Bradford Teaching Hospitals NHS Foundation Trust Evidence appendix Trust Headquarters Date of inspection visit: Bradford Royal Infirmary 9 to 11 January 2018 and 6 to 8 Bradford February 2018 West Yorkshire BD9 6RJ Date of publication: xxxx> 2018 Tel: 01274 542200 www.bradfordhospitals.nhs.uk This evidence appendix provides the supporting evidence that enabled us to come to our judgements of the quality of service provided by this trust. It is based on a combination of information provided to us by the trust, nationally available data, what we found when we inspected, and information given to us from patients, the public and other organisations. For a summary of our inspection findings, see the inspection report for this trust. Facts and data about this trust Details of sites and locations registered with CQC A list of the acute and community hospitals at the trust is below: Details of any Name of acute Geographical area Address specialist services hospital site served provided at the site Children Community Nurse Team Bradford Royal Duckworth Ln, Bradford Medical Care Bradford Infirmary BD9 6RJ Outpatients Surgery Eccleshill 450 Harrogate Road, Community Eccleshill , Bradford, West Outpatients Eccleshill Hospital Yorkshire, BD10 0JE 98 Kirkgate, Shipley, West Shipley Hospital Outpatients Shipley Yorkshire. BD18 3LT 20171116 900885 Post-inspection Evidence appendix template v3 Page 1 Children Community Nurse Team St Luke's St Luke's Hospital, BD5 Medical Care Bradford Hospital 0NA Outpatients Surgery Westbourne 26 Heaton Road, Bradford, Medical care Westbourne Green West Yorkshire BD8 8RA Outpatients Westwood Park Diagnostic and Swift Drive, off Cooper Medical care Westwood Park Treatment Lane. BD6 3NL Outpatients Centre (Source: Trust Website) Bradford Teaching Hospitals NHS Foundation Trust provides acute clinical services from the above locations. We inspected at Bradford Royal Infirmary which is the larger of two main hospital sites providing acute clinical services for. The hospital is based in Bradford and provides all clinical services from urgent and emergency care to maternity and services for children and young people. The trust has over 800 beds including 60 maternity beds and 22 critical care beds at Bradford Royal Infirmary. The trust saw over 93,500 inpatient admissions between December 2016 and November 2017. There were also over 519,000 outpatient attendances in the same period. There were over 123,000 A&E attendances. The trust was inspected in October 2014 and January 2016. At the comprehensive inspection in October 2014 we found the trust was in breach of regulations relating to care and welfare of people, assessing and monitoring the quality of the service, cleanliness and infection control, safety, availability and suitability of equipment and premises, respecting and involving service users and staffing. We issued a number of notices which required the trust to develop an action plan for how they would comply with the regulations where breaches had been found. We reviewed the trust’s progress against the action plan during the follow-up inspection in January 2016. We found that there had been improvements in some of the services and this had resulted in a positive change in the overall ratings from the previous CQC inspection, notably in critical care and outpatients and diagnostic imaging. However, the ratings remained the same in accident and emergency, surgery, medicine and children’s and young people’s services. This was because we either did not see significant improvement from our previous inspection or because we identified new areas of concern. The trust has a financial turnover of £393,573,000 and had a £11m deficit for 2017/18. NHS improvement (NHSi) reported that the trust had a good track record of ensuring delivery of overall financial plans. The trust achieved the financial plan and exceeded the control total in 2016/17. The trust also achieved its cost improvement programme (CIP) plan on a recurrent basis in 2016/17. The Friends and Family Test was launched in April 2013. It asks people who use services whether they would recommend the services they have used, giving the opportunity to feedback on their experiences of care and treatment. The trust scored above the England average for recommending the trust as a place to receive care from Dec 2016 to August 2017 but scored similar to the England average from September 2017 to November 2017. However, the trust response rate was 14.8% against a 22.7% England average. Is this organisation well-led? 20171116 900885 Post-inspection Evidence appendix template v3 Page 2 Leadership The trust board consisted of: The Chair (appointed in November 2016) Chief Executive Officer (appointed in January 2015) Director of Governance and Corporate Affairs / Deputy Chief Executive (appointed in February 2015) Medical Director (appointed in May 2015) Chief Nurse (appointed in August 2016) Director of Human Resources (appointed in December 2008) Director of Finance (appointed in August 2012) Chief Operating Officer (appointed in February 2018) Director of Informatics (appointed in September 2013) Director of strategy and Integration (appointed in August 2016) Eight Non-executive Directors The trust board had the appropriate range of skills, knowledge and experience to perform its role. The board of directors’ portfolios covered all key areas. The current chair, chief nurse and director of strategy and integration had been appointed since our last inspection in 2016. The chief operating officer (COO) was appointed in February 2018 having been in an interim COO role since January 2018. The director of governance and corporate affairs planned to retire at the end of March 2018. The assistant director of governance and risk had been identified to take this role from April 2018. The trust had appointed three non-executive directors since our last inspection in 2016. This included two non-executives that joined in December 2017 and February 2018. The non- executives were knowledgeable, competent and had the appropriate skills and experience relevant to their roles. They had worked in leadership and management positions in the NHS, education, voluntary and private sectors. They had a background in a range of areas including business planning, law and accountancy. The non-executive team provided appropriate challenge and were positive about trust leadership. They demonstrated a clear understanding that cost improvements and financial performance should not compromise patient care and safety. The chair, executive and non-executive directors demonstrated a clear understanding of the priorities and challenges facing the trust. Senior leaders spoke with insight about key risks around workforce, maintaining operational performance and financial pressures. These challenges were articulated in the clinical service strategy and were recognised in the corporate risk register and Board Assurance Framework. We carried out checks to determine whether appropriate steps had been taken to complete employment checks for executive and non-executive directors in line with the Fit and Proper Persons Requirement (FPPR) (Regulation 5 of the Health and Social Care Act (Regulated Activities) Regulations 2014). This regulation ensures that directors of NHS providers are fit and proper to carry out this important role. We looked at the executive and non-executive director employment files, which were completed in line with the FPPR regulations. The council of governors approved the appraisal process for the chair and non-executive directors. Performance appraisals for non-executive directors went to the nominations and remuneration committee. Newly appointed executive and non-executive directors underwent formal induction, which included mandatory training and a local induction plan specific to their role. Most staff reported that the leadership team were visible and approachable. The executive and non-executive directors undertook a scheduled programme of walkabouts across the directorates 20171116 900885 Post-inspection Evidence appendix template v3 Page 3 and reported these back at board meetings. The chief executive also engaged with staff through regular informal talks. There were processes in place for leadership development and succession planning across the senior and divisional management levels. The leadership strategy 2017– 2022 set out how the trust aimed to meet the leadership strategic aims and objectives in the people strategy 2017 – 22. A leadership and management development framework was launched in 2017. This outlined the plan to deliver training and development to staff in leadership roles across the trust, including senior leaders. Potential or future leaders were identified through appraisals, career development conversations and/or informally, through recognising skills and capability. Of the executive board members at the trust, none were black and minority ethnic (BAME) and 50.0% were female. Of the non-executive board members 38.0% were BAME and 25.0% were female. This was not fully representative of the local demographics. Staff group BME % Female % Executive directors 0.0% 50.0% Non-executive directors 38.0% 25.0% All board members 19.0% 38.0% (Source: Routine Provider Information Request (RPIR) – Board Diversity) Vision and strategy The trust published its refreshed mission and vision statements along with its strategic objectives in August 2017. The trust’s mission was "To provide the highest quality healthcare at all times”. The trust's vision