North Cumbria University Hospitals NHS Trust Annual Report and Accounts 2018/19 1 Contents Foreword ................................................................................................................ 4 1. PERFORMANCE REPORT ................................................................................ 7 1a Overview ............................................................................................................... 7 Our Year at a Glance .......................................................................................... 8 Our Values .......................................................................................................... 9 Our Priorities 2018/19 ....................................................................................... 10 Principal Activities of the Trust .......................................................................... 10 Our Key Issues and Risks ................................................................................. 12 1b Performance Analysis ......................................................................................... 12 Care Quality Commission (CQC) Registration and Inspections ........................ 20 Our Achievements 2018/19 .................................................................................. 29 2. Accountability Report ........................................................................................ 32 3a Corporate Governance Report ............................................................................ 32 Charitable Funds ............................................................................................... 43 Annual Governance Statement 2018/19 ............................................................... 46 3c Remuneration and Staff Report ........................................................................... 63 Staff Numbers and composition ........................................................................ 63 Remuneration Report ........................................................................................... 79 3d Parliamentary Accountability and Audit Report ................................................... 88 Statement of the Chief Executive’s Responsibilities as the Accountable Officer of the Trust ............................................................................................................... 88 Statement of Directors’ Responsibilities in Respect of the Accounts .................... 89 Head of Internal Audit Opinion .............................................................................. 90 4. FINANCIAL STATEMENTS 2018/19 .................................................................. 105 5. QUALITY ACCOUNTS 2018/19 ......................................................................... 106 PART 1 INTRODUCTION ................................................................................... 108 What is a Quality Account? .............................................................................. 108 Chief Executive Statement .............................................................................. 109 Statement of Directors’ in respect of the Quality Account ............................... 111 PART 2: PRIORITIES FOR IMPROVEMENT AND STATEMENTS RELATING TO QUALITY OF NHS SERVICES ........................................................................... 112 Our Priorities ................................................................................................... 112 CQUIN Priorities 2018/19 ................................................................................ 113 2 Mandatory Statements of Quality Standards ................................................... 114 Performance in National and Clinical Audit ..................................................... 130 Clinical Research ............................................................................................ 170 Review of Services – Mandatory Statements .................................................. 172 Data Quality..................................................................................................... 172 Information Governance 2018/19 .................................................................... 173 Being Open and Duty of Candour ................................................................... 178 PART 3: OTHER INFORMATION ....................................................................... 181 Care Quality Commission (CQC) Registration and Inspections ...................... 181 Delivering Our Quality Improvement Plan 2018/19 – Key Headlines ............... 183 Appendix A - Quality Improvement Plan 2018/19 – Delivery Summary .......... 201 Annex 1: Statements from commissioners, local Health watch organisations and Overview and Scrutiny Committees ................................................................ 212 AUDITORS STATEMENT ............................................................................... 220 GLOSSARY .................................................................................................... 221 3 Foreword 2018 was a special year for the NHS as it turned 70 years old on 5 July. To mark the occasion, we held a variety of celebrations looking back at how the NHS and its staff has saved and transformed so many lives and also looking to the future. The future of the NHS is very much centred on much closer working between health and care partners. During 2018/19, we are pleased to say that our work to integrate our services made great strides. In May 2018, the North Cumbria Health and Care System was confirmed by NHS England as part of the next wave of Integrated Care Systems (ICS), putting our area at the forefront of national policy. This has given us the green light to further integrate health and care services across organisational boundaries, making it easier for teams to work together for the benefit of patients and communities. As part of our system working, we have also been progressing the merger of North Cumbria University Hospitals NHS Trust (NCUH) and Cumbria Partnership NHS Foundation Trust (CPFT) which is set to take place in October 2019. Since April 2018 we have been working as a joint Trust Board across the two organisations and our teams are working closely together so this next step feels like a natural progression. As part of the joint Trust Board, Professor Robin Talbot is now joint Chair of both NCUH and CPFT after Gina Tiller retired as Chair of NCUH in March 2019. We would like to thank Gina for her passion and commitment to North Cumbria during her six years in post. A programme management approach has been adopted to prepare for and manage the merger transaction. Work streams led by Executive Directors deliver the required activity and report progress into the Programme Board which is chaired by the Chief Executive. CPFT’s Governors Council are engaged in the process and have been involved in the review and development of the Constitution for the new Trust. At the time of writing, following agreement from CPFT Governors Council in November 2018 and approval of the Strategic Case by NHS Improvement (NHSI) in February 2019, activity is underway to prepare for both Trusts to merge to become a single organisation. The aim is that the new Trust will ‘go-live’ in October 2019 following approval of the Full Business Case by the Board in June 2019, and subject to successful progress through the Transactions process with NHSI. As this transaction is technically an acquisition of NCUH by CPFT the merged Trust (name not yet confirmed at time of writing) will be a Foundation Trust. 4 One of the ways we are working to join up health and adult social care services in north Cumbria is in the development of eight Integrated Care Communities (ICCs) to enable closer working, help people to stay well and provide more out of hospital care. The first phase of ICCs aimed to increase the capacity of community teams to keep more people at home and support people to leave hospital sooner. This has already had a significant impact with hundreds of people avoiding a hospital stay. As well as investment in out-of-hospital care, we have also seen great progress this year with our major investment projects at the acute hospitals. The demolition of the old tower block at the Cumberland Infirmary is making way for the new £35m cancer centre with construction set to begin in summer 2019. The centre will open in summer 2021 and will offer services to patients across the north of the county, including radiotherapy and chemotherapy. At West Cumberland Hospital, the redevelopment work is continuing with cardiology, vascular and breast services moving into a newly refurbished area. Work will continue into the forthcoming year with the demolition of the older buildings meaning the new hospital will be more visible when you arrive at the hospital. We are also developing new ways of working at West Cumberland Hospital in order to provide a more joined-up service. The Same Day Health Centre opened in the Outpatients department at February 2019 which offers Copeland patients more appointments for those who need to see a GP, nurse or other primary care staff urgently. In terms of performance this year, the Trust has continued to be in the top quartile nationally for performance against the 95% four hour emergency care standard which translates to more patients being seen quicker when they need us the most. In addition, we have significantly reduced delayed transfers of care which means people