Enhanced Quality
Governance Reporting
2011/12
1
Enhanced Quality Governance
Reporting
This section gives a brief overview of the arrangements in place to govern service quality and
which signposts the reader to where quality governance and quality are discussed in more
detail in the Annual Report – summarising briefly how the Foundation Trust has had regard to
Monitors quality governance framework in arriving at its overall evaluation of the organisations
performance, internal control and board assurance framework and a summary of action plans
to improve the governance of quality.








Information on how the Trust is using its foundation trust status to develop its services
and improve patient care can be found on page 16-17
Performance against key healthcare targets can be found on page 53-54
Arrangements for monitoring improvements in the quality of healthcare and progress
towards meeting any national and local targets, incorporating Care Quality
Commission assessments and reviews and the Trusts response to any
recommendations made can be found on page 54
Progress towards targets as agreed with local commissioners and details of key
quality improvements can be found on page 44-49
Information on new or revised services can be found on page 23
Information on service improvements following staff or patient surveys/comments and
Care Quality Commission reports can be found on page 58-60 and76
Information on improvements in patient/carer information can be found on page 56
Information on complaints handling can be found on page 54- 56
From Quarter 2 of 2011/12 the Trust did not meet all the applicable national requirements and
minimum standards for acute Trusts detailed in Monitor’s Compliance Framework due to
exceeding the C. difficile trajectory for 2011/12. The RNHRD has had 4 cases of C.difficile
during 2011/12, one in Q1, 1 in Q2 and 2 in Q3. A fifth case attributed in error in Q4 to the
RNHRD in a patient who tested positive after being transferred from the RNHRD has been
removed from the Health Protection Agency database in line with the agreed Algorithm for
Apportioning Clostridium difficile Infection.
Detailed root cause analysis is completed on each case with identified areas for learning
disseminated to staff, actions taken to reduce C.difficile infection include, updating of Trust
policy with addition of new treatment guidelines for infected patients, additional training for
clinical and non clinical staff in infection control procedures, introduction of a new cleaning
agent which is more effective, enhanced deep cleaning of clinical areas, new policy on use of
antibiotics to provide guidance to prescribers, de-cluttering of the environment, replacement
of chairs in patient areas, introduction of new uniforms and new uniform policy implemented.
Stakeholder Relations
The RNHRD works in partnership with a range of NHS Trusts to facilitate the delivery of high
quality patient care. These partnerships include service level agreements with the Royal
United Hospitals NHS Trust for delivery of a wide range of support services such as
Microbiology, Pharmacy, library facilities and specialist medical and nursing staff who provide
care in conjunction with RNHRD staff. We employ a range of specialist staff from other NHS
Trusts to support the delivery of specialist paediatric services, orthopaedics and dermatology.
During 2011/12, we forged partnerships with Macmillan and the National Specialist
Commissioning Group with a view to developing new services for cancer survivors in
2012/13.
2
NHS Foundation Trust Code of
Governance
The Trust considers that it complies with the specific disclosure requirements set out in
Monitor’s best practice advisory document “The NHS Foundation Trust Code of Governance”.
Particular provisions within the Code addressed in this report are as follows:
 A statement of how the Board of Directors and the Board of Governors operate,
including a high-level statement of which types of decisions are to be taken by each
of the Boards and which are to be delegated to management by the Board of
Directors (Code of Governance ref. A.1.1); page 32 in this report.
 The names of the Chairman, the deputy Chairman (where there is one), the Chief
Executive, the Senior Independent Director and the Chairmen and members of the
Nominations, Audit and Remuneration Committees (A.1.2); pages 28 and 38-39
 The number of meetings of the Board of Directors and those committees and
individual attendance by Directors (A.1.2); page 38 in this report.
 The names of the Non-Executive Directors whom the Board determines to be
Independent, with reasons where necessary (A.3.1); page 37 in this report.
 A description of each Director’s expertise and experience (A.3.4); from page 36-38.
 A clear statement about the Board of Directors’ balance, completeness and
appropriateness (A.3.4); page 36 in this report.
 The names of the Governors and details on their constituency, whether they are
elected or appointed and the duration of their appointments, together with details of
the nominated lead Governor (B.1.3); page 33 in this report.
 The number of meetings of the Board of Governors and individual attendance by
Governors and Directors (B.1.3); pages 33-34 in this report.
 The other significant commitments of the Chairman and any changes to them during
the year (C.1.7); page 36 in this report.
 A separate section describing the work of the Nominations Committee, including the
process it has used in relation to Board appointments and an explanation if neither
external search consultancy nor open advertising has been used in the appointment
of a Chairman or Non-Executive Director (C.1.14); page 39 in this report.
 How performance evaluation of the Board of Directors, its committees and its
Directors has been conducted (D.2); page 29 in this report.
 As part of the remuneration disclosures of the annual report, where an Executive
Director serves as a Non-Executive Director elsewhere, whether or not the Director
will retain such earnings (E1.3); pages 29 and 36 to 38 in this report.
 An explanation from the Directors of their responsibility for preparing the Financial
Statements and a statement by the auditors about their reporting responsibilities
(F.1.1); page 91 of this report.
 A statement from the Directors that the business is a going concern, with supporting
assumptions or qualifications as necessary (F.1.2); page 86 in this report.
 A report that the Board has conducted a review of the effectiveness of the group’s
system of internal controls (F.2.1); page 85 – 86 in this report.
 A separate section describing the work of the Audit Committee in discharging its
responsibilities (F.3.3); page 38-39 in this report.
 Where the Board of Governors does not accept the Audit Committee’s
recommendation on the appointment, reappointment or removal of an external
auditor, a statement from the Audit Committee explaining the recommendation and
the reasons why the Board of Governors has taken a different position (F.3.5); page
39 in this report.
 An explanation of how, if the auditor provides non-audit services, auditor objectivity
and independence is safeguarded (F.3.8); page 39 in this report.
 Contact procedures for members who wish to communicate with Governors and/or
Directors (G.1.4); page 34 in this report , and
 The steps the Board has taken to ensure that members of the Board, and in particular
the Non-Executive Directors, develop an understanding of the views of Governors
and members about their NHS Foundation Trust (G.1.5); page 32 in this report.
3
Council of Governors
This Foundation Trust has a framework of local and national accountability through members,
and of governance through our Council of Governors and Board of Directors. Our Council of
Governors has an invaluable role in representing members’ views, contributing to the Trust’s
strategic direction and ensuring that the Board of Directors meets its terms of authorisation.
Relationship with the Board of Directors
The Board of Directors is collectively responsible for the exercise of the powers and the
performance of the Trust. The role of the Board of Directors is to provide active leadership of
the Trust. It is responsible for the operational running of the Trust and for ensuring
compliance with our terms of authorisation, constitution, mandatory guidance issued by
Monitor, relevant statutory requirements and contractual obligations.
The Board sets the Trust’s strategic aims, but in setting forward plans takes into consideration
the views of the Council of Governors. The Board is responsible for ensuring that the
necessary finance resources are in place for the NHS Foundation Trust to meet its objectives.
The Council of Governors
The Council of Governors provides a direct link to our community and represents the interest
of members and stakeholder organisations in the stewardship and development of the Trust.
The Council of Governors ensures that the Trust is responsive to the needs and values of all
stakeholders; patients, public, staff and partners organisations. The Council of Governors
holds the Board to account for the performance of the Trust, including ensuring that the Board
acts so that the Trust does not breach the terms of its authorisation. The Council of
Governors regularly feeds back information about the Trust, its vision and its performance to
the membership constituencies and stakeholder organisations that either elected or appointed
them.
In addition the Council of Governors has statutory responsibilities which are set out on page
35.
Representatives from the Council of Governors attend the Board Meetings on a rotational
basis and present the views of the Council and the members. Non-Executive Directors have
a link into one of three Governors committees: Governance, Service Development and
Delivery, and Membership. This allows individual members of the Board to understand the
views of the Council of Governors. Further feedback is directed to the Board through the
Chair of the Board who regularly meets with the Chairs of the three committees.
Governors of the Council are appointed or elected for a two or three-year period. At the end
of this period, elected Governors have the opportunity to stand for re-election and appointed
Governors may be re-appointed by their organisation for a further two or three-year period.
The maximum term for all members of the Council of Governors is nine years.
Constituencies
The Council of Governors is made up of three constituencies as well as appointed partnership
organisations as follows:
 The Public constituency is made up of non-patient members
 The Patient constituency is made up of patients of the Trust
 The Staff constituency is made up of employees of the Trust.
The table below shows the composition of the Council of Governors during 2011/12, the
constituency or organisation each Governor represents how the Governors were
elected/appointed and the length of office.
There have been six formal meetings of the Council of Governors between April 2011 and
March 2012. Attendance by Governors, Directors and Non-Executive Directors is also shown
in the table below.
4
Elected Governors – Public constituency
Name
Judith Beresford Smith
Hilary Elms
Peter Miles
Francis Ring
Ben Rogers
Shirley Arayan
Favre Armstrong
Rosemarie Cole
Jane Crow
Date elected
/ re-elected
01/04/2011
01/04/2011
01/04/2011
01/04/2011
01/04/2011
01/04/2011
01/04/2011
01/04/2011
01/04/2011
Term of
Office
3
3
3
3
3
3
3
3
3
Attendance at
meetings
7/7
6/7
2/7
5/7
7/7
1/7
6/7
7/7
5/7
Date elected
/ re-elected
01/04/2011
01/04/2011
01/04/2011
01/04/2011
01/04/2011
01/04/2011
01/04/2011
Term of
Office
3
3
3
3
3
3
3
Attendance at
meetings
3/7
6/7
7/7
7/7
3/7
6/7
7/7
Elected Governors – Patient constituency
Name
Judith Plante Cleall
Donn Boyland
Robert Slade
Judy Coles(Nominated Lead Governor)
Jean Leitner Hartley
George Odam
Vivienne Pozo
Elected Governors - Staff
Name
Yvonne Glenn
Candy McCabe (resigned 31/03/2012)
Janice Book (resigned 31/03/2012)
Date elected / reelected
01/04/2011
02/06/2010
01/04/2011
Term of
Office
3
3
3
Attendance at
meetings
2/7
3/7
3/7
Appointed / reappointed
03/11/2011
29/01/2012
21/05/2010
Term of
Office
2
2
2
Attendance at
meetings
5/7
7/7
4/7
16/12/2011
25/03/2011
26/05/2010
24/04/2010
20/11/2011
2
2
2
2
2
2/3
7/7
7/7
3/7
0/1
28/02/2011
2
5/7
30/03/2011
2
5/7
Appointed Governors
Name
Organisation
Tim Bilham
Sara Brooks
Dr Anthony
Clarke
Derek Thorne
Peter Haines
Dr Nick Hall
Jo Hunt
Debbie Cook
Bath University
Action for ME
BANES Council
Sue Meadows
Connie Wright
BANES PCT
Headway
BIRD
Arthritis Care
National Ankylosing
Spondylitis Society
National Osteoporosis
Society
BANES LINKS
5
Directors’ attendance
Name
Position
Peter Franklyn
Stephen Cole
Niall Bowen
Christopher Johns
Sir Peter Spencer KCB
Kirsty Matthews
Steven Haynes
Rachel Hepworth
Dr Tim Jenkinson
Dr Ashok Bhalla
Annie Kelly
Hayley Sewell
Trust Chair & Chair of the Council of Governors
Non Executive Director
Non Executive Director
Non Executive Director
Non Executive Director
Chief Executive
Director of Finance (until December 2011)
Director of Finance (from January 2012)
Medical Director (until August 2011)
Medical Director (from August 2011)
Director of Operations and Clinical Practice
Director of Governance
Attendance at
meetings
6/6
3/6
3/6
3/6
3/6
5/6
3/4
2/2
0/2
1/4
2/5
3/6
Elections to the Council of Governors
No elections were held in 2011/2012
Vacancies on the Council of Governors
The vacancies on the Council of Governors at the end of 2011/2012 were as follows:
Constituency
Public
Patient
Staff
Appointed
Vacancies
0
3
3
0
The Council of Governors meets formally six times a year and informally four times a year,
and additionally when called. Council Governors are requested to attend all of these
meetings. In addition to this time commitment for Council of Governors meetings, the Trust
holds an Annual Members Day, which the Council are asked to attend. Council Governors
also have the opportunity to be involved in sub-groups and promotional work.
All Council Governors complete an annual declaration of interest. This information is available
from the Membership Support Team:
RNHRD NHS Foundation Trust
FREEPOST SN1301
Upper Borough Walls
Bath
BA1 1RL
Telephone: 01225 465941 x295
Email: nhsft@rnhrd.nhs.uk, Website: www.rnhrd.nhs.uk
Members can contact the Council of Governors or request information on Council of
Governors meetings and attendance by Council Governors at these meetings through the
Membership Support Team.
6
The Monitor Code of Governance and the Trust’s Constitution set out various powers of, and
obligations upon Council Governors, as summarised below:
 to represent members and partner organisations from the local health economy
 to feed back information to members
 to receive, consider and provide feedback on the Trust’s Annual Report and Financial
Statements and Annual Plan
 to take responsibility for appointing, re-appointing and removing the Chair and other NonExecutive Directors
 to decide the remuneration and allowances and the other terms and conditions of office
of the Chair and Non-Executive Directors and to review this on an annual basis.
 to be involved in agreeing a process for and outcome of evaluation of the Chair and NonExecutive Directors
 to approve the appointment, re-appointment or removal of the Chief Executive Officer
 to appoint and remove the Trust’s auditor
 to develop the Trust’s membership in line with the Trust’s Membership Strategy
 to act in the best interests of the Trust and adhere to its values
 to engage in dialogue with the Trust’s Board of Directors and invite members of the
Board to their meetings as appropriate
 to hold the Board of Directors to account for the performance of the Trust, ensuring that it
does not breach its terms of authorisation and informing Monitor if there is a risk of these
being breached
 to undertake an annual self-evaluation of its own collective performance and its impact on
the Trust and develop an Annual Work plan arising from this evaluation
 to regularly communicate the outcomes of their involvement within the Trust to members,
including their impact and effectiveness.
Members of the Board of Directors attend the Council of Governors’ six formal meetings. The
Chief Executive provides updates to the Council on the present work of the Trust and takes
feedback, the Finance Director provides information on the present financial situation and the
Council has the opportunity to put questions to the Finance Director and feed-in their views and
opinions. Representatives from the Non-Executive Directors attend the Council of Governors’
formal meetings. In addition representatives from the Council of Governors attend open board
meetings. Non-Executive Directors (NEDs) sit on committees along-side the Council Governors,
e.g. the Audit Committee. NEDs also attend, with the rest of the Board, the Annual Members Day
to meet active interested members. This day is an opportunity for market research and to find out
members’ views of the hospital's services
7
Board of Directors
Statement about the balance, completeness and appropriateness of
the membership of the Board
The Board structure has remained unchanged in 2011/12 following organisational changes
introduced in May 2010. The Board consists of 5 Non-Executive Directors, of whom one is the
Chair, and 4 Executive Directors. The Director of Governance attends the Board meetings in a
non-voting capacity.
Governance requirements have been met through the Chair and Non-Executive Directors roles
on committees and their attendance at Board meetings. There is a clear separation of the roles of
the Chair and the Chief Executive. The Chair has responsibility for the running of the Board and
the Council of Governors, setting the agenda for the Trust and for ensuring that all directors are
fully informed of matters relevant to their roles.
Members of the Board have a wide range of experience from both the public and private sectors.
The Chair and Non-Executive Directors have combined experience of health and social care,
business delivery, corporate finance, education, the charitable sector, the armed forces and the
civil service. Executive Directors have extensive experience in the NHS and private sector. Short
biographies are detailed below.
Non-Executive Director appointments to the Board may be terminated at the wish of the
incumbent, or by the Council of Governors ratified by a two-thirds majority. A term of office for
Non-Executive Directors is three years. All Non-Executive Directors are Independent Directors in
line with the NHS Trust Code of Governance. The Trust holds a public Register of Interests which
is available from the Chief Executive’s Office.
The Chair conducted appraisals of the Chief Executive and with Governors, forming the
Nominations Committee, of the Non-Executive Directors in 2011/12. The Executive Directors
were appraised by the Chief Executive.
The Trust’s internal auditors completed a full assessment of the provisions set out in the Code of
Governance during 2011/12 assessing the Trust as Green.
The Board of Directors
Peter Franklyn, Chair
Peter was appointed Chair of the Trust in August 2010 for three years. He brings nine years of
recent practical experience delivering healthcare as Chief Executive of the Royal Hospital for
Neuro-disability. His previous career was in the armed services. He is also a Trustee of St John’s
Hospital, a charity dedicated to meeting the needs of the poor and needy of Bath since 1174.
Peter is also Chair of the Trust’s Council of Governors, and Chair of the Remuneration
Committee.
Niall Bowen, Non Executive Director
Niall was appointed in Dec 2010 for a term of three years. Niall has extensive experience of
developing, managing and leading businesses in highly competitive pharmaceutical and
healthcare markets, including the establishment of an award-winning homecare service and the
integration of a specialist clinical nutrition company. He has an MBA from Bath University and
has been awarded an Honorary Doctorate in Business Administration by Queen Margaret
University of Edinburgh, and is a Non Executive Director of GP Care UK Ltd. Niall is the Chair of
the RNHRDs’ Charitable Funds Committee.
Stephen Cole, Non Executive Director
Stephen was appointed by a Monitor Intervention Order as Interim Chair in April 2009. He stood
down as Chair in August 2010 agreeing appointment as a Non-Executive Director for a term of
three years. He chairs the Finance and Activity Committee and is a member of the Audit and
Charitable Funds committees. Stephen, an FCA, was formerly for 21 years a Partner at KPMG
8
LLP where he obtained significant corporate experience. Stephen currently is also Honorary
Treasurer and Trustee of InControl Partnerships Limited, a charity the principal activity of which is
acting as a proponent of self-directed support (which includes personal health budgets), and a
partner of The Brighton Creamery LLP, trading as Boho Gelato.
Christopher Johns, Non Executive Director – Senior Independent Director (from September 2010)
Chris was appointed in October 2007 for a period of three years, which, in October 2010, was
extended for a further three years. In September 2010 Chris became the Senior Independent
Director. Chris has a background in the management and regulation of social care. He has
worked in local and central government and in the voluntary sector. Chris is currently a senior
lecturer at the University of Wales Institute, Cardiff. Chris is a Trustee of Tubbs Charity. Chris is
the lead Non Executive Director for integrated governance and quality assurance (including
infection control) at the RNHRD, and sits on this committee. Chris is also the Trust lead for health
and safety.
Sir Peter Spencer KCB, Non Executive Director – Vice Chair (from September 2010)
Peter was appointed in December 2007 for a term of three years, which, in December 2010 was
extended for a further three years. In September 2010 Peter became Vice Chair. Peter has had a
distinguished career in the Royal Navy where he finished his service as Second Sea Lord and
Commander in Chief Naval Home Command. In 2003 he retired from the Royal Navy and
became a senior civil servant in the Ministry of Defence, as Chief of Defence Procurement, until
April 2007. Since then he has taken on the position of Chief Executive of Action for ME. He was
appointed as a Public Appointments Assessor in April 2012. Peter is Chair of the RNHRD Audit
Committee.
Kirsty Matthews, Chief Executive Officer
Kirsty was appointed Interim Chief Executive Officer by Monitor in April 2009 and then Chief
Executive following an interview process in August 2010. Prior to her appointment as Chief
Executive, Kirsty had served as Interim Chair appointed by a Monitor intervention in December
2008 and as a Non Executive Director from December 2007. Kirsty was previously Director of
strategy for a private healthcare provider and has a background in general management in the
NHS and business development in the private sector. Kirsty is educated to Masters Degree level.
Steven Haynes, Director of Finance (until December 2011)
Steven was appointed Interim Finance Director in January 2010 and was made permanent
Director of Finance in May 2010. Steven is a qualified accountant and has worked in senior
positions in NHS Finance since 1990.
Rachel Hepworth, Director of Finance (from January 2012)
Rachel Hepworth was appointed Director of Finance in January 2012. Rachel is a qualified
accountant with CIPFA and has a degree in psychology. Rachel has worked in NHS finance since
2002 in a variety of organisations, most recently at the Cambridgeshire Community Services NHS
Trust.
Dr Tim Jenkinson, Medical Director (until August 2011)
Tim was appointed as Medical Director in April 2007. Tim started as a Consultant in
Rheumatology and Sports Exercise Medicine at the Trust in 2000. He is an Honorary Senior
Lecturer in Sports and Exercise Medicine at the University of Bath and is an Honorary Senior
Medical Advisor to the Football Association.
Dr Ashok, Medical Director (from August 2011)
Dr Ashok Bhalla joined the hospital as a consultant in rheumatology and metabolic bone disease
in 1988. He trained in Manchester and London, and completed a medical fellowship in the US at
Harvard Medical School and Massachusetts General Hospital. Dr Bhalla’s specialist interests
include inflammatory arthritis, osteoporosis and other metabolic bone diseases, chronic pain and
fibromyalgia. He helped to establish the hospital’s pain management service. Dr Bhalla is active
in research and has presented original work at national and international meetings.
9
Rayna McDonald, Director of Operations and Clinical Practice, Director of Infection Prevention
and Control, and Deputy Chief Executive (from May 2010 until August 2011, currently on
maternity leave)
Rayna joined the Trust in February 2010 as Operations Lead on secondment from her position as
Divisional Manager, Elective Services at Basingstoke and North Hampshire NHS Foundation
Trust. She was appointed as Director of Operations and Clinical Practice at the RNHRD in May
2010. Rayna has worked in a range of clinical, management and academic positions in various
NHS and academic organisations. She is a Registered General Nurse, a graduate of the NHS
Management Training Scheme, and holds a Postgraduate Diploma in Management (Health) and
a Bachelor of Nursing (hons). Rayna has published and presented research papers at a variety of
international nursing conferences.
Annie Kelly, Acting Director of Clinical Practice and Operations, Director of Infection Prevention
and Control and Deputy Chief Executive (from August 2011)
Annie joined the Trust in July 2011 for an interim period of one year to cover the maternity leave
of the permanent post holder. She has 31 years of nursing experience across acute and
community settings and latterly worked as Director of Nursing for Wiltshire PCT and Wiltshire
Community Health Services. Annie is educated to Masters level and has worked in a variety of
senior nursing roles in Bristol and the north east of England. She has a clinical background in
orthopaedics and has a strong interest in infection control and developing clinical practice.
Hayley Sewell, Director of Governance
Hayley was appointed to the Board in 2005 and has responsibility for Governance. She has 25
years experience in the NHS and completed the NHS Clinical Strategist Programme at INSEAD
in 2003, an MSc from Kings College London in 1994 and began her NHS career as a Chartered
Physiotherapist.
A full declaration of interests of the members of the Board is available from the Board Secretary.
Board of Directors’ attendance
Name
Peter Franklyn
Niall Bowen
Stephen Cole
Christopher Johns
Sir Peter Spencer
Kirsty Matthews
Steven Haynes
Rachel Hepworth
Dr Tim Jenkinson
Dr Ashok Bhalla
Rayna McDonald
Annie Kelly
Hayley Sewell
Trust Board
(From 12 meetings)
12/12
12/12
11/12
12/12
11/12
12/12
08/09
03/03
05/05
06/08
04/04
Audit Committee
(From 5 meetings)
05/05
04/05
05/05
03/05
03/03
02/2
-
Remuneration Committee
(From 1 meeting)
1/1
1/1
1/1
1/1
1/1
-
07/08
11/12
In attendance
5/5
-
Audit Committee
Audit Committee Membership: Peter Spencer is Chair of the Committee. Stephen Cole (NED)
and Niall Bowen (NED) are the other two members. The Chief Executive, Director of Finance and
Director of Governance are in attendance at the meetings along with two Governors. There were
five meetings of the Audit Committee in 2011/12:
Name
Peter Spencer
Niall Bowen
Role
Chair
NED
Attendance at meetings
5/5
5/5
10
Stephen Cole
Kirsty Matthews
Steven Haynes
Rachel Hepworth
Hayley Sewell
NED
CEO
Director of Finance
Director of Finance
Director of Governance
4/5
3/5
3/3
2/2
5/5
During 2011/12 the Audit Committee has continued to discharge its responsibilities in accordance
with its Terms of Reference and the requirements of the Code of Governance and the Audit Code
for Foundation Trusts. In particular the main performance evaluation activities have been:








strategic risk management with particular emphasis on mitigating risks to health
standards and risks to the financial status of the Trust
reviewing reports from the sub committees with responsibility for risk namely the Finance
and Activity Committee and Integrated Governance and Quality Assurance Committee
considering the major findings of internal audit investigations (and management’s
response), and ensuring co-ordination between the Internal and External Auditors to
optimise audit resources
conducting the annual self-assessment against the Code of Governance and standard
format and producing an action plan for implementing further improvements
feedback from the representatives from the Council of Governors who attended Audit
Committee meetings
private discussions with the internal and external auditors to get their feedback on Audit
Committee processes and effectiveness
tracking the implementation of a consolidated list of all audit recommendations. This is
now reported at every meeting of the Audit Committee
reviewing its Terms of Reference.
The external auditor is independently appointed by the Council of Governors from an approved
list recommended by the Board of Directors.
To ensure the independence of its external auditors, the Trust is careful not to commission
relevant PricewaterhouseCoopers staff to perform operational roles. This assurance is also
maintained by the firm’s own internal practices.
Nominations Committee of the Council of Governors
The Nominations Committee of the Council of Governors is the committee responsible for the
appointment, appraisal and remuneration of the Chair and other Non-Executive Directors of the
Board. The following Governors served as members of the Nominations Committee in 2011/12;
Judy Coles (Lead Governor and Chair), Francis Ring, Judith Beresford-Smith, Rosemary Cole,
Robert Slade. One Nominations committee meeting was held in 2011/12, to discuss the appraisal
and remuneration of Non-Executive Directors. There were no appointments made in 2011/12.
Individual attendance by directors was as follows:
Name
Peter Franklyn
Chris Johns
Role
Chair
NED/Senior Independent
Director
Attendance at meetings
1/1
1/1
11
Membership
Membership is free; there are no obligations for people who sign up as a member. On the
registration form there are three levels of membership:
Level 1
Keep in touch. All members receive a regular newsletter and information.
Level 2
Get involved. Some members choose to be consulted on plans for future
development of the hospital and its services and attend the Annual Members
Day.
Level 3
Work with us. For further active membership involvement some members stand
for election to the Council of Governors. There are also individual volunteer
opportunities within the hospital.
Constituencies
There are three membership constituencies in the RNHRD membership. The criteria are as
follows:
Public constituency
Individuals are eligible to become members of the public constituency if:



they live in England or Wales
they are not eligible to become a member of the staff constituency
they are not a member of the patient constituency.
The minimum number of members of the public constituency is 400.
Staff constituency
Individuals are eligible to become members of the staff constituency if they:


are employed under a contract of employment by the Trust (provided that Non-Executive
Directors of the Trust shall not be regarded as employees for this purpose); or
are employed or engaged through a designated Trust provider and otherwise exercise
functions on behalf of the Trust.
Individuals shall only be eligible to become members of the staff constituency if:



they are employed by the Trust under a contract of employment which has no fixed term
or a fixed term of at least 12 consecutive months; or
they have been continuously employed by the Trust for at least 12 months;
they have been employed by a designated Trust provider or been exercising the Trust’s
functions for a continuous period of 12 months.
The minimum number of members of the staff constituency is 100.
Patient constituency
Individuals are eligible to become members of the patient constituency if:



they are a patient or carer;
they are not eligible to become a member of the staff constituency; and
they are not a member of the public constituency.
Individuals who are eligible to join the patient constituency will be allocated to the patient
constituency unless they notify the membership office that they wish to be allocated to the public
constituency. The minimum number of members of the patient constituency is 500.
Membership numbers
In March 2012, the RNHRD had 5184 members, with 3702 patient and carer members, 1021
public members and 466 staff members.
12
Membership 2011/12
patients/public
Membership 2011/2012
Staff
Age
0-16
17-21
22+
Ethnicity
White
Mixed
Asian & Asian British
Black or Black British
Other
Gender
Male
Female
Trans-Gender
Disability
0
13
4594
0
9
457
4506
14
44
20
139
400
9
23
1524
3195
Data not available
79
381
0
78
7
18
10
Further information on the diversity of the Trust’s membership can be obtained from the
Membership Support Team.
Membership strategy
This strategy is written by the Council of Governors’ Membership sub group and:
 defines the membership community and how the Trust will establish a more diverse and
representative membership
 recognises that the process of building a meaningful membership involves effective
communication between the Trust and members
 sets out the Council of Governor’s accountability and responsibility and how the Trust will
work in partnership with the Council of Governors to achieve this
 sets out how the members and membership support the marketing and communication
strategy and promote the Trust and patient choice to the wider-public.
 outlines how the Trust evaluates the success of membership.
Over the last year, the governors have effectively communicated with members through
newsletters, in June 2011 and January 2012. They used the June newsletter to distribute
questionnaires to gain the views of members on key topics of interest and to advertise their email
address info@rnhrdgov.org.uk
Members can also contact Governors or Directors may do so through the Membership Support
Service at the hospital. Email nhsft@rnhrd.nhs.uk
Members were invited to attend our Annual Members Day in September 2011. The event was
our seventh members’ day and the first that we combined with our Annual General Meeting. This
was an opportunity to provide information on the work of the Trust and its Financial Statements
and gather feedback from members. Sessions included:





Research and its impact delivery of care
Rheumatology – treatment of Ankylosing Spondylitis
Pain Management – Complex Regional Pain Syndrome
Services to Support Ex-Military Personnel
Following a questionnaire to members the governors held a discussion session to
capture the views of members on their priorities regarding the hospital
We also invited members to:



attend Council of Governors meetings
join the Council of Governors Membership Sub-group
apply for volunteer roles
13


attend the Trust’s AGM
join the Friends of the Min.
The Trust aims to have a diverse and representative membership. We have a system which
informs all new patients about membership opportunities. Our Council of Governors have
produced an information pack for their use in promoting the Trust and membership to local
groups. They have also organised monthly coffee mornings at the hospital to communicate with
and obtain feedback from members and patients.
The majority of patient involvement activities through the year have been organised as part of
membership activities. However other activities include monthly Patient Literature Group
meetings and a thriving volunteer programme.
14
Quality report
Part 1: Statement on quality from the Chief Executive
As Chief Executive Officer I am delighted to acknowledge the high quality of care provided to our
patients. The steps we have put in place during 2011/12 to further improve quality include:





embedding the new board structure with a Director of Operations and Clinical Practice to
strengthen leadership and professional accountability
adding two new measures to our adverse event reporting, unexpected deaths and
number of patients with catheter infections which are reported monthly to board and will
allow trend analysis and identification of areas for improvement.
continuing with monthly board patient safety walk rounds which demonstrate to the
organisation the board’s commitment to patient safety
regular local patient satisfaction surveys undertaken monthly which inform quality
improvement plans and provide assurance to our commissioners.
“Tea with Matron” sessions have been introduced which provide an additional
opportunity for patients to give face to face feedback on their experience in an informal
setting.
In ensuring the continuous improvement of the quality of our services we receive support from our
Council of Governors who feedback to us on issues of quality through a number of routes.
Our quality report from page 44 demonstrates: the achievement of national quality indicators with
the exception of the C.difficile target in 2011/12; our registration with the Care Quality
Commission, without conditions at the end of quarter 4; and the positive feedback from our
patients through the National CQC survey of Adult Inpatients and Outpatients in the NHS 2011.
Kirsty Matthews
Chief Executive
30th May 2012
15
Part 2. Priorities for improvement and statements of assurance from
the Board.
Priorities for improvement in 2011/12
Following feedback from patients through the National CQC Survey of Adult Inpatients in the NHS
2011 results for RNHRD, complaints and PALs and patient feedback to the Council of Governors,
feedback from the wider public through the Annual Members Day, LINKs, feedback from
commissioning PCTs through the CQUIN and feedback from staff through the national patient
safety programme and review of the risk register the following quality improvements were agreed
by the Board and outcomes for 2011/12 are noted in the table below;
2011/12 Priorities for
improvement
100% of inpatients who
have a diagnosis of
pulmonary embolus
(PE) or deep vein
thrombosis (DVT) to
have a root cause
analysis (RCA)
undertaken. To ensure
the learning from the
RCA shared and
disseminated internally
within the hospital and
also within the wider
community***
Date Source
2011/12 Outcomes
Quarterly Clinical Risk
Committee Report to IGQAC.
IGQAC Report to Board.
Quarterly quality report to host
PCT.
Annual Quality Report
100% of inpatients who had a
diagnosis of PE or DVT had a
root cause analysis
undertaken. There were 2
patients diagnosed with DVT
during 2011/12 and both cases
had full root cause analysis
undertaken which were
reviewed by the trust clinical
risk committee and shared with
host PCT.
To improve the
management of
patients with catheter
associated urinary
infections by reducing
the incidence of
infections. To ensure
all patients with a
urinary catheter in situ
have an assessment
and review to clearly
indicate the rationale
for the catheter.****
To implement the
SKIN( Surface, Keep
moving, Incontinence
management &
Nutrition care) bundle
for all patients with
pressure areas graded
at 2 and above and to
initiate the practice of
intentional rounding in
line with National
objectives in relation to
tissue viability.****
Quarterly Clinical Risk
Committee Report to IGQAC
(Integrated Governance and
Quality Assurance Committee).
IGQAC Report to Board.
Quarterly quality report to host
PCT.
Annual Quality Report
This was a new indicator
introduced during 2011/12. All
patients with a urinary catheter
in situ now have an
assessment and review to
clearly indicate the rationale for
the catheter. Monthly reporting
of numbers of patients with
catheters and number of
urinary tract infections allows
analysis of trends and
identification of areas for
improvement.
This was a new indicator
introduced during 2011/12.
Fully implemented during
2011/12. 1 patient developed a
grade 2 pressure ulcer. Root
cause analysis undertaken and
areas for learning disseminated
Quarterly Clinical Risk
Committee Report to IGQAC.
IGQAC Report to Board.
Quarterly quality report to host
PCT.
Annual Quality Report
Clinical Effectiveness
16
Introduction in the use
of the Goal Attainment
Score (GAS) to
demonstrate a high
standard of both patient
participation and
outcome measure of
recovery sufficient to
record the patient
journey and benchmark
the service and its
process in relation to
adult inpatients on the
Neuro- Rehabilitation
Unit. ***
IGQAC Report to Board.
Quarterly quality report to host
PCT.
Annual Quality Report
This was a new indicator
introduced during 2011/12.
GAS scores reported
throughout 2011/12.
Percentage of goals achieved,
Q1 = 55%, Q2 = 59%, Q3 =
60% and Q4 = 80%. Baseline
data has been used to develop
a CQUIN target with
Commissioners for 2012/13.
To achieve a reduction
in average length of
stay for rheumatology
admissions to 8 days,
supporting improved
outcomes for patients
through preventing
delays to them leaving
hospital, and enabling
their care to be
provided in the most
appropriate setting.***
To reduce avoidable
admission to
rheumatology in patient
services.***
This will include the
development of a rapid
access assessment
day case facility to
provide alternatives to
in patient admission.**
IGQAC Report to Board.
Quarterly quality report to host
PCT.
Annual Quality Report
2010/11 baseline rheumatology
length of stay was of 9.2 days.
Reduction in rheumatology
average length of stay to 8
days or less achieved in each
quarter of 2011/12
IGQAC Report to Board.
Quarterly quality report to host
PCT from Q2.
Annual Quality Report
This was a new indicator
introduced during 2011/12.
Target to agree new inpatient
admission criteria with host
PCT was met following an audit
of rheumatology admissions.
Day case facility introduced as
alternative to inpatient
rheumatology admission.
National CQC Survey of Adult
Inpatients in the NHS 2011
results for the RNHRD presented
to Board and host PCT on
publication by Care Quality
Commission (Spring/Summer
2012).
2011/12 Quality Report
In the National CQC Survey of
Adult Inpatients in the NHS
2011 results for the RNHRD
the Trust scored 7.5 (compared
with a score of 74% for 2010.
The scoring has changed from
a % in 2010 to a score out of
10 in 2011) for the question;
Did you ever use the same
bathroom or shower area as
patients of the opposite sex?
Patient Experience
In the National CQC
Survey of Adult
Inpatients in the NHS
2010 results for the
RNHRD the Trust
scored 74% for the
question;
Did you ever use the
same bathroom or
shower area as
patients of the opposite
sex? There are no
multiple use mixed sex
bathrooms on the
wards, therefore the
Trust will hold focus
groups with patients to
highlight how we can
improve the Trust’s
performance in this
area.*
17
The Council of
Governors and the
National CQC Survey
of Adult Inpatients in
the NHS 2010 results
for the RNHRD have
both highlighted a need
to improve
communication with
patients on leaving the
hospital. The areas for
improvement
highlighted by the
National CQC Survey
of Adult Inpatients in
the NHS 2010 results
for the RNHRD were:
National CQC Survey of Adult
Inpatients in the NHS 2011
results for the RNHRD presented
to Board and host PCT on
publication by Care Quality
Commission (Spring/Summer
2012).
2011/12 Quality Report
1. Were you given clear
information about your
medicines?*
This was an improvement on
the 2010 National CQC Adult
Inpatients survey score of 71%.
In 2011 the Trust scored 85 for
the question
2. Did a member of staff
explain the risks and benefits of
the operation or procedure?*
1. Were you given clear
information about your
medicines*
This was an improvement on
the 2010 National CQC Adult
Inpatients survey score of 83%.
2. Did a member of
staff explain the risks
and benefits of the
operation or procedure*
Improve the outpatient
experience regarding:
1. Contacting the
appointments office
through improved
technology * & **
2. Environment in the
outpatient department.*
& **
3. Access to patient
information regarding
expert groups.*
In the National CQC Survey of
Adult Inpatients 2011 results
are presented as a score out of
ten, the Trust scored 8.8 for
the question
Complaints and PALs reported
quarterly to IGQAC.
IGQAC and Quarterly Quality
Report to Board.
Quarterly quality report to host
PCT.
Annual Quality Report
We extended our local inpatient
survey to include questions
about patient’s understanding
of the medicines they receive.
During 2011/12 there were 85
complaints through PALs or
written complaints about
contacting the appointments
office. As a result of patient
feedback we now include our
email address on all letters to
patients and we encourage
patients to use this to improve
access to our appointments
office.
We have implemented a new
telephone system which allows
a greater number of calls to be
handled and we are in the
process of training staff in this
new system.
We purchased new seating to
improve the patient
environment in out patients.
We have installed a hearing
loop and minicom system to
improve communication with
patients who have hearing loss.
We have launched a charitable
appeal to raise funds for a
programme of refurbishment
and improvements in the
outpatients area.
18
Our rheumatology specialist
nurse has developed a DVD
and patient leaflet which has
been launched nationally to
provide support and
information for patients with
this condition.
Reduce number of
delayed follow-ups in
Rheumatology.* & ***
Monthly report to Board on
number of delayed follow ups.
Complaints and PALs reported
quarterly to IGQAC.
IGQAC and Quarterly Quality
Report to Board.
Quarterly quality report to host
PCT.
Annual Quality Report
The delayed rheumatology
follow up appointments were
managed successfully in
2011/12
Ensure that the Trust
continues to achieve 18
week referral to
treatment target for
95% of referrals
Monthly report to Board
Quarterly quality report to
IGQAC and host PCT.
Annual Quality Report
The trust continued to achieve
the 18 week referral to
treatment target each month
during 2011/12
Priorities for improvement in 2012/13
The priorities have been identified through: Feedback from patients through the National CQC Survey of Adult Inpatients and
Outpatients in the NHS 2011 results for RNHRD, complaints and PALs*
 Feedback from the Council of Governors.**
 Feedback from commissioning PCTs through the CQUIN***
 Feedback from staff through the national patient safety programme and review of the risk
register and staff survey.****
Priorities
for
improvement 2012/13
Patient Safety
C. difficile to improve
performance against
local agreed target of 6
cases for 2012/13***
2011/12 performance =
4 cases of C.difficile
Introduction of a new
data collection for NHS
Patient Safety
Thermometer –
improve collection of
data in relation to
pressure ulcers, falls,
urinary tract infections
in those with a catheter
and VTE***
Maintain achievement
of key patient safety
training targets
Monitoring
Measurement
Reporting
Report actual
number of cases
Number of patients
acquiring C. difficile
infection at the
RNHRD each month
Monthly snapshot of
all patients on
inpatient wards
Data will be collated
using the NHS
Patient Safety
Thermometer tool,
on a single day per
month, this will be
uploaded to the
NHS information
centre
Monthly reporting to
Board, quarterly
reporting to IGQAC,
host PCT and
Monitor and Annual
Quality Report
Quarterly report to
IGQAC and host
PCT and Annual
Quality Report
Monitor percentage
actual against
targets each month
Achievement
against targets
Monthly reports to
Board and Quarterly
reports to IGQAC
19
throughout 2012/13**
Safeguarding (80% for
level 2), fire (80%), fire
marshall (100%),
infection control patient
and non-patient
contact (80%), manual
handling patient and
non-patient contact
(80%), life support
basic and life support
intermediate (100%).
Clinical Effectiveness
Establish a new
dedicated
rheumatology helpline
at the RNHRD for
health professionals***
Discharge summaries
to be received by GPs
within 24hrs of
discharge***
Patient Experience
Improve information to
patients who have a
delay in the start of
their outpatient
appointment* & **
2011/12 performance =
8 PALs/complaints
To introduce additional
measures relating to
the management of
staff experiencing work
related stress. In the
2011 NHS National
Staff survey 37% of
staff reported they
suffered work-related
stress in the last 12
months.****
Improve access to the
appointments
department* & **
2011/12 performance =
85 PALs/complaints
about access to the
appointments
department
Improve the outpatient
environment** & ***
and PCT and
Annual Quality
Report
Analysis of calls on
a quarterly basis
Report on the
number of calls to
the host PCT Quality
Review Group.
Quarterly reports to
IGQAC and host
PCT and Annual
Quality Report
Monthly score card
Percentage of
discharge
summaries received
within 24 hrs to be
95% or greater.
Quarterly reports to
IGQAC and host
PCT and Annual
Quality Report
Complaints
regarding failure to
advise patient of
delay in start of their
out patient
appointment
Number of
complaints
regarding failure to
advise patient of
delay in start of their
outpatient
appointment.
Quarterly reports to
IGQAC and Annual
Quality Report
Sickness absence
reporting, number of
completed stress
audits received,
NHS National Staff
survey Results
2012, audit of work
related stress
conversations held
between managers
and staff who are
not absent with
work related stress
Complaints
regarding access to
appointments
department
Number of staff
absent.
Number of staff
reporting they suffer
work related stress
in the 2012 NHS
Staff Survey
Staff absence
reporting monthly to
managers and
EMG.
Annual stress audit
results to Health
and Safety
Committee.
HR key indicators to
Board quarterly and
Annual Quality
Report
Number of
complaints
regarding access to
appointments
department
Quarterly report to
IGQAC, PCT and
Board and Annual
Report
Feedback from PCT
inspection visits and
PEAT inspection
which includes a
Governor/LINk
Improve score for
the environment in
this area in 2013
PEAT assessment.
Quarterly report to
IGQAC, PCT and
Board and Annual
Report
Six monthly audit on
a minimum of 25
clinical records to
confirm compliance
20
representative
Statements of assurance from the Board

Information on the review of services:
During 2011/12 the Royal National Hospital for Rheumatic Diseases NHS FT did not sub-contract
any Services.

Information on participation in clinical audits and national confidential enquiries:
During 2011/12 2 national clinical audits and 1 national confidential enquiry covered NHS
services that the RNHRD provides.
During 2011/12 the RNHRD participated in 100% of the national clinical audits and 100% of
the 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 the RNHRD participated in
during 2011/12 are as follows:
Acute Care – National Cardiac Arrest Audit
Long Term Conditions – Chronic Pain
NCEPOD Cardiac Arrest Procedures
The national clinical audits and national confidential enquiries that the RNHRD participated in,
and for which data collection was completed during 2011/12, 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 Audit RNHRD
was eligible to participate in
during 2011/12
Number of cases submitted to each audit
as percentage of number of registered
cases required by the terms of that audit
Acute Care – National Cardiac
Arrest Audit
No cardiac arrests occurred during data
collection period therefore no cases
submitted.
Long Term Conditions – Chronic
Pain
Dr Peter Brook has been co-ordinating the
trust’s contribution to the National Pain Audit.
This began with qualitative service outline
information. Quantitative and qualitative data
was then gathered from patients during
outpatient clinics as part of the national audit.
The first phase of data collection has been
completed and the patients will be followed
up six months after their initial contact. The
data collected has been related to treatments
delivered and patient satisfaction.
NCEPOD – Cardiac Arrest
Procedures
No cardiac arrests occurred during data
collection period therefore no cases
submitted
The report of 1 national clinical audit, National Pain Audit Database, was reviewed by the
provider in 2011/12. The report detailed database information only and therefore no action
was required to improve the quality of healthcare provided.
The Integrated Governance and Quality Assurance Committee monitors the completion of
local audits and action plans, including National Patient Safety Campaign and NICE audits at
21
quarterly meetings during 2011/12. In addition the RNHRD took action in the following to
improve the quality of healthcare provided;












Pressure ulcer – further action on implementation and monitoring of the
“SKIN bundles” across the Trust
Continence – introduction of urinary catheter insertion “bundle” with monthly
monitoring
Falls – Intentional rounding process developed
Medicines management – monitoring of rheumatoid arthritis outcomes score
on a monthly basis
Endoscopy – review and development of new admission forms
VTE – review and use of PDSA cycles to continuously review process to
ensure compliance
Anti TNF - increase in the number of patients with non-inflammatory arthritis
discharged from follow up to GPs with the GPs involvement,
Review and standardisation of handovers with inclusion of safety brief, use of
white boards and MDT handovers on neuro rehabilitation
Infection control – Environmental developments new disinfectants used,
housekeeper processes reviewed.
Infection control - Hand hygiene signage updated
Infection control - C. difficile practice reviewed and additional training
provided
Information on participation in clinical research:
The number of patients receiving NHS services provided by the Royal National Hospital for
Rheumatic Diseases NHS FT that were recruited during that period to participate in research
approved by a research ethics committee was 561.

Information on the use of the CQUIN framework:
A proportion of Royal National Hospital for Rheumatic Diseases NHS FT income in 2011/12 was
conditional upon achieving quality improvement and innovation goals agreed between the Royal
National Hospital for Rheumatic Diseases NHS FT 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 (CQUIN) payment framework. Further details of the
agreed goals for 2010/11 and for the following 12 month period are available online at:
http://www.monitor-nhsft.gov.uk/sites/all/modules/fckeditor/plugins/ktbrowser/_openTKFile.php?id=3275
The monetary total for the amount of income for 2011/12 conditional upon achieving quality
improvement and innovation goals was £128,331 which was received in full.

Information relating to registration with the Care Quality Commission and periodic/special
reviews:
The Royal National Hospital for Rheumatic Diseases NHS FT is required to register with the Care
Quality Commission and its current registration status is that there are no conditions related to
this Trust’s registration.
The Care Quality Commission has not taken enforcement action against the Royal National
Hospital for Rheumatic Diseases during 2011/12.
The Royal National Hospital for Rheumatic Diseases has participated in special reviews or
investigations by the Care Quality Commission relating to the following areas during 2011/12.
The Care Quality Commission completed an unannounced inspection visit at the RNHRD on
25.10.11 Following the unannounced inspection the CQC issued one compliance action (as their
report concluded that the Trust was not meeting Outcome 07 - safeguarding people who use
services from abuse, as a number of staff had not received training in safeguarding vulnerable
adults and children) and one improvement action (as their report recommended the Trust made
22
improvements regarding Outcome 14, Supporting staff as appraisal levels had not met the Trust
target at Quarter 2). The Trust completed all actions to address the compliance action and
improvement action by 31.12.11. The CQC forwarded a report to the Trust on 28.02.12
confirming it was compliant with Outcome 07 and Outcome 14.

Information on the quality of data:
The Royal National Hospital for Rheumatic Diseases NHS FT submitted records during 2011/12
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: 98.5% for admitted patient care;
99.7% for outpatient care; and there is no percentage for accident and emergency care
as there is no accident and emergency service provided by the Trust.
which included the patient’s valid General Practitioner Registration Code was: 99.8% for
admitted patient care; 100% for outpatient care; and there is no percentage for accident
and emergency care as there is no accident and emergency service provided by the
Trust.
The Royal National Hospital for Rheumatic Diseases NHS FT Information Governance
Assessment Report overall score for 2011/12 was 81% and was graded green.
The Royal National Hospital for Rheumatic Diseases NHS FT was subject to the Payment by
Results clinical coding audit during the reporting period by the Audit Commission and the error
rates reported in the latest published audit for that period for diagnoses and treatment coding
(clinical coding) were:
Area audited
%
Procedures
incorrectly
coded % Diagnoses coded incorrectly
% of episodes % of spells
changing
changing
HRG
HRG
Primary
Secondary
Primary
Secondary
General
Medicine
0.0%
0.0%
14.0%
8.4%
0.0%
0.0%
Random
Sample
2.2%
0.0%
7.0%
9.5%
10.0%
10.0%
Overall
1.1%
0.0%
10.5%
9.1%
5.0%
5.0%
The results should not be extrapolated further than the actual sample audited.
reviewed was General Medicine plus a random sample across all activity.
The service
The Royal National Hospital for Rheumatic Diseases NHS FT will be taking the following actions
to improve data quality:
 correct recording of primary diagnosis, especially around issues with hiatus hernia
and osteoarthritis coding;
 reduction in coding of non-relevant information;
 improved coding of relevant co morbidities
 develop the Policy and Procedures document to include all the codes used
historically at the Trust, ensuring that are approved by clinicians.
 work with clinicians to improve the availability of discharge letters to support accurate
coding and to ensure that clinicians are clearly differentiating current conditions and
chronic conditions.
Part 3. Other information

An overview of the quality of care offered by the RNHRD NHS FT based on performance
in 2011/12 against indicators selected by the Board in consultation with stakeholders.
23
Quality overview
Indicator
Data Source
2011/12
2010/11
2009/
10
2008/09
2007/08
0
0
0
0
0
4
1
0
3
7
Meet essential
/core standards
regarding quality
& safety
Data reported nationally
and data governed by
standard national definition
Data reported nationally
and data governed by
standard national definition
Data reported to Care
Quality Commission and
reported through quality
report to PCT
Met
during
Q1, Q2
and Q4
Met
Met
Met
Met
Indicator
Data Source
2011/12
2010/11
2009
/10
2008/09
2007/08
Data reported through
Healthcare Commission
special data collection and
reported through quality
report to PCT
Met
Met
Met
Met
Met
Number of written
complaints regarding
availability of follow up
appointments reported
through quality report to
PCT and annual report.
Data reported through
quarterly quality report to
Board and PCT
5
2
3
15
0
Met
Met
Met
Met
Met
National CQC Survey of
Adult Inpatients in the NHS
2011 results for the
RNHRD question on
mixed-sex bathroom or
shower areas by
percentage who answered
no to the question “Whilst
staying in hospital, did you
ever share the same
bathroom or shower area
as patients of the opposite
sex?”
Number of Complaints or
PALs on this issue
reported in Quality Report
to PCT
Number of written
7.5
74%
79%
39%
40%
85
10
34
30
6
23
11
17
18
8
Patient Safety
MRSA
bacteraemia
C.difficile
Clinical
Effectiveness
The Trust will
continue to
implement NICE
Guidelines
relevant to the
Trust services
Improve
availability of
follow up
appointments
Meet core
standards
regarding
clinical
effectiveness
Patient
Experience
Improve
Bathroom
facilities and
signage on
wards
Improve
telephone
access for
appointments
All written
24
complaints to
continue to be
managed
effectively
locally within
policy
timescales.
complaints
received and number
managed locally within
national complaints policy
timescales.
complai
nts
received
20 of
which
were
manage
d locally
within
the
national
complai
nts
policy
timescal
es.
complaint
s
received.
10 of
which
were
managed
locally
within the
national
complaint
s policy
timescale
s.
As there was a significant increase in the number of complaints about telephone access for
appointments email access was introduced.

Performance against key national priorities and National Core Standards
All foundation trusts are required by the NHS Operating Framework 2011/12 to measure
performance against quality, resources and reform. These performance measures have been
defined by the Department of Health (Please refer to http://www.dh.gov.uk/en/Publicationsand
statistics/Publications/PublicationsPolicyAndGuidance/DH 123592 to download the Technical
Guidance PDF)
The criteria for the inclusion of cases in the mandatory indicator are set out below;
C.difficile:




patients aged 2 or more
a positive laboratory test result for CDI recognised as a case according to the Trust's
diagnostic
Positive results on the same patient more than 28 days apart should be reported as
separate episodes, irrespective of the number of specimens taken in the intervening
period, or where they were taken.
The Trust is deemed responsible. This is defined as a case where the sample was taken
on the fourth day or later of an admission to that trust (where the day of admission is
day one).
MRSA:
 An MRSA bacteraemia is defined as a positive blood sample test for MRSA on a patient
(during the period under review).
 Reports of MRSA cases include all MRSA positive blood cultures detected in the
laboratories, whether clinically significant or not, whether treated or not
 The indicator excludes specimens taken on the day of admission or on the day following
the day of admission.
 Specimens from admitted patients where an admission date has not been recorded, or
where it cannot be determined if the patient was admitted, are also attributed to the trust.
 Positive results on the same patient more than 14 days apart are reported as separate
episodes, irrespective of the number of specimens taken in the intervening period, or
where they were taken.
25
The RNHRD did not achieve all national quality performance targets during 2011/12. Those that
are set out in the Compliance Framework and relevant to the Trust are:





Clostridium difficile year on year reduction (to fit the trajectory for the year as agreed with
PCT = 3 cases in 3 separate patients). The Trust did not meet this performance target as
there were 4 cases of Clostridium difficile in 2011/12 against a trajectory of 3.
Methicillin Resistant Staphylococcus Aureus (MRSA); number of infections. The Trust
had a target of 0 cases. The Trust met this performance target as there were no MRSA
bacteraemia infections in 2011/12.
th
Referral to treatment waiting times; non-admitted (95 percentile). The Trust met this
performance target throughout 2011/12.
th
Referral to treatment waiting times; admitted (95 percentile). The Trust met this
performance target throughout 2011/12.
Certification against compliance with requirements regarding access to healthcare for
people with a learning disability. The Trust met this performance target throughout
2011/12.
CQC registration and compliance with essential standards of quality
and safety


The Board declared full compliance with the CQC Essential Standards of Quality and
Safety in Q1 and Q2 of 2011/12.
The Care Quality Commission completed an unannounced inspection visit at the RNHRD
on 25.10.11. Following the unannounced inspection the CQC issued one compliance
action as their report concluded that the Trust was not meeting Outcome 07 - safeguarding
people who use services from abuse, as a number of staff had not received training in
safeguarding vulnerable adults and children (the trust reported that 67% of eligible staff had
received this training at the end of Q1 against a trust target of 80%) and one improvement
action (as their report recommended the Trust made improvements regarding Outcome 14,
Supporting staff as appraisal levels had not met the Trust target at Quarter 2). The Trust
completed all actions to address the compliance action and improvement action by
31.12.11, reporting that by the end of Q3 100% of eligible staff had completed level 1 adult
safeguarding training and 87% had completed level 2 adult safeguarding training and 98%
had completed level 1 safeguarding children training and 84% had completed level 2
safeguarding children training. The CQC forwarded a report to the Trust on 28.02.11
confirming it was compliant with Outcome 07 and Outcome 14. At the end of Q4 98% of
eligible staff had completed level 1 adult safeguarding training and 85% had completed
level 2 adult safeguarding training and 98% had completed level 1 safeguarding children
training and 83% had completed level 2 safeguarding children training. The board declared
full compliance with the CQC Essential Standards of Quality and Safety at the end of Q4.
The safeguarding adults (level 2) training is mandatory for certain categories of staff; the training
course must be completed every 3 years. The requirement to complete this item of mandatory
training will be determined by reference to the Trust’s mandatory training matrix. The percentage
completion is a snapshot as at 31st March 2012, which has been calculated by comparing the
number of staff for whom this training is identified as being mandatory, and the number of staff
whose training accreditation was up to date as at this date.
The auditors undertake work on one indicator which is chosen locally by the Governors, therefore
it was agreed that the auditors would look at a specific indicator in the area of safeguarding adults
level 2 mandatory training, as information on this indicator is included in the Quality Report.
Complaints
Information on complaints handling
The Trust has an established Patient Advice and Liaison Service (PALS). This service is
available to provide patients and their carers and families with confidential information, advice
and support. PALS provides information about the hospital, the NHS, and organisations and
support groups outside the NHS. They help resolve concerns when patients are using hospital
26
services and work with patients to improve hospital services, by listening to their experiences and
ensuring that staff who deliver the services are aware of and address any issues raised.
Written complaints
The Trust received 23 written complaints in 2011/12. 20 of the responses were within the
timeframes set out in the national complaints policy. The reasons for not achieving this for 3
cases were; seeking an independent opinion, time taken to complete the investigation and an
administration error. All patients were contacted to explain the reason for the delay in receiving
the final response.
No complaints received in 2011/12 were referred to:
 the Health Service Commissioner to consider
The subject matter of complaints that the responsible body received;
1
1
5
3
5
6
0
1
0
0
1
Admissions, discharge and transfer arrangements
Aids, appliances, equipment
Appointments Delay/ Cancellation
Attitude of staff
All aspects of clinical treatment/ care
Communication verbal/ written
Policy and commercial decisions
Personal records
Patient privacy and dignity
Failure to follow procedure
Patient property
Matters of general importance arising out of those complaints, or the way in which the complaints
were handled and action taken are detailed in the table below;
Matters of importance arising
out of complaints
Patient found chairs on
outpatient waiting areas and
clinic rooms difficult to use,
causing discomfort.
Delay in informing GP and
patient of results resulted in
unnecessary changes to
medication.
Concerns regarding a patient’s
weight changes and dietary
requirements
Delay in follow up appointment
for patients.
Information provided to patients
prior to the caudal epidural
procedure
Patient’s family detailed points
of concern regarding nursing
levels in HDU.
Patient’s family detailed points
Action taken
complaints
as
a
result
of
written Complaint
wellfounded
Purchase of a lumbar cushion to attach to
Yes
chairs in outpatient department waiting area
when required by patients to improve back
support.
A critical incident session was added to the
Yes
doctors’ postgraduate meeting once every four
months to discuss critical issues and learning
from complaints.
Nutritional Steering Group set up by Catering Yes
Manager and Speech and Language
Therapists to address nutritional issues and a
review of menus regarding provision of energy
and protein was conducted.
Increased outpatient department capacity, by Yes
providing additional waiting list clinics and
revising follow-up booking system, to enable
patients to book their follow-up appointment at
the patient reception immediately following
their consultation.
Diagnostic Unit Team reviewed and updated
Yes
the patient information leaflet to ensure it
captures all treatment options.
Matron moved her office and a band 7 ward
Yes
manager was recruited to the Neurorehabilitation unit to provide improvements to
leadership and co-ordination of care.
27
of concern regarding storage of
equipment and furniture in HDU.
Standards identified when storing equipment
and furniture.
Missing patient’s clothing.
Police Liaison Officer increased informal drop- Yes
in visits to the hospital. Posters displayed to
highlight the need for vigilance regarding
property. A new laundry policy was produced
by nurses and the infection control nurse.
Reviewed written literature to inform for
Yes
patients of what to do when in a flare.
Patient detailed points of
concern regarding access to
urgent treatment when in flare.
Difficulties in contacting the
appointments
office
by
telephone.
Highlighting
incorrect
information in clinical letter.
Complainant detailed issues
regarding the attitude of nursing
staff on the Rheumatology
ward.
Patient did not receive a timely
response to emails sent to
employees in the hospital.
Reduction in phone lines. More staff to
answer calls and a call waiting system to
improve the management of patient calls.
Alternative methods of contact being
publicised eg. email.
Correct information included in patient’s health
records.
PALS have increased their presence on the
ward in an attempt to identify any issues t the
time that they occur. The full details will then
be passed on to Matron and the CRPS team to
address with nursing staff and patients
immediately and identify any actions for
improvement.
Matron and CRPS team to identify appropriate
training for nurses on the rheumatology ward.
System set up to ensure colleagues can
access administrators’ email inbox to enable
them to prioritise and deal with emails received
when they are away from work.
Yes
Yes
Yes
Yes
Improvements in Patient/ Carer Information
The Patient Experience and Membership Manager is the Chair of the Trust’s Patient Literature
Group. This group’s membership represents patients from all of the hospital’s specialties. Since
it began in November 2005 the group has reviewed over 200 leaflets and pieces of information
produced for patients and carers, by staff in the Trust. All literature is reviewed to ensure
information is accessible to and appropriate for patients, and produced to Trust standard. The
group has also developed a policy to assist staff when producing patient information and
literature, and a monitoring system to ensure the literature is meeting the Trust’s standards. This
policy was reviewed in June 2011.
Equality Delivery System
During 2011/12 the Trust has used the Equality Delivery System (EDS) to review its equality
performance and to identify future priorities and actions. The EDS is designed to support NHS
organisations to deliver better outcomes for patients and communities and better working
environments for staff. It is a tool to help organisations start the analysis that is required by
section 149 of the Equality Act 2010 – the public sector Equality Duty.
The EDS comprises of 18 outcomes grouped around four goals. It is around these that the
Trust’s performance has been analysed, graded and action for improvement determined. The
resulting prioritised quality objectives and associated actions will be fed into mainstream patient
and workforce initiatives and reported and acted on through mainstream business planning for
2012/13.
Further information regarding equality and diversity can be obtained from the Trust’s Equality
Lead.
28
A summary of workforce equality statistics are detailed below:
Age
0-16
17-21
22+
Ethnicity
White
Mixed
Asian & Asian
British
Black or Black
British
Other
Gender
Male
Female
Trans-Gender
Employees
2011/12
Employees
2010/11
Employees
2009/10
Employees
2008/09
Membership
2011/12
0
9
451
0
9
451
0
12
455
0
12
402
0
13
4594
400
9
399
8
23
399
9
359
6
4506
14
26
19
44
21
22
20
23
18
14
10
9
12
9
139
79
381
78
380
81
386
67
348
0
0
1524
3195
Data not
available
7
8
0
Disability
7
7
78
Clinical Effectiveness
Clinical effectiveness is a quality improvement process that seeks to improve patient care and
outcomes through a systematic review of care against explicit criteria and the implementation of
change. The Trust has a commitment to clinical effectiveness and audit, to evidence-based
medicine, monitoring practice and continuously improving local and national standards.
Members of staff from the Trust have significant input to clinical guidelines developed by national
professional bodies and bodies such as the National Institute for Health and Clinical Excellence
(NICE). In 2011/12 the following staff have contributed to the development of national guidelines:
Sue Brown, Clinical Nurse Specialist in Connective Tissue Diseases has been involved in the
following national initiatives; invited committee member representing the British Health
Professionals in Rheumatology and the RCN Rheumatology Forum in a BSR national guidelines
on the management of SLE October 2011 invited member to British Health Professionals in
Rheumatology Clinical Advisory Group September 2011 and invited member UK Health
Professionals Scleroderma Network March 2012
Professor Candy McCabe, Professor of Nursing and Pain Sciences and Dr Jenny Lewis, Senior
Clinical Research Occupational Therapist, have contributed to the Complex Regional Pain
Syndrome National Guidelines that were published in November 2011 by the Royal College of
Physicians
Dr Jacqui Clinch – Consultant in Paediatric Rheumatology and Chronic Pain and Dr Hannah
Connell – Consultant Clinical Psychologist have been working with the British Pain Society to
develop National Guidelines of Paediatric Chronic Pain.
Dr E Korendowych, Consultant Rheumatologist, is a clinical expert nominated by the British
Society of Rheumatology (BSR) for the NICE appraisal of Etanercept, Adalimumab and Infliximab
as well as appraisals of Golimumab for psoriatic arthritis. Dr Korendowych, Prof McHugh, Dr
Tillett and Nicola Waldron are part of the BRS Guidelines working group developing updated
guidelines for PsA patients receiving biologic therapy. These guidelines are now competed and
awaiting ratification from the BSR.
Dr Lance McCracken, Consultant Clinical Psychologist and Suzy Williams, Pain Services,
contributed to the Clinical Guidelines for Pain Management Programmes being revised by the
British Pain Society.
29
Professor Neil McHugh, Consultant Rheumatologist, is member of the NICE psoriasis guideline
development group and Chair of the BSR subcommittee for ‘The 2011 BSR guidelines for the
treatment of psoriatic arthritis with biologics’ and is a member of the EULAR taskforce for
guidelines on management of Psoriatic Arthritis which was published 2011 in the Annals of
Rheumatic Disease.
Dr Raj Sengupta Consultant Rheumatologist is a member of the AR UK Study Group for
Spondyloarthropathy.
Structures are in place to ensure that we audit against any national guidelines relevant to this
Trust.
National CQC Survey of Adult Outpatients and Inpatients in the NHS
2011 results for the RNHRD
To improve the quality of services that the Trust delivers, it is important to understand what
patients think about their care and treatment. One way of doing this is by asking patients who
have recently used the Trust’s services to tell us about their experiences.
National CQC Survey of Adult Out patients in the NHS 2011 results for the
RNHRD
The outpatient survey report provides the results of the fourth survey of adult outpatients in NHS
Trusts in England. The results from Royal National Hospital for Rheumatic Diseases NHS
Foundation Trust are based on 578 respondents.
The results are displayed on the CQC website in summary format at
http://www.cqc.org.uk/surveys/outpatient. The comparison with the expected range for each
group of questions, listed in the section heading column in the table below, is presented as a
simple statement (better, about the same or worse than other Trusts).
Table 2. CQC Summary Presentation of 2011 Outpatient Survey Results
Section heading
Before the appointment
Waiting in the hospital
Hospital environment and facilities
Tests and treatments
Seeing a doctor
Seeing another professional
Overall about the appointment
Leaving the outpatients department
Overall impression
Score out of 10 for RNHRD
NHS FT
7.63
4.62
8.69
7.99
9.07
8.92
8.45
7.61
8.98
How this score compares
with other Trusts
About the same
About the same
About the same
About the same
About the same
About the same
About the same
Better
About the same
The results of the 2011 out patient survey showed that the RNHRD had the highest score
achieved for all Trusts for the following 2 individual questions:
 Were you given enough privacy when discussing your condition or treatment?
 Did you receive copies of letters sent between hospital doctors and your family doctor
(GP)?
The RNHRD had 1 individual question scored in the lowest 20% for the outpatient survey:
 Were you told how long you would have to wait?
The RNHRD had 6 individual questions scored in the top 20% for the outpatient survey;
 How long after the stated appointment time did the appointment start
This demonstrates that the RNHRD performs better for appointments starting on time but for
those appointments that did not start on time i.e. patients waiting longer than 15 minutes, the
Trust scored worse regarding telling patients how long they would have to wait.
 Did the staff treating and examining you introduce themselves?
30




Did doctors and/or staff talk in front of you as if you weren’t there?
Were you given enough privacy when discussing your condition or treatment?
Did you receive copies of letters sent between hospital doctors and your family doctor
(GP)?
Overall, did you feel you were treated with respect and dignity while you were at the
Outpatients Department?
The Trust will be implementing an action plan to improve performance in areas highlighted by the
survey results.
National CQC Survey of Adult Inpatients in the NHS 2011 results for the RNHRD
318 patients who were inpatients at the RNHRD completed the National CQC Survey of Adult
Inpatients in the NHS 2011 between October 2011 and January 2012, a response rate of 65%
compared with 53% nationally. There were 61 questions relevant to the services provided by the
Trust.
The benchmark reports were redesigned this year, replacing the previous reports produced for
the national surveys which contained scores out of 100, instead the data presents the data as a
score out of 10 and describes whether trusts are performing better, worse or about the same as
most other trusts in the survey.
Section heading
Waiting list and planned
admissions
Waiting to get a bed on a ward
The hospital and ward
Doctors
Nurses
Care and treatment
Leaving hospital
Overall views and experiences
Score out of 10 for RNHRD
NHS FT
7.6
9.7
8.7
8.6
8.5
7.6
7.5
7.4
How this score compares
with other Trusts
Best performing trusts
Best performing trusts
Best performing trusts
About the same
About the same
About the same
Best performing trusts
Best performing trusts
The results of the 2011 inpatient survey showed that the RNHRD had the highest score
achieved for all Trusts for the following section scores;
 waiting list and planned admissions
 waiting to get a bed on a ward
 the overall views and experiences
The results of the 2011 inpatient survey showed that the RNHRD had the highest score
achieved for all Trusts for the following individual questions:
 was your admission date changed by the hospital
 did you have somewhere to keep your personal belongings whilst on the ward
 were you told how you could expect to feel after you had the operation or procedure
 did you receive copies of letters sent between hospital doctors and your family doctor
 during your hospital stay, were you ever asked to give your views on the quality of your
care
 while in hospital, did you ever see any posters or leaflets explaining how to complain
about the care you received?
There were no questions where the Trust was rated as performing worse than most other
trusts.
The RNHRD NHS FT was rated as performing better than most other Trusts in the following
questions,

Overall, from the time you first talked to a health professional about being referred to
hospital, how long did you wait to be admitted to hospital?
31



















How do you feel about the length of time you were on the waiting list?
Were you given a choice of admission dates?
Was your admission date changed by the hospital?
From the time you arrived at the hospital, did you feel that you had to wait a long time
to get to a bed on a ward?
Did you ever share a sleeping area with patients of the opposite sex?
How clean were the toilets and bathrooms that you used in hospital?
Did you feel threatened during your stay in hospital by other patients or visitors?
Did you have somewhere to keep your personal belongings whilst on the ward?
How would you rate the hospital food?
Were you offered a choice of food?
Did you get enough help from staff to eat your meals?
Were you told how you could expect to feel after you had the operation or procedure?
Did you feel you were involved in decisions about your discharge from hospital?
Discharge delayed due to wait for medicines/to see doctor/for ambulance.
How long was the delay?
Did you receive copies of letters sent between hospital doctors and your family doctor
(GP)?
Overall, did you feel you were treated with respect and dignity while you were in the
hospital?
During your hospital stay, were you ever asked to give your views on the quality of your
care?
While in hospital, did you ever see any posters or leaflets explaining how to complain
about the care you received?
The Trust invited our commissioners BANES/Wiltshire PCT, BANES/Wiltshire OSC and local
LINK and Council of Governors to comment about our 2011/12 Quality Account. The following
comments were received:
32
2011/12 Quality Report feedback from the RNHRD NHS FT Council
of Governors
Feedback from RNHRD NHS FT Council of Governors 4.05.12
How does the trust engage with the Council of Governors re Quality?
The Trust engages with the Governors in the following ways:






2 Governors present at all Board meetings;
Invitation to all Governors to attend open board meetings
2 Governors present at Audit Committee meetings;
Presentations by Directors at Council of Governors meetings;
Presentations by Directors at Annual Members Day.
3 Chairs of Governor sub-committees meet with Chair prior to Council of Governor
meetings to report sub-committee findings
The Trust provides quality information to the Council of Governors in the following ways:



Board reports from February 2012 all Board meetings are open meetings and Governors
also attend any closed sessions
The Governors who attend the Board receive monthly performance reports on national
quality indicators and vital aspects of care and quarterly more detailed reports e.g.
complaints and PALs which includes Council of Governor coffee morning comments;
The Quality Report was presented to the Governors for comment on 17 April 2012,
following an initial presentation to the Council of Governors in March 2012.
The Council of Governors are satisfied that the information within the Quality Report is
consistent with information collected and received by the Council of Governors:




For example, information continues to be obtained through Board reports and feedback
to Council of Governors at regular monthly Coffee mornings and their experience when
visiting the trust or as a patient.
2 issues of the Governors’ newsletter “Min Matters” have been circulated to all members
and an email address has been set up by Governors to allow member feedback
Through the newsletter Governors collected data on member’s feedback using a
questionnaire on priority areas for information.
Governors collected feedback from members at the Annual Members Day which has
been analysed and action taken on points raised.
The Trust has engaged with the Council of Governors for their feedback on priority areas
for improvement and these have been included in the Quality Report.
These priority areas were identified following a presentation by Directors at the Annual Members
Day and feedback from members that attended. The Director of Governance gave a presentation
at March 2012 CoG meeting requesting feedback on priority areas for improvement for including
in the Quality Report.
Feedback from the Governors’ regarding priority areas for quality
improvement was agreed at the Service Delivery and Development Sub-Committee meeting on 4
May 2012.
G Odam, J Beresford-Smith, C Wright, S Brooks and J Coles, Council of Governors. 4th May 2012
33
Bath and North East Somerset
Local Involvement Network
10th May 2012
Response to RNHRD NHS FT Quality Account 2011/2012
We note that the Directors' report presents a robust picture of the NHS Foundation
Trust’s performance, which complies with the requirements in preparing the Quality
Report.
The statements in the Draft Quality Account have reviewed the quality of performance in
2011/2012, concentrating on what needs most attention to further improve delivery of
services at the RNHRD NHS FT.
We appreciate the endorsement of the Chairman and the Chief Executive of the Trust.
We are satisfied that the account demonstrates a well established pattern in collecting
feedback from stakeholders, collating information from a variety of consultations to
improve services for patient care. It is also clear that research carried out at the Trust is
excellent in influencing high quality, specialist clinical practice. We note that the Trust’s
resources are used to benefit patient care despite the present economy.
The Chief Executive’s endorsement of the Quality Accounts assures us that the Trust’s
services are regularly scrutinized to ensure that essential standards are met.
We are charged as B&NES Local Involvement Network to review the information in the
RNHRD NHS FT Quality Account 2011/2012 and to respond objectively on what has
been reported.
34
1. Do the priorities of the RHRD NHS FT reflect the priorities of the local population?
We scrutinized the Draft Report and are assured that the Account reflects the continuous
checks on service and care delivery noting feedback from stakeholders, patients and public to
influence future action where necessary.
* The Trust engages with PCT- The Director of Communications attends some
Council of Governors meetings and Annual Members Day.
*The Local Involvement Network is represented by 3 members; 1 Appointed Governor.
 2 Elected Governors who are also members of LINKs

 Members of LINKs engage with the local population in collecting data relating to local
needs.
 * Partner organizations from the local Health community serve as Appointed

Governors. Some are related charities.
 * The Trust works with Bath&NE S Council.
*All Governors are members of sub – committees.
All Governors may attend Open Board meetings.
The diverse membership of the Trust represents a wide range of members from the local
community which ensures a knowledge of the health needs of the local population, and that
those needs are addressed, provide a balanced view and added value, strengthening the
Governor’s role.
2. Are there any important issues missed in the Quality Account?
The Quality Report is comprehensive in covering the requirements of information
relating to:*Patient Safety.
*Clinical Effectiveness.
*Patient Experience.
We are assured that there will be continuous improvement of the quality of services with
support from the Council of Governors who feedback issues of quality through a number of
routes.
*The role of governor reporting is defined by Board priorities and National Frameworks.
There is little mention of the importance of training for governors
and how input from governors can improve performance of trusts beyond expectation.
The Trust has introduced a more formal training for new governors this year which has
strengthened the understanding and interaction of members.
The governors took part in presentations to the local General Hospital working towards
Foundation Trust. This has had an impact on the recruitment for membership of governors for
the hospital. This may have an influence
on RNHRD NHS FT Governors in defining their role in serving and improving
35
knowledge across the health community to improve the Quality of scrutiny as Governors.
3. Has the Trust demonstrated that they have involved patients and the public
in the production of the Quality Account?
Embedded in the Philosophy of public patient involvement and representation practices have
bee developed to reinforce systems which demonstrate a commitment to inclusion.
* Questionnaires
*Coffee mornings
* Matron teas providing patients with face to face feedback with a professional
in an informal setting.
* Newsletters with questionnaires.
* Presentations to clubs and societies.
* Appointed governors as conduits for information..
* PALS identifying compliments and complaints.
*Patients are involved in the development of new innovative services.
4. Is the Quality Account clearly presented for patients and public?
This is a comprehensive Quality Report delivering information and highlighting critical needs.
It provides assurance for improvements to meet the needs of the health community and deliver high
quality care informed by outstanding research and dedication from staff.
The Patient Literature Group scrutinizes all information given to patients informing and educating the
patient regarding their conditions treatments and care, ensuring all literature is meeting the Trust’s
high standards.
Prepared by Connie Wright
(B&NES LINK appointed representative),
Hilary Elms- B&NES LINK
Ben Rogers – B&NES LINK
10/05/2012
36
Quality Account Response Form For:
The Royal National Hospital for Rheumatic Diseases NHS Foundation Trust
The Guidance issued to OSCS on 16/3/11 suggested that OSCs’ might like to comment on’ the 4
areas below.
Local Authority
Details / Comments
Bath & North East Somerset Council
Official Title of the
OSC
Wellbeing Policy Development and Scrutiny Panel
Does a providers
priorities match
those of the public?
Do you believe that
there are significant
omissions of issues
of concern that had
previously been
discussed with
providers in relation
to Quality Accounts?
Has the provider
demonstrated they
have involved
patients and the
public in the
production of the
Quality Account?
any comment on
issues the OSC is
involved in locally?
We believe that the RNHRD’s priorities match those of the public.
Any other
Comments
We do not believe there have been any significant omissions in
the RNHRD’s quality accounts.
There is evidence of both in-patient and out-patient surveys being
used to inform the quality accounts, though more qualitative data
such as quotes from patients or members of the public would be
welcomed in future.
Although we have not been involved with any issues locally with
the RNHRD, the Panel did appreciate the Chief Executive
attending their meeting in March to give a presentation about the
current situation with the RNHRD and their future plans.
We feel that the final draft of this year’s quality accounts would
benefit from a glossary of terms to aid lay reader’s understanding.
Although we were disappointed to see a rise in the number of
cases of C. difficile from one case to five cases this year, we note
that firstly, this still represents a low number of cases and
secondly that the RNHRD has already taken steps to prevent
further cases by using new disinfectants and offering training to
staff.
We also noted that there has been a rise in the number of
complaints from 11 to 23 but there is evidence that actions,
particularly in the outpatient setting, have been taken to resolve
these.
We are pleased to note the National CQC survey of adult
inpatients shows that patients felt that they were treated with
dignity and respect whilst staying at the RNHRD and we note that
patients rated the RNHRD highly in terms of overall care.
37
Your contact details:
 Committee
 Chairman
 Scrutiny
Contact
Lauren Rushen | Policy Development and Scrutiny Officer
Policy Development and Scrutiny (Democratic Services)
Bath & North East Somerset Council
38
Kirsty Matthews
Chief Executive
RNHRD NHS FT
Upper Borough Walls
Bath
BA1 1RL
Trust HQ
St Martin’s Hospital
Clara Cross Lane
Bath
BA2 5RP
30th May 2012
Fax: 01225 831326
Tel: 01225 831499
Dear Kirsty
NHS Bath and North East Somerset (B&NES) has taken the opportunity to review the Quality Account
prepared by the Royal National Hospital for Rheumatic Diseases NHS Foundation Trust (RNHRD) for
2011/12. It is our view that the account is comprehensive and accurate.
In a joint vision to maintain and continually improve the quality of services, NHS B&NES and the Royal
National Hospital Rheumatic Diseases (RNHRD) have worked in collaboration to establish a
comprehensive quality framework that includes nationally mandated quality indicators alongside
locally agreed quality improvement targets.
The National NHS Contract and Commissioning for Quality and Innovation (CQUIN) scheme provide
further support for ensuring robust quality measures are in place. Through the National Inpatient
Survey, RNHRD, despite its overall performance decreasing, has in fact maintained good performance
in most areas. Within the CQUIN scheme, RNHRD carried out local patient surveys which focused on
maintaining dignity, the results of these were excellent. In addition to reviewing the results of the
patient survey, NHS B&NES carried out quality assurance visits and as part of this process we
interviewed patients. We have received excellent feedback from patients at these visits. Other CQUIN
schemes agreed in 11-12 related to length of stay, reducing avoidable admissions to the rheumatology
ward, goal setting for patients who required rehabilitation for neurological conditions and management
of venous thrombus embolus (VTE).
There are robust arrangements in place with RNHRD to agree, monitor and review the quality of
services, covering the key quality domains of safety, effectiveness and experience of care. This is
managed through the Clinical Quality Review Group (QRG) that meets quarterly, with representation
from senior clinicians and managers from both the RNHRD and NHS B&NES (including GP
colleagues), to review, monitor and provide assurance in relation to quality of care. Areas for
improvement are identified and agreed within the QRG process and we monitor action plans until
improvements are achieved. In addition to the QRG there are a number of community wide groups
where quality improvement, assurance, learning and development take place .The RNHRD is actively
involved in these groups.
39
In 2011-12, RNHRD continued with their standing invitation for the PCT to attend their Integrated
Governance, Quality and Assurance Committee. This is a good example of their willingness to be
open and engage with the PCT.
Through the quality framework for 2011/12 the RNHRD have improved the safety, effectiveness and
patient experience of their services across a range of key areas; these are described in this Quality
Account. NHS B&NES have also received assurance throughout the year from the RNHRD in relation
to key quality issues, both where performance has improved and where it occasionally fell below
expectations with remedial action plans put in place and learning shared across the organisation and
the health community, for example, achievement of mandatory training targets.
During 2010/11 NHS B&NES has carried out quality assurance visits including several specifically
relating to infection prevention and control at the RNHRD; the purpose of the visits is to observe and
review key quality indicators. We also carried out a review of the RNHRD complaints process, this
assured us that RNHRD are responding comprehensively to complainants and learning from them.
These activities facilitate triangulation of information and assurances in relation to quality issues
across the Trust. As a result of the quality assurance visits, recommendations are made to providers;
RNHRD has accepted our recommendations and provided evidence of implementation.
The priorities for 2012/13 have been developed in partnership and NHS B&NES endorse the
proposals set out in the Quality Account. We believe these to be representative for the patient
population and services provided by RNHRD. We are pleased that the indicators chosen for 12/13 are
clinically focused and are linked to areas for improvement.
NHS B&NES can confirm that we consider that the Quality Account contains accurate information in
relation to the quality of services they provide to the residents of B&NES and beyond.
Yours sincerely
Ed Macalister-Smith
Chief Executive Officer
NHS B&NES and Wiltshire PCT Cluster
40
Independent Auditor’s Report to the Board of Governors of Royal National Hospital for
Rheumatic Diseases NHS Foundation Trust on the Annual Quality Report
We have been engaged by the Board of Governors of the Royal National Hospital for
Rheumatic Diseases NHS Foundation Trust to perform an independent assurance
engagement in respect of the Royal National Hospital for Rheumatic Diseases NHS
Foundation Trust’s Quality Report (the ‘Quality Report’) and specified performance
indicators contained therein.
Scope and subject matter
The indicators in the Quality Report that have been subject to limited assurance consist of the
national priority indicators as mandated by Monitor:
 MRSA; and
 C-Difficile
We refer to these national priority indicators collectively as the “specified indicators”.
Respective responsibilities of the Directors and auditors
The Directors are responsible for the content and the preparation of the Quality Report in
accordance with the assessment criteria referred to on page 53 of the Quality Report (the
"Criteria"). The Directors are also responsible for their assertion and the conformity of their
Criteria with the assessment criteria set out in the NHS Foundation Trust Annual Reporting
Manual (“FT ARM”) issued by the Independent Regulator of NHS Foundation Trusts
(“Monitor”). In particular, the Directors are responsible for the declarations they have made in
their Statement of Directors’ Responsibilities.
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether
anything has come to our attention that causes us to believe that:
 The Quality Report does not incorporate the matters required to be reported on as
specified in Annex 2 to
 Chapter 7 of the FT ARM;
 The Quality Report is materially inconsistent with the sources specified below; and
 The specified indicators have not been prepared in all material respects in
accordance with the Criteria.
We read the Quality Report and consider whether it addresses the content requirements of
the FT ARM, and consider the implications for our report if we become aware of any material
omissions.
We read the other information contained in the Quality Report and consider whether it is
materially inconsistent with:













Board minutes for the period April 2011 to June 2012;
Papers relating to Quality reported to the Board over the period April 2011 to June
2012;
Board minutes for the 2011/12 financial year and up to the date of signing the report
(the period);
Council of Governors minutes for the 2011/12 financial year;
Quality and Compliance committee minutes for the 2011/12 financial year;
Papers relating to quality reported to the Board over the period;
Feedback from the commissioners dated [currently outstanding];
Feedback from governors dated 4 May 2012;
Feedback from LINKS dated 10 May 2012;
The Trust’s complaints report published under regulation 18 of the Local Authority
Social Services and NHS Compliance Regulations 2009 dated 4 May 2012;
Latest national patient survey dated 14 February 2012;
Latest national staff survey dated 24 April 2012;
The Head of Internal Audit’s annual report over the Trust’s control environment dated
23 May 2012; and
41

CQC quality and risk profiles dated 6 April 2011, 30 June 2011, 31 July 2011, 30
September 2011, 25 October 2011, 30 November 2011, 3 January 2011, 29 February
2012, and 2 April 2012.
We consider the implications for our report if we become aware of any apparent
misstatements or material inconsistencies with those documents (collectively, the
“documents”). Our responsibilities do not extend to any other information.
We are in compliance with the applicable independence and competency requirements of the
Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team
comprised assurance practitioners and relevant subject matter experts.
This report, including the conclusion, has been prepared solely for the Board of Governors of
Royal National Hospital for Rheumatic Diseases NHS Foundation Trust as a body, to assist
the Board of Governors in reporting Royal National Hospital for Rheumatic Diseases NHS
Foundation Trust’s quality agenda, performance and activities. We permit the disclosure of
this report within the Annual Report for the year ended 31 March 2012, to enable the Board of
Governors to demonstrate they have discharged their governance responsibilities by
commissioning an independent assurance report in connection with the indicators. To the
fullest extent permitted by law, we do not accept or assume responsibility to anyone other
than the Board of Governors as a body and Royal National Hospital for Rheumatic Diseases
NHS Foundation Trust for our work or this report save where terms are expressly agreed and
with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement in accordance with International Standard
on Assurance Engagements 3000 ‘Assurance Engagements other than Audits or Reviews of
Historical Financial Information’ issued by the International Auditing and Assurance Standards
Board (‘ISAE 3000’). Our limited assurance procedures included:






Evaluating the design and implementation of the key processes and controls for
managing and reporting
the indicators;
Making enquiries of management;
Limited testing, on a selective basis, of the data used to calculate the indicator back
to supporting documentation;
Comparing the content requirements of the FT ARM to the categories reported in the
Quality Report; and
Reading the documents.
A limited assurance engagement is less in scope than a reasonable assurance engagement.
The nature, timing and extent of procedures for gathering sufficient appropriate evidence are
deliberately limited relative to a reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial
information, given the characteristics of the subject matter and the methods used for
determining such information. The absence of a significant body of established practice on
which to draw allows for the selection of different but acceptable measurement techniques,
which can result in materially different measurements and can impact comparability. The
precision of different measurement techniques may also vary. Furthermore, the nature and
methods used to determine such information, as well as the measurement criteria and the
precision thereof, may change over time. It is important to read the Quality Report in the
context of the assessment criteria set out in the FT ARM and the Directors’ interpretation of
the Criteria in the section ‘Performance against key national priorities and National Core
Standards’ in the Quality Report. The nature, form and content required of Quality Reports
are determined by Monitor. This may result in the omission of information relevant to other
users, for example, for the purpose of comparing the results of different
NHS Foundation Trusts.
42
In addition, the scope of our assurance work has not included governance over quality or nonmandated indicators in the Quality Report, which have been determined locally by Royal
National Hospital for Rheumatic Diseases NHS Foundation Trust.
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to
believe that:
 The Quality Report does not incorporate the matters required to be reported on as
specified in annex 2 to
 Chapter 7 of the FT ARM;
 The Quality Report is materially inconsistent with the sources specified in the list
above; or
 The specified indicators have not been prepared in all material respects in
accordance with the Criteria.
PricewaterhouseCoopers LLP
Chartered Accountants
31 Great George Street
Bristol
BS1 5QD
30 May 2012
The maintenance and integrity of the Royal National Hospital for Rheumatic Diseases NHS
Foundation Trust’s website is the responsibility of the directors; the work carried out by the
assurance providers does not involve consideration of these matters and, accordingly, the
assurance providers accept no responsibility for any changes that may have occurred to the
reported performance indicators or criteria since they were initially presented on the website.
43
Annex to the quality report
2011/12 Statement of Directors’ Responsibilities in Respect of the
Quality Report
The directors are required under the Health Act 2009 and the National Health Service (Quality
Accounts) Regulations 2010 to prepare Quality Accounts for each financial year. Monitor has
issued guidance to NHS foundation Trust boards on the form and content of annual Quality
Reports (which incorporate the above legal requirements) and on the arrangements that
foundation Trust boards should put in place to support the data quality for the preparation of
the Quality Report.
In preparing the Quality Report, directors are required to take steps to satisfy themselves that:

The content of the Quality Report meets the requirements set out in the NHS
Foundation Trust Annual Reporting Manual;

the content of the Quality Report is not inconsistent with internal and external sources
of information including:
-
Board minutes and papers for the period April 2011 to June 2012;
-
Papers relating to Quality reported to the Board over the period April 2011 to
June 2012;
-
Feedback from the commissioners dated 30/05/2012
-
Feedback from governors dated 04/05/2012
-
Feedback from LINks dated 10/05/2012
-
The Trust’s complaint report published under regulation 18 of the Local Authority
Social Services and NHS Complaints Regulations 2009, dated 30/05/12
-
The 2011 national out patient survey published 14/02/12;
-
The 2011 national in patient survey published 24/04/12;
-
The head of Internal Audit’s annual opinion over the Trust’s internal control
environment dated 23/05/12;
-
Care Quality Commission quality and risk profiles dated 06/04/2011, 30/06/11,
31/07/11, 30/09/11, 25/10/11, 30/11/11, 31/01/11, 29/02/12, and 02/04/12.

The Quality Report presents a balanced picture of the NHS foundations Trust’s
performance over the period covered;

The performance information reported in the Quality Report is reliable and accurate;
44

There are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Report, and these controls are subject to review to
confirm they are working effectively in practice;

The data underpinning the measures of performance reported in the Quality Report is
robust and reliable, conforms to specified data quality standards and prescribed
definitions, and is subject to appropriate scrutiny and review; and

The Quality Report has been prepared in accordance with Monitor’s annual reporting
guidance (which incorporates the Quality Accounts regulations) (published at
www.monitor-nhsft.gov.uk/annualreportingmanual) as well as the standards to support
data quality for preparation of the Quality Report (available at www.monitornhsft.gov.uk/annnualreportingmanual).
The directors confirm to the best of their knowledge and belief they have complied with the
above requirements in preparing the Quality Report.
By order of the Board
30th May
Chairman Peter Franklyn
30th May
……………………………………
.Chief Executive Kirsty Matthews
45