LUTON & Luton and Dunstable DUNSTABLE University Hospital HOSPITAL NHS Foundation Trust Annual Report and Accounts for the period April 2017 to March 2018 incorporating Quality Account Luton and Dunstable University Hospital NHS Foundation Trust Annual Report & Accounts for the period April 2017 to March 2018 incorporating Quality Account Presented to Parliament pursuant to Schedule 7, paragraph 25 (4) (a) of the National Health Service Act 2006 © 2018 Luton and Dunstable University Hospital NHS Foundation Trust Contents INTRODUCTION 3 FINANCIAL PERFORMANCE REPORT 95 Awards and Congratulations 4 Review of Financial Performance 96 About this Report 9 Remuneration report 98 Chief Executive Introduction 10 Fundraising and Charitable Donations 99 Chairman’s Statement 11 ANNUAL GOVERNANCE STATEMENT STRATEGY 13 AND ACCOUNTS 103 Annual Report Executive Summary 14 Statement of the Chief Executive’s Responsibilities 104 2018/19 Strategic Approach 19 Annual Governance Statement 2017/18 105 Maintaining our Performance 23 Independent Audit Opinion 113 Corporate Objectives 24 Foreword to the Accounts 118 Service Developments Planned 25 Statement of comprehensive income 119 Performance against Corporate Objectives 2017/18 29 Statement of financial position 120 Service Developments 2017/18 34 Statement of changes in equity 121 Improving Quality 36 Statement of cash flows 122 OPERATIONAL PERFORMANCE REPORT 39 APPENDIX 1 QUALITY ACCOUNT 161 Principal activities of the Trust 40 What is a Quality Account? 162 Review of Operational Performance 42 About Our Trust 163 Regulatory Quality CQC Performance 43 1. A Statement on Quality from the Chief Executive 165 2. Report on Priorities for Improvement in 2017/18 167 OUR PATIENTS, OUR STAFF AND OUR PARTNERS 55 3. Priorities for Improvement in 2018/19 180 Our Patients 56 4. Statements related to the quality of services provided 192 Our Staff 60 5. A Review of Quality Performance 204 Equality and Diversity 70 6. Statement of Directors’ responsibilities Working with our Partners 74 in respect of the Quality Report 235 7. Comments from stakeholders 236 GOVERNANCE REPORT 75 8. Independent Auditor’s Assurance Report 239 Board of Directors 76 9. Glossary of Terms 241 Committees of the Board of Directors 84 Appendix A - Clinical Audits Reports 243 Audit and Risk Committee 85 Appendix B – Trust Committee Structure 262 Council of Governors 88 Foundation Trust Membership 92 L&D: INTRODUCTION Introduction Awards and Congratulations 4 About this Report 9 Chief Executive Introduction 10 Chairman’s Statement 11 3 ANNUAL REPORT & ACCOUNTS 2017/18 & ACCOUNTS REPORT ANNUAL Awards and Congratulations Awards and Congratulations Our staff Luton and Dunstable University Hospital Foundation Trust were announced as the only Hospital to meet all three performance targets on the BBC NHS tracker. In November 2017, the L&D CEO informed all staff saying: ‘We are very proud of all L&D staff for their contribution towards our performance achievements that have been announced this week. We know that it hasn’t been easy to hit these targets and we know that the coming few Official Opening of The Rahul months are going to be extremely challenging as we Joshi Unit head into winter (Monday was our busiest ever day in A&E with 359 attendances) but we are confident that, working together, we will be able to meet this challenge Dr Joshi was a much loved and well respected doctor and continue to provide our patients with the best here at the Luton and Dunstable University Hospital who possible care.’ sadly died, aged 46. He is greatly missed but will always be remembered. Engagement 2017 – Good, Better, Best Events In dedication of his hard work and incredible The Trust held two lots of staff engagement events in achievements, the new haematology Unit was dedicated 2017, one in July and one in December. Staff were invited in his name. The Rahul Joshi Unit was officially opened to attend one of numerous sessions during the week long by Dr Joshi’s family on Wednesday 20th September. The events to hear about the L&Ds current news and aims unit is open for patients with Haematology and oncology for the next few months. Staff were also encouraged to related illnesses and will enable a team of specialist participate in work to help shape the future plans of the medical and nursing staff to support these patients in the L&D. They also gave the Board an opportunity to thank best possible environment. staff for their hard work. The events were very well attended and feedback from staff was extremely positive. 4 ANNUAL REPORT & ACCOUNTS 2017/18 & ACCOUNTS REPORT ANNUAL Engagement 2017 L&D: INTRODUCTION Luton Community Service Awards - Midwifery Awards Healthcare Hero, Farida Parker At the Annual Midwifery Conference held on 5 May - The L&D is very proud that International Day of the Midwife – Award Winners were: Farida Parker, a Respiratory Nurse here at the hospital won • Mary Edmondson the Healthcare Hero Award at • Jayne McLean the annual Luton Community • Piper Carla-Louise Awards in October 2017. • Michelle Causer • Giselle Cook Farida Parkar was nominated • Elizabeth Godwin by a group of grateful patients, • Kelly Belcher who are seen on a regular • Christine Mcmahon basis in outpatients or when • Tina Mccann they are admitted into Hospital. She said “I felt very • Emma Sherwood humbled to be nominated and honoured to receive the • Ward 32 award on behalf of the Respiratory team who all play a big part in the service we provide”. UCL Medical School Awards Nursing Awards Name and Proclaim Award Throughout the academic year, UCL Medical School At the Annual Nursing Conference held on 12 May - students and staff have the opportunity to acknowledge International Nurses Day - the following Annual Awards people who have impressed and inspired them at UCL were presented: Medical School. We are very pleased that Dr Samia Nesar was commended by a student. We would like to thank Dr Student Nurse of the Year – Danielle McLaughan Nesar for her hard work and contribution. Clinical Support Staff of the Year – Charles Addai Top Administrator Award Most Promising New Graduate (The Aimee Varney Throughout the academic year, the students are Award) – Daniella Lehotska asked, via the online evaluation questionnaires, to nominate teachers and administrators who have made Mentor of the year – Laura Cruise an especially positive contribution to their learning and experience at UCL Medical School. Ms Su Gill has Innovation in Care – Community Midwifery Team received an award as a Top Administrator and we would like to thank her for all the support she gives medical Team of the Year – EAU 1 students at the L&D. Nurse of the Year (The Erma Bristol Miller Award) – Martha Simango 5 Annual Nursing conference award winners Annual Midwifery conference award winners Our volunteers Volunteer Long Service Awards Luton’s Best ‘Service with a Smile’ On 3 January 2018, more than 100 volunteers attended Award– Pearl Hinds our Annual Thank You and Volunteer Long Service Awards which were hosted by Trust Chair Simon Linnett. We are very proud that one of our wonderful volunteers, High Sheriff of Bedfordshire, Vinod Tailor presented the Pearl Hinds, was recognised locally at the Luton’s Best awards, including a very special award to recognise 30 Awards ceremony when she won the ‘Service with a years of voluntary service to the L&D. Smile’ award. Award recipients were: Pearl was nominated by staff on our Children’s Unit. They said: “Pearl and her smile are infectious! She is one of 5 Years Awards the team and just gives so much. She’s always happy and Alwiya Aboudi cheerful and brightens the day of all of us. The children Kay Crossland benefit so much from her happy disposition, her time and Margaret Duffy her caring nature - it certainly goes a long way to making Beverly Campbell them feel more at ease and supporting their recovery. Janet Graham and John Graham We treasure her and truly cannot thank her enough for Ester Jackson what she does. We are so pleased that she has won this Matt James award.” Oliver Pena Colin Rutter 10 Year Awards Dianne Foyle Wendy Harding Icilda Mayhew Frisco Smith Daphne Venstone Vivienne Whitton 15 Year Awards Beryl Barclay Judy Tungate Judy Fleckney Susmita Shah A special award was also presented to Bernadette Lana for an amazing 30 years service to volunteering Pearl Hinds - Service with a Smile’ Award at the L&D. Bernadette is one of those people who it is impossible to praise highly enough. She has been a Roman Catholic visitor and Eucharistic Minister for 30 6 years and she now co-ordinates a team of people who ensure that people are visited and receive the support ANNUAL REPORT & ACCOUNTS 2017/18 & ACCOUNTS REPORT ANNUAL that they need. Thank you to all our volunteers. They provide such an invaluable service and support to our patients and staff. L&D: INTRODUCTION Volunteer long service all Award Winners Our Governors The L&D became a Foundation Trust with a Council of Governors in 2006. Each Governor is able to stay for a maximum of three terms of office and during 2017, one of our Governors, Mr John Harris reached the end of their third term which equated to nine years’ service on the Council of Governors. The Trust and the Council of Governors join in thanking them for all their hard work over the years. Their support by representing the views of the local people and staff, and helping the hospital to shape its plan for the future has been invaluable. 7 Mr John Harris L&D: About this Report INTRODUCTION The report follows best corporate practice reporting on the Trust’s strategy and performance against the objectives. The report presents information on national targets and financial performance and also gives a review of the quality of services.