Annual Report 2013/14
Financial and Quality Accounts
www.hacw.nhs.uk
2
Annual Report 2014-15
Contents
Message from the Chairman and Chief Executive
About The Trust
04
06
Strategic Report
08
Plans for 2014/15
Sustainability report
Performance against key performance indicators
10
11
16
Quality Accounts
22
Our Response to the Francis Enquiry
Review of 2013/14
Other news ……
2013/14 Quality Account Priorities
Review of 2013/14 - Patient Safety
Our 2013/14 CQUIN Performance
Looking Forward
CQUINS for 2014/15
2013/14 Quality Account Technical Section – Mandatory
Mandated Indicators
23
30
36
40
49
52
53
55
56
62
Financial statements
73
Operating and financial review (OFR)
Annual Governance Statement
Remuneration Report
92
103
115
Audit Committee Annual Report 2013/14
122
Details of Directors
Glossary of terms used in Annual Report
125
128
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Message from
the Chairman and
Chief Executive
Arrow Valley, Redditch
2013/14 has been a good year for Worcestershire Health
& Care NHS Trust with a number of high points and great
achievements. Many of these are featured in our Look
Back document which accompanies this Annual Report.
The priority for providing high quality care has always
been central to the Trust’s vision and values. The focus
on being able to show how we are doing this, and
measure whether we are getting it right, has never
been greater than now. This year’s Quality Account
summarises the progress we have made during the
year, shows some of the measures we use to tell us how
close we are to meeting our goals and puts forward the
quality improvements we intend to make in 2014/15. The
Quality Account provides an opportunity to evidence our
commitment to sustaining services of the highest quality
which make a real difference to the health and wellbeing of the people we serve.
However, like all NHS providers, we face the challenge of
maintaining and where possible improving quality at the
same time as having to make unprecedented financial
4
savings. This really tests the ability of our staff to think
and work differently, to be imaginative in solving the
problems we face and to really question whether what
we are doing is always the best thing for our patients.
We have risen to the challenge and firmly believe that
we will continue to do so. The approach taken is broadly
three-fold:• Firstly, to transform our services so that they reflect
patient expectations and the national policy directions
to provide more care closer to home;
• Secondly, to make sure that as an organisation we work
in ways which maximise efficiency and deliver the best
possible value for money;
• Thirdly, to seek opportunities to strengthen our
business in line with national policy and ensure we
remain efficient and sustainable.
In relation to transforming services we have already
made changes, following extensive consultation, to our
short breaks service for young people and have plans to
re-configure some of our Child Development centres so
Annual Report 2014-15
that they offer a better overall service for more people.
Since our last report, we have opened a new ‘state of the
art’ in-patient unit, New Haven in Bromsgrove, for older
people with dementia and other forms of mental illness
whilst at the same time investing in community mental
health services so that fewer beds are required on our
other wards. In 2014/15 we anticipate a strengthening
of the role our community hospitals play so that patients
with more complex conditions can be treated closer to
home. Our transformation agenda will always involve
extensive patient and public consultations so that noone’s voice is lost.
In terms of efficiency and value for money, our SMART
programme was launched during the year to focus on
non-pay costs and to date we have achieved reductions
in travel and energy costs, and have improved our
procurement processes for the goods and services we
need to buy. SMART working can deliver much more and
contribute greatly to the sustainability of the Trust.
Chris Burdon
Chairman
Opportunities for growth taken during the year enabled
us to maintain our total income, offsetting tariff
reductions and other changes made to our base contacts.
In order to maintain progress towards achieving
Foundation Trust status, thereby enabling our future
direction to be determined locally through our members
and governors, we need to continue to provide
high quality services whilst maintaining financial
sustainability. We anticipate a Chief Inspector of Hospitals
visit shortly to assess quality, and sustainability will be
dependent upon achieving further efficiency savings to
build upon the £15m already delivered over the last two
years. We have every confidence that with the on-going
commitment and support of our staff our organisation is
capable of meeting the ever increasing challenges ahead.
We confirm that to the best of our knowledge the
information in this report is accurate.
Sarah Dugan
Chief Executive
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About The Trust
Responsive: Focusing on the needs and expectations of
people using our services
Worcestershire Health and Care NHS Trust was
established on 1 July 2011 in response to the
Department of Health’s ‘Transforming Community
Services’ initiative.
The Trust manages the vast majority of the services which
were previously managed by Worcestershire Primary Care
NHS Trust’s Provider Arm, as well as the mental health
services that were managed by Worcestershire Mental
Health Partnership NHS Trust which sought dissolution as
part of the process.
Community and mental health services are provided
to a population of approximately 560,000 across
Worcestershire’s 500 square miles, covering the city
of Worcester together with the towns of Bewdley,
Bromsgrove, Droitwich, Evesham, Kidderminster,
Malvern, Pershore, Redditch, Stourport, Tenbury Wells
and Upton-Upon-Severn.
The Trust works closely with the three local Clinical
Commissioning Groups (Redditch & Bromsgrove, Wyre
Forest and South Worcestershire), Worcestershire Acute
Hospitals NHS Trust, Worcestershire County Council
and a number of other statutory and non-statutory
organisations.
The Trust has defined a set of values that clarify what it
believes in and how it will behave:
Courageous: Displaying integrity, loyalty and the
courage to always do what is right
Ambitious: Striving to innovate and to improve through
effective teamwork
Empowering: Empowering people to take control of
their own health and wellbeing
Supportive: Enabling our staff to achieve their full
potential and take pride in the services that they deliver
The Trust Strategic Goals explain what the Trust aims to
achieve, these goals are:
• We will always provide an excellent patient experience
• Our services will always be safe and effective
• We will work in partnership to improve the integration
of health and care
• Our organisation will be efficient, inclusive and
sustainable
These four strategic goals have been translated into
specific corporate objectives that relate to the strategic
goals. Ten Corporate Objectives have been defined and
these are:
• To stimulate a revolution in the way we engage with
patients
• To redesign clinical pathways
• To ensure patient safety
• To ensure seamless care through integrating services
• To strengthen leadership within our services
• To develop our workforce
• To improve our use of technology
• To develop business opportunities
• To deliver our efficiency programme
• To make effective use of our estate
CARE S
Courageous
6
Ambitious
Responsive
EMpowering
Supportive
Annual Report 2014-15
Our Services:
Bringing together the range of community and mental
health services previously provided by Worcestershire
Primary Care NHS Trust and Worcestershire Mental Health
Partnership NHS Trust has offered opportunities to
improve integration and partnership working which are
central to the Trust’s objectives.
The services provided by the Trust are divided into five
service delivery units (SDUs):
• Community Care
Community Care provides in-patient, out-patient and
community services on a locality basis to adults and
older adults across Worcestershire. With five Community
Hospitals, four older adult mental health in-patient
wards, district nursing and podiatry, as well as numerous
specialist services, this is the Trust’s largest service
delivery unit.
• Adult Mental Health
The Adult Mental Health Service Delivery Unit provides
mainly community and in-patient services to adults
with mental health needs across Worcestershire, with
community mental health services being delivered
through integrated health and social care teams.
• Children, Young People and Families
The Children, Young People and Families Service Delivery
Unit provides general child health and specialist mental
health services to children, young people and their
families across Worcestershire.
• Specialist Primary Care
The Specialist Primary Care Service Delivery Unit provides
sexual, dental, and offender health services.
• Learning Disabilities
The Learning Disabilities Service Delivery Unit provides
adult and children’s respite, out-patient and community
contact activity for people with Learning Disabilities and
their families, mainly for the population of Worcestershire
The area we serve:
The Trust provides a wide range of community and
mental health services across the county. Services are
focused on supporting patients to live independently at
home, reducing the need for patients to be admitted into
hospital. Where admission is appropriate the Trust makes
use of Community Hospitals and mental health in-patient
units across the county to provide care as close to home
as possible.
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Strategic Report
Looking back
This section summarises the Trust’s performance during
2013/14 and the key developments that took place
during the year.
During 2013/14, the Trust successfully delivered a range
of national, regional and local performance targets.
Highlights included:
• 18-week referral to treatment waiting times targets
achieved.
• Minor Injuries Unit’s target of admitting, transferring or
discharging patients within 4 hours of arrival achieved.
• C.difficile trajectory achieved with only 5 cases against a
target of 10.
• Delay transfers of care target for Mental Health patients
achieved.
• Target achieved for patients on Care Programme
Approach, discharged from a Mental Health inpatient
unit and followed up within 7 days.
In addition, the Trust delivered on all of the CQUINs
agreed for 2013/14 and met all of its financial statutory
duties.
With regards to developments, 76 priority schemes were
identified in 2013/14. Of these, 58 were delivered, 7 were
longer term schemes and on plan at the end of the year,
3 were removed or revised, whilst 8 slipped and have
been rolled forward to 2014/15.
Looking ahead
Our plans for the future seek to improve the patient
experience by reducing the transfer of patients between
services, teams and professions. Reducing unnecessary
boundaries between services was one of the motivations
for establishing the Trust with its broad portfolio and
some of the early successes demonstrate the benefits
that can be achieved. Examples include improved
transition arrangements for CAMHs patients and more
effective care for patients with dementia that are
admitted to community hospitals and/or supported by
our community teams.
8
Extending these principles of integration is a consistent
theme across the range of improvements planned over
the next 5 years. Ultimately some care may need to be
provided in hospital. This may be through an urgent
unplanned episode or through a planned care pathway.
Regardless of the reason for admission the Trust will
support transfer of care as close to home as possible as
soon as it is clinically appropriate.
The Trust has identified a series of work programmes
that focus on achieving this aim through improvements
in specific care pathways and the integration of services.
The major programmes have been identified as
‘transformational programmes’ as they will contribute
significantly to a change in the provision of care across
the Trust and in some cases the broader health economy.
In addition to the major transformational programmes
the Trust is committed to continuous improvement
across all services which are reflected in smaller scale
service redesign in each Service Delivery Unit.
The major transformational programmes are:
• Sub acute care in the community - strengthening the
role of community hospitals, increasing the acuity of
patients that can be safely managed in community
hospitals and establishing a more integrated model of
care.
• Care closer to home - the development of integrated
community teams serving a neighbourhood,
• Older Adult Mental Health,
• Adult Mental Health,
• Children and Family Services,
• The development of integrated services including
Health and Social Care integration.
Annual Report 2014-15
Service capacity and developments:
The Trust is working with commissioners to agree the extent to which its vision for the future can be supported
through specific developments in out of hospital care. In the absence of specific agreements, the Trust has modelled
a number of different future scenarios and ensured that the actions are defined that ensure the organisation remains
sustainable under each scenario. These scenarios are illustrated in the graph below.
Figure 1: Alternative growth projections
Alternative Futures
400,000
350,000
300,000
250,000
200,000
150,000
100,000
50,000
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
Scenario 1 (limited investment)
Scenario 2 (progressive development of the community)
Scenario 3 (major strategic change)
Scenario 4 (significant disinvestment)
The development of a 5-year plan for the health and social care economy supports the Trust Board development
plan. In particular, there is a commitment to developing stronger community based services. There are a number of
strategic groups that are driving this broad strategic direction including the Health and Well Being Board, the Well
Connected Programme Board and the Urgent Care Strategy Board.
These groups and their programmes of work support the Trust’s strategic goals and will be used to shift the Trust’s
overall position to one of growth.
Strategic Report
9
Plans for 2014/15:
This sets out the organisation’s priorities and plans
for 2014/15 to 2015/16 and includes the key work
programmes that have been agreed for the various
corporate departments and the 5 service delivery units.
Detailed action plans, with quarterly milestones, have
also been developed and these will be monitored via the
Trust’s performance review process.
In addition to these priorities and work programmes, the
Trust has to deliver against a range of statutory targets
and standards including:
• 18-week referral to treatment waiting time targets
• Zero tolerance of waits over 52 weeks
• MIU attenders admitted, transferred or discharged
within 4 hours
• Compliance with mixed sex accommodation
• CPA follow up within 7 days
• Psychological therapy access
• MRSA zero tolerance
• Delivery of agreed C. difficile trajectory
Over the next two years the Trust anticipates income
to be:
Workforce Plan
Over the next two years the Trust will implement a range
of efficiency measures which will have a net impact of
reducing the overall budgeted workforce from 3,414
WTE to 3,140 WTE. These changes are delivered through
a series of projects; each of which has a detailed project
plan and is assessed for potential impact on quality
through the Trust Quality and Equality Impact process.
Plans are developed working with staff and the Trust also
has a formal process for engaging staff before changes
are implemented. The range of projects also results in
changes to roles and skill mix.
Foundation Trust Application
Since its establishment in July 2011, the Trust has had a
programme in place to achieve Foundation Trust status.
The programme has helped to strengthen governance
arrangements and ensure the organisation has a capable
Board. The Trust will continue its path towards FT status
during 2014/15. It is anticipated that the Trust will be
reviewed by the Chief Inspector of Hospitals in the
second quarter of 2014/15 and is working towards being
licenced as a Foundation Trust in Quarter 1 of 2015/16.
2014/15 income – £167.8m
2015/16 income – £165.4m
The Trust plans to deliver an efficiency programme
that will achieve an annual surplus in line with
Monitor requirements, specifically:
2014/15 – £2.5m surplus, 1.5% of turnover
CIP £7.7m
2015/16 – £2.6m surplus, 1.6% of turnover
CIP £7.7m
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Annual Report 2014-15
Sustainability report:
The incentive to reduce the effect we have on our
environment is stronger than ever; doing so not only
helps to reduce the impact of climate change but also
saves money and improves our efficiency. Our staff and
patients benefit too: sustainable lifestyles, with more
active travel and less energy intensive diets, are healthier
lifestyles.
The Trust emits 8,957 tonnes of CO2 equivalents a year
(based on 2010/11 consumption figures), costing us
£3.8 million. Our target for reduction figure is 7,466
tonnes CO2e by 2015. To date, the Trust has implemented
the following projects supporting this ambitious target.
• Hydrotherapy pool cover, pump replacement and
control modifications at Osborne Court
• Cavity Wall Insulation at the Robertson Centre and the
Lucy Baldwin Unit, Kidderminster Hospital
• Installation of renewable technology in large scale
capital projects where feasible (Solar Panels at
Newhaven)
• Energy efficiency (lighting and sensors) infused in large
scale capital projects (Hub project at Princess of Wales
Community Hospital)
• Installation of LED lighting throughout the Trust
premises
• Continuing sub metering programme (Steam meter at
the Robertson Centre)
• Rainwater Harvesting at Link Nurseries
• Zone Control Heating at Evesham Community Hospital
• Maintenance upgrades (Eco set points, control
modifications etc.)
• Continued estate rationalisation.
Strategic Report
Contracts
The Trust currently procures its energy supply
requirements through the Government Procurement
Service (GPS). Its priority is to provide procurement
savings for central government, health and the wider
public sector. By procuring energy through the GPS we
get the best value energy on the market (due to the large
buying power of the GPS). The GPS ensure tariff charges
are competitive, not least because of the overall buying
power but also savings from wholesale procurement and
procuring in advance.
The Trust now has energy contracts in place with the
following government preferred energy suppliers:
• Corona (contract to 31/03/2016)
• British Gas (contracting to 2017)
• EDF (contract to 31/03/2016)
Due to existing/rolling contracts and supplier transfer
rejections the Trust has struggled to transfer several sites
(Malvern Hospital, Pershore Hospital, Beacon Centre, 71
Ludlow Road, Tudor Lodge and Kidderminster Health
Centre). The Trust has put these on new competitive
energy contracts for a period to coincide with the expiry
of the framework contracts so a complete re-tendering
exercise can be undertaken at that point.
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Travel
Marketing and Communications have launched the Trust’s new SMART brand and logo. SMART is really about us
working more efficiently to save money and a SMART Board has been established to identify specific initiatives to
generate savings, including a focus on new ways of working which could potentially have a beneficial impact on our
CO2 footprint.
The focus on reducing staff travel during 2013/14 is expected to reduce our CO2 emissions. Whilst it is difficult to
separate the impact of agenda for change re-imbursement rates, the estimated reduction from 2012/13 to 2013/14 is
42,810 miles (this equates to 14.4 tonnes of CO2).
Figure 1: Carbon Dioxide Emissions resulting from Trust operations
The green line in the graph illustrates that the Trust is reducing its emissions (Actual) against both the “Do Nothing”
and “Target emissions” lines. At the end of the 2012/13 financial year we calculated that the CO2 emissions had
reduced to 8597 tonnes against the trajectory target of 8296 tonnes. The graph also shows the estimated 2013/14
year end position.
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Annual Report 2014-15
Resource
2011/12
2012/13
2013/14
15,587,000.00
17,665,000.13
18,545,803.24
3,185.20
3,609.84
3,934.31
29.09
0.00
0.00
tCO2e
0.01
0.00
0.00
Use (kWh)
0.00
0.00
0.00
tCO2e
0.00
0.00
0.00
6,315,871.49
6,875,111.12
6,637,322.65
3,434.43
3,682.93
2,853.05
6,619.64
7,292.77
6,787.36
£ 1.1m
£ 1.5m
£ 1.4m
Use (kWh)
Gas
tCO2e
Use (kWh)
Oil
Coal
Use (kWh)
Electricity
tCO2e
Total Energy CO2e
Total Energy Spend
Table 1: Carbon emissions from Energy
The table above illustrates that our measured energy carbon emissions have decreased by 505.41 tonnes this year.
However, this is primarily due to the increased proportion of renewable electricity we are receiving from one of our
electricity suppliers and more accurate consumption data from buildings we occupy on the Acute Trust land.
Water
Mains
m3
tCO2e
Water & Sewage Spend
2011/12
2012/13
2013/14
101390
70760
61804
35
24
56
£235,704
£190,806
£166,655
Table 2: Water Consumption for the Trust
Our water consumption has continued to reduce in comparison to previous financial years. This is due to
improvements in billing, fault reporting and estate rationalisation.
Strategic Report
13
Figure 4: Trust waste production
Our waste production has continued to reduce in comparison to previous years. This is due to changes to classification
of the Trust waste streams, treatment/disposal of waste and improved quantification.
Some of the Trust’s 2013-14 figures are estimated based on ERIC data.
The entity’s employees:
The entity’s employees: including an account of the entity’s equal opportunities policy. Also required is an analysis of
the gender distribution in the categories; Directors, Other senior managers and Employees.
Category of Trust employees
Sum of WTE
Headcount at 31.3.2014
Directors
7.00
15
Female
3.00
4
Male
4.00
11
Employee
3,158.06
4,098
Female
2,693.16
3,533
Male
464.90
565
SMT
17.60
18
4.60
5
13.00
13
3,182.66
4,131
Female
Male
Grand Total
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Annual Report 2014-15
Social and community issues:
Up until July 2013 the Trust had a Community
Engagement Committee, which was a sub-committee
of the Trust Board. The Community Engagement Team
developed a Community Engagement Strategy, which
has successfully taken forward the work of the subcommittee.
Over the last twelve months engagement and
consultation work has been focused according to
impact, interest and investment. To this end, the Trust
has conducted full consultations with patients, carers
and representatives of interested groups, who would be
impacted by proposed service changes. The comments
received were collated, reported on and fed into the
creation of new care pathways and, where necessary,
has been shared with the Health Overview and Scrutiny
Committee and Children and Young People Overview
and Scrutiny Panel. The Trust has also worked with
interested groups and individuals and has offered those
who want to be involved in the work of the Trust, lots of
different opportunities from attendance at forums and
events, to taking part in working groups, to sharing their
patient stories and taking part in films for staff training.
The level of interest shown has allowed the Trust to set
up a Quality Account Working group, an Organisational
Values Working group and led to regular and increased
attendance at forum meetings.
creation of a new Partnership Forum and a Youth Board
whilst continuing to reach other ‘seldom heard groups’
such as the travelling community.
Business Information and History:
Worcestershire Health and Care NHS Trust was
established on 1 July 2011 to manage the vast majority
of the services which were previously managed by NHS
Worcestershire’s Provider Arm, as well as the mental
health services that were managed by Worcestershire
Mental Health Partnership NHS Trust. Bringing together
the range of services provided by the two organisations
has offered opportunities to improve integration and
partnership working which are central to the Trust’s
objectives.
The Trust is a community based provider of
comprehensive health and social care services, expertise
and choices for people with a range of health needs
and/or disabilities. These services are provided in a wide
range of community settings. These include people’s
own homes, community clinics, outpatient departments,
community inpatient beds, prisons, schools and GP
practices. We also provide in-reach services into acute
hospitals, nursing and residential homes and social care
settings.
One off quality events have considered such matters
as the Francis Report, the Sub-Acute pathway and
the Complaints process. The Trust has also sought to
reach out to more patients and carers and in addition
has sought the views and opinions of staff, through
the Clever Together digital campaign. As a result of a
survey of the Trust’s members over 200 more members
indicated they were keen to get involved by attending
forums, sitting on interview panels and taking part in
patient led assessments of the clinical environment.
The Trust has maintained its links with a variety of
other groups and organisations. In total the Trust has
engaged with 50 groups, non-statutory and statutory
organisations during the last year. 2013/14 saw the
Strategic Report
15
Performance against key performance indicators:
Care Programme Approach (CPA) follow up contact within seven days of
discharge from hospital
The Trust’s performance in this area is measured on a quarterly basis as part of the Trust Development Authority’s
Accountability Framework indicators. In order to achieve the highest level of compliance in this area (“Performing”)
the Trust must achieve 95% of inpatients on CPA, followed up within seven days of discharge from hospital.
The Trust is pleased to report that a level of ‘Performing’ was consistently achieved, with scores over 97%, for each
quarter in 2013/14. The quarterly scores are shown in Table below.
Percentage of people on CPA followed up within 7 days of discharge from hospital
Performance
Threshold
95% or over
Actual Quarterly Performance 2013/14
Quarter 1
Quarter 2
Quarter 3
Quarter 4
98.9%
97.2%
99.0%
99.5%
Minimising Delayed Transfers of Care
Measuring delayed transfers of care forms part of the Trust Development Authority’s Accountability Framework, and
helps the Trust to assess the impact of community-based care in facilitating timely discharge from hospitals.
People should receive the right care in the right place at the right time and we must ensure that people move on from
the hospital environment once they are safe to transfer.
The indicator seeks to encourage organisations to work in partnership to minimise the number of patients remaining
in hospital settings who are ready for discharge.
The definition is as follows: “the number of patients (acute and non-acute, aged 18 and over) whose transfer of care
was delayed, expressed as a percentage of the number of consultant and non-consultant led occupied beds.”
In order to achieve the highest level of compliance in this area (“Performing”) the Trust must keep delayed transfers of
care to 7.5% or less during each quarter.
The Table below shows the Trust’s position for 2013/14. The Trust is pleased to report that a level of ‘Performing’ was
consistently achieved, with scores under 5.1%, for each quarter in 2013/14.
We routinely monitor our performance in this area across all services and where performance consistently falls
below target we implement recovery plans that are monitored by the Trust Board. We actively work with our partner
organisations to minimise any delays.
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Annual Report 2014-15
Percentage delayed transfers of care
Performance
Threshold
7.5% or less
Actual Quarterly Performance 2013/14
Quarter 1
Quarter 2
Quarter 3
Quarter 4
4.1%
4.5%
4.3%
5.1%
The number of admissions to the Trust’s mental health acute wards that were gate kept by the Assessment and
Home Treatment Teams
When service user admissions are assessed (“gate kept”) by their local Assessment and Home Treatment Team, service
users have the opportunity to be treated in their own home. Wherever possible we offer service users the choice
to be supported in their own home as an alternative to hospital admission. This is recognised as best practice and
monitored by the Trust Development Authority’s Accountability Framework.
The method for calculating performance is as follows: “the number of admissions to the Trust’s acute wards (excluding
internal transfers between wards, patients recalled from community treatment orders and patients on leave under
Section 17 of the Mental Health Act) that were gate kept by the Assessment and Home Treatment team prior to
admission. An admission has been ‘gate kept’ if the team assessed the service user before admission and involved
them in the decision making process that resulted in the hospital admission. This is expressed as a percentage of total
admissions to the Trust’s acute mental health wards.”
In order to achieve the highest level of compliance (“Performing”) the Trust must ensure that 95% of admissions to
acute mental health wards were gate kept by the Assessment and Home Treatment Teams.
The 2013/14 performance is shown in the Table below. The Trust is pleased to report that a level of ‘Performing’ was
consistently achieved, with scores over 97%, for each quarter in 2013/14.
Percentage of admissions to mental health acute wards that were gate kept
Performance
Threshold
95% or over
Strategic Report
Actual Quarterly Performance 2013/14
Quarter 1
Quarter 2
Quarter 3
Quarter 4
98.8%
98.7%
97.4%
97.7%
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Percentage of patients readmitted to hospital within
28 days of being discharged
monitor success in avoiding (or reducing to a minimum)
readmissions following discharge from hospital.
Measuring the percentage of patients who were
readmitted to hospital as an emergency within 28 days
of being discharged provides information to help us
The following table shows the quarterly percentage
of all inpatient admissions that were readmitted in an
emergency within 28 days of the previous discharge.
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Ages 0-14
0.0%
0.0%
0.0%
0.0%
Ages 15+
2.1%
2.5%
1.1%
2.9%
Patient experience of community
mental health services
To improve the quality of services that the Trust delivers,
it is important to understand what people think about
their care and treatment. One way of doing this is by
asking people who have recently used our services to tell
us about their experiences.
To assist with this, each year a survey of people aged 18
and over accessing community mental health services is
conducted and collated by the Care Quality Commission.
A questionnaire was sent to 850 people who accessed
community mental health services between 1st July
2012 and 30th September 2012. A total of 269 people
responded, giving a 32% response rate for the Trust. This
compares to the national response rate of 29%.
An excerpt of the survey results, specifically covering the
patient’s experience of contact with a health or social
care worker, is shown in the table below. The full report
has been published by the CQC and is available on their
website.
Patient experience of contact with a health or social
care worker
Listening: for the health or social care worker seen most recently was listening
carefully to them.
Involvement: for the health or social care worker seen most recently taking
their views into account
Trust and confidence: for having trust and confidence in the health or social
care worker seen most recently
Respect and dignity: for being treated with respect and dignity by the health
or social care worker seen most recently
Time: for being given enough time to discuss their condition and treatment
with the health or social care worker seen most recently
Overall experience of contact with the health or social care worker seen most
recently.
Trust’s 2013
score. (score
out of 10)
Compared with the
national response,
we scored:
9.0
Better
8.6
2.5%
8.5
About the same
9.5
About the same
8.4
About the same
8.8
About the same
Figures taken from the CQC website: http://www.cqc.org.uk/survey/mentalhealth/R1A
18
Annual Report 2014-15
The Trust’s performance against the 2013/14 key national targets
Objective
Perform
Under
Current
Performance
(March 2014)
95%
95%
94%
98.3%
18
18
20
14.3
Maximum time of 18 weeks from point of referral to treatment in aggregate patients on an incomplete pathway
92%
92%
91%
99.9%
MIU Clinical Quality - Unplanned Reattendance Rate
5%
5%
6%
1.0%
MIU Clinical Quality - Total time in MIU (95th Percentile)
235
235
240
97
MIU - Maximum waiting time of four hours from arrival to admission/transfer/
discharge
95%
95%
94%
100.0%
MIU Clinical Quality - Left without being seen (LWBS) rate
5%
5%
6%
0.4%
MIU Clinical Quality - Time to initial assessment (95th Percentile)
15
15
> 15
11.0
MIU Clinical Quality - Time to treatment (minutes - median)
60
60
80
11
Infection Control - Methicillin-Resistant Staphylococcus Aureus (MRSA)
0
0
1
1 YTD
Avoidance of Mixed-Sex Accommodation (Community Hospitals)
100%
100%
90%
100%
Venous Thromboembolism (VTE) Screening
100%
95%
< 90%
97.4%
Target/
Limit
Measure
Maximum time of 18 weeks from point of referral to treatment in aggregate non admitted
18 Week Referral To Treatment (RTT) - 95th Percentile (Weeks Waiting)
To Ensure
Patient Safety
Statutory basis:
This Order establishes a National Health Service trust
called the Worcestershire Health and Care National
Health Service Trust. The Order sets out the functions
of the Trust, the number of executive and nonexecutive directors of the Trust, the operational date
(the date on which the Trust assumes all its functions)
and the accounting date of the Trust. It dissolves the
Worcestershire Mental Health Partnership National
Health Service Trust, which was established by the
Worcestershire Community and Mental Health National
Health Service Trust (Establishment) Order 1999.
Further explanation:
There are no items in the financial statements considered
to have a strategic significance for 2013/14. In terms of
Strategic Report
Performance Threshold
the Going Concern considerations the Trust auditors
have accepted that the Trust has an excellent track record
of delivering its key financial duties and has a robust
Long Term Financial plan that includes a detailed cost
improvement programme.
Equality and Diversity and Human
Rights
We recognise that everyone is diverse and value all
individuals for their contribution to the Trust through
their experience, knowledge and skills. The Trust fully
endorses the principles of Equality and Diversity in
respect of Trust employees, service users (patients, carers,
visitors and communities) and partners (health and social
care economy, voluntary/third sector etc.).
Our Equality and Inclusion Policy embraces the Equality
Act 2010, setting the standards and expectations of the
19
Trust both internally and externally regarding the values
and commitment of the Trust to deliver high quality
healthcare that is fair and equitable. The Policy will be
reviewed to ensure it is current and reflects changes in
legislation, for example changes to marriage which now
incorporates same sex couples.
The Public Sector Equality Duty is a requirement on
all public sector organisations to make society fairer
by tackling discrimination, advancing equality of
opportunity and fostering good relations regardless
of age; disability, gender reassignment, marriage civil
partnership, pregnancy and maternity, race, relation
or belief, sex and sexual orientation, known as the 9
protected characteristics. We take every opportunity
to strengthen our approach to equality and diversity
through design, delivery and review of all of our
functions, policies and practices. This is achieved by
undertaking:
• Equality Analysis (also known as Equality Impact
Assessment), a way of identifying the impact the policy/
function may have on the protected characteristics and
persons/groups who do not share these characteristics
but could experience inequality e.g. carers, the homeless
or travelling communities and record the evidence to
demonstrate the consideration given and take action to
eliminate or reduce any negative impact that may exist.
• Equality Delivery System (EDS) - designed by the NHS for
the NHS, to improve equality performance and deliver
better outcomes for patients, communities and staff
which are personal, fair and diverse. Central to the EDS,
the Trust is required to analyse our equality performance
against 18 outcomes grouped under four goals:
• Better health outcomes for all
• Improved patient access and experience
• Empowered, engaged and inclusive staff
• Inclusive leadership.
The Trust engages with a wide range of stakeholders from
across protected groups, patient groups, community
organisations, the voluntary sector and statutory
organisations and other interested groups to grade
our performance, set equality objectives and develop
an action plan. This is an on-going and continuous
undertaking.
20
To ensure the best healthcare delivery possible our
Interpreting and Translation services have been reviewed
and developed to reflect the changing landscape of
languages spoken in Worcestershire. Polish is the most
common spoken language after English and is spoken
in all 6 districts of Worcestershire. This is then followed
by Urdu and closely by Panjabi (predominately in the
Redditch and Worcester districts). There are a further
22 languages where 300 people or more speak that
language in Worcestershire. A new booking system
means that Trust staff have access to interpreters and
translators which includes British Sign Language and
Easy Read translation 24 hours a day, seven days a week
providing (services) face-to-face or telephone services.
The Trust is committed to ensuring employees work in an
environment characterised by dignity and respect. Every
person working for the Trust has a personal responsibility
for implementing and promoting Equality, Diversity &
Human Rights. It is expected that employees will treat
each other, service users and partners in the same way
with a view to creating a service that is fair and accessible
to all.
For further information please visit:
http://www.hacw.nhs.uk/our-services/equality-anddiversity/
Emergency Preparedness:
The Trust continues to work with local responders
to ensure that it is able to provide the best possible
response to a major emergency.
There is a Major Incident Plan in place which is regularly
tested and reviewed in line with the requirements of
the NHS Commissioning Board EPRR Framework. The
Trust also has a Business Continuity Plan which ensures
that critical services can still be delivered in exceptional
circumstances. The Trust has an established Emergency
Planning, Resilience and Response (EPRR) sub-committee
which provides assurance that we are able to meet our
statutory and contractual requirements in relation to
EPRR.
Annual Report 2014-15
Principles for Remedy:
Our Complaints Policy abides by the good practice
‘Principles for Remedy’ and aims to produce reasonable,
fair and proportionate responses to complaints.
The principles are:
• Getting it right
• Being customer focussed
• Being open and accountable
• Acting fairly and proportionately
• Putting things right
• Seeking continuous improvement
Getting involved:
We are committed to engaging patients, service users,
their families and carers, members of the community
and local organisations in the planning, development
and monitoring of Trust services. The Trust wants to hear
the views and concerns of the communities it serves.
Involving the community is important because it assists
us in making decisions and shaping services to meet the
needs and preferences of those who use them. One way
the Trust seeks to do this is by holding forums across the
county. Forums consist of a presentation by Trust staff
about service developments, and the members give
opinions about changes, suggest ways to improve the
experience of those people who use our services, and
also advise on developments or changes occurring in
each locality.
Anyone who would like to come along to a forum, you
would be warmly welcomed. You may be a patient,
carer, member of the public or involved in a group or
organisation. You may be interested in all our services or
only one of them. Your voice and opinions matter.
Strategic Report
Looking after our staff:
As services change, the roles for some of our staff may
change too. Some may be required to learn new skills to
meet the demands of a new or different role and in those
instances the Trust will support the individual to help
make sure they are equipped to do the job.
Our commitment is, where possible, to re-deploy affected
staff into alternative posts, and re-train people as
required so our high standards are maintained.
In short we want to support the staff we currently have.
For those staff whose roles change we fully recognise
the importance of supporting them and their managers
throughout. Over
the next five years our workforce numbers overall will
reduce but we aim to manage this through redeployment
and planned turnover, such as retirements.
Whistleblowing:
As a Trust we are committed to ensuring staff are
encouraged to flag up anything which concerns them. In
fact one of the key messages to staff following the Francis
Report has been to take a step back and look critically at
services to see if they are up to standard.
We have also made a point of re-iterating our
whistleblowing policy to staff so they are comfortable
with the process and the options available should
they feel something needs bringing to attention. We
pride ourselves on being an open and transparent
organisation. We are confident that we have a culture
and an environment that does encourage staff to come
forward but we know we need to keep on top of this. Our
message to staff is clear: if it’s not right, speak up! This is
in keeping with one of our key values which are about
displaying integrity, loyalty and the courage to always do
what is right.
21
Quality Accounts
Statement on Quality from the Chief
Executive
Providing high quality care has always been central to
the Trust’s vision and values and has always driven our
decision making. Reviewing what we have achieved
and whether we are getting it right for our patients is a
key step towards ensuring we constantly improve. This
Quality Account summarises the progress we have made
in the last year, shows some of the measures we use to
tell us whether we are making progress, and outlines
our priorities for quality improvement for the next 12
months. It is our opportunity to share our commitment
to sustaining the highest quality services that make a
genuine and meaningful difference to the people who
use our services.
A key milestone in the last year was the publication of
our outline response to the findings of the Francis Inquiry
in June 2013. We held a special patient forum event to
review the findings of the report, and held a series of
staff workshops which helped us reflect on the learning
in the report and develop an action plan that applied
this learning and improvements to our own services. We
recognise that there are areas for improvement, but our
action plan will help to ensure that quality continues to
be an absolute priority in the months ahead. We continue
to review in detail all of the patient feedback that we
receive locally and thank all of our patients for taking the
time to share their thoughts with us.
While it is vitally important that we learn from national
reports and local feedback where care has not been of
a high standard, we should also take time to be proud
of our achievements. Some of these are set out in this
Quality Account. Achieving high quality care is only
possible through the activities of a highly skilled and
committed workforce and I would like to thank all of
our staff for their on-going commitment and dedication
to providing the best possible service we can for our
patients.
22
Chief Executive “I believe to the best of my knowledge
and belief the information in this document is accurate.”
Sarah Dugan
Chief Executive
Statement on Director’s
Responsibilities
There are proper internal controls over the collection and
reporting of indicators and the data underpinning the
indicators is robust and reliable.
Introduction to the Quality Account
This Quality Account is Worcestershire Health and Care
NHS Trust’s report to the public about the quality of the
services we provide. It summarises our challenges and
achievements from the last year, setting out how well we
did in achieving the five selected priorities from 2013/14
as well as other quality improvement measures.
The quality of services we deliver is monitored closely
throughout the year by the Trust Board using a raft
of indicators, patient experience feedback, and staff
involvement and by visiting and getting involved with
clinical services. Further information on the way we track
our services can be seen on our website and at a variety
of public forums throughout the year.
Looking ahead we have defined three Quality Account
priorities for improvement over 2014/15 which are
described further on in this document. Firstly though, we
would like to take you through a review of some of the
things the Trust has been doing over the last 12 months.
Annual Report 2014-15
Our Response to the
Francis Enquiry
February 2013 saw the publication of Robert Francis QC’s
final report of the Mid Staffordshire NHS Foundation
Trust Public Inquiry. In November 2013 the Government
responded in their report ‘Hard Truths’. Since then there
have been a number of high profile reports about quality
in the NHS, all of which shine a light on care failings.
website and complaints are reported to every Trust
Board.
• We continue to work with the patient/carer groups and
forums who provide important feedback on experience
of using our services.
At the Trust’s Quality and Safety Committee in March
2013, usual business was suspended to allow members
of the committee to review the recommendations
applicable to the Trust and consider the actions that we
needed to take as an organisation.
• We are piloting values based recruitment and appraisals
and there is a new monthly staff award to recognise
those staff that go beyond the call of duty.
What have we done since the
publication of the Francis Report?
• We have undertaken a comprehensive review our
staffing establishment and taken action to ensure the
staffing levels are safe.
• We reviewed ourselves against all of the 290
recommendations in the Francis Enquiry.
• We have developed the Patient Safety Walkabout
programme, which gives frontline staff an opportunity
to raise patient safety issues with Board members.
• We developed an action plan to monitor ourselves
against agreed actions and reported on this at Quality
and Safety Committee and Trust Board. The action
plan is published on the Trust website. We reviewed
ourselves against the recommendations in the
subsequent Berwick, Keogh and Clywd reports and
incorporated this into the plan.
• We have held a number of focus groups, where we
listened to the views of our staff, our patients and our
members.
• We have reviewed and re-launched our Raising
Concerns at Work Policy (Whistle-blowing Policy).
• We have improved our response times to complaints.
A summary of all complaints are published on the Trust
Quality accounts
• We have improved our incident reporting culture.
• Every Trust Board meeting includes a Patient Story. This
provides patients with the opportunity to tell the Board
directly about their experiences of using Trust services,
both positive and negative.
• We have launched a patient experience/feedback
website and have undertaken the ‘Pause for Thought’
campaign with staff. Many staff also took part in
‘walking in their shoes’ initiative.
• We are developing an ‘early warning system’, so that
teams who may need support can be identified earlier.
The following provides a high level update on progress
with the Trust’s action plan as of March 2014.
23
Issues Identified
Leads
Outstanding Actions
CULTURE
The NHS and all who
work for it must adopt
and demonstrate
a shared culture in
which the patient is the
priority
in everything done
(Francis)
Healthcare employers
recruiting nursing staff
should assess candidates’
values,
attitudes and behaviours
towards the well-being
of patients and their
basic care needs (Francis)
The development of
the ‘cultural barometer’
should continue. This will
determine if a
workplace is suffering
from a problem with
staff attitudes or
organisational approach.
(Clywd/Hart)
Associate
Director of
HR
Ensure vision and values understood by staff through:
• Recruitment of staff based
on values
• Recruitment of staff based
on capacity for care and compassion
• Appraisal process supports
measuring staff against
values
• Set out clear expectations
in job descriptions and
contracts ‘Pledge to Care’ to
incorporate ‘6 Cs’ – launch
day to be held in June followed by inaugural nursing
committee meeting.
Development of in-house
bank will to help ensure
agency and bank staff have
the same value ethos as permanent staff.
Complete assessment of levels of achievement in Equality
Delivery System in June.
Head of
Organisational
Development
STANDARDS OF CARE:
Deputy
Healthcare
Director of
professionals should be Nursing
prepared to contribute
to the development
of, and comply with,
standard
procedures in the areas
in which they work
(Francis)
Providers should invest
in building capability
within their
organisations to enable
staff to contribute to
improvement of the
quality and
safety of services to
patients (Berwick)
24
Trust Nursing Committee to
be established, reporting to
Quality and Safety Committee.
Nursing metrics to be rolled
out to more services.
Competency framework
in development to ensure
staff have the right skills and
knowledge for their role.
Multi-disciplinary Mortality
Group to be established to
review clinical records for
evidence of any omissions/
issues with care.
Planned
Review/
Completion Date
September
2014
July 2014
Progress/Evidence – March
2014
Values based recruitment
and appraisal testing
underway.
Staff Friends and Family
Test and pulse surveys
undertaken for ‘temperature
checks’ with associated
action plans.
Extensive, well-evaluated
training programmes for
team leaders.
Mentoring system in place.
Whistleblowing policy relaunched and re-badged.
Monthly staff award for ‘living
the values’.
In-house bank established
with staff working to Trust
policy/cultures.
On line nursing metrics
published by ward in spring
2014. Metrics now being
rolled out to other services.
Screens to be in place on
all wards by summer 2014
displaying staffing levels and
associated safety data for
that clinical area.
External reviews by CCGs
positive.
Successful nursing
documentation launched in
community hospitals January
2014 – now roll out to other
services.
Audit records of unexpected
deaths reported quarterly.
Clinical audit programme on
track.
Mandatory training levels
now above 90% across Trust.
Annual Report 2014-15
Issues Identified
Leads
STAFFING LEVELS:
Boards and leaders of
organisations should
utilise
evidence-based acuity
tools and scientific
principles to determine
the staffing they
require in order to safely
meet their patients’
needs. They should make
their
conclusions public and
easily accessible to
patients and carers and
accountable to
regulators.
Healthcare organisations
should ensure that
staff are present in
appropriate numbers
to provide safe care at
all times and are wellsupported (Berwick).
Director
of Quality
(Executive
Nurse)
DATA QUALITY:
The first priority for any
organisation charged
with responsibility
for performance
management of a
healthcare
provider should
be ensuring that
fundamental patient
safety and quality
standards are being
met. Such an
organisation must
require convincing
evidence to be
available before
accepting that such
standards are being
complied with (Francis)
Mortality data
Keogh Improve data quality
(p16)
Head of
Quality
Governance
Quality accounts
Planned
Review/
Outstanding Actions
Completion Date
Regular staffing levels reports July 2014
to Board.
Staffing levels made available
to public.
Consideration of impact on
community teams staffing
levels.
Progress/Evidence – March
2014
Establishment levels
ascertained using acuity
tools.
Dashboards and processes
introduced in readiness for
full publication of staffing
levels in June 2014.
Staff using Ulysses to report
staffing level incidents. These
are directly reported to the
Director of Quality, Deputy
Director of Nursing and
Medical Director.
Screens on entrance to wards
to be fitted. These will display
staffing levels and patient
safety data.
Staffing levels to be
published on Trust website.
Quality Goals dashboard and
Patient Safety Incident reports to be refined to include
Statistical Process Controls
and Pareto 80/20 principles.
Data Quality Group to develop work plan to include data
quality assurance measures
for identified data sets.
Data analysis to be fed back
to clinical teams more clearly.
Review of quality of data
in line with Monitor’s Quality Governance Assurance
Framework (QGAF) action.
July 2014
Review of quality metrics
dashboards underway with
revised dashboard in draft
ready for July Board meeting.
Data quality improvement
plan.
Service Line Reports in
development with assistance
from clinical teams.
Mortality Group established
to review mortality across the
Trust.
Service Line Reporting in
development.
25
Issues Identified
Leads
Outstanding Actions
FINANCIAL PRESSURES:
Impact and risk
assessments should
be made public, and
debated publicly,
before a proposal for
any major
structural change to
the healthcare system
is accepted (Francis)
Placing the quality of
patient care, especially
patient safety, above all
other aims.
(Berwick)
STAFF DEVELOPMENT,
TRAINING AND
LEADERSHIP:
The NHS should
continually and
forever reduce patient
harm by embracing
wholeheartedly an ethic
of learning. (Berwick)
Staff need
to be adequately
trained, supervised and
supported to deal with
complaints effectively.
(Clwyd/Hart)
Director
of Quality
(Executive
Nurse)
Competency framework
in development to ensure
staff have the right skills and
knowledge for their role.
Medical
Director
Complaints workshops to
continue to be delivered
to staff in areas where high
number of complaints/PALS
issues received.
Deputy
Director of
Nursing
Trust Nursing Committee to
be established, reporting to
Quality and Safety Committee.
26
Nursing metrics to be rolled
out to more services.
Competency framework
in development to ensure
staff have the right skills and
knowledge for their role.
Multi-disciplinary Mortality
Group to be established to
review clinical records for
evidence of any omissions/
issues with care.
Planned
Review/
Completion Date
July 2014
July 2014
Progress/Evidence – March
2014
Supervisory ward managers
now in place.
Leadership training delivered
– these courses receive
excellent feedback from staff.
Mandatory training
compliance running at near
90% - benchmarking shows
this is above average.
On line nursing metrics
published by ward in spring
2014. Metrics now being
rolled out to other services.
Screens to be in place on
all wards by summer 2014
displaying staffing levels and
associated safety data for
that clinical area.
External reviews by CCGs
positive.
Successful nursing
documentation launched in
community hospitals January
2014 – now roll out to other
services.
Audit records of unexpected
deaths reported quarterly.
Clinical audit programme on
track.
Mandatory training levels
now above 90% across Trust.
Annual Report 2014-15
Planned
Review/
Issues Identified
Leads
Outstanding Actions
Completion Date
Increase use of the family and July 2014
Head of
PATIENT EXPERIENCE/
Quality
friends test (awaiting national
INVOLVEMENT
Governguidance).
The patients must be
Develop exit questionnaire as
ance
the first priority in all
standard for patients who are
of what the NHS does
discharged from service.
Head of
(Francis)
Communi- Quality Account priority in
Patients and their carers ty Engage- relation to young people acshould be present,
ment and cessing Sexual Health services to be undertaken.
Patient
powerful and involved
Develop universal admisat all levels of healthcare Involvesion and discharge processes
organisations from wards ment
which includes good comto the boards of Trusts.
munication with carers,
(Berwick)
family and other health care
providers to ensure seamless
Trusts should ensure that
services.
there is a range of basic
information and support
available on the
ward for patients (Clwyd/
Hart)
COMPLAINTS:
Trusts must constantly
promote to the
public their desire to
receive and learn from
comments and
complaints; constant
encouragement should
be given to patients
and other service users,
individually and
collectively, to share
their comments and
criticisms with the
organisation (Francis)
Respond directly, openly,
faithfully, and rapidly to
safety alerts, early warning
systems, and complaints
from patients and staff
(Berwick) Patients, carers
and members of the
public should be confident
that their feedback is
being listened to and see
how this is impacting on
their own care and the
care of others (Keogh)
Quality accounts
Quality
Governance Manager
Improve assurance and
evidence that learning from
complaints is shared across
the organisation.
Revised Complaints Policy to
be ratified and monitored for
effective implementation.
Duty of Candour Policy to be
ratified and monitored for effective implementation.
Survey of complainants who
have received response to
assess their experience of
the Trust’s complaints system
and approach.
July 2014
Progress/Evidence – March
2014
Patient surveys evidenced
high satisfaction with quality
of care.
Increased number of patient
surveys.
Webpage now live.
Carers Policy in place.
Patient representatives on
many groups in the Trust.
Patient representative
volunteers assisting with
patient suveys.
‘Walk in Their Shoes’ day.
Pause for Thought campaign
in March 2013.
Focus groups Offender
Healthcare services.
Community Engagement
– multiple initiatives and
established Patient Forums.
Patient Action Group
established and helping
collect patient surveys.
Patient stories to board.
Complaints training
delivered to services who
receive the highest number
of complaints.
Improved response times to
complaints.
Quality of complaints
responses improved.
Additional training provided
to Investigating Officers.
Safety Alert system in the
Trust to be transferred to
the Ulysses system. This will
provide additional assurance
that appropriate actions are
taken.
27
Issues Identified
Leads
Outstanding Actions
INCIDENTS AND
SERIOUS INCIDENT
REPORTING:
Reporting of incidents
of concern relevant
to patient safety,
compliance with
fundamental standards
or some
higher requirement of
the employer needs to
be not only encouraged
but insisted upon
(Francis)
Head of
Quality
Governance
Adverse Incident Policy to be
ratified and monitored for effective implementation.
Promote understanding
through clinical teams that
line managers need to give
constructive feedback to staff
who report incidents.
Shared learning from incidents reported through Team
Brief.
Evidence greater triangulation of incident data with
complaints and claims and
risk registers in quality reports.
All leaders concerned
with NHS healthcare
– political, regulatory,
governance, executive,
clinical and advocacy
– should place quality
of care in general,
and patient safety in
particular, at the top
of their priorities for
investment, inquiry,
improvement,
regular reporting,
encouragement and
support (Berwick)
Employers need to
improve their support
of staff around
implementing guidance
on reporting of serious
incidents (Berwick)
28
Planned
Review/
Completion Date
Juy 2014
Progress/Evidence – March
2014
Incident reporting culture
improved over year.
Detailed incident reports
provided to Trust committees
and clinical teams.
Safety Thermometer audits
undertaken each month.
Service line reporting in
development to promote
triangulation of data.
Annual Report 2014-15
Issues Identified
Leads
WHISTLEBLOWING:
A “duty of candour”
should be imposed on
NHS staff (Francis)
Director
of Quality
(Executive
Nurse)
Every healthcare
organisation and
everyone working for
them must be honest,
open and truthful in
all their dealings with
patients and the public,
and organisational and
personal interests must
never be allowed to
outweigh the duty to
be honest, open and
truthful (Francis).
Embracing transparency
unequivocally and
everywhere, in the
service of accountability,
trust, and the
growth of knowledge
(Berwick)
Planned
Review/
Outstanding Actions
Completion Date
Duty of Candour policy in de- July 2014
velopment based on national
review. To be ratified.
Staff to be supported to
be open with patients and
families in line with Duty of
Candour – including explanations of why services might
be constrained.
The Trust web site will be
used to make available to the
public information regarding
our care and performance.
Nursing Staffing Levels in
Inpatient Areas
It is widely accepted that staffing levels are linked to the
safety of care and that staffing shortfalls increases the
risk of patient harm and poor quality care.
Over the last year in the Trust we have developed a
process for capturing staffing levels on a shift by shift
basis on each of the 10 community hospital wards and
the 6 wards across adult mental health and older adult
mental health. The aim is to support and reinforce the
ability and judgement of healthcare professionals and
managers in decisions on staffing levels both on a daily
basis and in the longer term.
Quality accounts
Progress/Evidence – March
2014
Whistleblowing Policy
revised and rebadged into
‘Raising Concerns’ with aim of
making it more accessible.
Duty of Candour Policy in
draft and out to consultation.
This allows ward staff to use their professional judgement
to determine if the ward activity levels are safely met by
the skill mix and staffing levels on the ward. The tool we
are using will be monitored daily by senior managers to
ensure that appropriate decisions are being made and
used as a mechanism for ensuring staffing issues are
escalated appropriately.
The Executive Nurse, Deputy Director of Nursing, relevant
Senior Managers and Matrons will have access to a 7
day prospective summary view of a database to enable
them to closely monitor staffing levels and to ensure
appropriate mitigating actions are taken where required.
Further detailed information regarding safe staffing
levels in the Trust is available on the internet, and each
ward is to have large television screens to display real
time data at the entrance to each ward.
29
Review of 2013/14
April saw the formal introduction of the new NHS
structure as outlined in the Health and Social Care Act
2012. It means that control for much of the NHS budget
is in the hands of Clinical Commissioning Groups, or
CCGs.
The CCGs are responsible for commissioning, or buying,
hospital, community and mental health services for the
people of Worcestershire. They are overseen by a national
organisation, NHS England.
Other changes to the NHS structure saw Public Health
fall under the remit of the local authority, Worcestershire
County Council. A new health and social care ‘consumer
champion’, HealthWatch has also been established.
Locally, HealthWatch Worcestershire is chaired by
Peter Pinfield and provides a channel for the public to
comment and raise concerns about services across the
health and social care system.
Public Backing for our Vision
The vast majority of those who attended our
engagement events last spring said they were in support
of our strategy to care for more people in or closer to
home.
We ran a round of hour-long events across the county
which together attracted 100 people.
A questionnaire handed out at the events shows support
for the Trust’s direction of travel. It asked whether people
supported the vision for more care in or closer to home,
and whether they remained supportive if that had the
potential for leading to fewer beds in our community
hospitals. Just over 90% of those who completed the
questionnaire said they were in favour of care in or
closer to home, with 60% in support if that led to a bed
reduction.
Trust’s Secure Suite Improving
Mental Health Care for County
Figures released earlier in the year showed The Trust’s
place of safety suite is helping to lower the number of
patients being detained in police custody.
The figures are collected when someone is detained
under section 136 of the Mental Health Act 1983. This
is for the person’s own protection and so they can be
medically assessed. When a person is detained they
have to be taken to a place of safety which could be a
specialised secure suite, a hospital or a police cell.
The Trust’s latest numbers show that 87% of people
detained in a place of safety were taken to the specialised
suite, with only 8 and 5 per cent going to police custody
and hospitals respectively. The Trust’s secure suite was
opened in 2007 at the Elgar Unit, Newtown Hospital in
Worcester, catering for the entire county.
Steve Goddard, Lead Acute Mental Health Practitioner
for the Trust, said: “We feel we’ve made significant
improvements around the detention of people under
the police powers of section 136. This is reflected in
the number of people taken to Newtown as opposed
to police custody. This is a far more appropriate place
to be when they are experiencing a crisis and prevent
criminalisation of mental health.”
New Haven – a New Kind of Facility
The New Haven mental health unit opened in
Bromsgrove on the site of the town’s community
hospital. This unit has changed the way older people
with mental health illnesses receive care and treatment
in an impatient environment.
New Haven is a true centre of excellence which serves
the whole county. It has 30 beds which benefit those
with varying degrees of dementia including Alzheimer’s,
acute depression, acute anxiety and psychosis.
Designed to inspire recovery and provide a stimulating
environment, New Haven is unique in its design for a
number of reasons:
30
Annual Report 2014-15
• Each patient has their own en-suite bedroom which
will help create a ‘home from home’ environment and
help ensure patients retain independence, privacy
and personhood. Each room includes a memory box
which is unique to each patient and provides added
mental stimulus which will aid recovery. The rooms also
provides a pleasant environment for families to visit and
spend time with their loved one.
• Large open courtyards and an allotment give patients
the opportunity to go outdoors and enjoy spending
time in pleasant surroundings.
• People with dementia often purposefully walk (wander)
and in their minds they are fulfilling a purposeful
activity such as picking children up from school. Long
corridors are not designed to support this and can
often lead to agitation and frustration. New Haven has
been specially designed with circulation loops, which
allows the patient to walk freely around the building.
Along the way special points of interest have been built
in, including a 1960s themed launderette, which will
provide an interactive and stimulating stop on their
journey, reducing agitation, frustration and anxiety.
• Art can be used to provoke thoughts and to stimulate
memory and is a key part of the design of the building.
An arts group was set-up to ensure the design of the
building and the artwork included in and around it
supports the ‘home from home’ and the ‘outdoors in’
theme. Projects include working with local artists on
the creation of memory panels which feature words and
objects which are important to them.
In February Ruth May, lead nurse for NHS England for the
Midlands and East Region visited New Haven. She was
extremely impressed with the care that was provided to
our patients and the environment we were operating
in. She went as far to say it was “stunning” and could
only recall one or two facilities nationwide that she
thinks could match ours for team approach and physical
environment.
Quality accounts
Trust’s Mental Health Employment
Scheme Bucks Trend
More people who have mental health issues are finding
jobs through our employment programme, bucking the
results of a national review released in July.
Research carried out by the King’s College London
suggested that the recession was having a profound
impact on people with mental health problems. Between
2006 and 2010, the rate of unemployment for those with
mental health problems rose twice as much as for other
people - from 12.7% to 18.2%. Men and those with low
levels of education were particularly affected, the study
said.
However our mental health employment team are
reversing this trend and have reported major success in
finding employment opportunities for its service users
over the last 12 months. The number of paid jobs entered
by service users has increased to 84, a 60% increase from
2011/12. This has contributed to the Trust’s Individual
Placement and Support service, which is responsible for
supporting service users to gain work experience and
ultimately get paid jobs, being accredited as a national
centre of excellence.
Jobs that people have been found have ranged from
catering and laundry work, to care work, teaching and
engineering with aerospace.
Pete Jordan, Worcestershire Health and Care NHS Trust’s
Service Manager for the Mental Health Employment
and Reablement Service, said: “Many of our people have
previously held down good jobs before experiencing
mental health difficulties. What we do now is to have
an employment worker based in each of our mental
health teams. They work alongside the clinical staff to
help rebuild people’s confidence and target potential
employers. The key issue is whether people want to work
and if they do, it is our job to give them hope and make
this happen”.
31
CAMHS Service Celebrates a Year of
Achievement
We reported how major improvements to
Worcestershire’s Child and Adolescent Mental Health
Service (CAMHS) have been made, a year after the service
was re-designed.
Worcestershire Health and Care NHS Trust’s CAMHS
team celebrated a year since a re-design with reduced
waiting times for service-users with the average wait for
a first appointment down to five weeks compared to 18
eighteen weeks prior to the re-design, which is notable
improvement.
Fran Tummey, CAMHS Clinical Manager for
Worcestershire Health and Care NHS Trust, said: “Staff
across CAMHS have worked hard to make the much
needed changes to the service and we now believe we
offer a more focussed mental health service with the
changes made based on user feedback. We will not
rest on our laurels and will continue to improve the
experience our children and young people and families
receive when they are referred.”
As well as reducing waiting times for the children and
adolescents, results from a survey have shown that
the majority of service users feel a positive impact on
their mental health after seeing staff. The survey results
showed that 78 per cent of Worcestershire children
and young people who access CAMHS reported their
difficulties were ‘much better’ or ‘a bit better’ after
receiving a service.
Staff Survey – What our Staff Told Us
The Trust currently employs 4131 staff equating to
3182.66 Whole Time Equivalents. Nurses make up the
largest professional group of staff followed by additional
clinical services staff (clinical support staff ).
Our workforce is generally representative of our
community in terms of ethnicity diversity with 12.24%
of staff classifying themselves as having an ethnic origin
other than White-British.
32
We understand that our workforce has a direct impact
on the quality of services provided and the experience
of patients. To this end we place great emphasis on staff
engagement, staff development and staff support. We
monitor mandatory training and appraisal rates closely
as we expect all of our staff to have the necessary skills
and support to do their jobs well. We run Leadership
Development Programmes which are very well
evaluated, and promote a culture of strong clinical
leadership. During the year we have progressed well
with our service transformation to meet the needs of
community services in the future.
The results of the 2013 NHS National staff survey were
formally released on Tuesday 25 February 2014. 422
responses were received from staff that took part in
the sample survey (random sample of 850 were sent
questionnaires) which resulted in a response rate of 50%
which is average for mental health/learning disability
trusts in England and compares with a response rate of
50% for the Trust in the 2012 survey.
We have responded to the findings of the staff survey
and produced an action plan that is being implemented.
The top 5 ranking scores from Staff Survey were:
• The number of staff receiving health and safety training
in last 12 months.
• The number of staff experiencing harassment, bullying
or abuse from patients, relatives or the public in last 12
months.
• Effective team working.
• The number of staff believing the trust provides equal
opportunities for career progression or promotion.
• The number of staff reporting errors, near misses or
incidents witnessed in the last month.
The top 12 most improved areas from 2011 to 2012:
• Percentage of staff having equality and diversity
training in last 12 months
• Percentage of staff having well-structured appraisals in
last 12 months
• Percentage of staff appraised in last 12 months
• Percentage of staff having well-structured appraisals in
last 12 months
• Percentage of staff appraised in last 12 months
Annual Report 2014-15
• Percentage of staff able to contribute towards
improvements at work
• Percentage of staff receiving job-relevant training,
learning or development in last 12 months
• Percentage of staff feeling satisfied with the quality of
work and patient care they are able to deliver
• Staff recommendation of the trust as a place to work or
receive treatment
• Effective team working
• Percentage of staff reporting errors, near misses or
incidents witnessed in the last month
• Fairness and effectiveness of incident reporting
procedures
Going forward we are undertaking regular local staff
surveys, and will be asking all staff whether they would
recommend the Trust as a place to work and whether
they would recommend the services to family and
friends. More information about our staff is contained in
the main Annual Report document.
Seal of approval for County’s Mental
Health Teams
Services which support people across Worcestershire
who have mental health problems were given a seal of
approval by a national accreditation scheme. The services
accredited were:
• Holt Ward
• Cromwell House
• Hadley PICU
• Harvington
• Hill Crest
• Keith Winter Close
• Crisis Assessment Team
• Home Treatment Teams covering Wychavon, Malvern
and Worcester
The programme provides quality assurance for service
users, carers, commissioners, regulators and staff. It is
only awarded to services that that have undergone a
rigorous programme of assessments to ensure they are
of high quality.
Quality accounts
Derek Hammond, Clinical Lead for Adult Mental Health,
said: “This accreditation is the equivalent of a Kite Mark
or a gold standard and is only awarded to those which
deliver the highest quality services. It should provide
service users, families, carers and the general public
reassurance and confidence that people who need these
services will get the very best care and support possible.”
External Visits and Inspections
The Care Quality Commission and our commissioners
undertake visits to a variety of Trust services throughout
the year to spend time with patients and staff and
gather information to assure them that our services are
safe and well managed. These visits and inspection can
be announced (i.e. where the Trust is notified of them
beforehand) or unannounced.
The visits and inspections bring increased benefits to the
Trust, and help to provide assurance on the continuous
improvement in the quality and safety of our services.
Following an external inspection the visiting body will
produce a report and action plans are implemented in
relation to any recommendations arising from the visit.
CQC Visits
The following locations were visited by the CQC during
2013/14 specifically to monitor our compliance with the
Mental Health Act:
• Witley Ward, Older Adult ward, Kidderminster
• Keith Winter Close, Adult recovery ward, Bromsgrove
• Holt Ward, Adult acute ward, Worcester
• Harvington, Adult acute ward, Kidderminster
• Hill Crest, Adult acute ward, Redditch
• Athelon, Older adult ward, Worcester
All of these visits have taken place on an unannounced
basis, and there have been no common themes requiring
addressing by the Trust noted by the CQC inspectors.
Inspectors have been largely complimentary about the
ward environment and staff attitudes to patients. As an
33
example, Holt was referred to as being “light, spacious
and welcoming”, patients told inspectors that staff were
“caring, friendly and helpful”. Hill Crest was “bright,
spacious and clean” and patients felt safe. Patients on
several of the wards told inspectors that they would
recommend the wards to family and friends.
The CQC are changing their approach to mental health
regulation and inspection. Future inspections will be
undertaken by teams rather than individuals and will
consider services as a whole, rather than focussing on
specific areas of care as they do currently.
Offender Healthcare Inspections
HMP Hewell
In June 2013 the CQC undertook an unannounced follow
up inspection of HMP Hewell, following on from an
inspection in November 2012.
The CQC looked at the personal care and treatment
records of people who use the service, took advice from
their pharmacist and reviewed the action plan, which
explained how the staff have improved the areas they
highlighted during their previous visit .
The CQC didn’t identify any areas of concern and they
recognise that some improvements are the subject of
further work by HMP estates staff, and took this into
account
HMP Oakwood
In June, the CQC and Her Majesty’s Inspector of Prisons
(HMIP) undertook an unannounced inspection of the
healthcare provision in HMP Oakwood. The CQC advised
the Trust of a failure to comply with Regulation 13
(Management of Medicines) of the Health and Social Care
Act (2008) Regulations 2010 (the Regulated Activities
Regulations 2010). The Trust recognises the severity of
the concerns found during the inspection, and we are
extremely regretful that our services did not meet our
own expected standards of care.
We implemented swift and thorough improvement
actions, and asked prisoners for their thoughts on how
the services should be improved.
34
The CQC re-inspected HMP Oakwood in October 2013
and lifted the warning notice. We have since made
further improvements and have sustained safe, good
quality care for patients in HMP Oakwood. We are in
close contact with the NHS England Local Area Team, The
Trust Development Authority, the Pharmacy provider
and the Prison Director to ensure there is a partnership
approach to sustaining the improvement actions. We
now undertake regular patient surveys and follow up
with a ‘You Said, We Did’ leaflet to prisoners to maintain
better communication and involvement.
The South Staffordshire Area Team and NHS England
undertook a visit to HMP Oakwood in November 2013
and noted many improvements.
Our learning from the events at HMP Oakwood have
been reviewed for relevance to HMP Hewell and HMP
Long Lartin, and to services in the rest of the Trust.
HMP Long Lartin
The South Staffordshire Area Team and NHS England
undertook a visit to HMP Long Lartin in November 2013
which produced largely positive findings, particularly in
relation to multi-disciplinary working.
Commissioner Visits
The following locations were visited by the CCG during
2013/14 in order that the CCGs could gain assurance
around the quality of care. The visits were a mixture of
announced and unannounced:
• The Princess of Wales Hospital, Bromsgrove
• Community Enhanced Care Team, Pershore
• Elgar Unit, Holt Ward, Athelon and Hadley, Newtown,
Worcester
• Malvern Community Hospital
• Evesham Integrated Care Team
• Evesham Community Hospital
• Tenbury Minor Injuries Unit
• Pershore Community Hospital
• Tenbury Community Hospital
The Joint Commissioning Unit undertook an announced
visit to Churchview respite services in Bromgsrove.
Annual Report 2014-15
The outcome from the vast majority of inspections has
very positive and it could be said that this is the most
common theme of the inspections.
Where issues or concerns are raised, in most cases,
actions to remedy them are very straightforward to
implement and achieve. Action plans are implemented
following all inspections to address any issues raised. The
implementation of the Action Plans is monitored by the
Quality and Safety committee.
CQC Quality and Risk Profiles
As part of their monitoring of providers’ compliance
with the essential standards of quality and safety, the
CQC produces a Quality and Risk Profile (QRP) which
gathers together information about a provider’s possible
risks. The profiles are produced 8 times a year. We have
maintained a low overall risk score in the QRPs during
the year.
West Midlands Quality Review
Service peer review programme for
long term conditions 2013
was not intended as an inspection or performance
management tool.
The WMQRS programme confirmed several areas
for improvement ,many of which had already been
highlighted by the Trust .The programme also
highlighted the unusual position in Worcestershire in
that the majority of specialist teams are employed by the
Acute Trust.
At the time of the review programme several streams
of work were planned or had commenced to address
these areas for improvement; it was also a period when
teams were integrating and not yet established. The
report has assisted the health economy with prioritising
areas for improvement. The greatest concern appeared
to be around the model for specialist care for people
with chronic neurological conditions, which was a
common theme for the region in the WMQRS overview
report. Representatives from across the health economy
have developed plans and ideas for improving the care
provision of people with long term conditions. As part of
an on-going process, the representatives regularly review
these plans together.
The full reports are available on the WMQRS website:
http://www.wmqrs.nhs.uk/publications
The West Midlands Quality Review Service (WMQRS)
visited Worcestershire in March 2013 to look at the
quality of care for people with long-term conditions
(LTC) across the local health economy, i.e. Worcestershire
Health & Care Trust, Worcestershire Acute Trust,
commissioners, primary care and linked services. They
measured services against quality standards, which
reflected national guidance.
The LTC care pathways reviewed were chronic
neurological conditions (such as Parkinson’s disease,
multiple sclerosis, epilepsy), diabetes, COPD (Chronic
Obstructive Pulmonary Disease), heart failure and
multiple long term conditions. This peer review
programme aimed to help organisations to improve
the quality of clinical services in a developmental and
supportive way, through acting as a `critical friend’ and
Quality accounts
35
Other news ……
Carole Shortlisted for HSJ Award
Carole Clive, Nurse Consultant for Infection Prevention
& Control, was announced as one of ten shortlisted
nationally for the Clinical Leader of the Year Award, which
is one of the categories in this year’s Health Service
Journal (HSJ) Awards.
Over 1000 entries were received for awards and Carole
said she was “shocked and delighted” to have been
initially nominated and then shortlisted. She also paid
tribute to her team saying: “it is testament to the work
that the team undertake across the Trust and county
to ensure high standards of infection prevention and
control and me being shortlisted is recognition of
everyone’s efforts and achievements.”
Sandra Brennan, Director of Quality & Director of
Infection Prevention & Control at the Health and Care
Trust, added: “It is typical of Carole to be modest about
her achievements. She is highly regarded by staff across
the Trust.”
Admiral Nurses Celebrate 10-year
Anniversary
Local carers and health professionals helped celebrate
the 10 year anniversary of Worcestershire’s dedicated
army of Admiral Nurses.
Worcestershire Admiral Nurses was launched in
Wychavon in 2003 supporting family carers who look
after people with dementia. The service has since spread
and are now the only county-wide Admiral Nursing
service in the UK. An event in the Guildhall, Worcester
saw carers, professionals and representatives from local
health organisations come together to pay tribute to the
team and mark this milestone.
A number of carers who have been supported by
Admiral Nurses attended the event and one of them,
Cheryl Hudson, whose father lived with dementia, was a
key speaker at the event. She praised the local Admiral
36
Nurses for the wonderful support and guidance offered
to her and her family and she paid special tribute to the
team’s lead, Helen Springthorpe.
Another carer, Anita Bailey from Evesham, attended
the celebration. She looks after her husband who was
diagnosed with Vascular Dementia at just 55 and she too
was full of praise for the support she’s received from her
local Admiral Nurses. She said: “They’re my life savers. I
don’t know what I’d do without my Admiral Nurse.”
Thank you to our Volunteers
We hosted a number of events throughout October 2013
as a way of saying thank you to the 180 volunteers who
dedicate their time to helping others.
Volunteers from across the county attended events held
in Tenbury Wells, Bromsgrove, Evesham and Worcester
which offered them the opportunity to socialise with
each other over a cup of tea and a scone.
They undertake a wide and varied range of roles within
the organisation from those who volunteer as porters
to those who provide hair dressing and beautician
services and everything in between. Some volunteers
simply spend time with patients and provide them with a
friendly face and someone to talk to.
Rachel Kirkwood, Head of Organisational Development,
said: “We are so grateful to all of our volunteers for
the help they give us and just wanted to show them
our appreciation and to let them know that they are
extremely valued by the Trust”.
High praise for our Language and
Learning Course
‘Language for Learning’ is a self-funding project jointly
owned by the Trust’s Speech and Language Team and
Worcestershire County Council. The project provides
training and resources to support all those working with
children and young people with speech, language and
communication needs.
Annual Report 2014-15
We began selling our training packages out of county
about 10 years ago and now we have a number of
authorities licensed to deliver the training. A survey
was conducted and the results, released in October,
were really positive. Trainers clearly feel competent and
supported in their role and value ‘Language for Learning’
training.
Well Connected Named National
Pioneer
In November, Care Minister Norman Lamb announced
that the county’s Well Connected programme had
been named as one of just 14 ambitious initiatives the
Government has selected to “blaze a trail for change” by
pioneering new ways of delivering co-ordinated or more
joined up care.
Well Connected aims to ‘join up your health and care’ –
helping the people of Worcestershire to ’be well and stay
well’, be involved in planning their own care and improve
the overall experience and coordination of the services
they receive.
The Well Connected programme brings together all the
local NHS organisations (our Trust, Worcestershire Acute
NHS Trust, and the Clinical Commissioning Groups),
Worcestershire County Council and key representatives
from the voluntary sector.
Sexual Health Campaign Launched
The trust launched a new campaign to raise awareness of
the dangers of unprotected sex.
The campaign was led by the Sexual Health team and
aims to highlight the consequences of unprotected
sex and coincides with the party season. It featured
an advent calendar style countdown to Christmas
which appeared on the Trust’s social networking
sites throughout December alongside the hashtag
#WrapUpThisChristmas. Each day in the calender
provided facts and stats or provided advice for people
Quality accounts
concerned that they may have put themselves at risk of
a Sexually Transmitted Infection (STI) or need emergency
contraception.
Launch of single point of access
South Worcestershire Adult Mental
Health
Our Adult Mental Health team launched a new Single
Point of Access (SPA) service within the South of the
County. It is commissioned by South Worcestershire CCG
to support health care professionals, predominantly
GPs, by providing a simple, easy way to refer both
urgent and routine adult mental health patients to
the most appropriate service. The aim is that it will
ensure one single point of contact for all adult mental
health referrals within South Worcestershire, a seamless
transition of care once the most appropriate service has
been identified and extensive knowledge of the services
available locally and what they can provide.
EIDS Scoops National Innovation
Prize
Our Early Intervention in Dementia Service (EIDS) which
provides early assessment, diagnosis and support for
people with dementia won a national innovation award.
The Early Intervention Dementia Service (EIDS) won a
national NHS Innovation Challenge Prize for Dementia
award. It’s run in collaboration with Janssen Healthcare
Innovation (JHI) and is part of the NHS Innovation
Challenge Prize Programme and the Prime Minister’s
Dementia Challenge.
EIDS was launched in 2010 to deliver a timely and person
centred approach to the assessment and diagnosis of
people with a suspected dementia, to help them to
live their lives as they would wish and to support their
families and carers. 2000 people have received an early
and timely diagnosis in the first three years of EIDS being
operational.
37
Mental Health Facility Passes
Inspection With Flying Colours
Tudor Lodge in Bromsgrove, a long-term residential unit
for people with long standing mental health problems,
passed an inspection by the Care Quality Commission
(CQC) with flying colours.
The CQC visited Tudor Lodge in January in an
unannounced routine inspection. As part of this
inspection, the CQC looked at the personal care or
treatment records of people who use the service and
observed how people were being cared for. Views of staff
and those who use the service were also sought.
In the report of the inspection, the CQC noted that
people told the inspectors things like: “I am happy living
here” and felt that their individual needs were being met
by the staff. They also said that they felt safe and it was
observed that the staff had a “kind and caring approach
towards the people they supported”. The CQC also said
that people were listened to and received a consistent
level of care that met their individual needs.
Mark Dickens, Adult Mental Health lead: “This also shows
consistency within our mental health inpatient services
as it comes off the back of five of our wards receiving
Royal College of Psychiatrists accreditations, four of them
accredited as “excellent”.
International Recognition for Early
Intervention
On Tuesday 28th January 2014 the Early Intervention
team were honoured to host a Nigerian delegation
of mental health professionals: 3 psychiatrists and
1 matron. This delegation was funded through the
Commonwealth Scholarship Commission, and they were
staying in Birmingham for a few weeks to receive training
in Behavioural Family Therapy (BFT) from the Meriden
Team. They chose to visit our service as a model of how
family interventions can be integrated within an Early
38
Intervention Service as this will be their goal on their
return to Nigeria.
Tony Gillam (EI clinical manager) started the day with
an overview of Worcestershire EIS and our experience
of implementing BFT within the service. Dr Alan Farmer,
Matthew Lammas and Vicky Wormleighton followed with
presentations on different aspects of the EI service and
the day finished with Professor Jo Smith describing the
development of Early Intervention services in the UK. Our
visitors left full of enthusiasm and gratitude for what they
had learnt and we were proud that they had chosen to
visit Worcestershire EIS.
More out of Hospital Support for
People with Eating Disorders
More people who have an eating disorder in
Worcestershire are getting the support they need at
home or out of hospital, with referrals into communitybased services on the up.
The Worcestershire Eating Disorder Service revealed a
rise in the number of people being referred, with figures
increasing by 48% since 2005. The rise in referrals is
attributed to a mix of increased awareness among the
public and professionals both of eating disorders in
general, but also of the out-of-hospital care and support
provided locally by the Trust.
The service works with people in the community and
receives around 210 referrals per year. It offers wide
ranging help and the team tailor each care plan to suit
the needs of every individual. They can offer sufferers
individual counselling, a course of cognitive behavioural
therapy, food and nutrition guidance, group work and
can also provide support with self-help manuals.
Kay Lobo, Eating Disorder Service Clinical Manager, said
the service was geared up to providing early communitybased support which reduced the risk of people getting
so poorly they needed hospital treatment: “Early
intervention and treatment can help a sufferer recover
more quickly and either prevent hospital admission or
shorten the length of their stay.”
Annual Report 2014-15
Pilot Scheme Reaping Benefits for
Mental Health Patients in Worcester
It is said that one of the best ways to deal with your
problems is to talk to those who have walked in your
shoes and this philosophy is being embraced in our Trust
through a new pilot scheme delivering real, tangible
benefits for local people with serious mental ill health.
Holt Ward is an 18 bedded mental health in-patient
unit for adults whose illness cannot safely be treated at
home or in the community. It is based on the Newtown
Hospital site and in October last year the Trust launched
a new Peer Support pilot scheme to help the ward’s
patients on their road to recovery.
Peer Support sees people with a lived experience of
mental illness provide help to those struggling with
similar problems. As part of the pilot four Peer Support
workers were employed by the Trust to work alongside
staff on the ward. Jodie, Joy, Mark and Paul have
completed a rigorous Peer Support training programme
and provide a different type of support which
Quality accounts
complements the professional nurses and doctors on the
ward. Support may be social, emotional or practical and
focuses on an individual’s strengths not weaknesses, and
works towards the individual’s wellbeing and recovery.
Marisa Manning, Holt Ward Manager, said: “Working
with the Peer Supporters on the ward has been a fresh
approach to working with patients.”
Our staff walk in their shoes
The Trust’s take on NHS Change Day was our “Walk in
their Shoes” initiative which asked staff to spend some
time experiencing what being a patient or service user in
our services is really like.
We know that patients generally experience excellent
levels of care and treatment in our services but that
doesn’t mean we are complacent and we recognise there
is always more we can do. Walk in their Shoes Day is a
chance for our staff to experience some of those things
which might seem small, such as being fed or having
your arm in a sling, but actually make a real difference to
the whole patient experience.
39
2013/14 Quality Account Priorities
For last year’s Quality Account we set five priorities for improvement. The progress of these is summarised ‘at a glance’
in the table below.
Objective
Achieved
Continue to improve our response times and learning
from complaints
a
a
a
Improved Use of Patient, Carer and Staff Feedback,
including the ‘Friends and Family’ Test
Improvement in the Capture of Real time feedback from
Patients
Almost
Achieved
Behind Schedule
a
We will have no incidents of avoidable pressure ulcers.
Improve Evidence that We Learn from Patient Safety
Incidents and Near Misses
a
Priority 1: Continue to Improve our Response Times and Learning
from Complaints
Result at end of
March 2014
What did we measure?
The percentage of complaints responded to within Policy timeframe (25 working days)
The Clwyd-Hart review into the handling of complaints
in the NHS was published in October 2013. The report
stemmed from the Francis Inquiry and echoes many of
the findings. We have added the recommendations from
this review into our Trust Francis Action plan so that we
can take forward the learning into our Trust. This work
is a developing framework and will be taken forward in
2014/15.
We carried ‘listening and learning from complaints’
forward as a priority from the previous year as Trust
Board and the people who we consulted on our 2013/14
priorities thought that this should remain at the forefront
of our quality measures.
During the year 2013/2014 the Patient Relations Team
40
100%
has received an increase overall in the contacts received
compared to the previous year. This is largely due to the
service being more visible to service users, carers and
their families. The Team have ensured that there is a wide
distribution of information about the Team that is easily
accessible to all. An interactive, ‘contact us’ page is also
available on the Trust’s website.
The Patient Relations Team Lead has undertaken training
sessions for healthcare staff within the Healthcare Teams
at each of the three prisons and this has improved the
quality of responses provided to prisoners from the
Healthcare Team.
Our Complaints Policy is in accordance with the
‘Principles for Remedy’ published by the Parliamentary
Annual Report 2014-15
and Health Service Ombudsman and the Trust aims to
produce reasonable, fair and proportionate responses to
complaints. The principles are:
• Getting it right
• Being customer focused
• Being open and accountable
• Acting fairly and proportionately
• Putting things right
• Seeking continuous improvement
During 2013/2014 the Trust has continued to focus on
improving the responses to complainants, both in terms
of timeliness and quality.
The Trust is required to respond to written complaints
within 25 working days. The average response time to
complaints was 15 working days, with the exception of
those complaints which required an extension to the 25
working day timescale.
The Trust received 284 written complaints during the
year compared to 302 in the previous year.
We regard every complaint and concern as a positive
opportunity to receive direct feedback on a patient’s
perception of the care they receive from us, and more
importantly, as an opportunity to learn how services
can be improved. All complaints result in a learning plan
whereby any changes or improvements are made and
tracked as a result of a complaint. Services share learning
in their own team meetings, and learning is shared more
widely through governance meetings and trust-wide
publications. A summary of all of our complaints is on
the Trust website.
We try to identify themes or trends from complaints,
but as the complaints we receive cover diverse services,
this can be a challenge. We do however find that
communication, or the lack of it, is at the heart of some
of the complaints. These are ‘one-offs’ in that there are no
services who have a trend of complaints in this area.
Examples of action taken and lessons learned during
2013/2014 include:
• Concerns were raised that medication was changed
abruptly – the team involved have reviewed their
processes for prescribing medication and have taken
Quality accounts
action to ensure the reasons for the changes are
recorded in the clinical records. Steps have also been
taken to ensure there is improved communication with
service users.
• The attitude of the nurse was perceived as being
detached – actions taken included improved
communication with the patient and their family. In
addition the nurse has reflected on how they may be
perceived in order to prevent another family feeling this
way.
• Patient felt there was a lack of respect towards them The nurse reflected on their behaviour and agreed they
had behaved in an unacceptable way. As a result of the
patient’s experience the nurse attended a workshop on
Delivering an Enhanced Patient Experience.
• Delay in Healthcare Team responding to prisoner
concerns – training has been provided by the Patient
Relations Team Lead to staff within the Healthcare Team
which has resulted in responses being provided in a
much more timely way.
• Medication had run out in one instance due to a
shortfall in the system – the Pharmacist for Offender
Health has undertaken a review into the system to
ensure medication is received when needed.
Compliments and Gifts
Compliments are an important part of patient feedback
and are seen as a means of learning how things have
gone well. It is always gratifying when someone takes the
time and trouble to voice their appreciation, particularly
at what might be a very difficult time for them.
During the year 2013/2014 2463 recorded compliments
were received, compared to the previous year when 686
compliments were recorded. The Trust also received 1448
gifts, compared to 1100 in the previous year.
Examples of compliments received include:
• We cannot thank you enough for the care and attention
you gave to our son.
• I am pleasantly surprised by the efficiency of staff and
how they put me at ease. Both nurses were excellent.
• Just a small thank you for all your kindness and
attention to mom in this last year of her life and also for
the support you have given us.
• Thank you so much for all the help and support given
41
to me during my time here. I am so grateful for all your
patience, guidance and sharing your knowledge with
me.
• Staff attitude was positive, kind, easy going yet practical
and professional, all at the same time. She made me feel
nice/better and I admire you all.
• Positive comments were made in respect to the
Healthcare Team by a prisoner in a letter to the Head of
Community Engagement at the prison.
PALS/Professional Enquiries
In 2013/2014 the Trust received 519 PALS enquiries,
which is an increase on the 250 received during the
previous year. The Patient Relations Team has been able
to resolve PALS enquiries, the majority of cases within
five working days. This has resulted in queries being
resolved quickly.
There were also 66 Professional Enquiries received during
the year, compared to 46 received in the previous year.
These include concerns from General Practitioners,
Members of Parliament and Solicitors and have all been
responded to within 10 working days.
If a complainant remains dissatisfied with the response
to their complaint they have the right to refer their
complaint to the Parliamentary and Health Service
Ombudsman (PHSO) and request an independent review.
During 2013/2014, ten complainants referred their
complaint to the PHSO. Of these, seven have been closed
with no action required, one complaint has been closed
requiring action regarding a communication plan and
two are currently being considered by the PHSO.
In addition, there is also a case open with the PHSO
that was received in the previous financial year, which
included recommendations and the Trust is taking action
on these.
Priority 2: Improved Use of Patient, Carer and Staff Feedback, including the
‘Friends and Family’ Test
Measure
Result at end of
March 2014
Increase the number of people surveyed each quarter during the year.
Achieved from 915 to
1,042 people surveyed.
The aim of undertaking surveys is to improve the experience of patients who use our services in the Trust.
The following Patient Experience data relates to:
• Community Hospital Inpatient Wards
• Minor Injury Units
• Outpatient Physiotherapy Departments
The Friends and Family Test Question (Would you recommend this service to your family and friends?) was asked in
above services, together with ‘free text’ comments from patients on the quality of care received. We asked over 50% of
patients who accessed the services.
42
Annual Report 2014-15
Period Three (1 Oct-31 Dec
2013)
Sample Size
Period Four (1 Jan-31 Mar 2014))
Net Promoter
score
Sample Size
Net Promoter
score
% Patients
Surveyed
Worcestershire Health
and Care NHS Trust
915
86
1,042
85
N/A
Community Hospitals
81
75
111
74
63.6%
Minor Injury Unit (MIU)
364
91
304
88
64.9%
Physiotherapy
470
84
627
85
54.9%
Recent examples of work undertaken, led by our Patient
Experience Lead Naomi Seers, are:
Prison Patient Experience Survey
Following a CQC inspection undertaken in HMP
Oakwood, Worcestershire Health and Care Trust
undertook a patient experience survey. We received a
large number of responses. The survey enabled prisoners
who use healthcare services in the prison to give free text
comments. Following feedback received a number of
changes relating to healthcare were made. This feedback
received was also shared both with patients and staff as
part of the Prisoner Forums. The survey was undertaken
again within HMP Oakwood and the feedback is currently
being reviewed. Following the success of the prison
patient experience work the survey has now been
undertaken in HMP Long Lartin and plans are in place to
undertake this in HMP Hewell.
Learning Disability Forums
Worcestershire Health and Care Trust currently receive
a limited amount of the patient experience feedback
from within the Integrated Learning Disability Service.
To ensure that we have the appropriate feedback
mechanism in place that meets the needs of the
Quality accounts
service we have held three learning disability forums
to share experiences and discuss options of a feedback
mechanism. The forums were held for patient and carers
currently accessing the integrated service. The feedback
is currently being reviewed and plans put in place to
progress this work.
National Staff Survey
The results of the 2013 NHS National staff survey were
formally released on Tuesday 25 February 2014.
422 responses were received from staff that took part
in the sample survey (random sample of 850 were send
questionnaires) which resulted in a response rate of 50%
which is average for mental health/learning disability
trusts in England and compares with a response rate of
50% for the Trust in the 2012 survey.
The Trust’s score for overall staff engagement in the 2013
was average when compared with Trusts of a similar type.
The staff ‘Friends and Family’ survey is now on the Trust
intranet site until June 2014 and we are undertaking
extra ‘Temperature Check’ surveys with staff to try and
learn more about how we can engage more fully.
43
Priority 3 - Improvement in the Capture of Real time feedback from Patients
Result at end of
March 2014
Measure
Register in place
Register of current patient surveys and themes
Patient feedback is important to us so we can understand
how the services we deliver impact on the people
receiving them. There is no single route to understanding
patient experience.
To give patients, service users, carers and family
members a new and simple way of telling us about their
experiences of the care they received, we launched a
Patient Experience website.
Patients or families can simply log on and tell us their
story. This will provide us with an invaluable way of
monitoring our performance so we can identify how we
can continue to improve our services and develop our
understanding of what matters most to the people we
care for.
We dedicated March 2014 as our Patient Experience
month. We really wanted to gather more views
from patients about what they think we do well and
where we might do better; it’s about getting a better
understanding of their experiences and perceptions
of our services. There are comment cards on our wards
for patients to complete but we realise this isn’t always
appropriate, so we asked our staff to ‘Pause for Thought’
during March and ask patients/service users or families
and carers to share their experiences of the care and
treatment they are getting.
By Pausing for Thought for just for a few minutes and
taking that time to listen, we think we can make the
kinds of changes which really do improve the whole
44
patient experience.
Cyrus Baria, one of our patient/community
representatives visited Tenbury hospital in March to gain
some patient feedback for us. Cyrus gave the following
feedback - “I visited Tenbury Wells Hospital for the
Nutrition and Hydration Tea Party yesterday. I met up
and talked to 9 people either whilst having tea in the
common room or by their own beds/bedside, as some
of them couldn’t come and join the party. Dianne Adams
had laid on a very good spread of sandwiches, cakes,
scones with cream and strawberry and cups of tea. This
was very well received by the patients.
This was my first visit to this hospital and I found it very
clean, friendly and welcoming. All the patients and
relatives I talked to, did not have one bad word to say.
They all said, the food was good, staff very friendly and
the staff really took care of them. One person said that
she was greeted with a mug of tea, biscuits and a glass
(real glass) of water. Sometimes its the small things which
makes a big difference.
One gentleman found his area of the ward, a bit
noisy. When I questioned him what was the issue,
his comments were, staff were laughing out loudly. I
placated him by saying at least it was a happy ward and
he agreed with me.
I also spoke to a couple of admin staff and the way they
look at the hospital was “this is my hospital”.
Annual Report 2014-15
Patient Experience Feedback Poster
Patient Experience Feedback posters have been designed
to be displayed in clinical areas to show the results in a
clear format from surveys. An example is given below
– the actual posters are much bigger than the picture
opposite!
MIU: Patient Experience Survey
LOCATION
364 patients from 4 sites (Bromsgrove,
Malvern, Tenbury and Evesham) took
part.
WAS THIS SERVICE EASY
TO ACCESS?
100%
364 out of 364 patients said this service
was easy to access.
HAVE STAFF
COMMUNICATED
WELL WITH YOU?
Extremely Well
312
Very Well
52
Not Well
0
Not at all Well
0
Total
364
HOW SATISFIED WERE
YOU WITH THE SERVICE
YOU RECEIVED TODAY?
400
Fantastic that staff engaged
with my daughter (the patient) –
quick, easy, stress free service.
Brilliant service – did
not have to wait and
was attended by very
professional staff
throughout my visit. My
sincere thanks to the staff.
Fast, efficient
service much
easier than A&E
– sorted out
within an hour
including xray!!
Staff very good.
THE FRIENDS AND FAMILY TEST
HOW LIKELY IS IT THAT YOU WOULD
RECOMMEND OUR DEPARTMENT TO FRIENDS
AND FAMILY IF THEY NEEDED SIMILAR CARE
OR TREATMENT?
89
Worcestershire Health and Care Trust
Patient Group
The above group was set up during the year. It is made
up of patient representative volunteers who are helping
us to implement the patient experience agenda. This can
be undertaking surveys, supporting ‘talking projects’ and
the group is also a critical friend for discussing initiatives
and ideas. We are grateful for the help of this proactive
group of people in helping us to better understand the
views of patients, service users and carers.
FRIENDS AND FAMILY SCORE:
300
200
100
0
All the staff were
polite and lovely
to us and I felt
very re-assured.
Extremely
Satisfied
Satisfied Dissatisfied
Quality accounts
This means 89% of
friends and family
are extremely likely
to recommend us!
45
Priority 4 - Pressure Ulcers
Measure
Result at end of
March 2014
Harm free care thought the Safety Thermometer – pressure ulcers
93.9% harm free from
pressure ulcers
We want to reduce the incidence of avoidable pressure
ulcers as we know pressure ulceration causes significant
pain and distress for patients when they occur. The Trust
has very few patients in our community hospitals who
have acquired pressure ulcers. However there are a larger
number of pressure ulcers in the community. This is
challenging to manage because many people are looked
after in the community by people that the Trust has no
responsibility for. The Trust is committed to reducing
pressure ulcers in the community setting and is taking
this forward as a priority into 2014/15.
Disappointingly, since June 2013, on the national Safety
Thermometer audits, the Trust has reported a higher
level of harm from pressure ulcers than the national and
regional average. However it should be noted that the
Safety Thermometer makes no distinction between those
ulcers developed in our care or elsewhere.
46
We have implemented a wide reaching strategic plan to
address this issue, and can evidence integrated working
within the health and social care economy to address the
causes of pressure ulcers.
We now produce weekly team level reports to show
where pressure ulcers are occurring. We draw detailed
analysis from our incident reporting system, and
thorough action plans from incidents are implemented.
There are some signs at the end of 2013/14 that the aims
of the plan are coming to fruition as there is evidence of
a slight downward trend.
The graph below sets out all pressure ulcers reported
in the Trust over the last 12 months – both those that
developed in our services and outside of them.
Annual Report 2014-15
The graph below sets out reported pressure ulcer
incidents in the community hospital wards per 1000
occupied bed days for the last 12 months. The graph
sets out all grades of pressure ulcers, avoidable and
unavoidable and includes those that have developed
both in our care and outside of our care.
The Department of Health definitions regarding
avoidable/unavoidable pressure ulcers are as follows:
Avoidable Pressure Ulcer: “Avoidable” means that the
person receiving care developed a pressure ulcer and
the provider of care did not do one of the following:
evaluate the person’s clinical condition and pressure
ulcer risk factors; plan and implement interventions
that are consistent with the persons needs and goals,
Although we often, rightly, concentrate on pressure ulcers
developed in our care, we are committed to working
together with our partners in the health economy so that
we can learn from each other, and support each other
in eradicating avoidable pressure ulcers wherever the
patient is receiving care.
On a more positive note, our Tissue Viability Consultant
Nurse, Jackie Stephen-Haynes and Rosie Callaghan,
Tissue Viability Nurse, won the British Journal of Nursing
Quality accounts
and recognised standards of practice; monitor and
evaluate the impact of the interventions; or revise the
interventions as appropriate.”
Unavoidable Pressure Ulcer: “Unavoidable” means that
the person receiving care developed a pressure ulcer
even though the provider of the care had evaluated
the person’s clinical condition and pressure ulcer risk
factors; planned and implemented interventions that
are consistent with the persons needs and goals; and
recognised standards of practice; monitored and
evaluated the impact of the interventions; and revised
the approaches as appropriate; or the individual person
refused to adhere to prevention strategies in spite of
education of the consequences of non-adherence”.
Pressure area care nurses of the year award for 2014
with their work on “The outcomes of a strategic plan for
essential skin care and pressure ulcer prevention in the
elderly in the care home setting across one primary care
organisation”.
We are committed to eradicating avoidable pressure
ulcers and we are taking this priority forward into next
year.
47
Priority 5 - Improve Evidence that We Learn from Patient Safety Incidents
and Near Misses
Measure
Result at end of
March 2014
Revised incidence reporting policy to further underpin the learning from incidents
Due to be ratified in
May 2014
Revised Route Cause Analysis training
Achieved
New patient safety reporting system which will give better reporting to teams so that
trends can be identified
Achieved
Professor Don Berwick, renowned international expert in
patient safety, was asked by the Prime Minister to carry
out a review following the publication of the Francis
Report.
His report makes recommendations for the NHS, its
regulators and the government to build a robust
nationwide system for patient safety rooted in a culture
of transparency, openness and continual learning
with patients firmly at its heart. We have taken these
recommendations and included them in our Francis
Action Plan and will be publishing a ‘Duty of Candour’
Policy in the summer of 2014/15.
Our quality measure of all ‘Incidents being reported
within 48 hours of the incident occurring’ has improved
during 2013/14 (86% in March 2014 compared to 71% in
April 2013) ) as required by Trust policy and seen as best
practice by the CQC.
Systems of disseminating learning exist within Service
Delivery Units via our Quality and Governance Leads,
Clinical Leads and Team Managers.
During 2013/14 there were some common themes
arising from investigations and recommendations
including:
• The need for staff to receive training in clinical record
keeping. As a result of this we have revised our training
and plan to launch an on-line, easily accessible training
48
package in early 2014/15.
• The need to ensure staff update care plans in a timely
manner. This is being followed through by using the
nursing metrics to track improvement initiatives.
• The need to ensure patients and service users are
involved in decision-making regarding their care, and
that this can be evidenced in the notes.
In the Trust we know we still have some way to go
in improving our shared learning from incidents. We
have however made some progress and have revised
our training for undertaking Route Cause Analysis
investigations. The feedback from the training has been
excellent and we have seen a steady improvement in the
quality of investigations which in turn has led to more
focussed and effective learning outcomes.
We introduced a new incident reporting system in
August 2013. The system is much easier for staff to use
and has led to an increase in the number of incidents
being reported. It is widely accepted that Trusts who
report more incidents have a more open safety culture.
As more incidents are reported and lessons learned, the
harm from incidents should reduce.
Annual Report 2014-15
Review of 2013/14 - Patient Safety
Falls Prevention
Falls are a major cause for concern for us. Unfortunately
people may be more likely to fall in-hospital than in
their own homes, as a result of being in an unfamiliar
environment. A full environment risk assessment is
carried out at least once a year to identify any extrinsic
factors that may influence fall rates across in-patient
services.
All patients who come into our hospitals are assessed
for their risk of falling, so that appropriate care can
To focus our falls prevention work efforts over the next
year, we have established a Trust wide group; the Falls
Improvement Group to lead the implementation of Royal
College of Physicians ‘Falls Safe Care Bundle’. The group is
chaired by the Deputy Director of Nursing and supported
by the Falls Prevention Coordinator with representatives
from training and development, quality governance,
nursing, medical, therapists and senior clinical managers.
The group will lead a strategy for the prevention and
Quality accounts
be planned to try and prevent a fall – for example by
providing a specialist bed.
We measure the overall rate of falls through our incident
reporting system and use the data to identify whether
falls occur on particular days or at particular times of the
day.
We review the root cause for all serious falls occurring
in hospital and have developed nursing indicators to
monitor improvement as a result of this work.
management of falls across inpatient and community
services and therefore bring together all the work that
has already been achieved, and identify the gaps for
further development. This will include progressing issues
on the assessment of osteoporosis, identification of
delirium, cognitive screening and immediate access to
walking aids.
49
Infection Prevention and Control
Actively minimising healthcare associated infections is a
priority in the Trust. We are committed to ensuring that
the risk of infections is kept to an absolute minimum.
During 2013/14 we maintained an excellent performance
on the prevention and control of infection across our
services.
For 2013/4, by year end the number of cases of
Clostridium Difficile (C-diff ) was below the target
threshold set by the commissioners.
Unfortunately we have had one case of MRSA
bacteraemia presenting in the year and as a result a full
investigation into the cause was undertaken.
Within the Trust it is widely acknowledged that infection
prevention and control is everyone’s responsibility; this is
in addition to the Infection Prevention and Control team
who provide specific advice and guidance to staff.
Across the Trust there have been a number of initiatives
to reduce infection:
• Ensuring staff attend appropriate training – the uptake
of infection control training by year end is at nearly 90%
• Promoting hand hygiene and undertaking audits
• An infection control charter for both patient, service
users, visitors and staff.
The PLACE team carried out the formal inspections
during 2013/14 and we are very pleased to have
maintained good or excellent standards across our sites.
Safeguarding
Activity continues in the Trust to ensure that vulnerable
children and adults are safeguarded since the last Quality
Account. The Integrated Safeguarding Team along with
the Safeguarding Working Groups have continued to
embed learning from safeguarding audits and reviews
in all aspects of the Trust’s work as the organisation
continues to develop a learning culture
50
Key Activities have been the following:
• Learning from multi agency Adult and Children’s Serious
Case Reviews
• Training and embedding a process for multi-agency
information sharing and working to safeguarding
children and young people form child sexual
exploitation
• Embedding a process for managing children and young
people at risk of suicide.
• Engaging in preparation with the Safeguarding Adult
Board for the implementation of the Care Bill
• Development and dissemination of guidance for
Managing Self Neglect in Adults.
• Preparation for single Agency Inspections of
Safeguarding Children Services by Care Quality
Commission
• Supporting staff with training, supervision and
reflection on safeguarding cases
• Embedding robust responses to domestic abuse where
children and adults at risk might be at risk of harm as a
direct result of learning from a Serious Case Review in
another County
• Delivery of in house domestic Abuse Training in
conjunction with the University of Worcester
Mandatory Safeguarding Training levels that must
be completed by all staff have now reached 96% for
safeguarding children and 94% for safeguarding adults.
The Trust maintains its approach of zero tolerance of the
abuse of children and adults who are at risk of harm.
Never Events
Never Events are defined by the Department of Health as
‘serious, largely preventable safety incidents that should
not occur if the available preventative measures have
been implemented by healthcare providers’. Fifteen of
the list of twenty five never events are relevant to the
Trust. There have been no occurrences of Never Events in
the Trust during 2013/14.
Annual Report 2014-15
Central Alerting System
The Central Alerting System is a means of alerting
health and social care providers to the important safety
information from a number of different sources. The
actions required as a result of the alerts can be minor
or involve significant change. During 2013/14 of all the
alerts received, were responded to within the required
timeframe.
Training and Development
and Development webpage which includes information
regarding mandatory and essential training for certain
staff groups, and also a weekly training bulletin
advertising internal and external courses that are on offer
to staff and information regarding completing e-learning.
Same-sex Accommodation
During 2013/14 we met the standards set by the
Government to provide accommodation for patients that
is not shared with the opposite sex.
Our Training and Development team assist with staff
development by working alongside them to develop
skills, knowledge and required competencies. Some
current work streams the team are actively involved
with include Nursing Metrics, Safer Nursing Care Tool,
High Impact Actions, Pledge to Care, the Skills Bus, Big
Recovery and the development of the new nursing
documentation for our community hospitals. Other
areas that we cover include pre-registration nursing
placements, preceptorship, specialist practitioner
support, clinical policies, and other streams of work
which support high quality care and professional
practise.
All mandatory courses are available through the
team and support for e-learning is available from our
dedicated administration team. Essential training
for certain staff groups such as MAPA, Diligent and
Resuscitation training are courses that many people think
are the limit of the courses offered by TDU. However we
offer a host of opportunities for development covering
Leadership development courses, coaching, Dementia
training, Mental Health first aid, Mentor updates,
Intermediate Skills Programme as well as many more.
Staff have access to the TDU webpage for up to date
information regarding available training for both clinical
and non-clinical staff.
The Training and Development Team has actively
supported trust staff throughout 2013/14 in achieving a
huge increase in the completion of mandatory training
for all staff groups. We have development a Training
Quality accounts
51
Our 2013/14 CQUIN Performance
Commissioning for Quality and Innovation (CQUIN) schemes require Trusts to improve quality and innovation by
discussing, agreeing and monitoring quality indicators with its commissioners. When the quality improvement goals
and indicators are achieved, the Trust earns a financial payment.
The indicators set out in the table below were set for 2013/14 and present our performance. We were pleased to have
achieved all of the quality improvement measures in our CQUINs and in some cases exceed them.
CQUIN Goal description
Achieved
1
Net Promoter ‘Friends and Family’ introduction and roll out
a
2
Roll out of three further patient experience questions
a
3
Triangulation of patient experience data
a
4
Safety Thermometer data submissions
a
5
Delivery of IV therapy training across community teams and community hospitals
a
6
Improving patient flow
a
7
Amber Care bundle
a
8
Advanced Care Planning
a
9
Improving the physical health care for people with severe and enduring mental health
problems
a
10
Engagement of family/friends and carers and advocates in the care planning process
a
11
Patients on CPA to have on discharge from acute or secondary care services an agreed
Crisis Support Plan
a
12
Patients on all clusters to have a review in line with at the expected review intervals
a
52
Annual Report 2014-15
Looking Forward
Quality Account Priorities for
2014/15
The priorities for the coming year were shaped by:
• the Trust’s own review of its quality performance, based
on information for example from our incident data and
complaints
• the Quality Account Working Group
• Staff survey
• Members survey
• Public website survey
• Engagement with our commissioners
• Engagement with the Trust Development Authority
The three priorities for 2014/15, progress on which will
be reported to our Quality and Safety Committee and
Trust Board throughout the year, are:
Priority 1 – Preventing Avoidable
Pressure Ulcers (carried forward
from 2013/14)
A pressure ulcer is an area of damage to the skin and the
underlying tissue, usually over a bony area of the body.
Pressure ulcers range in severity from skin discolouration
to severe open wounds.
Why are we focussing on preventing
pressure ulcers?
• Pressure ulcers cause patients long term pain and
distress
• Pressure ulcers can mean longer stays in hospital
• Avoidable pressure ulcers are widely seen as a key
indicator of the quality of nursing care.
• Giving clear information on what to look for helps
patients and carers avoid pressure ulcers.
How are we going to achieve this goal?
We already have policies and procedures in place for
preventing, assessing and treating pressure ulcers
and we know that there are already many examples of
excellent practice.
We will build on this good work with a focussed plan:
• The Quality Team will produce a weekly report from
Quality accounts
Ulysses, our incident reporting system, indicating all
pressure ulcers by grade
• All grade 2 pressure ulcers on the weekly report will be
targeted by Team Leads to prevent escalation to grade
3.
• All grade 2 pressure ulcers will have documentation and
process of assessment and treatment checked by team
leader/ ward manager.
• Ward Managers/ team leaders will review patients
within 24 hours of any pressure area damage being
identified in order to accurately prescribe and /or ensure
appropriate equipment is in place
• All Grade 2 pressure ulcers will be discussed by Ward
Manager/ team leader with nursing team as part of
weekly meetings to ensure the plan of care is working
and is appropriate
• All Grade 3 and 4 pressure ulcers will undergo a rapid
review, whereby a round table meeting is carried out
within 2 weeks of the pressure ulcer being reported.
This will determine the Route Cause of the pressure
ulcer and will facilitate shared, effective learning and
improvement.
What measures will we use?
We will track and report on the number of avoidable
pressure ulcers. A baseline figure will be calculated from
the 2013/14 data. This will be reported monthly to the
Quality and Safety Committee.
Priority 2 – Improving the care for
people with Dementia and their
carers
Dementia is caused when the brain is damaged by
diseases, such as Alzheimer’s disease or a series of
strokes. Alzheimer’s is the most common cause of
dementia but not all dementia is due to Alzheimer’s. The
symptoms that someone with dementia experiences will
depend on the parts of the brain that are damaged and
the disease that is causing the dementia.
Symptoms of Dementia may include memory loss and
difficulties with thinking, problem-solving or language.
These changes are often small to start with, but for
someone with dementia they have become severe
53
enough to affect daily life. A person with dementia may
also experience changes in their mood or behaviour.
Why are we focussing on Dementia care?
The numbers of people with dementia or signs of
dementia admitted to Community Hospitals are
increasing. A range of support can help a person and
their family to live well with dementia. It is a challenge
to obtain patient feedback on care from this group of
people, so that we know whether the measures we are
put in place really help..
How are we going to achieve this goal?
• Dementia Care Mapping (DCM) has been recommended
by the National Institute for Health and Clinical
Excellence as a method for improving care practice
for people with dementia. DCM is an observational
method used to evaluate the experience of people with
dementia.
• Specially trained staff will observe and record care from
the patient’s point of view over a 6 hour period. The data
is then analysed and is fed back to staff as a means of
changing and improving the patients’
• We will implement Dementia Care Mapping (DCM) in
the Community Hospitals.
All young people, including those aged under 16, are
entitled to confidential sexual health and contraceptive
advice and treatment. Access to confidential sexual
health services, both in schools and in the community,
is one of the ways in which young people can be
supported to stay safe.
Why are we focussing on young person’s
experiences?
We recognise that meeting the particular needs of young
people is a key component in ensuring our services are
effective.
We wanted to include a priority in the accounts that
would tell us more about the services we provide for
young people. The Youth Board were asked for their
views and the attitude of workers in sexual health
services came out as one of the things young people
think is important.
How are we going to achieve this goal?
This indicator will require asking the identified carer
questions related to their experience of the Community
Hospital in addition to that of their relative/friend
The Department of Health has the ‘ You’re Welcome’
quality criteria which lays out principles to help health
services become young people friendly. ‘You’re Welcome’
can increase health workers skills in working effectively,
appropriately and sensitively with young people. Our
Sexual Health services have been working with the
‘You’re Welcome’ criteria for some time so we want to
know what young people think of our services.
What measures will we use?
What Measures will we Use?
We will undertake two carer surveys, one at the
beginning of the year and then one towards the end
of the year when the Dementia Care Mapping actions
will have been implemented. We will then compare the
results to measure whether the actions have resulted in
an improved experience for people with dementia and
their carers.
Priority 3 – Understanding
and Improving Young People’s
Experiences of Sexual Health
Services
54
We will ask young people through a survey about their
views. We will look at ways of how we can do this whilst
ensuring confidentiality is not at risk.
We will ask staff who work in the services for their own
views about the quality of service provided.
We will then implement any changes from the feedback
and repeat the survey to assess whether any changes
have led to improvements.
Annual Report 2014-15
CQUINS for 2014/15
The following CQUINS have been agreed with our commissioners for 2014/15. We are committed to delivering these
quality improvements and will be reporting on our progress with each of them to Trust Board and our commissioners
during the year.
Service Included in CQUIN
CQUIN Theme/
Title
Safety Thermometer- Tissue
Viability
Friends and Family Test
(FFT) - staff
FFT Patients (awaiting
national guidance for
community trusts)
Older
Adult
Mental
Health
Tissue Viability – RCAs
Hydration
Physical health for patients
with schizophrenia
Communication with GPs
a a a a a a a
Patient Family and friends test.
a
a (PICU)
Dementia Care Mapping.
Carer experience. Staff confidence
a
a
a a
a
a
a
Staff Family and Friends Test
Repeat Point Prevalence
Multiple indicators
Clinical lead in wider strategy.
7 day reviews in RCAs
Hydration bundles. Training.
Peer audit
Cardio metabolic assessment for
patients with schizophrenia
Focussing on patients on CPA,
demonstrating an up-to-date care
plan has been shared with the GP
a
Analysis of the health needs of
population, and health related
goals in Health Action Plan
(HAP)
a
Offender health (still to
be agreed)
Quality accounts
Learning
Disability
Reduction in incidents of Grade
2,3 & 4 pressure ulcers
Health Action Plans for
people with a Learning
Disabilities
Breast Feeding uptake
Primary
Care
Offender
Brief Description of indicators
Health
care
a a a
a
a a a a a a a
Patient Flow
Dementia
Community
Care
Children,
Young
MenPeotal
ple
Health
and
Families
a
a
(HV)
Well man clinics
Promotion of breast feeding.
55
2013/14 Quality Account Technical Section –
Mandatory Statements
The following section contains the mandatory
statements common to all Quality Accounts as required
by the regulations set out by the Department of Health.
Review of services
During 2013/14 the Worcestershire Health and Care Trust
provided and/or sub contracted 5 NHS services.
• Community Care
• Adult Mental Health
• Children, Young People and Families
• Specialist Primary Care
• Learning Disabilities
The Worcestershire Health and Care NHS Trust has
reviewed all the data available to them on the quality of
care in five of these NHS services.
The income generated by the NHS services reviewed
in 2013/14 represents 100 per cent of the total income
generated from the provision of NHS services by the
Worcestershire Health and Care NHS Trust for 2013/14.
Participation in clinical audits
During 2013/14 eight national clinical audits and one
national confidential enquiry covered NHS services that
Worcestershire Health and Care NHS Trust provides.
During this period Worcestershire Health and Care NHS
Trust participated in 100% national clinical audits and
100% national confidential enquiries of the national
clinical audits and national confidential enquiries which
it was eligible to participate in. The national clinical audits and national confidential
enquiries that Worcestershire Health and Care NHS Trust
was eligible to participate in during 2013/14 were:
• National Audit of Schizophrenia
• National Audit of Psychological Therapies for Anxiety
and Depression (NAPT)
• Prescribing Observatory for Mental Health (POMH-UK)
Topic 13a: Prescribing for ADHD
• POMH-UK Topic 7d: Monitoring of patients prescribed
Lithium
• POMH-UK Topic 4b: Prescribing Anti Dementia Drugs
• National Confidential Inquiry into Suicide and Homicide
by people with Mental Illness (NCISH)
• BASHH Management of young people attending sexual
health clinics
• Profession specific stroke audit
• English National Memory Clinics Audit
The national clinical audits and national confidential
enquiries that Worcestershire Health and Care NHS
Trust participated in, and for which data collection was
completed during Worcestershire Health and Care NHS
Trust are listed below alongside the number of cases
submitted to each audit or enquiry as a percentage of
the number of registered cases required by the terms of
that audit or enquiry. National clinical audits 2013/14
Participation
% cases submitted
POMH-UK Topic 13a: Prescribing for ADHD
Yes
n/a
POMH-UK Topic 7d: Monitoring of patients prescribed Lithium
Yes
n/a
POMH-UK Topic 4b: Prescribing Anti Dementia Drugs
Yes
n/a
Other national audits
Yes
National Audit of Schizophrenia
Yes
77%
National Audit of Psychological Therapies for Anxiety and Depression
(NAPT)
Yes
n/a
Prescribing Observatory for Mental Health (POMH-UK)
56
Annual Report 2014-15
Continued...
National clinical audits 2013/14
Participation
% cases submitted
British Association for Sexual Health and HIV (BASHH) Management of
young people attending sexual health clinics
Yes
n/a
Profession specific stroke audit
Yes
n/a
English National Memory Clinics Audit
Yes
n/a
Prescribing Observatory for Mental Health (POMH-UK)
The reports of five national clinical audits were reviewed by the provider in 2013/14 and Worcestershire Health and
Care NHS Trust intends to take the following actions to improve the quality of healthcare provided.
Subject of audit
Standard where audit
identified need for
improvement
Actions that have been put in
place since audit
Outcome
POMH-UK Topic 13a:
Prescribing for ADHD
Initiating drug treatment
for ADHD: Before starting
drug treatment, children,
adolescents and adults with
ADHD should have a full pretreatment assessment
Checklist for doctors on
medication form being used
countywide
Revised “Green Sheet”
in use.
Maintenance treatment:
monitoring of BP, heart rate
and growth
Checklist for admin staff to
ensure all necessary paperwork is
included in notes (green sheet)
All paperwork in single
file easily accessible
to doctors and admin
staff in paediatrics and
CAHMS.
Symptom monitoring of
medicated children
Symptom monitoring
questionnaire researched, agreed
and easily available
Symptom monitoring
questionnaire in use.
POMH-UK Topic 7d:
Monitoring of patients
prescribed Lithium
Weaknesses were failure to
measure Weight or BMI or
waist circumference should be
completed before initiating
treatment.
Commitment made to measure
weights of people with LD
receiving lithium and document in
notes
Easy-read information
about lithium is
available to give to
patients.
British Association for Sexual
Health and HIV (BASHH)
Management of young people
attending sexual health clinics
Young people’s proforma
should be standardised across
the service
Young person’s proforma
standardised with the imminent
arrival of electronic notes in the
service
Awaiting electronic
notes system
National Audit of Psychological Evaluating the effectiveness of
Therapies for Anxiety and
interventions
Depression (NAPT)
CORE Outcome Measure currently
being piloted as a way of
evaluating both individual and
group therapeutic interventions.
Data collection
underway. Report due
end of May 14.
Profession specific stroke audit No further action required
N/a
N/a
English National Memory
Clinics audit
N/a
N/a
Quality accounts
No further action required
57
The reports of 28 local clinical audits were reviewed by the provider in 2013/14 and Worcestershire Health and Care
NHS Trust intends to take the following actions to improve the quality of healthcare provided. Please note this is a
sample only to give an idea of the spread of audit work across the services.
Subject of audit
Standard where audit identified need
for improvement
Protected mealtimes
Patient asked if they need the toilet prior to Staff prompted to start toileting
meal
procedure for all patients ½ hour prior to
mealtime
Amount eaten to be recorded
Complete the food diary or food chart/
nutrition care plan.
Training has been rolled out re
documentation and competency
documents have been introduced onto
one of the wards.
Ensure those patients requiring a red tray
are given a red tray
Venous Thrombo-embolism Follow national and local standards for VTE
(VTE) Screening on Older
screening.
Adult Mental Health
Inpatients wards
Audit of WHO checklist for
ECT
Safer sleeping audit
Ensure patient ID verification is being
performed
Ensure out of county babies are risk
assessed, either by midwife or HV
Audit of the standardised
children’s’ equipment list
Equipment to be requested from the
standard list only
58
Actions that have been put in place
since audit
Introduce a visual prompt (red dot) next
to patient’s name to indicate to catering
staff that the patient requires a red tray.
Document in handover sheet.
Results presented to all consultants to
take immediate action and maintain
patient safety.
To be specifically included in Junior
Doctor induction programmes, and
highlighted to ward managers.
Guidelines to be developed for VTE
screening in Older Adult mental health
inpatients.
Patient ID checks are completed in all 5
modalities
Section added into the Worcestershire
Safer Sleeping Guideline for out of county
babies.
All HV and Community midwife team
leads informed of addition to policy
so they are clear of their roles and
responsibilities.
Monitored via ICES equipment panel data.
Annual Report 2014-15
Continued...
Audit of opioid prescribing
in palliative care
All specialist and generalist palliative care
providers to give consistent advice based
on NICE & APC guidance
Management of know side effects
Management of
Resuscitation & Medical
Emergencies: Salaried
Dental Service
Knowledge of responsibilities, duties,
training, risk assessment, equipment and
drugs, emergencies outside the dental
surgery
Older Adult Mental Health
and Driving audit
Feedback and education sessions from
specialist palliative care providers in the
planning.
Introduction of a patient information
leaflet.
Information shared with Trust
Resuscitation training team in order
to increase awareness of the specific
areas that need to be stressed during
training courses where dental team are in
attendance.
All patients undergoing a new referral
Driving status has been added to the Risk
assessment should have their driving status Assessment section on the template for
discussed and recorded in correspondence. OA Wyre Forest Team.
Participation in clinical research
Statements for the CQC
The number of patients receiving NHS services provided
or sub-contracted by Worcestershire Health and Care
NHS Trust in 2013/14 that were recruited during that
period to participate in research approved by a research
ethics committee was 20 (National Institute of Health
research portfolio studies only).
Worcestershire Health and Care NHS Trust is required to
register with the Care Quality Commission and its current
registration status is registered. Worcestershire Health
and Care NHS Trust has no conditions imposed on its
registration.
Participation in clinical research demonstrates
Worcestershire Health and Care NHS Trust’s commitment
to improving the quality of care we offer and to making
our contribution to wider health improvement.
Goals agreed with Commissioners
A proportion of Worcestershire Health and Care NHS
Trust income in 2013/14 was conditional on achieving
quality improvement and innovation goals agreed
between Worcestershire Health and Care NHS Trust
and any person or body they entered into a contract,
agreement or arrangement with for the provision of NHS
services, through the Commissioning for Quality and
Innovation payment framework.
Further details of the agreed goals for 2013/14 and
for the following 12 month period are available
electronically at www.hacw.nhs.uk
Quality accounts
The Care Quality Commission issued one warning notice
against Worcestershire Health and Care NHS Trust during
2013/14.
Following an inspection of the healthcare provision in
HMP Oakwood in June 2013 the CQC advised the Trust
of a failure to comply with Regulation 13 (Management
of Medicines) of the Health and Social Care Act (2008)
Regulations 2010 (the Regulated Activities Regulations
2010) at HMP Oakwood. The Trust recognises the severity
of the concerns found during the inspection, and we are
extremely regretful that our services did not meet our
own expected standards of care.
The CQC re-inspected HMP Oakwood in October 2013
and lifted the warning notice. We have since made
further improvements and have sustained safe, good
quality care for patients in HMP Oakwood. We are in
close contact with the NHS England Local Area Team, The
Trust Development Authority, the Pharmacy provider
and the Prison Director to ensure there is a partnership
approach to sustaining the improvement actions.
59
We are fully committed to continuing the effectiveness of actions we have put in place, both now and in the future.
Worcestershire Health and Care NHS Trust has not participated in any special reviews or investigations under section
48 of the Health and Social Care Act 2008 by the CQC during 2013/14.
Data Quality
Worcestershire Health and Care NHS Trust will be taking the following actions to improve data quality.
Improving Community Care Ethnic Origin Coding
Since April 2013, monthly information has been shared with clinicians, and performance reported to the Trust’s
Finance & Performance Committee. Throughout the year, there has been an upward trend in performance as shown in
the following table:
Month
Jun 13
Sep 13
Dec 13
Mar 14
Completeness
57.9%
53.0%
82.5%
85.2%
The Trust will continue to work with clinicians and report performance on a monthly basis, to ensure a score of 95%
can be achieved and maintained.
Other areas for development
For the Financial Year 2014/15, Worcestershire Health and Care NHS Trust will be taking the following actions to
improve data quality.
Inpatient: Primary Diagnosis.
Action
By whom
Timescale
Monthly lists of episodes with a missing primary
diagnosis to be produced and sent to Service Delivery
Units.
Information Dept
On-going
Diagnosis code identified and the relevant PAS updated.
MH Clinicians / RWP Coders
On-going
Undertake an analysis of inpatient units to determine
whether there are any specific wards where coding
completeness is consistently low.
Information Dept
April 2014 onwards
Share analysis with SDU Leads as part of monthly
performance dashboard
Information Dept
April 2014 onwards
60
Annual Report 2014-15
Secondary Uses Service
Worcestershire Health and Care NHS Trust submitted
records during 2013/14 to the Secondary Uses Service
for inclusion in the Hospital Episode Statistics which are
included in the latest published data.
The percentage of records in the published data which
included the patient’s valid NHS Number was:
• 99.8% for admitted patient care
• 99.9% for outpatient care
Worcestershire Health and Care NHS Trust was not
subject to the payment by results clinical coding audit
during 2013/14 by the Audit Commission.
Information Governance
The requirements of Information Governance are central
to the way we operate to ensure all data we collect is
held safely and securely.
The percentage of records in the published data which
included the patient’s valid general medical practice was:
• 99.9% for admitted patient care
• 99.8% for outpatient care
Information Governance (IG) Toolkit Grading
Clinical coding error rate
Personal Data as Reported to the Information
Commissioners Office:
The Trust achieved a score of 77% and were graded
‘satisfactory’, which is the highest grade achievable. There
is no longer a RAG rating on the IG Toolkit.
SUMMARY OF SERIOUS INCIDENT REQURING INVESTIGATION INVOLVING PERSONAL DATA AS REPORTED TO
THE INFORMATION COMMISSIONER’S OFFICE IN 2013-14
Date of Incident
August 2013
Nature of Incident
Loss of paperwork
– a ward handover
sheet was found at a
railway station and
was handed into the
local Press
Nature of Data
Involved
Name, age, GP
name, diagnosis,
past medical history,
mobility, nursing
interventions
required, discharge
information
Number of data
subjects affected
Notification Steps
Individuals
contacted and
offered support
18
Press statement
released
Full investigation
undertaken
Internal processes have been reviewed, improved and updated
Further action on
information risk
Quality accounts
The Trust will continue to monitor and assess its information risks, in light of the events
noted above, in order to identify and address any weaknesses and ensure continuous
improvement of our policies and procedures
61
Mandated Indicators
Care Programme Approach (CPA) follow up contact within seven days of
discharge from hospital.
The Trust’s performance in this area is measured on a quarterly basis as part of the Trust Development Authority’s
Accountability Framework indicators. In order to achieve the highest level of compliance in this area (“Performing”)
the Trust must achieve 95% of inpatients on CPA followed up within seven days of discharge from hospital.
The Trust is pleased to report that a level of ‘Performing’ was consistently achieved, with scores over 97%, for each
quarter in 2013/14. The quarterly scores are shown in Table 1 below.
Table below: Percentage of people on CPA followed up within 7 days of discharge from hospital.
Performance
Threshold
95% or over
Actual Quarterly Performance 2013/14
Quarter 1
Quarter 2
Quarter 3
Quarter 4
98.9%
97.2%
99.0%
99.5%
Minimising Delayed Transfers of Care
Measuring delayed transfers of care forms part of the Trust Development Authority’s Accountability Framework, and
helps the Trust to assess the impact of community-based care in facilitating timely discharge from hospitals.
People should receive the right care in the right place at the right time and we must ensure that people move on from
the hospital environment once they are safe to transfer.
The indicator seeks to encourage organisations to work in partnership to minimise the number of patients remaining
in hospital settings who are ready for discharge.
The definition is as follows: “the number of patients (acute and non-acute, aged 18 and over) whose transfer of care
was delayed, expressed as a percentage of the number of consultant and non-consultant led occupied beds.”
In order to achieve the highest level of compliance in this area (“Performing”) the Trust must keep delayed transfers of
care to 7.5% or less during each quarter.
Table 2 shows the Trust’s position for 2013/14. The Trust is pleased to report that a level of ‘Performing’ was
consistently achieved, with scores under 5.1%, for each quarter in 2013/14.
We routinely monitor our performance in this area across all services and where performance consistently falls
below target we implement recovery plans that are monitored by the Trust Board. We actively work with our partner
organisations to minimise any delays.
62
Annual Report 2014-15
Table below: Percentage delayed transfers of care.
Performance
Threshold
7.5% or less
Actual Quarterly Performance 2013/14
Quarter 1
Quarter 2
Quarter 3
Quarter 4
4.1%
4.5%
4.3%
5.1%
The number of admissions to
the Trust’s mental health acute
wards that were gate kept by the
Assessment and Home Treatment
Teams
When service user admissions are assessed (“gate kept”)
by their local Assessment and Home Treatment Team,
service users have the opportunity to be treated in their
own home. Wherever possible we offer service users
the choice to be supported in their own home as an
alternative to hospital admission. This is recognised as
best practice and monitored by the Trust Development
Authority’s Accountability Framework.
The method for calculating performance is as follows:
“the number of admissions to the Trust’s acute wards
(excluding internal transfers between wards, patients
recalled from community treatment orders, and patients
Performance
Threshold
95% or over
Quality accounts
on leave under Section 17 of the Mental Health Act) that
were gate kept by the Assessment and Home Treatment
team prior to admission. An admission has been ‘gate
kept’ if the team assessed the service user before
admission and involved them in the decision making
process that resulted in the hospital admission. This is
expressed as a percentage of total admissions to the
Trust’s acute mental health wards.”
In order to achieve the highest level of compliance
(“Performing”) the Trust must ensure that 95% of
admissions to acute mental health wards were gate kept
by the Assessment and Home Treatment Teams.
The 2013/14 performance is shown in Table 3. The Trust
is pleased to report that a level of ‘Performing’ was
consistently achieved, with scores over 97%, for each
quarter in 2013/14.
Table below: Percentage of admissions to mental
health acute wards that were gate kept.
Actual Quarterly Performance 2013/14
Quarter 1
Quarter 2
Quarter 3
Quarter 4
98.8%
98.7%
97.4%
97.7%
63
Percentage of patients readmitted to hospital within 28 days of being
discharged.
Measuring the percentage of patients who were readmitted to hospital as an emergency within 28 days of being
discharged provides information to help us monitor success in avoiding (or reducing to a minimum) readmissions
following discharge from hospital. The following table shows the quarterly percentage of all inpatient admissions that
were readmitted in an emergency within 28 days of the previous discharge.
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Ages 0-14
0.0%
0.0%
0.0%
0.0%
Ages 15+
2.1%
2.5%
1.1%
2.9%
Patient experience of community mental health services.
To improve the quality of services that the Trust delivers,
it is important to understand what people think about
their care and treatment. One way of doing this is by
asking people who have recently used our services to tell
us about their experiences.
To assist with this, each year a survey of people aged 18
and over accessing community mental health services is
conducted and collated by the Care Quality Commission.
A questionnaire was sent to 850 people who accessed
community mental health services between 1st July
2012 and 30th September 2012. A total of 269 people
responded, giving a 32% response rate for the Trust. This
compares to the national response rate of 29%.
An excerpt of the survey results, specifically covering the
patient’s experience of contact with a health or social
care worker is shown in Table 6 below. The full report
has been published by the CQC and is available on their
website.
Table below: Patient experience of contact with a health or social care worker:
Trust’s 2013
score. (score
out of 10)
Compared with the
national response,
we scored:
Listening: for the health or social care worker seen most recently was listening
9.0
carefully to them.
Better
Involvement: for the health or social care worker seen most recently taking
their views into account
8.6
About the same
Trust and confidence: for having trust and confidence in the health or social
care worker seen most recently
8.5
About the same
Respect and dignity: for being treated with respect and dignity by the health
9.5
or social care worker seen most recently
About the same
Time: for being given enough time to discuss their condition and treatment
with the health or social care worker seen most recently
8.4
About the same
Overall experience of contact with the health or social care worker seen most
recently.
8.8
About the same
Figures taken from the CQC website: http://www.cqc.org.uk/survey/mentalhealth/R1A
64
Annual Report 2014-15
Worcestershire Health
Overview and Scrutiny
Committee (HOSC)
Comments 2014
Patient Safety Incidents
The number of patient safety incidents reported in the
Trust during 2013/14: 5,362
The number of patient safety incidents that resulted in
severe harm or death: 72 (1.34%)
Examples of Patient Safety Incidents that result in
severe harm are grade 4 pressure ulcers (both avoidable
and unavoidable) and falls where the patient sustains
a fracture. All such incidents undergo a thorough
investigation to establish the root cause of the incident,
and in many instances nothing could have been done to
prevent the incident.
Where a death is recorded on the system, this is
where a patient who is known to our services dies
unexpectedly – this does not mean that the death was
preventable. Large scale investigations are undertaken
in such instances to establish if the care provided in our
services was safe and appropriate, and whether there
was anything that could have been done to prevent the
death.
Quality accounts
In making its response, the HOSC considers information
made available throughout the year which is supported
by the Quality Account. The information received on
a regular basis regarding Worcestershire Health and
Care Trust (the Trust) includes regular bulletins, specific
presentations about proposals for significant changes,
and board meetings, which HOSC’s two lead members
attend.
Overall Comments
1. The Quality Account is very easy to read which makes it
accessible and reassuring to the public.
2. The report is very positive about its performance this
year, but also points out the areas where improvement
is needed.
3. Whilst recognising that community hospitals are only a
part of the Trust’s services, it is believed that the public
would expect the role of community hospitals and
medical care in prisons to be referred to.
Review of 2013/14
1. The snapshot review is accessible to the reader and it
is appreciated that inclusion of excessive performance
criteria and data can be overwhelming to the public.
However it is suggested that the report makes
this clear and includes a link to the more detailed
information and data available on the public website,
for those who may be interested.
2. New Haven – a new kind of facility (for older people
with mental health illnesses) – the appropriateness
of the word ‘recovery’ is queried, although it is
appreciated that it is a nationally recognised term
within mental health.
3. Child and Adolescent Mental Health Service (CAMHS)
– the Trust is congratulated on reducing average
appointment waiting times from 18 to 5 weeks, and
is encouraged to work towards reducing this further.
(Children’s Scrutiny Panel Chair may have further
comment)
4. West Midlands Quality Review Service peer review
programme for long term conditions 2013
5. The Trust is encouraged to clarify the situation
regarding the model for specialist care for people with
chronic neurological conditions.
65
CCG Response to
Worcestershire Health
& Care Trust Quality
Account 2013/14
Quality Account Priorities – progress review
and looking forward
1. Continue to improve our response times and learning
from complaints (Priority 2) – it would be helpful to
include some background information in order to
provide reassurance to the reader that learning has
taken place.
2. Pressure ulcers (priority 4) are distressing for patients
and the need to continue to focus on reducing
pressure ulcers is recognised. It is appreciated that
the Trust has been working hard to progress this and
now has better reporting mechanisms in place to
monitor documentation and assessment. The difficulty
in inherited patient cases is appreciated. It would be
helpful to clarify the term ‘avoidable pressure ulcer’.
3. Commissioning for Quality and Innovation (CQUIN) for
2014/15 – improving patient flow is also being looked
at through a HOSC desktop exercise and the HOSC will
liaise with the Trust on this.
4. Plans to understand and improve young people’s
experiences of sexual health services are pleasing.
2013/14 Quality Account Technical Section –
Mandatory Statements
1. Statements for the CQC (p36) - It would be helpful
to clarify the background to the CQC’s warning
notice issued against the Trust in respect of offender
healthcare, and it is concerning that provision of
medical care within the prison environment has
become increasingly challenging.
2. Summary of serious incident (p38) – the commentary
gives reassurance that this was a one-off incident.
Worcestershire Health Overview and Scrutiny
commentary
In providing this response, the three Clinical
Commissioning Groups (CCGs) for Worcestershire
(NHS South Worcestershire CCG, NHS Redditch and
Bromsgrove CCG and NHS Wyre Forest CCG), considers
the regular information and assurance generated
through the Clinical Quality Review and other associated
on-going Quality Assurance processes.
Based on the on-going assurance processes adopted
within the Trust and the information available to
us, commissioners believe this provides a broadly
representative and balanced perspective of the quality
of healthcare provided. However comments have been
included to reflect areas where further information
would have been helpful to more accurately describe the
Trust outputs in relation to quality improvement over the
last 12 months.
Overall comments
It is encouraging to continue to see the breadth of work
and achievement against existing quality standards and
initiatives across the three domains of patient safety,
patient experience and clinical effectiveness.
The account is written in plain English format and is
very ‘readable’. Quality improvements are well detailed
and are to be congratulated. The ‘Snapshot Review
2013/14’ provides a helpful and informative summary of
achievements over this period. Improvement priorities
for 2014/15 are detailed in a concise and ‘readable’
format, with purposeful explanations of what the Trust
hopes to achieve; why it was identified as priority and
how it is planned to achieve improvements.
The achievement against the quality improvement
measures within the CQUIN scheme for 2013/14 is
indicative of a commitment to delivering high quality
and safe care for patients, and the inclusion of 2014/15
CQUIN scheme detail is welcome.
The Trust achievement in improving its complaints
handlings processes and its focus on translating learning
into sustained improvement is to be congratulated.
There is provision of very detailed information regarding
learning from individual clinical audits and what actions
the Trust have taken to achieve improvement, which
66
Annual Report 2014-15
shows a commitment to understand and learn where
improvement is needed.
The improvements in the Trust’s systems and processes
in identifying; investigating and learning from patient
safety incidents are noted, and the Trust’s continued
commitment to further improve is to be commended.
There are number of areas detailed below where
commissioners believe that more information would
be helpful in highlighting where improvement activity
has been focussed across all services. Inclusion of the
following information would provide a more balanced
account of how services have developed over the year:
• The document focuses on the achievements made
within Mental Health Services but does not, for
example, reflect the areas of improvement made
following additional investment in Community Services
and Integrated Care Teams, or the impact of the role
of the new Care Home Practitioner within South
Worcestershire in enhancing the quality of care and
experience for care home residents.
• An update on developments within Children’s Services
would have been helpful i.e. School Nursing Services;
Health Visitors; Children’s Nursing Service.
• Preventing Avoidable Pressure Ulcers (Priority 1 carried
over from 2013/14). It would be helpful to understand
what has been learned from investigations over the
last year and how the Trust responded in translating
learning into actions to achieve improvement.
• Detail regarding the impact of patient falls and the
work planned to reduce incidents of this nature would
help provide assurance that the Trust continues to be
focussed on this area of potential harm.
• It would be helpful to see more detail regarding ‘Staff
Survey’ results i.e. what was raised and how the Trust
listened and responded to its staff. This would provide a
more balanced view of how the organisation responds
and acts upon feedback. It is also unclear what the
‘5 top ranking scores’ on page 5 means – again more
explanation and context would be helpful.
Commissioners will continue to hold the Trust to account
for performance against the priorities and improvement
targets detailed in this Quality Account during 2014/15,
through the existing Quality Assurance processes
Quality accounts
established with the Trust.
NB Offender Healthcare Services.
Currently the Trust delivers Offender Healthcare Services
for a number of West Midland’s Prisons. These services
are currently commissioned through Staffordshire and
Shropshire Area Team as lead commissioner for the West
Midlands, who monitor performance of the Trust in this
area. As such this response by the three Worcestershire
CCGs has not commented on any areas relating to
Offender Healthcare specifically.
Changes Made as a Result of
Feedback from HOSC and the CCGs
We would like to thank HOSC and the CCGs for taking the
time to read the draft Quality Account and for providing
helpful feedback.
The Trust provides a wide range of services, and we
have to make difficult decisions regarding how much
information can be included in the Quality Account
whilst keeping the document within the recommended
number of pages. Further information about Trust
services is provided in the annual report and is available
on the Trust’s website.
The following changes were made to the Quality Account
as a result of the feedback:
• Clarification of the CQC’s warning notice issued against
the Trust in respect of offender healthcare.
• Further background information for learning from
complaints
• Addition of the definition of the term ‘avoidable’ and
‘unavoidable’ pressure ulcer included.
• Additional information regarding falls prevention work
in the Trust
• Additional information regarding learning from
investigations
• More context around the staff survey and staff
engagement is contained within the annual report.
On behalf of NHS Redditch and Bromsgrove,
South Worcestershire and Wyre Forest Clinical
commissioning groups (CCGs).
67
Worcestershire Healthwatch
comments on the Worcestershire Health and Care Trust
Quality Account 2013/14
The response by Healthwatch Worcester does include
other information provided by the Worcestershire Health
and Care Trust (the Trust) on a regular basis throughout
the year which underpins the information provided
by the Quality Account. This includes reviewing and
responding where appropriate, to written materials,
attending Trust Board Meetings and Presentations
explaining the work of the Trust, including proposals for
significant changes to the service.
General Comments.
1. One important objective of the Quality Account is to
inform members of the public and service users what
the Trust has been doing throughout the year, the
achievements and the improvements it has made and
to point out where the Trust needs to perform better.
While it does that, it is hard to believe that the average
member of the public is going to wade through a
report this size. Notwithstanding the requirements on
the Trust to meet a set standard for reporting, a pithier,
user friendly document aimed at the general public
would seem timely.
2. The report contains many examples of improvements
to the Services provided by the trust and rightly
recognises the hard work of staff at all levels this year,
it does however, highlight areas where improvement
need to be made
3. We appreciate that Community Hospitals are an
important part of the trusts services to the general
Worcestershire Community However; we would also
expect the work of Community Hospitals and medical
care in prisons to be reported.
4. Healthwatch would also like to see information on the
provision of tier 3 & 4th beds for children. We would
expect to have information on the number of children
in those facilities and where those beds are and finally
some information on outcomes.
5. WE were greatly heartened to see a significant
reduction in waiting times for CAMHS. This Service
faces great pressures and it would have been helpful
to have reassurance that the improvements could be
maintained.
6. While it is appreciated that the Trust has more beds for
those with serious Mental Health conditions, it would
be useful to know how many patients are successfully
placed in the local hospital. Travel by families,
68
particularly, those without transport is becoming more
problematical.
7. Significant changes are taking place in the Children’s
Respite Services. Fewer days are being offered to
parents and there is the prospect of variable days
being introduced. Healthwatch would like reassurance
that parents have been involved and meaningfully
consulted on the proposed changes.
8. The Trust is to be congratulated in the successful
efforts it has made in significantly improving
employment for those with Mental Health conditions.
All the more laudatory in a period of recession.
9. We note with interest the use of people who have
experienced mental health conditions in hospital
treatment teams and are impressed by the results. We
appreciate this is a relatively new departure but are
intrigued by the possibility of such a development in
other areas of the service.
10. We would like to add our support to the trusts vision
that whenever possible services should be provided
in a person’s own home and we look forward to the
vision being converted to a reality. However, we
also recognise that some beds will be needed in
Community Hospitals and that the balance requires
fine judgements and delicate handling.
Quality Account Priorities – progress
review and looking forward.
1. We would find it useful to understand how learning
from complaints manifests itself in improvements in
the service. We would also be interested to learn if that
process contained a module or section on Customer
Care, since many complaints contain concerns about
poor communication with carers.
2. We note that the Trusts objective to eradicate pressure
ulcers, are behind schedule. While we appreciate the
difficulties we would encourage the trust to continue
to strive to eliminate those ulcers that are avoidable.
It would be useful to understand when ulcers are
unavoidable.
3. We support the Trust plans to improve Sexual Health
Services for young people.
Annual Report 2014-15
Statement of directors’
responsibilities in respect of
the Quality Account
Quality Account Technical SectionMandatory Statement
We would find it helpful to understand the circumstances
in which the warning was issued by the CQC, In view
of reports that there are difficulties with Healthcare
in Prisons and Worcestershire Health Trust have
responsibilities her, more information would be
welcome.
Worcestershire Healthwatch.
Statement of directors’ responsibilities in respect of the
Quality Account
The directors are required under the Health Act 2009
to prepare a Quality Account for each financial year.
The Department of Health has issued guidance on the
form and content of annual Quality Accounts (which
incorporates the legal requirements in the Health Act
2009 and the National Health Service (Quality Accounts)
Regulations 2010 (as amended by the National Health
Service (Quality Accounts) Amendment Regulations
2011).
In preparing the Quality Account, directors are required
to take steps to satisfy themselves that:
• The Quality Account presents a balanced picture of the
Trust’s performance over the period covered;
• The performance information reported in the Quality
Account is reliable and accurate;
• There are proper internal controls over the collection
and reporting of the measures of performance included
in the Quality Account, and these controls are subject
to review to confirm that they are working effectively in
practice;
• The data underpinning the measures of performance
reported in the Quality Account is robust and reliable,
conforms to specified data quality standards and
prescribed definitions, and is subject to appropriate
scrutiny and review; and
• The Quality Account has been prepared in accordance
with Department of Health guidance.
The directors confirm to the best of their knowledge and
belief they have complied with the above requirements
in preparing the Quality Account.
By order of the Board
25 June 2014 ________________________________
Chair
25 June 2014
_________________________________
Chief Executive
Quality accounts
69
70
Annual Report 2014-15
Quality accounts
71
72
Annual Report 2014-15
Financial statements
The Financial Statements shown on
the following pages are a summary of
the information set out in the Trust’s
statutory accounts for the year ended
31 March 2014. The Annual Report
and Accounts (ARA) document is
available on request from the Director
of Finance at Isaac Maddox House,
Shrub Hill Road, Worcester, WR4 9RW
(Tel. 01905 760020).
expenditure within its capital resource limit.
The operating revenue surplus of £2.9m, includes an
additional £0.6m on a non-recurrent basis, and was
delivered on a turnover of £172m. The cash and capital
out-turns were both satisfactorily managed, the latter to
within a thousand pounds of the agreed limit.
The 2014/15 budgets have been approved by the Trust
Board and Service Delivery Unit managers can look
forward to operating and managing services in the
knowledge that their budgets have been adequately
funded for inflation and that the Trust has a contingency
reserve of 1%.
The annual report itself comprises of:
• Strategic report (replaces the business review),
• Directors’ report,
• Remuneration report
• A statement of the Accountable Officer’s responsibilities
• A Governance Statement
• The primary financial statements and notes to the
accounts.
• The audit opinion and report.
I am pleased to report that the Trust is well placed to
deliver its healthcare responsibilities over the longer
term with the Trust Board having approved a robust
5 year long term financial plan and integrated
business plan.
It is pleasing to report that for the third consecutive year
the Trust has achieved each of its statutory financial
duties by delivering overall financial balance, operating
within its external financing limit and managing capital
The Trust is proud of the achievements delivered over the
last year and looks forward with confidence to 2014/15
and beyond.
These plans are currently being updated and are being
critically appraised and tested to ensure that there will be
no diminution in the quality of our services.
The external auditors have issued an unqualified opinion on the Trust’s 2013/14 annual report and accounts.
That opinion confirmed that the information given in the 2013/14 annual report is consistent with the financial
statements.
Worcester Cathedral and the River Severn, Worcester
Financial accounts
73
Statement of Comprehensive Income for year ended 31 March 2014
2013-14
£000
2012-13
£000
Employee benefits
(129,458)
(124,255)
Other Operating costs
(41,755)
(43,224)
Revenue from patient care activities
165,726
155,906
Other Operating revenue
6,588
14,929
Operating surplus/(deficit)
1,101
3,356
Investment revenue
39
35
Other gains and (losses)
0
(363)
Finance costs
(205)
(204)
Surplus/(deficit) for the financial year
935
2,824
Public dividend capital dividends payable
(713)
(986)
Retained surplus/(deficit) for the year
222
1,838
Impairments and reversals
41
(272)
Net gain/(loss) on revaluation of property, plant & equipment
3,527
0
Net gain/(loss) on revaluation of intangibles
0
0
Net gain/(loss) on revaluation of financial assets
0
0
Net gain/(loss) on other reserves
0
0
Net gain/(loss) on available for sale financial assets
0
0
Net actuarial gain/(loss) on pension schemes
0
0
Reclassification adjustment on disposal of available for sale financial assets
0
0
Other Comprehensive Income for the year
3,568
(272)
Total Comprehensive Income for the year
3,790
1,566
Retained surplus/(deficit) for the year
222
1,838
Prior period adjustment to correct errors
0
0
IFRIC 12 adjustment
0
0
Impairments
2,672
667
Adjustments iro donated asset/gov’t grant reserve elimination
26
17
Adjustment re Absorption accounting
0
0
Adjusted retained surplus/(deficit)
2,920
2,522
Other Comprehensive Income
Financial performance for the year
The Trust’s Reported NHS financial performance position is derived from its retained surplus, but adjusted for the
following:
a) Impairments to Fixed Assets 2013/14 which were based upon the District Valuer’s report on the Trust’s land and
buildings.
b) Depreciation on donated assets.
74
Annual Report 2014-15
Statement of Financial Position as at 31 March 2014
31 March 2014
31 March 2013
£000
£000
Property, plant and equipment
89,762
43,241
Intangible assets
4
36
Investment property
0
0
Other financial assets
0
0
Trade and other receivables
0
0
Total non-current assets
89,766
43,277
Inventories
433
444
Trade and other receivables
4,020
7,707
Other financial assets
0
0
Other current assets
0
0
Cash and cash equivalents
12,520
9,105
Total current assets
16,973
17,256
Non-current assets held for sale
1,185
1,150
Total current assets
18,158
18,406
Total assets
107,924
61,683
Trade and other payables
(15,354)
(17,102)
Other liabilities
0
0
Provisions
(1,371)
(910)
Borrowings
(38)
(76)
Other financial liabilities
0
0
Working capital loan from Department
0
0
Capital loan from Department
(764)
(764)
Total current liabilities
(17,527)
(18,852)
Non-current assets plus/less net current assets/liabilities
90,397
42,831
Non-current assets:
Current assets:
Current liabilities
Financial accounts
75
Statement of Financial Position as at 31 March 2014 continued
31 March 2014
31 March 2013
£000
£000
Non-current liabilities
Trade and other payables
0
0
Other Liabilities
0
0
Provisions
(2,535)
(1,889)
Borrowings
0
(38)
Other financial liabilities
0
0
Working capital loan from Department
0
0
Capital loan from Department
(4,753)
(5,517)
Total non-current liabilities
(7,288)
(7,444)
Total Assets Employed:
83,109
35,387
Public Dividend Capital
34,732
34,181
Retained earnings
35,074
(90)
Revaluation reserve
13,277
1,270
Other reserves
26
26
Total Taxpayers’ Equity:
83,109
35,387
FINANCED BY:
TAXPAYERS’ EQUITY
The financial statements on pages 74 to 80 were approved by the Audit Committee under the delegated
authority of the Trust Board on 5 June 2014 and signed on its behalf by:
Sarah Dugan
Chief Executive
76
Annual Report 2014-15
Statement of Changes in Taxpayers’ Equity For the year ended 31
March 2014
Public
Dividend
capital
Retained
earnings
Revaluation Other
reserve
reserves
Total
reserves
£000s
£000s
£000s
£000s
£000s
34,181
(90)
1,270
26
35,387
Retained surplus for the year
0
222
0
0
222
Net gain / (loss) on revaluation of property, plant, equipment
0
0
3,527
0
3,527
Balance at 1 April 2013
Changes in taxpayers equity for 2013-14
Net gain / (loss) on revaluation of intangible assets
0
0
0
0
0
Net gain / (loss) on revaluation of financial assets
0
0
0
0
0
Net gain / (loss) on revaluation of assets held for sale
0
0
0
0
0
Impairments and reversals
0
0
41
0
41
Other gains/(loss)
0
0
0
0
0
Transfers between reserves*
0
162
(162)
0
0
Transfers under Modified Absorption Accounting - PCTs & SHAs
0
43,381
0
0
43,381
Transfers to/(from) Other Bodies within the Resource Account
Boundary
0
0
0
0
0
Transfers between Revaluation Reserve & Retained Earnings in
respect of assets transferred under absorption
0
0
0
0
0
Reclassification Adjustments
On Disposal of Available for Sale financial Assets
0
0
0
0
0
Reserves eliminated on dissolution
0
0
0
0
0
Originating capital for Trust established in year
0
0
0
0
0
New PDC Received**
551
0
0
0
551
PDC Repaid In Year**
0
0
0
0
0
PDC Written Off
0
0
0
0
0
Transferred to NHS Foundation Trust
0
0
0
0
0
Other Movements in PDC In Year
0
0
0
0
0
Net Actuarial Gain/(Loss) on Pension
0
0
0
0
0
Net recognised revenue/(expense) for the year
551
43,765
3,406
0
47,722
Transfers between reserves in respect of modified absorption PCTs & SHAs
0
(8,601)
8,601
0
0
Balance at 31 March 2014
34,732
35,074
13,277
26
83,109
Financial accounts
77
Statement of Changes in Taxpayers’ Equity For the year ended 31
March 2014 contined.
Balance at 1 April 2012
Public
Dividend
capital
Retained
earnings
Revaluation Other
reserve
reserves
Total
reserves
£000s
£000s
£000s
£000s
£000s
32,412
(2,038)
1,652
26
32,052
Changes in taxpayers equity for 2012-13
Retained surplus/(deficit) for the year
0
1,838
0
0
1,838
Net gain / (loss) on revaluation of property, plant, equipment
0
0
0
0
0
Net gain / (loss) on revaluation of intangible assets
0
0
0
0
0
Net gain / (loss) on revaluation of financial assets
0
0
0
0
0
Net gain / (loss) on revaluation of assets held for sale
0
0
0
0
0
Impairments and reversals
0
0
(272)
0
(272)
Movements in other reserves
0
0
0
0
0
Transfers between reserves*
0
110
(110)
0
0
Release of reserves to Statement of Comprehensive Income
0
0
0
0
0
0
0
0
0
0
Reclassification Adjustments
Transfers to/(from) Other Bodies within the Resource Account
Boundary
On Disposal of Available for Sale financial Assets
0
0
0
0
0
Reserves eliminated on dissolution
0
0
0
0
0
Originating capital for Trust established in year
0
0
0
0
0
New PDC Received
2,718
0
0
0
2,718
PDC Repaid In Year
(949)
0
0
0
(949)
PDC Written Off
0
0
0
0
0
Transferred to NHS Foundation Trust
0
0
0
0
0
Other Movements in PDC In Year
0
0
0
0
0
Net Actuarial Gain/(Loss) on Pension
0
0
0
0
0
Net recognised revenue/(expense) for the year
1,769
1,948
(382)
0
3,335
Balance at 31 March 2013
34,181
(90)
1,270
26
35,387
Notes:
* Transfers between reserves relates to backlog depreciation.
** The values for new PDC received in year and PDC repaid in year relate to the transfer of assets between
this Trust and Worcestershire Acute Hospitals NHS Trust.
78
Annual Report 2014-15
Statement of Cash Flows for the year ended 31 March 2014
2013-14
2012-13
£000
£000
Operating Surplus/Deficit
1,101
3,356
Depreciation and Amortisation
2,881
2,288
Impairments and Reversals
2,672
667
Other Gains / (Losses) on foreign exchange
0
0
Donated Assets received credited to revenue but non-cash
0
0
Government Granted Assets received credited to revenue but non-cash
0
0
Interest Paid
(157)
(153)
Dividend paid
(649)
(1,053)
Release of PFI/deferred credit
0
0
(Increase)/Decrease in Inventories
11
(22)
(Increase)/Decrease in Trade and Other Receivables
3,623
4,092
(Increase)/Decrease in Other Current Assets
0
0
Increase/(Decrease) in Trade and Other Payables
(3,442)
1,829
(Increase)/Decrease in Other Current Liabilities
0
0
Provisions Utilised
(434)
(198)
Increase/(Decrease) in Provisions
1,493
666
Net Cash Inflow/(Outflow) from Operating Activities
7,099
11,472
Interest Received
39
35
(Payments) for Property, Plant and Equipment
(4,584)
(8,748)
(Payments) for Intangible Assets
0
0
(Payments) for Investments with DH
0
0
(Payments) for Other Financial Assets
0
0
(Payments) for Financial Assets (LIFT)
0
0
Proceeds of disposal of assets held for sale (PPE)
1,150
949
Proceeds of disposal of assets held for sale (Intangible)
0
0
Proceeds from Disposal of Investment with DH
0
0
Proceeds from Disposal of Other Financial Assets
0
0
Proceeds from the disposal of Financial Assets (LIFT)
0
0
Loans Made in Respect of LIFT
0
0
Loans Repaid in Respect of LIFT
0
0
Rental Revenue
0
0
Net Cash Inflow/(Outflow) from Investing Activities
(3,395)
(7,764)
NET CASH INFLOW/(OUTFLOW) BEFORE FINANCING
3,704
3,708
Cash Flows from Operating Activities
CASH FLOWS FROM INVESTING ACTIVITIES
Financial accounts
79
Statement of Cash Flows for the year ended 31 March 2014 continued
2013-14
2012-13
£000
£000
CASH FLOWS FROM FINANCING ACTIVITIES
80
Public Dividend Capital Received
551
2,718
Public Dividend Capital Repaid
0
(949)
Loans received from DH - New Capital Investment Loans
0
3,000
Loans received from DH - New Working Capital Loans
0
0
Other Loans Received
0
0
Loans repaid to DH - Capital Investment Loans Repayment of Principal
(764)
(464)
Loans repaid to DH - Working Capital Loans Repayment of Principal
0
0
Other Loans Repaid
(76)
(76)
Cash transferred to NHS Foundation Trusts
0
0
Capital Element of Payments in Respect of Finance Leases and On-SoFP PFI and LIFT
0
0
Capital grants and other capital receipts
0
0
Net Cash Inflow/(Outflow) from Financing Activities
(289)
4,229
NET INCREASE/(DECREASE) IN CASH AND CASH EQUIVALENTS
3,415
7,937
Cash and Cash Equivalents ( and Bank Overdraft) at Beginning of the Period
9,105
1,168
Effect of Exchange Rate Changes in the Balance of Cash Held in Foreign Currencies
0
0
Cash and Cash Equivalents (and Bank Overdraft) at year end
12,520
9,105
Annual Report 2014-15
Pension Liabilities
Past and present employees are covered by the provisions of the NHS Pensions Scheme. Details of the benefits
payable under these provisions can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions. The
scheme is an unfunded, defined benefit scheme that covers NHS employers, GP practices and other bodies, allowed
under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that
would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the scheme
is accounted for as if it were a defined contribution scheme: the cost to the NHS Body of participating in the scheme is
taken as equal to the contributions payable to the scheme for the accounting period.
Other Creditors include £1,730,000 pension costs at 31 March 2014 (£1,616,000 at 31 March 2013). The accounting
policy for Pensions and outline of the scheme is set out on page 23 of the Trust’s Annual Accounts.
The remuneration report on page 115 of the Annual Report provides the details of the pension entitlements of Senior
Managers.
Better Payment Practice Code
Measure of compliance
2013-14
2013-14
2012-13
2012-13
Number
£000
Number
£000
Total Non-NHS trade invoices paid in the year
30,580
31,961
31,900
27,527
Total Non-NHS trade invoices paid within target
29,686
31,191
31,093
27,087
Percentage of NHS trade invoices paid within target
97.1%
97.6%
97.5%
98.4%
Total NHS Trade Invoices Paid in the Year
669
16,727
987
19,193
Total NHS Trade Invoices Paid Within Target
651
16,679
977
19,135
97.3%
99.7%
99.0%
99.7%
Non-NHS Payables
NHS Payables
Percentage of NHS Trade Invoices Paid Within Target
The Better Payment Practice Code requires the Trust to aim to pay all valid invoices by the due date or within 30 days
of receipt of a valid invoice, whichever is later.
Prompt Payments Code:
The Trust has applied to join the prompt payment code in accordance with David Nicholson’s letter of 18 May 2009.
Financial accounts
81
Related party transactions
Details of related party transactions with individuals are as follows:
Age UK Herefordshire and Worcestershire (spouse of Trust Chairman is Head
of Finance of this related party)
Payments to
Related Party
Receipts from
Related Party
Amounts
owed to
Related
Party
Amounts
due from
Related
Party
£
£
£
£
684
0
0
0
Worcestershire Health and Care NHS Trust is a corporate trustee of Worcestershire Health and Care NHS Trust
Charitable Funds (Charity No. 1060335) The Trust has received revenue payments from this Charity, which
are summarised below. The unaudited summary financial statements of this Charity are included in the
Trust’s annual report.
Payments to
Related Party
Receipts from
Related Party
Amounts
owed to
Related
Party
Amounts
due from
Related
Party
£
£
£
£
0
17,983
0
0
The transactions between the Trust and the Charity are:
Administration fee
The Trust has not made any provisions for doubtful debts in respect of transactions with related parties.
The Department of Health is regarded as a related party. During the year Worcestershire Health and
Care NHS Trust has had a significant number of material transactions with the Department and with
other entities for which the Department is regarded as the parent Department. The entities where these
transactions were at least £500,000 in value for the year are:
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Annual Report 2014-15
Related Party
Birmingham Cross City CCG
Birmingham South and Central CCG
Health Education England
Herefordshire CCG
NHS England (Arden, Herefordshire & Worcestershire Area Team)
Purpose of Transaction
Supply of Healthcare
Supply of Healthcare
Funding for Training
Supply of Healthcare
Supply of Healthcare
NHS England (Shropshire and Staffordshire Area Team)
Redditch and Bromsgrove CCG
South Worcestershire CCG
Worcestershire Acute Hospitals NHS Trust
Supply of Healthcare
Supply of Healthcare
Supply of Healthcare
Purchase/Supply of
Healthcare
Supply of Healthcare
Wyre Forest CCG
In addition, the Trust has had a number of material transactions, a total of at least £100,000 in value in year, with other
central and local government bodies. These transactions have been with:
Related Party
Bromsgrove District Council
HM Revenue & Customs
Malvern Hills District Council
NHS Pensions Agency
Redditch Borough Council
Staffordshire County Council
Worcestershire City Council
Worcestershire County Council
Wychavon District Council
Wyre Forest Council
Financial accounts
Purpose of Transaction
Payment of Rates
Payment of Income Tax
Payment of Rates
Payment of
Superannuation
Payment of Rates/Supply
of Healthcare
Supply of Healthcare
Payment of Rates
Supply of Healthcare/
Staff Costs
Payment of Rates/Rent
Payment of Rates
83
NHS Trust Charitable Funds 2013-14
The unaudited summary financial statements for the Worcestershire Health and Care NHS Trust Charitable Funds
(Charity No. 1060335) are shown below:
Unaudited Statement of financial activities for the year ended 31 March 2014
Recommended categories by activity
Unrestricted
funds
Restricted funds
Endowment
funds
Total 2013/14
Total 2012/13
£000
£000
£000
£000
£000
Incoming resources
Incoming resources from generated funds
0
0
0
0
0
37
150
0
187
184
0
0
0
0
0
Investment income
10
19
0
29
24
Total incoming resources
47
169
0
216
207
Costs of Generating Funds
0
0
0
0
0
Investment management costs
2
2
0
4
4
Charitable activities
7
52
0
59
92
Governance costs
7
13
0
20
19
Other resources expended
0
0
0
0
22
16
67
0
83
138
31
102
0
133
70
8
9
0
17
55
39
111
0
150
125
Total funds brought forward at 1 April 2013
251
633
0
884
759
Total funds carried forward at 31 March 2014
290
744
0
1,034
884
Voluntary income
Activities for generating funds
Resources expended
Total resources expended
Net incoming/(outgoing) resources before other
recognised gains/(losses)
Gains and losses on investment assets
Net movement in funds
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Annual Report 2014-15
NHS Trust Charitable Funds 2013-14
Unaudited Balance Sheet as at 31 March 2014
Unrestricted
funds
Restricted funds
Endowment
funds
Total 2013/14
Total 2012/13
£000
£000
£000
£000
£000
Fixed assets
Investments
253
696
0 949
784
253
696
0
949
784
Stock and work in
progress
0 0 0 0
0
Debtors
1
3
0 4
4
36
48
0 84
107
37
51
0
88
111
0 3
0 3
11
Net current assets
37
48
0
85
100
Total net assets
290
744
0
1,034
884
Unrestricted funds
290
0 0 290
251
Restricted income
funds
0 744
0 744
633
Endowment funds
0 0 0
0 0
290
744
0
1,034
884
Total fixed assets
Current assets
Cash at bank and in
hand
Total current assets
Creditors: amounts
falling due within
one year
Funds of the Charity
Total funds
Financial accounts
85
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Financial accounts
87
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Annual Report 2014-15
Financial accounts
89
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Financial accounts
91
Operating and financial review (OFR)
1. Nature, objectives and strategies of the business.
This provides an understanding of the NHS body, including a description of:
The location and type
of facilities provided
and the structure of the
business including its
main services and users
The Trust is one of two local National Health Service organisations that provide healthcare
services commissioned by the three Clinical Commissioning Groups in Worcestershire and
other neighbouring Commissioners, including Worcestershire County Council. 85% of the
Trust’s £172m income will be secured through CCG commissioning arrangements, with
7% commissioned by NHS England and 8% through the Public Health service within the
Local Authority.
The Trust is the main provider of community, specialist primary care and mental health
services to the population of Worcestershire and beyond. Many of our services, including
learning disability services are integrated with Worcestershire County Council and we
work in partnership across the county with voluntary organisations, our commissioners
and communities to deliver high quality services.
The Trust’s main responsibilities cover:
1. Working to deliver the best possible healthcare to the Trust’s patients in hospital, in
the community and at home. For example the Trust provides these services from 150
properties across Worcestershire, including the community hospitals in Bromsgrove,
Evesham, Pershore, Malvern and Tenbury along with various health centres and clinics.
The Trust also delivers mental health in-patient care from four hospitals in Worcester,
Redditch, Bromsgrove and Kidderminster. The Trust has a total of 402 inpatient beds.
2. Safeguarding the organisation’s assets and public funds.
3. Maintaining a sound system of internal control that supports the achievement of the
organisation’s objectives.
4. Reporting upon its performance across the Targets and Performance indicators required
by the Trust Development Authority; and to the Department of Health.
5. Delivering healthcare that is good value for money.
The Trust is governed by a Board, which is supported by the following formal committees
who meet on a regular basis throughout the year to review and assess and regulate the
activities and responsibilities of the Trust:
• Finance and Performance
• Quality and Safety
• Audit
• Remuneration
• Charitable funds
• Community Engagement (up to July 2013)
The Board has also established a Foundation Trust Programme Board to oversee the Trust’s
application for NHS Foundation Trust status and a Partnership Forum is being developed
to facilitate joint working and sharing of information across partner organisations. This
forum is not a Board committee.
The Trust currently measures performance against three performance regimes, which
are the Trust Development Authority Provider Management Regime, the Mental Health
Performance Framework and Monitor’s Compliance Framework.
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Annual Report 2014-15
The 5 Service Delivery Units (SDUs) are responsible for the delivery of services, including
all aspects of performance, quality, activity, assurance and financial matters, as well as
significantly contributing to strategy and service development. The corporate services
‘wrap around’ SDUs to support overall strategic planning, implement and deliver against
plans and provide assurance against all governance frameworks.
The 5 Service Delivery Units are:
• Community care
• Adult Mental Health
• Children, Young People and Families
• Specialist Primary Care
• Integrated Learning Disability
The external
Worcestershire Health and Care NHS Trust serves a population of approximately 569,000
environment in which it across an area of approximately 500 square miles, with a relatively high proportion of
operates
residents aged 65 and above, whereas in Worcester City there is a significant student
population.
A brief history of the
NHS body and its
statutory background
Disclosure on legacy
balance transfers
Worcestershire Health and Care NHS Trust was established on 1 July 2011 to manage the
vast majority of the services which were previously managed by Worcestershire PCT’s
Provider Arm, as well as the mental health services that were managed by Worcestershire
Mental Health Partnership NHS Trust. Bringing together the range of services provided by
the two organisations has offered opportunities to improve integration and partnership
working which are central to the Trust’s objectives.
The Trust is a community based provider of comprehensive health and social care services,
expertise and choices for people with a range of health needs and/or disabilities. These
services are provided in a wide range of community settings. These include people’s own
homes, community clinics, outpatient departments, community inpatient beds, prisons,
schools and GP practices. We also provide in-reach services into acute hospitals, nursing
and residential homes and social care settings.
In accordance with the Health and Social Care Act 2012, Strategic Health Authorities
and Primary Care Trusts were dissolved on 1 April 2013 and their assets and liabilities
transferred to successor bodies in the NHS or to other entities. Under the terms of the
Property Transfer Scheme: Schedule of properties and property related assets and
liabilities, a number of assets and liabilities were transferred from Worcestershire Primary
Care Trust to the Trust on that date. The most significant of these were:
• Evesham Community Hospital
• Malvern Community Hospital (Seaford Court)
• Princess of Wales Community Hospital
• Tenbury Community Hospital
These assets and liabilities are associated with the Transforming Community Services
(TCS) plan, under which the responsibility for providing many services previously
provided by the Worcestershire Primary Care Trust passed to the Trust on 1 July 2011.
The accounting arrangements in respect of these transfers are outlined in Note 1.3 to the
Annual Accounts.
Financial accounts
93
The objectives of the
Trust over the long
term, the time scale
used being dependent
on the type of
objective. Objectives
will be defined in terms
of non-financial and
financial performance
The Trust has developed a five year integrated business plan that sets out the strategic
direction for the organisation. The Trust’s vision is to be:
‘A leading organisation that works effectively in partnership with our stakeholders
to deliver high quality integrated health and care services’
The Trust has defined a set of values that clarify what it believes in and how it will behave:
• Courageous:Displaying integrity, loyalty and the courage to always do what is
right
• Ambitious: Striving to innovate and to improve through effective teamwork
• Responsive:Focusing on the needs and expectations of people using our services
• Empowering:Empowering people to take control of their own health and wellbeing
• Supportive:Enabling our staff to achieve full potential and take pride in the
services that they deliver.
To achieve the Trust Vision four strategic goals have been set out, these are:
• We will always provide an excellent patient experience
• Our services will always be safe and effective
• We will work in partnership to improve the integration of health and care
• Our organisation will be efficient, inclusive and sustainable
Following the formal establishment of the Trust further work has been undertaken to
develop a clinical strategy. It sets out how the organisation will drive forward clinical care
and improvements in quality over the next 5 years. The following statement summarises
the Trust’s Clinical Strategy:
‘We deliver high quality expertise and choices for people with a range of health
needs and/or disabilities that enable people to live independently or as close to
home as possible’
The Trust’s strategic goals have been subdivided into corporate objectives that are more
specific. The ten corporate objectives are listed below, the Trust defines specific projects
to deliver each of the corporate objectives:
• To stimulate a revolution in the way we engage with patients
• To redesign clinical pathways
• To ensure patient safety
• To ensure seamless care through integrating services
• To strengthen leadership within our services
• To develop our workforce
• To improve our use of technology
• To develop business opportunities
• To deliver our efficiency programme
• To make effective use of our estate
As part of the Trust’s planning process it has developed a clear plan for each of the
services that it currently delivers and also considered market opportunities that could
build on the strengths of the organisation. The Trust has ambitious plans to develop its
services so that it is in a stronger position to work with partners across the health and
social care community to support people to live independently at home or as close to
home as possible through the provision of high quality, integrated health care.
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Annual Report 2014-15
The directors’ strategies
for achieving the
objectives of the NHS
body and the effect
of past and current
actions undertaken.
This includes the Key
Performance Indicators,
both financial and
non-financial, used by
the directors to assess
progress against their
stated objectives
At the start of the year the Board recognised, as it has in previous years, that it had a series
of development needs and has throughout the year worked to ensure that the Directors
continue to enhance and develop their skills and competencies to deliver the Trust’s
vision. During 2013/14 the Chairman and Chief Executive have both been subject to 360
degree appraisal as part of their respective personal development. The afternoon of each
of the six public Board meetings and an additional five days have been used to address
specific Board development needs; or to dedicate time to consider a particular strategic
issue e.g. the Francis report.
The Trust’s aims and objectives are to establish mechanisms for monitoring and reviewing
management performance and to ensure the Trust’s objectives are met, to oversee the
delivery of planned services, to develop and maintain an annual business plan and to
ensure that national policies and strategies are effectively addressed and implemented
within the Trust. Key issues remain the quality and safety of services provided, identifying
risks to strategic goals, identifying and delivering cost improvement programmes and
achieving Foundation Trust status. The Executive Directors have all agreed personal
objectives with the Chief Executive which delivers their contribution to the Trust’s
strategies and key objectives. The Directors cascade their objectives to the Associate
Directors, who in turn discuss and agree the objectives that they lead on. The Associate
Directors then follow the same annual process with the Service Delivery Unit Leads and
other Heads of Service.
The formal committees to the Board meet on a regular basis throughout the year to
review and assess progress with the delivery of the Trust’s strategies and objectives.
The Committees are supported in their work by other key stakeholder meetings, such
as the Contract Management Board, which is chaired by the one of the local Clinical
Commissioning Groups.
The Chairman of each Committee presents a report to the Board on the important matters
considered by their respective Committees.
The Trust Board also receives performance reports at every meeting.
The organisation’s key priorities and plans for 2013/14 include the work programmes
that have been agreed for the various corporate departments and the 5 service delivery
units. Detailed action plans, with quarterly milestones, have also been developed and are
monitored via the Trust’s performance review process.
In addition to these priorities and work programmes, the Trust has to deliver against a
range of statutory targets and standards including:
• 18 week referral to treatment waiting time targets
• Zero tolerance of waits over 52 weeks
• Minor Injuries Unit attenders admitted, transferred or discharged within 4 hours
• Compliance with mixed sex accommodation
• Care Programme Approach follow up within 7 days
• Psychological therapy access (subject to commissioner funding)
• Zero tolerance of Meticillin-resistant staphylococcus Aureusis (MRSA)
• Delivery of agreed Clostridium difficile (Cdiff ) Infection rate trajectory
The Trust has also agreed a number of Commissioning for Quality and Innovation
payments (CQUINS) for 2013/14, including the engagement of family/friends and carers/
advocates in the care planning process and improving the physical health care for people
with severe and enduring mental health problems. The financial plan for 2013/14 builds
on the financial position delivered in 2012/13 and the financial requirements of being a
Foundation Trust. The financial plan looks to increase the overall surplus, create stronger
contingency flexibility and deal with the legacy issues brought forward from both
previous organisations.
Financial accounts
95
2. Development and performance of the business for the period under review and in the future
The significant features
of the development
and performance of the
NHS body in the year
The major service transformation programmes that the Trust will focus on over the next 5
years are:
• Extended Primary Care Teams
• Community Enhanced Care Teams
• Community Treatment Hubs
• Mental Health Inpatient and Community Care (including Personality Disorders)
• Psychiatric Liaison
• Learning Disability Crisis and Resolution Service
• Health and Social Care Integration
• Children’s Services
Although these areas of work represent major transformation there are significant
programmes of change and development across the organisation which have been
phased over the 5 year timeframe of the integrated business plan.
The Trust received additional recurrent funding of £1,142k in 2013/14 in respect of the
following service developments:
• Enhanced Care Development £500k,
• Increase Administration support for the Admissions Prevention Service £17k,
• Additional Weekly Blood Collection - HMP Long Lartin £3k,
• LD Enhanced Community Service £333k,
• Chlamydia Screening £37k,
• Fall Specialist Physiotherapist £22k,
• Health Visitor expansion £210k and,
• £20k additional recurrent investment in Every Child a Talker (ECAT).
The Trust’s performance against the 2013/14 key national targets are reported upon on
page 19.
Analysis of the main
trends and factors that
Directors consider
likely to impact on the
future, including the
development of new
services or the benefits
expected from capital
investment
The main trends and factors that Directors consider likely to impact on the future include
the requirement for delivering the Trust’s £7.7m cost improvement programme, in a
recurrent manner; the development of service line reporting and the achievement of
Foundation Trust status. The target date for Foundation Trust is currently uncertain due
to the revised application process, which now involves the Chief Inspectors visit. This is
a new form of Care Quality Commission (CQC) inspection, which reviews the quality of
care and patient experience across a range of health facilities. If this is cleared it will be
followed by a Board to Board meeting with the Trust Development Authority before an
inspection by Monitor, the economic regulator.
Currently, the Trust does face a degree of delivery risk, for planned CIP schemes, arising
from Commissioner approval.
The main Capital developments planned within the 2014/15 £6.4m programme concern
the implementation of the Estates Strategy (£3.4m), Backlog Maintenance (£0.8m),
Information Technology (£0.9m), Ward Refurbishment (£0.3m) and PLACE (Patient Led
Assessments of the Care Environment) £0.4m.The balance of £0.6m will be invested in
areas such as equipment replacement, anti-ligature works and invest to save schemes.
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Annual Report 2014-15
The current level
of investment
expenditure; and
planned future
expenditure and how
this will assist the NHS
body to achieve its
objectives
In 2013/14 the Trust used internally generated funds from depreciation and brought
forward revenue surpluses and an asset sale to cover a capital programme of £5.6m. The
Trust’s main strategic scheme last year was the completion of the modernisation of New
Haven, an Older Adult MH Inpatient facility, which cost £1.2m in year.
The Trust also spent £1.3m on implementing its estates strategy, £1.2m on backlog
maintenance, £0.5m on ward refurbishments and £0.4m was spent on PLACE.
The other areas of substantial expenditure included the replacement of equipment £0.4m,
anti-ligature works of £0.2m and information technology £0.4m.
Overall there was an £1k under spend against the Trust’s 2013/14 Capital Resource Limit.
3. The resources, principal risks and uncertainties and relationships that may affect the entity’s long term
value
A description of the
resources available to
the NHS body and how
they are managed
For 2013/14, the total turnover for the Trust (mainly received via healthcare contracts with
the three Worcestershire Clinical Commissioning Groups, Worcestershire County Council
and other NHS Commissioners) was £172m (£171m last year). Budgets are set throughout
the Trust up to this limit and it is the responsibility of Budget Holders to ensure that the
Service Delivery Units are managed within the allocated budget. Progress during the year
on this important area of responsibility is reported at Trust Board meetings and in detail
at the Finance and Performance Committee. The business of the Trust is governed by
the Trust’s Standing Orders and Standing Financial Instructions; and spending decisions
regulated through an approved Scheme of Delegation.
The Reported NHS Financial Performance for the year ended 31 March 2014 is an end of
year surplus of £222k. This is adjusted for two technical items:
• impairments of the Trust’s assets (due to professionally assessed building valuations)
£2,672k and,
• depreciation on the Trust’s donated assets £26k.
The Adjusted Retained Surplus is therefore £2,920k, which is in accordance with the plan
and target surplus agreed with the Trust Development Authority.
The key strengths and
resources, tangible
and intangible, which
assist it in the pursuit
of its objectives and, in
particular, those items
that are not reflected in
the balance sheet
Financial accounts
The Trust employs 3,200 whole time equivalent staff and has a skilled and committed
workforce to meet the challenges of delivering high quality healthcare. The significant
contribution made by the Trust’s staff at all levels across clinical and non-clinical activities
continues to be a key factor in the Trust’s success.
Another major strength of the Trust is its strong and positive partnerships with others
which help the Trust to achieve its objectives. Our key partnerships include:
• The Trust Development Authority,
• Clinical Commissioning Groups, for the provision of healthcare,
• Worcestershire County Council, for the pooled budget arrangements covered by section
75 of the NHS Health Act and Joint Commissioning Unit,
• Worcestershire Acute Hospitals NHS Trust, in the sharing of support services such as
Information Technology,
• Staff Side Representatives.
97
Disclosure of strategic,
commercial, operational
and financial risks
where these may
significantly affect the
NHS body’s strategies
and development
The Board Assurance Framework is a document in which the Trust Board sets out what it
considers to be the most significant risks it sees in meeting its 2013/14 objectives. Annual
workshops are arranged for the Board to review the framework by the Trust’s Internal
Auditors.
The Trust has identified a range of potential risks to achieving its strategic goals, across
clinical, non-clinical and financial sectors. The risks have been identified from the
Strengths, Weaknesses, Opportunities and Threats (SWOT) and other analyses and Service
Delivery Unit risk logs and they have been mapped against the Assurance Framework,
which the Board reviews at regular intervals.
The Board have identified the following as its top risks to delivering its annual plan. These
were identified at a Board Governance Assurance Framework workshop on 13 February
2013 and are as follows:
• Lack of comprehensive patient and public feedback,
• Local health and social care economy is not sustainable,
• Serious failure in quality of care provided,
• Inadequate IT systems including a lack of integrated electronic patient record,
• Commissioning decisions and processes inhibit implementation of strategic plans,
• Failure to identify and deliver cost improvement plans over a rolling 5-year period.
Action plans are in place to manage these risks, which are subject to scrutiny by the
relevant Board committee.
The Trust has identified the following future risk(s):
The directors’ policy
for managing principal
risks is to be disclosed
Risk
Mitigation
Over the next 5 years the
potential impact of cost
improvement programmes
(CIPs) on quality of services.
Impact assessments
undertaken on CIPs relating
to the delivery of clinical
services.
Outcome
In the period 1 April 201331 March 2014 there has
been no adverse impact
on the quality of clinical
services.
The Trust currently assesses and monitors risk by a variety of methods, not least via an
assurance framework. This is the key document for the Trust Board to ensure all principal
risks against strategic goals and associated corporate objectives are identified, managed,
controlled and reported upon. The assurance framework is presented to, and discussed
by, the Trust Board at each public meeting.
The Risk Management processes are guided and provided for by the Risk Management
Strategy. This sets out the organisation’s approach to risk and defines responsibilities and
roles of the Chief Executive, Directors, senior managers and all other staff in relation to
the effective delivery of the risk management agenda. It also highlights the links between
Risk Management, the Assurance Framework and the business planning process. There
is documented guidance for staff supported by comprehensive Policies and Procedures
available via the Trust’s intranet.
Whilst ultimate accountability rests with the Chief Executive, responsibility for risk
management has been delegated to the executive leads for risk. The Director of Quality
(Executive Nurse) and Medical Director have joint delegated responsibility for clinical risk
management and clinical governance. The Director of Finance is responsible for financial
risk management. The Company Secretary has delegated responsibility for managing
the strategic development and implementation of corporate risk management and
assurance, and is responsible for the development and maintenance of the Corporate Risk
Register. The work of the Quality and Safety Committee is supported by a number of sub
committees and working groups including the Clinical Risk Group.
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Annual Report 2014-15
As part of the risk management strategy, training is delivered to managers and to
other staff across the Trust, both at induction to the Trust and also as part of on-going
development. Areas covered include: risk management, risk assessment, incident
reporting, health and safety, infection control and the handling of complaints.
The key elements of the Risk Management strategy focus on:
• Individual and corporate responsibility,
• A structured framework for the management of risk with a clear definition of the roles
and responsibilities for directors, managers, clinicians and allied health professionals,
• A purposeful approach to enabling the Trust to embed risk management within its
structure and so support the Trust in meeting its new functions and objectives,
• Compliance with all relevant statutory and non-statutory standards relating to the
assessment and control of risk,
• Identifying, and where possible eliminating, risk and controlling any remaining risk,
• Monitoring the controls and procedures to ensure effective risk management within the
Trust.
Increasingly formal risk assessments are being undertaken locally. If advice and/or training
is required on clinical risk assessment this will be provided by the Quality Governance
Department. If advice and/or training is required on non-clinical/generic risk assessment
this will be provided by the Risk and Security Manager and/or Health and Safety Manager.
Risk assessment and incident reporting systems remain important to the on-going
assessment of risk. Evaluation of any, or all, control measures are considered, not only by
line management but also by the Quality Governance Department. This provides a robust
double check within the system.
All cost improvement plans are subject to a detailed quality and equality impact
assessment involving the Director of Quality (Executive Nurse) and Medical Director and/
or their nominees.
In respect of the publication of the report of the second Francis Inquiry into Mid
Staffordshire NHS Foundation Trust the Trust Board is reviewing ward staffing levels.
Implementation of the action plan relating to the Francis report and subsequent Berwick
and Keogh reports is overseen by the Quality and Safety Committee.
Information about
significant relationships
with stakeholders,
which are likely,
directly or indirectly,
to influence the
performance of the
Trust
Financial accounts
The Trust has good working relationships with a wide range of partners ranging from local
Clinical Commissioning Groups, Suppliers, Staff Side Representatives and employees to
the Worcestershire County Council for the delivery of healthcare through the Section 75
pooled budgets.
These strong and positive partnerships are a major strength helping the Trust to achieve
its objectives.
99
4. Position of the business, including a description of the capital structure, treasury policies and objectives
and liquidity of the entity both in the period under review and in the future.
The events that have
impacted on the
financial position of
the NHS body during
the year, and factors
that are likely to
affect the financial
position going
forward
The Trust commenced the financial year with a robust set of budgets and a 1% Contingency
Reserve, which was created in order to help the Trust manage risks and cost pressures and
unexpected service demands arising during the course of the year.
The main cost pressures reported to the Finance and Performance Committee during
2013/14 were as follows:
• Locum consultants
• Continence Service
• Bank and Agency costs
• Increase in legal fees
This is the Trust’s third Annual Report and this year’s surplus of £2.9m has been recorded on
a turnover of £172m, which is 1.69% up from 1.48% last year and 0.8% in 2011/12.
Looking forward the medium term financial position has a robust base with the Trust being
able to confidently forecast a £2.5m (1.5%) surplus position for 2014/15, having created and
maintained a Contingency Reserve (1%) for non-recurrent purposes.
Accounting policies
Standard NHS accounting policies have been adopted. The Trust has prepared its 2013/14
focusing on those
draft Final Accounts in a form that complies with the International Financial Reporting
which have required Standards (IFRS) and submitted them to the Department of Health and Auditors by the
the particular exercise required date of 23 April 2014.
of judgement and
which have changed
during the year
Continuity of Service
Risk Rating
The Continuity of Service Risk Rating used by Monitor, the Economic Regulator of
Foundation Trusts, focusses on the issues of liquidity and capital servicing. The Trust’s risk
rating overall at the end of March 2014 was a satisfactory 4, out of maximum of 5, that is
consistent with an aspirant Community Foundation Trust.
Cash flow issues
During the year the Trust took active measures to secure its working capital and cash
which supplement
liquidity. This initiative and move above the 10 days minimum operating cash required
information provided by Monitor, resulted in an increase in cash for 2013/14 of £2.4m.This over-delivery is
in the annual
allowable by the Trust Development Authority and there is no adverse impact on the Trust’s
accounts
performance against its External Financial Limit (EFL).
Carrying value versus
market value of land
The carrying value of the Trust’s land is £19.9m, which is based upon the District Valuation
Office’s valuation as at 31 March 2014.
5. Policies adopted and the extent to which they have been successfully implemented regarding
environmental, social and community issues:Sustainability report
This is included on page 11 of this report under the heading ‘Sustainability report’.
Emergency prepared- This is included on page 20 of this report under the heading ‘Emergency preparedness’.
ness
Complaints handling
procedure and
principles for remedy
Better Payments
Practice Code
This is included on pages 40 and 41 of this report under the heading ‘Continue to Improve
our Response Times and Learning from Complaints’.
The Trust’s measure of compliance on the Better Payments Practice Code is shown on page
81 of this report.
The Trust has for the second year running achieved full compliance on all 4 measures.
100
Annual Report 2014-15
Prompt Payments
Code
The Trust has applied to become a signatory to the Prompt Payments Code, and
authorisation is awaited, pending receipt of references.
The action taken to
maintain or develop
the provision of
information to and
consultation with the
Trust’s employees
The Trust has agreed over 80 Corporate policies and 35 Human Resource policies, which are
all shown on the Trust’s website.
While a majority of the policies are Health and Care Trust policies, some have been brought
over from either Worcestershire Primary Care NHS Trust or Worcestershire Mental Health
Partnership NHS Trust and will be replaced over the coming months by Trust Policies.
Every week the Chief Executive issues an update to all staff to share the latest news
regarding on-going developments. On a monthly basis a more detailed Team Brief is
provided to Directors for dissemination to all staff.
Health and safety
The Trust employs two staff to provide competent and professional support, advice and
guidance on all matters relating to health, safety and security:
• Risk & Security Manager
• Health & Safety Manager / Security Specialist
Their role is to ensure the Trust complies with all health and safety legislation applicable
to the Trust’s activities, its employees and non-employees; as well as compliance with NHS
Protect Security Standards. The Polices on the Trust’s website are as follows:
Health and Safety
Display Screen Equipment
First Aid
Control of Substances
Hazardous to Health
Substance Misuse
Stress
Slip, Trip & Fall
Medical Gases
New & Expectant Mothers
Young People at Work
Safe Management of
Contractors
Safer Handling
Latex
Fire Safety
Safe use of Mobile Phones
Lone Working
Personal Safety
Security
Lock Down
Waste Management
CCTV
Water Hygiene, Air
Conditioning & Legionella
Asbestos
Risk Assessment
Policy in relation to
disabled employees
and on equal opportunities
This is included on page 19 of this report under the heading ‘Equality and Diversity and
Human Rights’.
Information on policies and procedures
relating to countering
fraud and corruption
The Trust’s Standards of Business Conduct and Anti-Bribery Policy were approved in
December 2011 and a copy is available to staff on the Trust’s website. The Local Counter
Fraud and Corruption Policy were added to the website after being approved in June 2012.
The Trust also employs a full time local counter fraud specialist.
The total days lost in 2013/14 were 32,631 (31,251 last year), which is 3,171 staff years (3,334
last year) with the average working days lost being 10 (9 last year).
External audit
disclosure
The Trust’s auditor is Grant Thornton and the agreed statutory audit fees for 2013/14 were
£69k (excluding VAT). In addition to these fees the Trust paid £10k (excluding VAT) for a
review of the Trust’s Quality Account.
The external auditors have issued an unqualified opinion on the Trust’s 2013/14 annual
report and accounts. That opinion confirmed that the information given in the 2013/14
annual report is consistent with the financial statements.
Other Auditor’s remu- Grant Thornton has, in addition to the statutory audit, also undertaken an Information
neration
Technology Strategy Review at a cost of £16k, which is within the limits allowed by the Audit
Commission.
Financial accounts
101
A statement that the
entity has complied
with HM Treasury’s
guidance on setting
charges for information
is required.
Serious untoward
incidents
Progress against agreed
non-financial targets
Social and community
issues
The Trust are fully compliant with HM Treasury’s guidance on setting charges for
information in areas such as medical records and Freedom of Information requests.
This is included on Page 61 of this report under the heading ‘Clinical coding error rate’
This is included on Page 19 of this report under the heading ‘The Trust’s performance
against the 2013/14 key national targets’.
Up until July 2013 the Trust had a Community Engagement Committee, which was a
sub-committee of the Trust Board. The Community Engagement Team developed a
Community Engagement Strategy, which has successfully taken forward the work of the
sub-committee.
Over the last twelve months engagement and consultation work has been focused
according to impact, interest and investment. To this end, the Trust has conducted full
consultations with patients, carers and representatives of interested groups, who would
be impacted by proposed service changes. The comments received were collated,
reported on and fed into the creation of new care pathways and, where necessary, has
been shared with the Health Overview and Scrutiny Committee and Children and Young
People Overview and Scrutiny Panel.
The Trust has also worked with interested groups and individuals and has offered those
who want to be involved in the work of the Trust, lots of different opportunities from
attendance at forums and events, to taking part in working groups, to sharing their
patient stories and taking part in films for staff training. The level of interest shown has
allowed the Trust to set up a Quality Account Working group, an Organisational Values
Working group and led to regular and increased attendance at forum meetings.
Social and community
issues
One off quality events have considered such matters as the Francis Report, the Sub-Acute
pathway and the Complaints process. The Trust has also sought to reach out to more
patients and carers and in addition has sought the views and opinions of staff, through
the Clever Together digital campaign. As a result of a survey of the Trust’s members
over 200 more members indicated they were keen to get involved by attending forums,
sitting on interview panels and taking part in patient led assessments of the clinical
environment.
The Trust has maintained its links with a variety of other groups and organisations. In total
the Trust has engaged with 50 groups, non-statutory and statutory organisations during
the last year. 2013/14 saw the creation of a new Partnership Forum and a Youth Board
whilst continuing to reach other ‘seldom heard groups’ such as the travelling community.
Persons with whom the The Trust works with a wide range of partners, from contracted and trade Suppliers, to
entity has contractual
those who jointly deliver services with us e.g. Worcestershire Clinical Commissioning
or other arrangements
Groups and Worcestershire County Council (for pooled budget arrangements and the
which are essential to the Joint Commissioning Unit). The Trust is performance managed by the Trust Development
business of the entity
Authority.
The entity’s employees:
Category of Trust Employees
Sum of WTE
Sum of Headcount
including an account of
Directors
7.00
15
the entity’s equal opFemale
3.00
4
portunities policy. Also
Male
4.00
11
required is an analysis
Employees
3,158.06
4,098
of the gender distribuFemale
2,693.16
3,533
tion in the categories:
Male
464.90
565
• directors
Senior Management Team
17.60
18
• other senior managers
Female
4.60
5
• employees
Male
13.00
13
Grand Total
3,182.66
4,131
102
Annual Report 2014-15
Annual Governance Statement
Annual Governance Statement covering the period
1 April 2013 – 31 March 2014
Scope of responsibility
As Accountable Officer, and Chief Executive of this Board,
I have responsibility for maintaining a sound system of
internal control that supports the achievement of the
organisation’s objectives. I also have responsibility for
safeguarding the public funds and the organisation’s
assets for which I am personally responsible as set out in
the Accountable Officer Memorandum.
Throughout the year the Trust has submitted monthly
compliance monitoring and board statements selfcertification returns to the NHS Trust Development
Authority (TDA). These inform the TDA about the Trust’s
performance across the three domains of quality and
governance, finance and delivering sustainability. The
March 2014 compliance monitoring submission states
that the Trust is not compliant against the standard
relating to the appointment of Governors, which will
happen later in the foundation trust application process.
It also highlights the areas where action plans need time
to bed in to resolve issues including those raised by the
CQC visit to HMP Oakwood in June 2013 and the more
recent performance issue that has been encountered
regarding the CPA 12 monthly reviews. In both cases I
am confident that the action taken has resolved these
matters.
Financial accounts
As an employer with staff entitled to membership of the
NHS Pension Scheme I confirm that control measures
are in place to ensure all employer obligations contained
within the Scheme regulations are complied with.
This includes ensuring that deductions from salary,
employer’s contributions and payments in to the
Scheme are in accordance with the Scheme rules, and
that member Pension Scheme records are accurately
updated in accordance with the timescales detailed in
the Regulations.
The governance framework of the
organisation
The following framework of Board Committees provides,
and comments upon, assurances to the Board and
enables the Board to direct me to address areas requiring
attention:
• Audit Committee
• Quality and Safety Committee
• Finance and Performance Committee
• Community Engagement Committee (up to July 2013)
• Charitable Funds Committee
• Remuneration Committee
The Board has also established a Foundation Trust
Programme Board to oversee the Trust’s application for
NHS Foundation Trust status and a Partnership Forum is
being developed to facilitate joint working and sharing
of information across partner organisations.This forum is
not a Board committee.
103
Jan Ditheridge n
1
1
1
1
8
8
8
6
4
1y 5
6
5
1
Extraordinary Trust Board
1
1
1
Informal Board Days/Sessions
8
7
8
1
8
Audit Committee
6
1y
1
Quality & Safety Committee
12
5n
12
2n
Finance & Performance Committee
12
9n
1
9
Charitable Funds Committee
4
Community Engagement Committee
2
1n
Remuneration Committee
6
6
FT Programme Board
9
7
11
3
6
6
6
1
1
1
7
7
7
3
5
10
10
Sue Harris
Bill Creaney s
1
6
Robert Mackie
Sarah Dugan
3
6
Sandra Brennan
David Priestnall
5
Trust Board
Meeting
Stephen Collman v
Martin Connor
6
Colin Phillips u
6
Peter Lachecki
6
Chris Burdon
5
Number held
Jill Gramann
Attendance by Board members at Trust Board and Board Committee Meetings 1 April 2013 to 31 March 2014
8
8
6
2
9
6
11
7
2
6
4
2
5
1
2
2
4
6
8
1
1
2
1
1
2
n Attended in observer capacity
y Attended to cover absence of a member
u
Indisposed with effect from 10/05/2013 and stepped down on 31/03/2014
s
Indisposed for a period during 2013/14 with phased return and reduced attendance at meetings
n
v
In post until 22 September 2013
In post in acting capacity from 23 September 2013 and substantively from 3 March 2014
104
Annual Report 2014-15
Executive Director – voting rights
a
a
a
Executive Director – non-voting
M
Individual’s Appraisal undertaken by Trust
Development Authority
a
M
M
F
M
M
F
a
a
a
a
a
a
Individuals’ Appraisals undertaken by Chief
Executive
Board and Board Committee Effectiveness
Each Board member has a set of objectives that are
agreed with their respective appraiser against which
performance is measured and which are subject to
formal appraisal at least annually. In terms of individuals’
performance on the Board, proformas are completed
by each Board member on an anonymised basis. These
invite Board members to comment on the contribution
they make to the Board and provide an overview of how
the Board as a whole is performing. This also informs
areas for development.
During 2013/14 the Chairman and Chief Executive have
both been subject to 3600 appraisal as part of their
respective personal development.
Annually Board committee members (other than Audit
Financial accounts
a
a
a
a
Gender
Individuals’ Appraisals undertaken by Chairman
Sue Harris voting wef 12/09/2013
a
Robert Mackie
a
Sandra Brennan
David Priestnall
a
Stephen Collman from 23/09/2013
Martin Connor
a
Jan Ditheridge to 22/09/2013
Jill Gramann
a
Bill Creaney
Colin Phillips
a
Sarah Dugan (Chief Executive)
Peter Lachecki
Non-Executive Director – voting rights
Chris Burdon (Chairman)
Balance, Completeness and Appropriateness of the Board membership 1 April 2013 to 31 March 2014
a
M
F
M
F
M
F
a
a
a
a
a
a
Committee) are asked to complete a proforma selfassessment checklist designed to elicit comment on the
effectiveness of the committee. The checklist is derived
from the proforma checklist for audit committees
published in the NHS Audit Committee Handbook. The
Audit Committee completes the latter checklist.
The five NEDs are determined by the Board to be
independent on the basis that none:
• has been an employee of the trust within the last five
years;
• has, or has had, within the last three years, a material
business relationship with the trust either directly, or as
a partner, shareholder, director or senior employee of a
body that has such a relationship with the trust;
• has received or receives additional remuneration from
105
the trust apart from a director’s fee, or is a member of
the trust’s pension scheme;
• has close family ties with any of the trust’s advisers,
directors or senior employees;
• holds cross-directorships or has significant links
with other directors through involvement in other
companies or bodies;
• has served on the board of the trust for more than nine
years from the date of their first appointment.
Non-Executive Director membership of Board
committees has subsequently been reviewed and
changes implemented on 1 April 2014. In accordance
with the Board’s succession plan 2 Non-Executive
Directors (Designate) were appointed in November 2013.
One of these, Rick Roberts, has been appointed to the
vacancy created by Mr Phillips’ departure. Mr Roberts
has a clinical background. In 2013/14 he has attended 3
Trust Board meetings, 1 Informal Board Day/Session, 4
Quality & Safety Committee meetings and has attended
1 Finance & Performance Committee meeting as an
observer. The other Non-Executive Director (Designate),
Steve Peak has attended 3 Trust Board meetings, 1
Informal Board Day/Session and 2 Finance & Performance
Committee meetings in this period.
At each formal Board meeting Board members are asked
to declare any conflict of interest. There have been no
departures from the requirements of the Standards
of Business Conduct and Anti-Bribery policy and the
overarching corporate governance framework.
The Board of the Trust provides its leadership and is
charged with securing the organisation’s long term
success. The Board is collectively responsible for
controlling the Trust. The Board sets strategic direction
and supervises the work of the executive to ensure
that corporate objectives and performance targets are
achieved. The Board makes those decisions reserved
unto itself, defines and sets the approach to risk and risk
management and conducts itself in such a way that it
takes the view of key stakeholders into account. The Trust
has continued to review and update self-assessments
against Monitor’s quality governance assurance
framework and the Department of Health’s and Monitor’s
board governance assurance framework.
106
The quality and safety of patient services has been
maintained overall and where specific shortcomings
have been identified such as at HMP Oakwood (see page
34) these have been addressed. There has been no loss
of control of the Trust’s finances. Performance levels have
been maintained against the key indicators contained
within the NHS performance framework, the Monitor
compliance targets, indicators and thresholds for
2013/14 and the mental health performance framework.
Chairs of Board Committees present reports to the
Board on the matters considered by their respective
Committees. In the case of the Audit Committee the
report informs the Board of the level of assurance that
has been given by Internal Audit on the reviews that
they have been commissioned to undertake in 2013/14.
23 reviews were undertaken during the year. 15 were
given significant assurance, 4 were given moderate
assurance and 4 were not assurance based reviews.
The Audit Committee report also informs the Board of
the programme of work that is undertaken by External
Audit. This provided assurance that their initial testing of
systems combined with a review of work undertaken by
Internal Audit had not highlighted any significant system
weaknesses or breakdowns in control. The Trust’s Local
Counter Fraud Specialist attends the Audit Committee
meetings as does the Trust’s Local Security Management
Specialist. During 2013/14 the committee extended its
remit to include oversight of the procurement function.
At their meeting on 12 March 2014 the Trust Board
agreed a proposal from the Audit Committee to establish
a sub-committee to oversee data quality improvement
with effect from 1 April 2014.
Annual Report 2014-15
Summary of Quality Governance
arrangements
An integrated performance report provides Trust
Board with assurance that the quality of services
being delivered is being carefully monitored and
that improvement measures are being implemented
where required. Oversight of the quality governance
arrangements rests with the Quality & Safety Committee.
This Board committee is chaired by a Non-Executive
Director and meets monthly.
The Trust has a Quality Governance Strategy structured
around the three domains of patient safety, clinical
effectiveness and patient experience. It sets the direction
for ensuring that people who use our services experience
the highest quality, safest and most effective care.
The strategy supports the delivery of nine, high level
cross-organisational Quality Goals. The Goals each have
sub-indicators to track progress towards achievement.
Performance is reviewed at each Quality and Safety
Committee and every meeting of the Board. Recovery
plans are implemented for those goals that are not
achieving their target performance.
The quality governance framework supports the Quality
and Safety Committee and promotes granulation of the
reports and associated outcomes. Each Service Delivery
Unit has a Quality Governance meeting to review their
own performance and to facilitate shared learning.
Unit Quality Leads provide narrative data to facilitate a
broader understanding of context and risk.
The best judges of the quality of care are the people who
use our services and our staff. We undertake staff ‘Pulse
surveys’ quarterly and have recently launched the staff
Family and Friends test to gauge whether staff consider
the services we provide are of a high quality. Regular
communications are sent out to staff from the Chief
Executive, with a clear email address and other routes for
staff to directly contact the executive team.
Our programme of patient experience work, patient
safety walkabouts, patient and staff stories to board,
together with analysis of complaints and compliments
provides rich information about where we are getting it
right, and where improvements are needed.
Arrangements for assurance on
the content and publication of the
Quality Account
The Trust Quality Account Working Group is responsible
for producing the Quality Account, ensuring that the
document complies with the Department of Health
requirements, and that the information contained in the
Account is balanced and accurate.
All Cost Improvement Programmes or new service
developments undergo a Quality and Equality Impact
Assessment, signed off by the Director of Quality
(Executive Nurse) and the Medical Director, and have
measurements identified to monitor longer term effects
on the quality of services.
The draft Quality Account is reviewed by the local Health
and Overview Scrutiny Committee, commissioners and
the Quality and Safety Committee before it is signed off
by Board and placed on the NHS Choices website. The
Account is subject to external audit regarding the quality
of the data included in the Account. This independent
assurance confirmed that the 2012/13 Quality Account
complied with national mandatory requirements and will
apply to the 2013/14 Quality Account.
Service Line Reporting has been developed for
nine quality metrics. This provides summary quality
performance data for each team and service in the Trust.
This is reviewed by the teams themselves and at the
Quality and Safety Committee to identify early warning
signs or trends over time and allows for benchmarking
between similar teams in the Trust. The Service Delivery
The Trust Board approved the 2012/13 Quality Account in
May 2013, including the adoption of the quality priorities
for 2013/14 which were:
• Improved use of patient, carer and staff feedback,
including the Family and Friends test,
• Improvement in the capture of real time feedback from
patients,
Financial accounts
107
• Continue to improve our response times and learning
from complaints,
• Improve evidence that we learn from patient safety
incidents and near misses,
• Continue the work to reduce avoidable pressure ulcers.
Progress with each of the priorities is monitored through
the Quality and Safety Committee.
Arrangements for assurance on
clinical audit, never events and
serious incidents
Clinical Audit
There is a 3 year rolling audit programme in the Trust
which is overseen by the Clinical Audit and Effectiveness
Group. This group, which is chaired by the Deputy
Medical Director, has good clinical representation, and
reports through to the Quality and Safety Committee
and Board both in terms of performance against the
plan and clinical outcomes as a result of the audits. The
Trust takes part in all national clinical audits that are
relevant to the Trust and subscribes to the Prescribing
Observatory for Mental Health audit programme. Further
narrative regarding the clinical audit programme and the
outcomes of audits is presented in the Quality Account.
Never Events and Serious Incidents
The Trust continues to support staff in the process of
identifying, reporting and managing incidents. The
Medical Director and Director of Quality (Executive
Nurse) jointly lead the Serious Incident Forum. Each
serious incident has a Root Cause Analysis undertaken
by a trained Investigating Officer. A roundtable is held for
each Serious Incident and action plans are overseen by
the aforementioned Forum.
Extensive, detailed reports on serious incidents are
presented to clinical services, operational Quality
Governance groups, Quality and Safety Committee
and Board. Robust, sustainable systems are in place to
maintain performance on serious incident closure times.
Comprehensive information regarding incidents and
Serious Incidents is included in the Trust Quality Account.
108
The risk of occurrence of Never Events is tracked through
the incident reporting system and clinical audit. The Trust
has had no incidents of Never Events reported to date.
The Quality Forum which reports to the Quality & Safety
Committee brings together the Quality Leads and the
Quality and Safety Team to check for cross-organisational
learning, and to identify trends from investigations.
External Review of the quality of
services provided
During 2013/14 inspections of Trust services have been
undertaken on:
• 13 occasions by local Clinical Commissioning Groups
• 1 occasion by the NHS Trust Development Authority
• 2 occasions by Her Majesty’s Inspectorate of Prisons
(HMIP) and the Care Quality Commission (CQC)
• 1 occasion by an external consultancy commissioned by
the Trust to review its self-assessment against Monitor’s
quality governance assurance framework
• 1 occasion by the Lead Nurse NHS Midlands and East
• 2 occasions by South Staffordshire Area Team
• 4 occasions by the CQC in relation to the Trust’s
compliance with the Mental Health Act and essential
standards of quality and safety
• 1 occasion by the Joint Commissioning Unit,
Worcestershire County Council
Overall the CCGs’ inspection visits were positive. Each
identified area for development has been incorporated
into action plans.
The Trust Development Authority’s inspection observed
very positive practice and identified a number of areas
for further consideration including continuing to
promote Board visibility with staff and communicating
the IT strategy to staff.
The joint HMIP and CQC inspection of HMP Oakwood
undertaken in June 2013 resulted in the issuing of a
warning notice in relation to medicines management.
Following representations from the Trust to the CQC the
Trust was given until 30 September 2013 to implement
an action plan to address the shortcomings identified.
Annual Report 2014-15
This deadline was achieved. Subsequently the CQC
revisited the prison on 7 & 8 October 2013 and reduced
the warning notice to two minor compliance issues.
The external consultancy’s review of the Trust’s selfassessment against Monitor’s Quality Governance
Framework provided positive feedback about quality
governance systems and suggested a number of
areas for development including checking that
communications were getting through to all areas and
increasing the number of posters outlining the vision
and values of the Trust.
Commenting on her visit to the recently opened New
Haven the Lead Nurse, NHS Midlands and East said she
could only recall one or two units that matched this
facility for team approach and physical environment.
The South Staffordshire Area Team visited in their
capacity as commissioners for offender health services.
They visited the healthcare facilities at HMPs Long Lartin
and Oakwood. Overall their feedback was positive. Areas
for development have been incorporated into action
plans.
As well as assessing the Trust’s compliance with the
Mental Health Act when visiting mental health facilities
in the Trust the CQC inspectors also assured themselves
that essential standards of quality and safety were being
maintained. No concerns were identified and their
feedback was very positive.
The Joint Commissioning Unit visited a unit where a
whistleblower had raised concerns with the CQC about
the management of the unit. The purpose of their visit
was to assure themselves that the remedial action plan
was being implemented.
The CQC’s Quality and Risk Profiles (QRP) are reviewed
to take account of, and to address, any newly identified
risks. There were no significant risks to report to the
Board from the QRPs published during 2013/14.
Financial accounts
Community Engagement
Over the last twelve months engagement and
consultation work has been focused according to
impact, interest and investment. To this end, the Trust
has conducted full consultations with patients, carers
and representatives of interested groups, who would be
impacted by proposed service changes. The comments
received were collated, reported on and fed into the
creation of new care pathways and, where necessary,
has been shared with the Health Overview and Scrutiny
Committee and Children and Young People Overview
and Scrutiny Panel. The Trust has also worked with
interested groups and individuals and has offered those
who want to be involved in the work of the Trust, lots of
different opportunities from attendance at forums and
events, to taking part in working groups, to sharing their
patient stories and taking part in films for staff training.
The level of interest shown has allowed the Trust to set
up a Quality Account Working group, an Organisational
Values Working group and led to regular and increased
attendance at forum meetings.
One off quality events have considered such matters
as the Francis Report, the Sub-Acute pathway and
the Complaints process. The Trust has also sought to
reach out to more patients and carers and in addition
has sought the views and opinions of staff, through
the Clever Together digital campaign. As a result of a
survey of the Trust’s members over 200 more members
indicated they were keen to get involved by attending
forums, sitting on interview panels and taking part in
patient led assessments of the clinical environment.
The Trust has maintained its links with a variety of
other groups and organisations. In total the Trust has
engaged with 50 groups, non-statutory and statutory
organisations during the last year. 2013/14 saw the
creation of a new Partnership Forum and a Youth Board
whilst continuing to reach other ‘seldom heard groups’
such as the travelling community.
109
Risk assessment
The Trust currently assesses and monitors risk by a variety
of methods, not least via an assurance framework. This
is the key document for the Trust Board to ensure all
principal risks against strategic goals and associated
corporate objectives are identified, managed, controlled
and reported upon. The assurance framework is
presented to, and discussed by, the Trust Board at each
public meeting.
The Risk Management processes are guided and
provided for by the Risk Management Strategy. This
sets out the organisation’s approach to risk and defines
responsibilities and roles of the Chief Executive,
Directors, senior managers and all other staff in relation
to the effective delivery of the risk management agenda.
It also highlights the links between Risk Management,
the Assurance Framework and the business planning
process. There is documented guidance for staff
supported by comprehensive Policies and Procedures
available via the Trust’s intranet.
Whilst ultimate accountability rests with the Chief
Executive, responsibility for risk management has been
delegated to the executive leads for risk. The Director of
Quality (Executive Nurse) and Medical Director have joint
delegated responsibility for clinical risk management
and clinical governance. The Director of Finance is
responsible for financial risk management. The Company
Secretary has delegated responsibility for managing the
strategic development and implementation of corporate
risk management and assurance, and is responsible for
the development and maintenance of the Corporate Risk
Register. The work of the Quality and Safety Committee is
supported by a number of sub committees and working
groups including the Clinical Risk Group.
As part of the risk management strategy, training is
delivered to managers and to other staff across the
Trust, both at induction to the Trust and also as part
of on-going development. Areas covered include: risk
management, risk assessment, incident reporting,
health and safety, infection control and the handling of
complaints. The extent and level of training is dependent
on a member of staff’s delegated responsibility.
110
Risk Management training in general can be evidenced
in the Induction Programme, various ad-hoc incident
reporting training sessions, risk refresher training and
written guidance disseminated to all Clinical and Service
leads. The legislative requirements of risk management
and risk assessment within a safe system of work are
actively promoted by the Trust.
A new on line incident reporting system was
implemented on 1 August 2013. The Trust utilises
the incidents, PALS & Complaints, Risk and Litigation
modules on the system.
The Incident Reporting Module has an e-mail trigger
facility, which alerts responsible managers to recent
incidents. A trigger is also sent to key governance staff
such as the Patient Safety Manager, Risk and Security
Manager and Quality Leads for each Service Delivery
Unit, who review recently submitted incidents and
forward guidance on the information which is needed to
complete the incident report to the responsible manager.
The software contains data entry forms, which are used
to record details of investigations, recommendations,
actions and lessons learned. Monthly incident data
reports are provided to the responsible managers and
monthly reports are provided to the Quality and Safety
Committee. These give all relevant details about the
incidents and managers provide further contextual
information to the Quality and Safety Committee to
facilitate the organisational learning from incidents.
Trend analysis reports are being developed to further
inform managers and senior managers about any
developing incident trends across the Service Delivery
Units and the wider Trust.
The need to engage each and every staff member and to
provide the appropriate level of training to them remains
a key objective and priority within the Trust. There are
systems in place for staff to raise concerns/risks/near
misses to allow action to be taken and for lessons to be
learnt.
Annual Report 2014-15
The risk and control framework
Risk Management Strategy
The key elements of the Risk Management strategy
focus on:
• Individual and corporate responsibility.
• A structured framework for the management of risk
with a clear definition of the roles and responsibilities
for directors, managers, clinicians and allied health
professionals.
• A purposeful approach to enabling the Trust to embed
risk management within its structure and so support
the Trust in meeting its new functions and objectives.
• Compliance with all relevant statutory and nonstatutory standards relating to the assessment and
control of risk.
• Identifying, and where possible eliminating, risk and
controlling any remaining risk.
• Monitoring the controls and procedures to ensure
effective risk management within the Trust.
Increasingly formal risk assessments are being
undertaken locally. If advice and/or training is required
on clinical risk assessment this will be provided by
the Quality Governance Department. If advice and/
or training is required on non-clinical/generic risk
assessment this will be provided by the Risk and Security
Manager and/or Health and Safety Manager.
Financial accounts
Risk assessment and incident reporting systems remain
key to the on-going assessment of risk. Evaluation of
any, or all, control measures are considered, not only by
line management but also by the Quality Governance
Department. This provides a robust double check within
the system.
All cost improvement plans are subject to a detailed
quality and equality impact assessment involving
the Director of Quality (Executive Nurse) and Medical
Director and/or their nominees.
In respect of the publication of the report of the second
Francis Inquiry into Mid Staffordshire NHS Foundation
Trust the Trust Board is reviewing ward staffing levels.
Implementation of the action plan relating to the Francis
report and subsequent Berwick and Keogh reports is
overseen by the Quality and Safety Committee.
The Trust has inherited accreditation at level 1 of the NHS
Litigation Authority (NHSLA) Clinical Negligence Scheme
for Trusts (CNST) from its predecessor organisations. This
entitles the Trust to a 10% discount on its premium for
CNST and the Risk Pooling Scheme for Trusts (RPST). At
level 1 assessors look for assurance that an organisation
can demonstrate the process for managing risks has
been described in approved documentation.
Further information is awaited from the NHSLA regarding
their intention to move away from assessing against the
risk management standards from 2014/15.
Risk management continues to be promoted and
embedded throughout the Trust.
111
Major Risks 2013/14
The Trust has identified the following in year risks:
Risk
Mitigation
Outcome
Challenges in the local health
economy such as the acute
services review and changing
and emerging commissioning
arrangements.
Active engagement in the acute services
review. Focused attention on developing
and maintaining relationships with
commissioning organisations.
Trust positioned to play a leading role in the
future delivery of services as determined by
the acute services review, e.g. Well Connected
Programme. Contracts with commissioners
have been signed off for 2014/15.
Identification and delivery of a
rolling 30 month programme of
cost improvements.
Focused attention to identify, on a
prospective basis, opportunities to increase
efficiency and cost effectiveness of delivery
of services. A programme management
office structure is in place with robust
project management applied to each CIP
scheme.
Increased confidence about deliverability of
recurrent CIPs.
Achieving a reduction in the
number of inherited patient
administration systems (PAS).
Option identified for rationalising the
existing number of systems and timescale
for doing so.
The Trust has procured a single PAS but issues
with the functionality and roll out of the
system are being taken up with the contractor.
Action plans are in place to manage the aforementioned risks. These are subject to scrutiny by the relevant Board
committee.
The Trust has identified the following future risk(s):
Risk
Mitigation
Over the next 5 years the
Impact assessments undertaken on CIPs
potential impact of cost
relating to the delivery of clinical services.
improvement programmes (CIPs)
on quality of services.
112
Outcome
In the period 1 April 2013 – 31 March 2014
there has been no adverse impact on the
quality of clinical services.
Annual Report 2014-15
Risks to Data Security and
Organisational Changes
Data Security
The Trust recognises the importance of the
confidentiality of, and the security arrangements in place
to safeguard, personal information about patients, staff,
other persons and commercially sensitive information.
Under the Data Protection Act 1998, the Trust is
registered with the Information Commissioner’s Office
for the purpose of processing personal information,
Reference Number Z2745227.
Information risk is managed and controlled by:
• The Director of Finance is the Senior Information Risk
Owner (SIRO) and takes overall ownership of the Trust’s
Information Risk Management Programme. The SIRO
undertakes annual training
• The Medical Director is the Caldicott Guardian
• All Information assets have been identified on the
Trust’s information asset register, Information Asset
Owners have been identified and information risk
assessments have been undertaken or are planned
• The information asset register is regularly reviewed by
the SIRO
• Defined authorised access to specific information
systems as documented in specific System Level
Security Policies
• A robust Information Governance Management
Framework is in place including:
o the terms of reference for the Information
Governance Steering Group and,
o key IG policies such as, Information
Governance, Safe Haven, Confidentiality,
Data Protection, Information Risk, Records
Management, Freedom of Information and IG
Incident Reporting
• The Information Governance Steering Group is chaired
by the Company Secretary and the SIRO and Caldicott
Guardian (Medical Director) are both members. All three
are Board Members
Financial accounts
• Annual completion and submission of the latest version
of the NHS Information Governance Toolkit (currently
version 11) was to a ‘satisfactory’ minimum Level 2
performance score
• The IG Toolkit return is subject to internal audit annually.
‘Significant’ assurance was given by internal audit for
version 11
• Confidentiality Agreement for Contractors including
authorised access for contractors who need or are
required to access information systems
• Mandatory annual IG training for all staff
• Trust induction including information governance
awareness raising and training
• All IG related incidents are reported on the Trust’s
incident reporting system and an automated email
is sent to the Information Governance Team for
investigation
• All IG Serious Incidents Requiring Investigation (SIRIs)
Level 2 (Reportable) are recorded on the IG Incident
Reporting Tool, on STEIS and are published on the
Trust’s website and in the Trust’s Annual Report
• A Service level agreement is in place with
Worcestershire Health ICT Services (WHICTS) which
requires compliance with the relevant standards in the
latest version of the DH Information Governance Toolkit
• WHICTS provided network, policy and access control
including: Network Security, Anti- Virus, Business
Continuity and Disaster Recovery, Information Security,
Internet and Email, Access Control and Mobile Device
Encryption
• The terms of reference of the Worcestershire
Countywide Information Governance Steering Group
whose members are drawn from: Worcestershire Acute
Hospitals NHS Trust, Worcestershire Health and Care
NHS Trust, 3 x NHS Clinical Commissioning Groups and
Arden Commissioning Support Service.
There has been one IG Serious Incident Requiring
Investigation (SIRI) Level 2 (Reportable) in the period
1 April 2013 – 31 March 2014 which is outlined under
the significant issues section on the final page of this
document.
113
Significant Issue(s)
Summary Of Serious Incident Requiring Investigations Involving Personal Data As Reported To The
Information Commissioner’s Office In 2013-14
Number of
data subjects
affected
Date of Incident
Nature of Incident
Nature of Data Involved
August 2013
Loss of paperwork – a ward
handover sheet was found
at a railway station and was
handed into the local press
Name, age, GP name, diagnosis,
past medical history, mobility,
18
nursing interventions required,
discharge information
Notification Steps
Individuals contacted
and offered support.
Press statement
released, full
investigation
undertaken
Internal processes have been reviewed, improved and updated
Further action on
information risk
The Trust will continue to monitor and assess its information risks, in light of the events noted above, in
order to identify and address any weaknesses and ensure continuous improvement of our policies and
procedures
Accountable Officer : Sarah Dugan, Chief Executive
Organisation: Worcestershire Health and Care NHS Trust
Signature:
Date: 31 March 2014
114
Annual Report 2014-15
Remuneration Report
Details of the
membership of
the Remuneration
Committee
The Remuneration Committee of the Trust is a sub-committee of the Trust Board, which
determines the remunerations, allowances and terms of service of the Chief Executive
and those Executive Directors reporting directly to the Chief Executive. The membership
of the Committee will comprise of the Chairman of the Trust and two Non-Executive
Directors. The Committee shall undertake the following duties:
a) To agree appropriate remuneration and terms of service for the Chief Executive and
other executive directors including:
• all aspects of salary (including any performance-related elements/bonuses),
• provisions for other benefits, including pensions,
• arrangements for terminations of employment and other contractual terms for all
Trust employees.
b) To monitor and evaluate the performance of individual Executive Directors
c) To advise on, and oversee, appropriate contractual arrangements for Executive
Directors, including the proper calculation and scrutiny of termination payments
taking account of such national guidance as is appropriate.
For 2013/14 the pay of the Directors and Senior Managers was increased by 1% from
April 2013 in line with NHS National Pay inflation.
The Trust Remuneration Committee approved a further pay increase for the Directors
and Trust Chief Executive from 1 October 2013 following a benchmarking exercise with
similar NHS Trust’s.
Pay Multiples
The remuneration and pension entitlements of Senior Managers are included in
the tables on pages 119, 120a and 120b of this report along with the pay multiples
section below.
Reporting bodies, including the Trust are required to disclose the relationship between
the remuneration of the highest paid Director in the Trust and the median remuneration
of the organisation’s workforce.
The banded remuneration of the highest paid Director in the Trust in 2013/14 was
£145k – £150k (£145k – £150k in 2012/13). This was 5.5 (5.5 in 2012/13) times the median
remuneration of the workforce which was £27k (£26k in 2012/13). In 2013/14 two
Doctors received remuneration in excess of the highest paid Director at £166k and £162k
respectively (in 2012/13 the two Doctors received sums of £165k and £153k).
Total remuneration includes salary, non-consolidated performance related pay,
benefits in kind as well as severance payments. It does not include employer pension
contributions and the cash equivalent transfer value of pensions.
Financial accounts
115
The policy on the
remuneration of senior
managers for current
and future financial
years
Reporting related
to the Review of Tax
arrangements of Public
Sector Appointees
This is decided by the Remuneration Committee and for 2013/14 the agreement was in
line with the national guidance.
The Trust has reviewed in detail the extent to which it complies with the new Annual
Report disclosure requirement in this area and considers that whilst the Trust doesn’t
have any arrangements to declare for 2013/14 there are some clinician commitments
associated with service level agreements that are under review and may transfer to the
payroll of neighbouring NHS Trusts/Foundation Trusts.
Negotiations are now underway, although the process may take some time to regularise
in the manner required by Her Majesty’s Treasury.
The two Disclosure tables required are shown below.
Off-payroll engagements Table 1:
For all off-payroll engagements as of 31 March 2014, for more than £220 per day and that
last longer than six months:
Number
Number of existing engagements as of 31 March 2014
53
Of which, the number that have existed:
for less than one year at the time of reporting
7
for between one and two years at the time of reporting
3
for between 2 and 3 years at the time of reporting
None
for between 3 and 4 years at the time of reporting
3
for 4 or more years at the time of reporting
36 are employed by another
Trust & 4 by a Foundation Trust
At this stage the Trust is not able to provide confirmation that all existing off-payroll
engagements have at some point been subject to a risk based assessment as to whether
assurance is required that the individual is paying the right amount of tax and, where
necessary, that assurance has been sought.
The majority of commitments the Trust has are ones that have been inherited and are
currently under review.
116
Annual Report 2014-15
Off-payroll engagements Table 2:
For all new off-payroll engagements between 1 April 2013 and 31 March 2014, for more
than £220 per day and that last longer than six months:
Number
Number of new engagements, or those that reached six
7
months in duration, between 1 April 2013 and 31 March
2014
Number of new engagements which include contractual As above
clauses giving the Trust the right to request assurance in
relation to income tax and National Insurance obligations
Number for whom assurance has been requested
6 as 1 is covered by the
Construction Industry
Scheme.
Of which:
assurance has been received
3 and 4 have been requested
assurance has not been received
4, but these have been
requested
engagements terminated as a result of assurance not
None
being received
None
Number of off-payroll engagements of board members,
and/or senior officers with significant financial
responsibility, during the year
Number of individuals that have been deemed “board
16
members, and/or senior officers with significant financial
responsibility” during the financial year. This figure
includes both off-payroll and on-payroll engagements.
The methods used
to assess whether
performance conditions
were met and why
those methods were
chosen. If relevant, why
the methods involved
comparison with
outside organisations
The objectives of the Directors are set in line with the Trust’s statement of overall
objectives.
The relative importance
of the relevant
proportions of
remuneration which
are, and which are not,
subject to performance
conditions
The Remuneration Committee uses baseline Director salaries, which are then benchmarked against similar NHS Trusts across the West Midlands.
A summary and
explanation of policy on
duration of contracts,
and notice periods and
termination payments
The policy on contracts is that they are all substantive and the contract follows the
national template. The majority of Director contracts include three months’ notice
period from the individual and six months from the Trust. Any termination payments are
contractual, in line with national guidance and the Trust Development Authority process.
Financial accounts
The overall corporate objectives are monitored and disclosed to the Board on a regular
basis as well as there being an individual assessment by the Chief Executive with each
Director. This is in line with NHS practice.
117
Details of the service
In 2013/14, 14 staff (5 last year) left the Trust under the NHS Redundancy Scheme. The
contract for each senior payments involved the sum of £428k (£151k last year). The staff leaving during the year
manager who has
included no (1 last year) senior managers at level 8a and above.
served during the year:
• date of the contract,
the unexpired term,
and details of the
notice period;
• provision for
compensation for early
termination; and
• other details sufficient
to determine the
entity’s liability in
the event of early
termination.
Pension Scheme and
liabilities of the Trust
NHS Creditors include £1.7m pension costs at 31 March 2014 (£1.6m at 31 March 2013).
The accounting policy for Pensions and outline of the scheme is set out on page 23 of the
Trust’s Annual Accounts.
Explanation of any
None were made in 2013/14.
significant awards made
to past senior managers
118
Annual Report 2014-15
Board of Directors Salaries and Allowances for Annual Report and
Accounts 2013/14
Expense payments (taxable)
total to nearest £100
Performance pay and bonuses
(bands of £5,000)
Long term performance pay
and bonuses (bands of £5,000)
All pension-related benefits
(bands of £2,500)
TOTAL (bands of £5,000)
Salary (bands of £5,000)
Expense payments (taxable)
total to nearest £100
Performance pay and bonuses
(bands of £5,000)
Long term performance pay
and bonuses (bands of £5,000)
All pension-related benefits
(bands of £2,500)
TOTAL (bands of £5,000)
2012/13
Salary (bands of £5,000)
Date Left Date Started Name and Title
2013/14
£’000’s
£’00’s
£’000’s
£’000’s
£’000’s
£’000’s
£’000’s
£’00’s
£’000’s
£’000’s
£’000’s
£’000’s
Chris Burdon,
Chairman
20 - 25
Nil
Nil
Nil
N/A
20 - 25
20 - 25
Nil
Nil
Nil
N/A
20 - 25
Jill Gramann,
Non-executive
Director
5 - 10
Nil
Nil
Nil
N/A
5 - 10
5 - 10
Nil
Nil
Nil
N/A
5 - 10
Martin
Connor, Nonexecutive
Director
5 - 10
Nil
Nil
Nil
N/A
5 - 10
5 - 10
Nil
Nil
Nil
N/A
5 - 10
Peter
Lachecki,
Non-executive
Director
5 - 10
Nil
Nil
Nil
N/A
5 - 10
5 - 10
Nil
Nil
Nil
N/A
5 - 10
David
Priestnal,
Non-executive
Director
5 - 10
Nil
Nil
Nil
N/A
5 - 10
5 - 10
Nil
Nil
Nil
N/A
5 - 10
Colin Phillips,
Non-executive
Director
5 - 10
Nil
Nil
Nil
N/A
5 - 10
5 - 10
Nil
Nil
Nil
N/A
5 - 10
Sarah
Dugan, Chief
Executive
135 140
4
Nil
Nil
60 62.5
195 200
135 140
15
Nil
Nil
(17.5 20)
115 120
Dr William
Creaney,
Medical
Director
115 120
Nil
Nil
Nil
17.5 20
135 140
115 120
Nil
Nil
Nil
20 22.5
135 140
Robert
Mackie,
Director of
Finance
110 115
Nil
Nil
Nil
55 57.5
170 175
100 105
Nil
Nil
Nil
7.5 - 10
110 115
Janet Ditheridge, Director
of Operations
Sep13
45 - 50
Nil
Nil
Nil
30 32.5
75 - 80
95 100
Nil
Nil
Nil
2.5 - 5
100 105
Financial accounts
119
Board of Directors Salaries and Allowances For Annual Report and
Accounts 2013/14 continued
Stephen Collman, Director
of Operations
Expense payments (taxable)
total to nearest £100
Performance pay and bonuses
(bands of £5,000)
Long term performance pay
and bonuses (bands of £5,000)
All pension-related benefits
(bands of £2,500)
TOTAL (bands of £5,000)
Salary (bands of £5,000)
Expense payments (taxable)
total to nearest £100
Performance pay and bonuses
(bands of £5,000)
Long term performance pay
and bonuses (bands of £5,000)
All pension-related benefits
(bands of £2,500)
TOTAL (bands of £5,000)
2012/13
Salary (bands of £5,000)
Date Left Date Started Name and Title
2013/14
£’000’s
£’00’s
£’000’s
£’000’s
£’000’s
£’000’s
£’000’s
£’00’s
£’000’s
£’000’s
£’000’s
£’000’s
Oct13
40 - 45
Nil
Nil
Nil
27.5 30
70 - 75
N/A
N/A
N/A
N/A
N/A
N/A
Sandra
Brennan,
Director of
Quality
90 - 95
Nil
Nil
Nil
32.5 35
125 130
90 - 95
Nil
Nil
Nil
(20 22.5)
65 - 70
Susan Harris,
Director of
Strategy and
Business Development
90 - 95
Nil
Nil
Nil
20 22.5
110 115
75 - 80
Nil
Nil
Nil
17.5 20
90 - 95
Robert
Hipwell, Board
Secretary
80 - 85
Nil
Nil
Nil
12.5 15
95 100
80 - 85
Nil
Nil
Nil
(25 27.5)
55 - 60
Notes:
1) The expense payment made to Sarah Dugan in both years relates to a leased vehicle used under the terms of the
Trust’s lease car policy.
2) The format required for reporting senior managers’ remuneration within the NHS has changed for the financial year
ending 31 March 2014 as prescribed by the Companies Act 2006 and The Large and Medium-sized Companies and
Groups (Accounts and Reports) Regulations 2008 (SI 2008 No 410).
3) The new salaries and allowances table requires disclosure of the value of future pension benefits that have accrued
to senior managers during the year, as well as additional disclosures relating to performance-related pay and
bonuses and these are totalled together with senior managers’ salary and expense payments to provide a total
value of salaries and allowances earned. Comparative figures for the year 2012-13 have been re-stated in this year’s
revised table.
120 A
Annual Report 2014-15
Total accrued pension at age 60 at 31 March 2014
(bands of £5,000)
Lump sum at age 60 related to accrued pension at
31 March 2014 (bands of £5,000)
Cash Equivalent Transfer Value at 1 April 2013
Cash Equivalent Transfer Value at
31 March 2014
Real increase in Cash Equivalent Transfer Value
Employer’s contribution to stakeholder pension
Date Left
Real increase in pension lump sum at aged 60
(bands of £2,500)
Real increase in pension at age 60 (bands of £2,500)
Date Started
Name and Title
Pension Benefits
£’000’s
£’000’s
£’000’s
£’000’s
£’000’s
£’000’s
£’000’s
£’000’s
Sarah Dugan, Chief Executive
2.5 - 5
10 - 12.5
45 - 50
140 - 145
727
825
83
0
Dr William Creaney, Medical
Director
0 - 2.5
5 - 7.5
10 - 15
40 - 45
222
267
40
0
Robert Mackie, Director of
Finance
2.5 - 5
7.5 - 10
20 - 25
70 - 75
313
376
57
0
Janet Ditheridge, Director of
Operations
Sep-13
0 - 2.5
2.5 - 5
30 - 35
100 - 105
557
628
29
0
Sandra Brennan, Director of
Quality
0 - 2.5
5 - 7.5
35 - 40
105 - 110
619
860
228
0
Susan Harris, Director of
Strategy and Business
Development
20 - 22.5
Nil
20 - 25
Nil
11
208
197
0
Robert Hipwell, Board
Secretary
0 - 2.5
2.5 - 5
40 - 45
125 - 130
901
974
54
0
Oct-13
0 - 2.5
2.5 - 5
20-25
60 - 65
247
302
25
0
Stephen Collman, Director of
Operations
Financial accounts
120 B
Reporting of other compensation schemes - exit packages
Exit package
cost band
(including
any special
payment
element)
Number of
compulsory
redundancies
Number
of other
departures
agreed
Cost of
compulsory
redundancies
Total
Cost of other
number
departures
of exit
agreed
packages
Number of
departures
where
special
payments
have been
made
Total cost
of exit
packages
Cost of
special
payment
element
included
in exit
packages
Number
£s
Number
£s
Number
£s
Number
£s
Less than
£10,000
3
18,971
0
0
3
18,971
0
0
£10,000£25,000
5
93,747
0
0
5
93,747
0
0
£25,001£50,000
3
81,675
0
0
3
81,675
0
0
£50,001£100,000
2
122,996
0
0
2
122,996
0
0
£100,001 £150,000
1
110,832
0
0
1
110,832
0
0
£150,001 £200,000
0
0
0
0
0
0
0
0
>£200,000
0
0
0
0
0
0
0
0
14
428,221
0
0
14
428,221
0
0
Totals
Notes:
All of the exit packages in year relate to compulsory redundancies.
121
Annual Report 2014-15
Audit Committee Annual Report 2013/14
1. Introduction
The Audit Committee is established under Board
delegation with approved terms of reference that are
aligned with the Audit Committee Handbook 2011,
published by the HFMA and Department of Health. The
Committee consists of three Non-Executive directors
and has met on six occasions throughout the financial
year. It has discharged its responsibilities for scrutinizing
the risks and controls which affect all aspects of the
organisation’s business.
2. Principal review areas
This annual report is divided into nine sections reflecting
the key duties of the Committee as set out of the revised
terms of reference, which were approved by the Trust
Board in March 2014.
2.1 Governance, risk management and
internal control
• The Committee has reviewed relevant disclosure
statements, in particular the Annual Governance
Statement together with the Head of Internal
Audit Opinion, external audit opinion and other
appropriate independent assurances and considers
that the Governance Statement is consistent with the
Committee’s view on the Trust’s system of internal
control. Accordingly the Committee supports the
Board’s approval of the Governance Statement.
• The Committee has reviewed the Assurance Framework.
It believes that the Framework used during the year was
fit for purpose and has reviewed evidence to support
this. The Framework is in line with Department of Health
expectations and has been reviewed by internal audit
and external audit to give additional assurance that this
opinion is soundly based.
• The Committee has reviewed the completeness of the
risk management system and the extent to which it is
embedded in the organisation. The Committee believes
that adequate systems for risk management are in place,
and that these systems are now embedded throughout
the whole organisation. At the February 2014
Committee meeting the external auditor introduced
a report entitled “Communication with the Audit
Committee“, which provided independent confirmation
that the systems are in place and operating as intended.
2.2 Internal audit: throughout the year the
Committee has worked effectively with
internal audit to strengthen the Trust’s
internal control processes. The Committee
has also in year:
• Received and considered the effectiveness of internal
audit, taking into account self-assessment review
alongside that of the Committee’s own review.
• Reviewed and approved the internal audit strategy,
operational plan and more detailed programme of work
at its February meeting.
• Considered the major findings of internal audit and
are assured that management have responded in an
appropriate manner and that the Head of Internal Audit
Opinion and Governance Statement reflect any major
control weaknesses.
• Discussed and agreed the actions required in 23 reviews
which were undertaken during the year. 15 were given
significant assurance, 4 were given moderate assurance
and 4 were not assurance based reviews. The exceptions
concerned:
• Procurement (Moderate Assurance).
• Data Quality (Moderate Assurance).
• Inpatient Core Clinical Documentation
Compliance – Mental Health (Moderate
Assurance)
• Medical Devices (Moderate Assurance)
• For Procurement the auditor identified that the Trust
had yet to develop a procurement savings plan and a
set of KPIs. It is acknowledged that these issues have
since been addressed.
• In the area of Data Quality audit testing identified
concerns with data capture.
• For Core Clinical Documentation Compliance (Mental
Health) discrepancies were identified with the recording
of some clinical assessments and indicators.
• For the Medical Devices review issues were identified
with the disposal of medical devices.
122
2.3 External Audit
• The Committee reviewed and agreed external audit’s
annual plan.
• The Committee reviews and comments on all the
reports prepared by external audit; including the
External Audit Annual Governance Report.
• The Committee will, on behalf of the Trust Board, review
and sign off the 2013/14 annual accounts, alongside
the External Audit Annual Governance Report on the 5
June. No issues have been raised to date, which give rise
to any concerns or issues of note.
• The Committee’s working assumption is that an
unqualified audit opinion on the Annual Accounts and
on the Trust’s Value for Money will be issued in early
June 2014.
• Received and considered the effectiveness of external
audit, taking into account a self-assessment review
alongside that of the Committee’s own review.
2.4 Management
• The Committee has continually challenged the
assurance process when appropriate and has
requested and received assurance reports from Trust
management and various other sources; both internally,
and externally throughout the year. This process has
also included calling managers to account when
considered necessary to obtain relevant assurance.
The Committee also works closely with the Trust’s
Contracting, Information and Performance Manager to
ensure that the assurance mechanism within the Trust
is fully effective and that a robust process is in place to
ensure that actions falling out of external reviews are
implemented and monitored by the Committee.
• The Committee receives a regular report on the business
of the other Board Committees and works particularly
closely with the Quality and Safety Committee, ensuring
that reports requiring their scrutiny do so before these
reports come to the Audit Committee.
2.5 Financial Reporting
• During the course of the year the Committee received
regular briefings from the Head of Finance (Systems
and Reporting) on emerging accounting and reporting
issues which were considered pertinent to the annual
accounts or the Committee in its wider Governance role.
• The Committee has reviewed and approved the Trust’s
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accounting policies for inclusion within the 2013/14
annual accounts.
• The Committee has reviewed the annual financial
statements before submission to the Board and
considers them to be accurate.
• On 8th May 2014 the Committee received a detailed
briefing on the Trust’s final accounts for 2013/14, which
covered all the significant accounting issues for the year.
2.6 Counter Fraud Service
• The Committee has reviewed and approved the annual
Counter Fraud plan, terms of reference and its progress
reports. A separate annual report is produced to cover
the work of the Local Counter Fraud Service.
2.7 Local Security Management
Specialist Service
• The Committee has reviewed and approved the annual
Local Security Management Specialist Service plan,
terms of reference and its progress reports. A separate
annual report is produced to cover the work of the
Service which is considered by the Committee prior to
submission to the Area Security Management Specialist
and NHS Protect.
2.8 Procurement
• At its February 2014 meeting the Committee took on
responsibility for oversight of the Procurement strategy,
including review and approval of the work plan
alongside in-year monitoring of delivery.
• The Committee reviewed and approved the 2014/15
work plan and noted the first progress report.
2.9 Data Quality Improvement Plan
• At its February 2014 meeting the Committee took on
responsibility for oversight of the Trust data quality
improvement plan, including review and approval of
the work plan alongside in-year monitoring of delivery
and therefore work in this area will not fully commence
until 2014/15.
• From 2014/15 the Committee will also have a new
sub-committee reporting to it covering the business
conducted on the Trust’s data quality improvement
plan.
Annual Report 2014-15
3. Other matters worthy of note
5. Conclusion
The Committee has reviewed the process and controls
the Trust has put in place to achieve its financial
obligations throughout the year. It further notes that the
Trust has achieved these financial obligations.
The Committee is of the opinion that this third annual
report is consistent with the draft Annual Governance
Statement, Head of Internal Audit Opinion and the
external audit review and there are no matters that the
Committee is aware of at this time that have not been
disclosed appropriately.
The Committee recognises the hard work that delivered
the financial outcome for the year ending 31 March
2014. Both the financial surplus and proximity of the
actual outcome to forecast are a reflection of sound
management.
Martin Connor
Chairman of Audit Committee
9 May 2014
4. Review of the effectiveness and
impact of the Audit Committee
The Committee has been active during the year in
carrying out its duty to provide the Trust Board with
assurance that effective internal control arrangements
are in place. Specifically the Committee has:• Reviewed the Assurance Framework and Risk Register
and has influenced the drafting and on-going
development of these tools.
• Reviewed its compliance with the Audit Committee
Handbook and has undertaken a self-assessment.
Actions arising from this self-assessment will be
included in the Audit Committee action plan.
• Secured the delivery of a 99.2% implementation rate on
internal audit recommendations with 362 actions being
implemented promptly against a plan of 365.
• Ensured that satisfactory progress is made with the
implementation of external Audit recommendations,
which by their nature are of a more strategic nature.
• Worked closely with the two audit service providers and
received annual confidential briefings from them.
• Reviewed and approved the Trust’s key financial policies
and procedures including salary sacrifice schemes
for cars and Information technology products and a
new lease car policy and ensured that they are fit for
purpose.
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Details of Directors
Directors’ interests:
The Trust has a Directors’ Register of Interests which is open to the public and may be accessed via the Trust’s internet
Our Board of Directors:
Chris Burdon, Chairman
Chris took up his appointment on 1 July 2011 having been Chairman designate since February
2011. He is the Chair of the Remuneration Committee. Chris was appointed as NED with NHS
Worcestershire in December 2008 and chaired their provider services Board. Chris held a series
of senior executive positions in the metal processing sector. His last post was with Bradken, an
Australian PLC, where he had responsibility for worldwide activity in the power generation and
cement production markets and the management of three sites in the UK.
Sarah Dugan, Chief Executive
Sarah took up post on 1 July 2011 having been Chief Executive designate since March 2011.
She is a member of the Quality & Safety and Finance & Performance Committees. Sarah
previously worked for NHS Dudley as Chief Executive. Sarah is a trained nurse. She has held
a wide range of senior positions with community and mental health service providers and in
commissioning organisations.
Sandra Brennan, Director of Quality (Executive Lead Nurse)
Sandra took up post with the Trust in July 2011 as Director of Quality (Executive Nurse). She is
a member of the Quality & Safety Committee. She previously worked for NHS Worcestershire
from December 2006 as Director of Clinical Development and Lead Executive Nurse. Prior to
this she was Director of Community Services and Nursing at North Birmingham Primary Care
Trust. Sandra has a background in nursing management.
Dr Bill Creaney, Medical Director
Bill took up post with the Trust in July 2011 as Medical Director. He is a member of the Quality
& Safety Committee. Previously he worked for Worcestershire Mental Health Partnership NHS
Trust as Director of Medical Development from October 2009 and prior to this, as Consultant
Old Age Psychiatrist from October 2006. Bill’s main responsibilities include Clinical Governance,
engagement of medical staff with Trust’s strategic goals and the Mental Health Act.
Bill’s previous experience includes working as a Consultant Old Age Psychiatrist and Associate
Medical Director at NHS Ayrshire & Arran.
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Annual Report 2014-15
Stephen Collman, Director of Operations
Stephen was the Deputy Director of Service Delivery with the Trust from August 2011.
He is responsible for the day to day running of the Service Delivery Units operations
and management teams. Stephen qualified as a Nurse in 1990. He has held a number of
management posts in mental health and community services.
Robert Hipwell, Company Secretary
Robert was previously the Company Secretary with Worcestershire Mental Health Partnership
NHS Trust. His responsibilities include Board support, corporate governance / assurance,
risk management, health and safety, and claims handling. Robert has over 30 years general
management experience in the NHS. He has held director appointments in community &
mental health NHS trusts between 1993 and 2001. From 2001 to 2005 he set up and led a
Support Services Agency which provided a broad range of services to five NHS organisations.
Robert Mackie, Director of Finance
Robert took up post with the Trust on 1 July 2011 as Director of Finance. He is a Member of the
Finance & Performance Committee. He previously worked for NHS Walsall, initially as Director of
Resources from October 2008 and then from November 2010 as Interim Chief Executive.
Robert is a qualified accountant and joined the NHS with the 1998 cohort of the national
financial management training scheme, having previously worked in general management
within the private sector.
Sue Harris, Director of Strategy and Business Development
Sue was appointed in May 2012. Sue is a member of the Finance & Performance Committee
and her Directorate responsibilities include strategy and business development, marketing
and communication, the Foundation Trust Programme, the Programme Management Office
and procurement. Prior to a secondment to the Strategic Health Authority in 2011 Sue was,
from 2009, Lead Commissioner for mental health services in Worcestershire. In this role she
led on strategic planning, performance management, resource allocation and market reform.
Previously a national director for Turning Point, Sue has 15 years business development
experience in the health and social care field.
Jill Gramman, Non-Executive Director
Jill has been a Non-Executive Director with the Trust since 1 July 2011. She Chairs the FT
Programme Board and is a member of the Finance & Performance and Audit Committees. She
has a special interest role in patient experience. In a previous role she heard appeals by patients
on section under the Mental Health Act. Jill is a former Director and Trustee of SCOPE and BILD.
She ran her own marketing research company for over 30 years. Jill is a Magistrate and recently
completed three years as Chair of the Kidderminster Bench. She is actively involved in a charity
supporting disadvantaged and disabled people in the shanty areas of Lima, Peru.
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Peter Lachecki, Non-Executive Director
Peter has been a NED with the Trust since 1 July 2011. He is the Chair of the Quality & Safety
Committee and one of its sub-committees – the Mental Health Act Monitoring Group. He has
his own marketing and management consultancy and has held previous senior marketing and
general management roles at Kraft Foods, both in the UK and Internationally.
Peter is also a NED for Gloucester Cathedral Enterprises and is a member of the governing body
of King’s School in Gloucester.
David Priestnall, Non-Executive Director
David has been a NED with the Trust since 1 August 2011. He is a member of the Audit
Committee and Chair of the Finance & Performance Committee. He is also Vice Chairman
and Senior Independent Director. David was previously a NED and Vice Chairman of NHS
Worcestershire. Prior to this he was Chairman of Wyre Forest Primary Care Trust and Assistant
Director of Housing for Birmingham City Council.
Martin Connor, Non-Executive Director
Martin has been a NED with the Trust since 1 July 2011. He is the Chair of the Audit and
Charitable Funds Committees and a member of the Quality & Safety Committee. He is also
a NED for the RAC Pension Scheme and Chair of their Audit and Governance Committee
as well as Treasurer of both DIAL, a disability charity as well as Sampad, a South Asian Arts
organisation.
Martin previously worked for the Department of Work and Pensions and spent 20 years
working for the RAC in a variety of senior management roles.
Steve Peak, Non-Executive Director (Designate)
Steve has been a NED (Designate) since 1 November 2013. He is a member of the Finance and
Performance Committee. He has his own management consultancy company, lectures for
Keele University and is Business Development Director for Vanguard Healthcare Solutions. Over the past 25 years he has held previous senior leadership roles in acute hospitals including
a period of time as CEO of Birmingham Women’s NHS Foundation Trust.
Rick Roberts, Non-Executive Director
Rick has been a Non-Executive Director with the Trust since 1 April 2014, having previously
served as a NED (Designate) from 1 November 2013. He is a member of both the Quality &
Safety Committee and the FT Programme Board.
Rick retired as Medical Director of the Birmingham Community Healthcare NHS Trust in April
2013, having served as an Executive Director in successive NHS Trusts for some 20 years.
Previous appointments include Clinical Director of the Birmingham Dental Hospital and
Consultant in Oral Surgery.
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Annual Report 2014-15
Glossary of terms used in Annual Report
A&E (Accident & Emergency)
The emergency departments of hospitals that deal with
people who need emergency treatment because of
sudden illness or injury. Sometimes these services are
referred to as casualty departments, or minor injury units.
Acute services
Medical and surgical interventions usually provided in
hospital. The Trust only provided these services up to
30th June 2011, after which date these services were
transferred to the local acute Trust.
Capital
CQUIN
This is the term used for Commissioning for Quality
and Innovation. This is a system introduced in 2009
to make a proportion of healthcare providers’ income
conditional on demonstrating improvements in quality
and innovation in specified areas of care.
In-patient
A person admitted on to a hospital ward for treatment.
International Financial Reporting Standard
(I.F.R.S.)
Expenditure on the acquisition of land and premises,
individual works for the provision, adaptation, renewal,
replacement and demolition of buildings, items or
groups of equipment and vehicles, etc. In the NHS,
expenditure on an item is classified as capital if it is in
excess of £5,000.
Issued by the International Accounting Standards Board,
financial reporting standards govern the accounting
treatment and accounting policies adopted by
organisations. Generally these standards apply to NHS
organisations.
Capital charges
Capital charges are a way of recognising the costs
of ownership and use of capital assets and comprise
depreciation and interest/target return on capital.
The Trust is required to put in place a major incident plan
that is fully compliant with the requirements of the NHS
Emergency Planning Guidance 2005 and all associated
guidance.
Care Quality Commission
Monitor
The Care Quality Commission use expert assessors to
determine annual ratings for NHS Bodies on the quality
of the services they operate.
Clinical Commissioning Groups (CCGs)
Major Incident plan
Monitor is a non-departmental public body established
in 2004. It is the public sector economic regulator of
NHS-funded health care services and its main duty is to
protect and promote the interests of patients.
Clinical Commissioning Groups (CCGs) will from 1.4.2013
commission the majority of health services, including
emergency care, elective hospital care, maternity
services, and community and mental health services. All
of the 8,000 GP practices in England are now part of a
CCG. There are 211 CCGs altogether, commissioning care
for an average of 226,000 people each. There are three
CCGs in Worcestershire.
NHS England
Corporate Governance
NHS Trusts
The system and rules of delegation by which
organisations are directed and controlled.
Formally established as the NHS Commissioning Board
on 1 October 2012, NHS England is an independent body
at arm’s length to the Government.
NHS Foundation Trusts
NHS hospitals that are run as independent, public benefit
corporations, which are both controlled and run locally.
NHS trusts are hospitals, community health services,
mental health services and ambulance services which
are managed by their own boards of directors. NHS
trusts are part of the NHS and provide services based on
the requirements of patients as represented by Clinical
Commissioning Groups (CCGs) and GPs.
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Outpatient
A person treated in a hospital but not admitted on to a
ward.
Payment by Results (PbR)
better planning of patient care and management of long
term conditions.
Reference costs
Transparent rules based system that sets fixed prices
(a tariff ) for clinical procedures and activity in the NHS,
enabling all trusts to be paid the same for equivalent
work.
Reference costs are the average cost to the NHS of
providing a defined service in a given financial year.
Reference cost data allows NHS trusts to compare their
costs to the NHS average and therefore benchmark their
relative efficiency.
P.E.A.T. (replaced by P.L.A.C.E.)
Revenue
The PEAT (Patient Environment Action) inspections
take place every year and comprise a team of health
professionals along with an independent patient
representative. The team assess each hospital they visit
in terms of cleanliness, hygiene, privacy, dignity, patient
information, food quality and service.
Performance indicator
Measures of achievement in particular areas used to
assess the performance of an organisation.
P.L.A.C.E.
Patient led assessments of the care environment
(formerly P.E.A.T.)
Primary Care Trust (PCT)
Primary Care Trusts ceased to operate from 31 March
2013 and were replaced by Clinical Commissioning
Groups.
Provisions
Provisions are made when an expense is probable but
there is uncertainty about how much or when payment
will be required, e.g. estimates for clinical negligence
liabilities. An estimate of the likely expense is charged
to the Trust’s Operating Cost Statement as soon as the
issue comes to light, although actual cash payment may
not be made for many years, or in some cases never. The
expense is matched by a balance sheet provision entry
showing the potential liability of the organisation.
Revenue is expenditure other than capital, for example,
staff salaries and drug budgets. Also known as current
expenditure.
Secondary care
Specialised medical services and hospital care, including
outpatient and in-patient services. Access is often via
referral from primary care services.
Strategic Health Authority (SHA)
Strategic Health Authorities ceased to operate from 31
March 2013 and were replaced by the Trust Development
Authority.
Trust Development Authority
The focus of the Trust Development Authority from 1
April 2013 is to provide leadership and support to all
non-Foundation Trust Hospitals and its goal is first and
foremost to help each and every Trust to improve the
services they provide for their communities.
Virement
The agreed transfer of money from one budget head,
income or expenditure, to another, within a financial
year. Virement is a measure of flexibility that allows
budget-holding managers to receive either increases
or decreases in their budgets in response to budget
variances which cannot be managed within the year. For
example activity levels are higher than those anticipated
when the budget was originally set.
Q.I.P.P.
Quality, Innovation, Productivity and Prevention schemes
which include Medicines use and procurement, staff
productivity, clinical support rationalisation and the
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Annual Report 2014-15
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Annual Report 2014-15