ANNUAL REPORT & ACCOUNTS 1st April 2012 to 31st March 2013 Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) of the National Health Service Act 2006. CONTENTS 1. Introduction Trust profile …………………………………………………………………………. 7 Statement by the Chairman and Chief Executive ………………………………. 9 2. Directors’ Report and Management Commentary Management commentary ………………………………………………………… 11 Our vision and strategy ……………………………………………………………. 16 Progress against our corporate objectives …………………………………..….. 16 Our priorities for future development …………………………………………….. 47 3. Quality Report Introduction …………………………………………………………………………. 49 Our priorities for 2012/13 ……. …………………………………………………… 65 Our priorities for improvement 2013/14 ………………………………………….. 87 Statements of assurance ………………………………………………………….. 95 Further performance information …………………………………………………. 117 Statements from other organisations …………………………………………….. 121 Statement of directors’ responsibilities …………………………………………… 124 4. Regulatory information Monitor regulatory ratings ………………………………………………………….. 130 Sustainability report ………………………………………………………………… 132 5. NHS Foundation Trust Code of Governance Board of Directors …………………………………………………………………… 136 Board sub committees………………………………………………………………. 144 Council of Governors ……………………………………………………………….. 148 Membership ………………………………………………………………………….. 152 6. Financial Report and Accounts Financial review ………………………………………………………………………. 156 Remuneration Report ………………………………………………………………... 158 Statement of Accounting Officer’s Responsibilities ………………………………. 164 Annual Governance Statement ……………………………………………………... 165 Financial Accounts …………………………………………………………………… 173 5 | P a g e Ashford and St Peter’s Hospitals NHS Foundation Trust Annual Report 2012-2013 6 | P a g e Ashford and St Peter’s Hospitals NHS Foundation Trust Annual Report 2012-2013 1. Introduction Welcome to our Annual Report which covers the financial period from 1st April 2012 to 31st March 2013. Trust profile Originally established in 1998 from the staff and in 2012/13 our turnover for the merger of Ashford and St Peter’s year was £232 million. Hospitals, the Trust has been on a long journey of development and improvement The Trust provides a whole range of to its current position as the largest services across its two hospital sites in provider of acute hospital services to Surrey - Ashford Hospital, situated along Surrey residents, and having become a the A30 close to the border with Foundation Trust in December 2010. Hounslow, and St Peter’s Hospital in Chertsey. The majority of planned care, Ashford and St Peter’s Hospitals NHS like day case and orthopaedic surgery Foundation Trust serves a population of and rehabilitation services, is provided at over 380,000 people living in the boroughs Ashford hospital, with more complex of Runnymede, Spelthorne, Woking and medical and surgical care and emergency parts of Elmbridge, Hounslow, Surrey services at St Peter’s Hospital. Heath and beyond. We employ 3,300 Contains: Ordnance Survey data © Crown copyright and database Our catchment area 7 | P a g e Ashford and St Peter’s Hospitals NHS Foundation Trust Annual Report 2012-2013 Our services We continue to provide the following hospital and community based health services to our catchment population: Admitted patient care for planned surgery and emergency medicine and surgery Accident and emergency services Critical care Outpatient services, both in the hospitals and across a number of community settings Community midwifery services Services are split across our two main hospital sites as follows: Ashford Hospital St Peter’s Hospital Day-case surgery Accident and emergency services Stroke and rehabilitation care Intensive care Elective orthopaedic surgery Emergency surgical and medical care Ophthalmology Elective and day-case surgery Outpatients (including paediatrics) and Orthopaedics (Rowley Bristow unit) diagnostics; X ray, ultrasound, and MRI scans Specialist brain injury unit Maternity care Paediatric services (children’s services) Neonatal intensive care unit which provides care for acutely ill babies Outpatients and diagnostics; X ray, ultrasound, CT scans, endoscopy (using cameras to look inside the body) and MRI scans Pathology services Paediatric services We run many specialist clinics in the community - for example at Woking, Weybridge, Walton and Cobham Community Hospitals, at the Heart of Hounslow Polyclinic, Teddington Memorial Hospital and others – providing more accessible care, closer to where our patients live. We’ve been busy ….. Over the last year we have: Treated 34,000 emergency admissions Admitted 34,000 people for planned inpatient and day case treatment Seen 92,000 people in our A&E department Seen 355,000 patients in our outpatient clinics Helped deliver 4,100 babies Had a turnover of £232m and generated an operating surplus of £3.4m 8 | P a g e Ashford and St Peter’s Hospitals NHS Foundation Trust Annual Report 2012-2013 Statement by the Chairman and Chief Executive Welcome to our Annual Report for 2012/13. Overall this has been another good year for Ashford and St Peter’s Hospitals NHS Foundation Trust, as we mark our second full year as a successful Foundation Trust. Central to our vision is to provide high this winter has seen hospitals up and quality care for everyone. With the recent down the country struggle to maintain the publication of the second Francis Report four hour waiting target. Within this looking into the failings in care at Mid context we are particularly encouraged Staffordshire NHS Foundation Trust, we that our performance has improved and are once again reminded of the that we met this important quality target for responsibility we carry on behalf of our most of the financial year. patients and the importance of working in a values-led, open and safe culture. There is no doubt one of this year’s highlights was welcoming Archbishop As you might expect, we have spent time Desmond Tutu and his daughter the with staff reflecting on the findings of this Reverend Mpho Tutu to St Peter's landmark report, working together to Hospital last October, to celebrate and join assure ourselves that something on that our workshop on equality. It was a real scale could never happen here. From the privilege to listen to the Archbishop’s Board to the front line we continue to inspirational address on equality and actively encourage, discuss and collect compassion, and we were honoured that feedback using what we hear to make the he and his daughter chose to join us. right improvements for patients. And with the introduction of the new Friends and Our staff have continued to work hard on Family Test from April, we look forward to behalf of patients but challenging times having an even richer source of feedback have had an impact on how certain groups down to ward level. are feeling. In the latest national staff survey, whilst our nursing staff have We have been particularly encouraged reported higher levels of job satisfaction, with our results from the national patient we know we need to do more to engage survey, which show good improvements and involve staff more widely. Next year for the third year running, especially in we’ll focus on developing our organisation how patients feel about nursing care. so staff feel more engaged and to improve Given that the quality of nursing care has their overall experience of working in our also been in the spotlight following the hospitals. In the meantime, to strengthen Francis Report, it is particularly reassuring clinical leadership and support more for our patients and their families to know devolved accountability, we have that our nurses are doing a good job. restructured our clinical services into four divisions*, and look forward to working We have also been working hard to with the new structure from 1st April. improve the experience of patients who come to our hospitals as an emergency. A sobering moment came last September, With the help of the Department of when our emergency resilience was put Health’s Emergency Care Intensive firmly to the test following a serious coach Support Team, we have put in place a crash on the A3. Declared as a major number of changes to help the flow of incident, seven hospitals were involved patients through our hospitals. Nationally with St Peter’s taking a total of 23 9 | P a g e Ashford and St Peter’s Hospitals NHS Foundation Trust Annual Report 2012-2013 casualties - mostly walking wounded - In her place we will be welcoming Louise around half the passengers involved in the McKenzie as our new Director of crash. Putting our plans into action in the Workforce Transformation. early hours of the morning, the response from our staff was immediate and Finally a big thank you to everyone who impressive. And although all Trusts plan has made a contribution over the last year; for such events, it’s a rare occurrence to to our staff and volunteers (who have to implement a major incident plan. impressively won The Queen’s Award for We would like to reiterate our thanks here Voluntary Service) but also to NHS to everyone involved and our pride in how colleagues, our partners in local voluntary well our staff rose to the challenge. and community organisations, carers, our Leagues of Friends, Hospital Radio Wey, We maintain a positive working and all those who raise funds for our relationship with our Council of Governors hospitals. Thank you. We also acknow- and wider membership, and Governors ledge the support from colleagues at the have continued their involvement with the