009, the opening of the boulevard in 2010, running through the middle of the site has brought into sharp focus the real vision that went into the design and planning of the whole site. We have spent this last year concentrating on settling in and delivering high quality, safe care to all our patients. Almost by definition, healthcare is a high risk area. Despite best efforts things do not always go as well as patients and staff would hope. Maintaining and improving patient safety is a primary concern for the organisation. As every hospital does, we are constantly seeking to reduce harm from patient safety incidents. At the beginning of this year we set some ambitious targets for improvement in some specific areas, and I’m pleased to report we were able to achieve almost everything we set out to do. The Trust Quality Accounts set out all of these achievements in detail but some of the headlines include a marked reduction in the number of serious incidents even from the small number we had previously recorded; achieving the national standard of 90% of all patients being assessed for the risk of developing thrombosis whilst in hospital; significant reduction in problems with medication; greatly improved performance in the national stroke audit with our score better than the national average. We also learned that over an earlier period, we were the best performing hospital nationally in outcomes following bowel cancer surgery. All of these improvements are a reflection of the care and attention that staff pay to safety and to ensuring that they offer every patient their best effort every time. Message from the Medical Director 7 We also set out to improve organ donation rates and with for their programme increasing the numbers of the support