Annual Report, Quality Report and Accounts 2017/18 Queen Victoria Hospital NHS Foundation Trust Annual Report, Quality Report and Accounts 2017/18 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 2 Queen Victoria Hospital NHS Foundation Trust Annual Report, Quality Report and Accounts 2017/18 3 Contents 1 Introduction 7 1.1 Chair’s introduction 8 2 Performance report 9 2.1 An overview of performance 10 2.2 Performance analysis 12 3 Accountability report 18 3.1 An overview of performance 19 3.2 Remuneration report 20 3.3 Staff report 27 3.4 NHS foundation trust code of governance disclosures 35 3.5 NHS Single Oversight Framework 48 3.6 Statement of the chief executive’s responsibilities as the accounting officer 49 of Queen Victoria Hospital NHS Foundation Trust 3.7 Annual governance statement 50 4 Quality report 57 Statement on quality 58 Priorities for improvement and statements of assurance from the board 59 Statement of assurance from the Board of Directors 77 Registration with the Care Quality Commission 86 National core quality indicators 92 NHS Improvement national priority indicators 102 Clinical effectiveness indicators 103 Statement of director responsibilities 116 Statement from third parties 117 5 Auditor’s report and certificate 121 6 Annual Accounts 127 Foreword to the accounts 128 Statement of comprehensive income 128 Statement of financial position 129 Statement of changes in taxpayers’ equity 130 Statement of cash flows 131 Notes 132 7 Appendices 155 7.1 Board of directors register 156 7.2 Council of governors register 157 7.3 Directors’ biographies 158 © 2018 Queen Victoria Hospital NHS Foundation Trust 4 Queen Victoria Hospital NHS Foundation Trust Annual Report, Quality Report and Accounts 2017/18 5 Introduction “We have the expertise and ability to deliver outstanding patient experience and world class clinical services whilst remaining efficient and financially sustainable.” 6 Queen Victoria Hospital NHS Foundation Trust 1 Annual Report, Quality Report and Accounts 2017/18 7 1.1 Chair’s introduction I am pleased to present the 2017/18 annual report, quality report and accounts for Queen Victoria Hospital NHS Foundation Trust. The Queen Victoria Hospital (QVH) has a proud heritage closely with our partner organisations within the NHS; and is known throughout the world for pioneering new we provide our expertise to neighbouring trusts and and innovative techniques and treatments. We continue benefit from the range of clinical services and back to receive excellent feedback from patients and have office functions provided in our partner trusts. maintained our reputation for delivering excellence. I would like to thank our staff, volunteers, governors The reputation of QVH as a centre of excellence comes and board members for all that they do to make sure from both our highly skilled clinicians and the individual our work reflects our values of humanity, pride and attention and care shown to every patient by the whole continuous improvement, and that QVH remains a team. Whether a patient benefits from one of the wonderful place to work and a truly exceptional place ‘world-first’ procedures described in our quality report to receive treatment. or from a tried and tested treatment, as one of the smallest trusts in the country we are able to offer an exceptional patient experience and our staff are able to make a real difference. In 2016 the Care Quality Commission rated us as ‘good’ with ‘outstanding’ patient care and we are committed Beryl Hobson to working towards every aspect of QVH being rated as outstanding. We will achieve that by continuing to work Chair Performance “QVH promotes a culture that encourages candour, openness and honesty at all levels” 8 Queen Victoria Hospital NHS Foundation Trust 2 Annual Report, Quality Report and Accounts 2017/18 9 2.1 Overview of performance contributing to strategic work in Kent. As a specialist In addition, QVH provides community-based clinical trust, we also play an important role in regional and services into which GPs can refer, based at a range of World class Statement from Chief Executive national developments in our areas of expertise. sites across Kent and Sussex. ✓ clinical services On April 2016 the Care Quality Commission stated In a tough year for the NHS as a whole it is testament that patient care at Queen Victoria Hospital (QVH) to the dedication of our staff that patient feedback A brief history of the Foundation Trust and its We provide a portfolio of world class services is outstanding. The inspectors found compassionate remains excellent. QVH is an excellent hospital bringing statutory background that are evidenced by clinical and patient outcomes and considerate care throughout the hospital, with together world class expertise and compassionate QVH is a specialist NHS hospital providing life-changing and underpinned by our reputation for high numerous examples of staff going above and beyond care. We look forward to maintaining our reputation reconstructive surgery, burns care and rehabilitation quality education, training and innovative research what would be expected. The CQC reported that for providing outstanding care for our patients and services for people across the South of England. and development. staff have a clear culture of compassion and an continuing to be a great place to work for our staff. Our world-leading clinical teams also treat common exceptionally strong awareness and empathy with conditions of the hands, eyes, skin and teeth for the As a specialist surgical hospital, without co-located patients, with excellent emotional support for both Statement of the purpose and activities of the people of East Grinstead and the surrounding area. general medical, paediatric and diagnostic services, patients and carers. Foundation Trust In addition, we provide a minor injuries unit, expert we must constantly review our admission and discharge criteria, our adherence to safety standards, and our This is a very high standard that we are proud to QVH is a regional and national centre for maxillofacial, therapies and a sleep disorders service. clinical partnerships with neighbouring trusts to ensure maintain. In June 2017 the national NHS inpatient reconstructive plastic and corneoplastic surgery, as well We are a centre of excellence, with an international we are providing a safe, effective service, particularly survey showed that the Queen Victoria Hospital scored as for the treatment of burns. It is a surgical centre reputation for pioneering advanced techniques and outside of normal working hours. better than other trusts across all ten relevant sections for skin cancer, head and neck cancer, and provides treatments. Everything we do is informed by our of the survey, with top scores in areas including patients microvascular reconstruction services for breast cancer passion for providing the highest quality care, the feeling well looked after by hospital staff, and being patients following, or in association with, mastectomy. best clinical outcomes and a safe and positive patient Operational involved in decisions about their care. In November QVH has links with the operational delivery network experience. ✓ 2017 QVH was the only trust categorised as ‘much for cancer and trauma care covering Kent, Surrey, and QVH was authorised as one of the country’s first excellence better than expected’ for both younger and older Sussex. In addition, QVH is involved in a number of NHS foundation trusts in July 2004. We have public children in the Care Quality Commission’s national multidisciplinary teams throughout the region. members in Kent, Surrey, Sussex and the boroughs of We provide streamlined services that ensure our patients are offered choice and are treated in a children and young people’s inpatient and day case In 2017/18, the principal activities of the Trust were the South London. timely manner. survey of 132 NHS acute trusts. provision of: Key issues and risks that could affect the The principal risk to delivery of this objective is the QVH is an exceptional place both to receive treatment • plastic surgery (including reconstructive surgery for Foundation Trust in delivering its objectives availability of specialist staff, especially in theatres and to work. However, recruitment and retention is one cancer patients) and burns care of the most significant challenges facing the NHS and is The Trust has a strategy called QVH 2020: Delivering and critical care. Other risk factors are late referrals • head, neck, and dental services (including associated impacting on QVH particularly in areas of national skills Excellence. It has developed its strategic emphasis from other trusts and less visibility of waiting lists at cancer surgery and orthodontics) shortage. We continue to devote considerable effort to across five domains of excellence which comprise the some spoke sites. The Trust has invested in a new data ensuring that we attract and retain the very best staff. • sleep disorders services following key strategic objectives. These are set out warehouse which will help with the visibility, and work Patients are referred to QVH from across the south • a wide range of therapy services and community- below and also include details of the principle risks is ongoing to ensure that the systems and processes for east and beyond. The vast majority of our patients get based services identified in each case. managing our waiting✓ lists are efficient and robust. our expert clinical help