2014/2015 · 35 diagnostics, therapeutics and central operations group 42 path links nhs pathology...

2014/2015 ANNUAL REPORT & ACCOUNTS

Northern Lincolnshire and Goole NHS Foundation Trust

2014/2015 ANNUAL REPORT & ACCOUNTS

Presented to Parliament pursuant to Schedule 7, Paragraph 25(4) (a)

of the National Health Service Act 2006

Togetherwe care, we respect, we deliver

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Contents6 Chairman’s foreword

8 Chief executive’s foreword

10 About the Trust

14 Strategic report

16 Directors’ report

21 Review of the year

22 Medicine group

24 Surgery and critical care group

27 Women and children group

30 Community and therapy group

35 Diagnostics, therapeutics and central operations group

42 Path Links NHS pathology service

43 Medical director

44 Chief nurse directorate

49 Organisational development and workforce

55 Directorate of estates and facilities

58 Sustainability report

60 Performance assurance directorate

64 Directorate of strategy and planning

68 How the Trust is run

68 Board of Directors

80 Remuneration report

87 Council of Governors

98 Annual governance statement 2014/15

109 Head of internal audit opinion on the effectiveness of the system of internal control at Northern Llncolnshire and Goole NHS Foundation Trust for the year ended 31 March 2015

113 Financial review

117 Independent auditors’ report to the Council of Governors of Northern Lincolnshire and Goole NHS Foundation Trust

125 The Trust annual accounts 2014/15

171 Annual quality report 2014/15


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Chairman’s forewordIt is a great pleasure to once again introduce the Trust’s annual report. This has been another year which has brought great challenges but equally great achievements.

In particular we have seen unprecedented increases in the volume of activity and the acuity of our patients. The need to deal with the numbers and acuity of patients while maintaining the quality and safety of the care they require has placed huge and relentless pressure on the Trust’s staff who have responded magnificently.

In her foreword the chief executive has confirmed her own commitment to quality and safety. Our staff have demonstrated they share her determination that there will be no compromise on this both now and in the future and they should all be very proud of what they have achieved.

It has also been a year during which we have begun to see the longer term challenges much more clearly. These are challenges to the clinical and financial sustainability not just to the Trust and its services but to the local health and care community as a whole.

Even more importantly the solutions to those challenges have begun to emerge through the work being undertaken by the Trust and the community through the Healthy Lives, Healthy Futures sustainable services programme.

The findings of the Keogh review in 2013 undoubtedly galvanised the Trust into making further changes. We had already identified areas for action prior to the Keogh review. Both these and others have been addressed with positive enhancements to patient care.

However our commitment to continuous improvement in quality and safety mean we need to make sure that those improvements are deeply embedded into the organisation and its culture. Equally important, we need to continue to search for ways to further improve our services and to make sure that all of our staff are engaged and supported in the achievement of this objective.

The progress made by the Trust’s staff was recognised in July 2014 when the Care Quality Commission recommended that the Trust should be removed from special measures, followed shortly by actual removal by Monitor who are the Trust’s independent regulator.

This was a real turning point for the organisation and staff should rightly feel proud that we reached this significant milestone on our journey of improvement. Throughout the annual report you will see examples of some of the improvements we have implemented over the last 12 months.

You will also see further evidence that we are not complacent and we acknowledge there is still work to do.

In my foreword to previous annual reports I dwelt on the scale of the challenge faced by the NHS and our local health and care community as we respond together to the unprecedented scale of savings and efficiencies which are required from every NHS organisation. The impact of this was already emerging in the

Trust’s 2013/14 financial results and the full implications are now clear. As you will see from the 2014/15 financial report we are declaring a £21.07million deficit (compared with a £5.5million deficit for 2013/2014). We are working closely with Monitor who are providing extremely valuable support and advice in addition to fulfilling their regulatory role.

The deficit is due in part to the unprecedented levels of activity and the increasing acuity of patients, which have both placed extra demands on our workforce to ensure we are providing safe, quality services. In addition to this, there is also pressure on our commissioners’ ability to support these changes with additional funding.

We are working with our commissioners to develop a sustainable model for the future but this may take some time to achieve. We are not alone in facing such a significant financial challenge.

Many hospital trusts are reporting similar or larger deficits, particularly those running smaller hospitals such as ours.

Our staff are well aware of the extent to which the relentless increase in demand for our services compounds the pressure on both services and finances. Those pressures will

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inevitably continue and we will respond to them in three ways.

Firstly, we must continue to improve the efficiency of our own operation. To achieve this the Trust has developed an internal Sustainability Plan, which builds on the cost improvement plans of previous years. The achievement of the Sustainability Plan will be a challenge but it is essential we are able to demonstrate to ourselves and ultimately to our stakeholders that we are, as an organisation, as efficient and effective as we can possibly be.

Secondly, we need to continue to work as a member of the local health and care community to ensure that the community as a whole is as efficient and effective as possible, in the best interests of our patients and the communities which we collectively serve.

To achieve this, the community has established the Healthy Lives, Healthy Futures programme which aims to provide sustainable, high quality services for the future across all of the locality’s health and social care providers. This will inevitably mean changes in the design of patient pathways and the way in which care is delivered both inside and outside the hospitals.

It will create challenges for the Trust and its staff but we are the largest and most capable organisation within the community and we have a particular responsibility to work with our partners to ensure that the Healthy Lives, Healthy Futures programme delivers the best outcome for our patients.

The appointment by the community of the Trust’s chief executive to act as the accountable officer of the Healthy Lives, Healthy Futures programme is potentially a turning point.

Thirdly, we must continue to support and develop the Trust’s workforce. We need to make sure that we have the right number of staff with the right balance of skills and experiences.

We must continue to look for innovative ways to strengthen the Trust’s position as an attractive employer in a highly competitive jobs market. Of equal importance we need to make sure that our staff feel that their contribution is recognised, that they are listened to and that they are empowered and accountable to deliver great care to our patients.

These are huge challenges especially in a time of austerity and at a time when many of the issues which are important to our staff are outside the Trust’s control. Nonetheless our progress to this point gives me confidence that we can go much further.

It remains the case that the quality and sustainability of our services depends upon the professionalism, skills and commitment of our staff and the determination and leadership of the chief executive and her team.

I would like to express my thanks and the thanks of the Board to our doctors, nurses, healthcare assistants, colleagues from the professions allied to medicine and all our other staff and their managers for their hard work and commitment over the past year. I would also like to thank our governors and the hundreds of volunteers who make such a difference in our services to patients.

I am sure that none of our staff have any illusions about the scale of the complexity of the challenges faced by the NHS and this Trust. However, I am convinced that by continuing to work together in the best interests of our patients we can face the future with confidence.

Dr Jim Whittingham

Chairman


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Chief executive’s forewordOur overarching priority as a Trust is to be safe and caring and I am adamant that there can be no compromise on this.

Our vision and values strengthen our commitment to patients and ensure we put them at the heart of everything we do. ‘Together we care, we respect and we deliver’ captures the heart of what we strive to do and this year we have continued to reinforce these values.

The quality of our services is of paramount importance to us. Safe, patient-focused, high-quality services are what we aim to provide in order for our patients to have a positive experience when they come through our doors.

We endeavour to capture the views of our patients through a variety of mechanisms including the daily menu cards which are given to every inpatient, the friends and family test, as well as the national patient surveys on accident and emergency care, maternity, inpatient and outpatient services.

Our ultimate aim is to ensure we listen and learn on how we can improve on people’s experience of coming into our hospitals. Our yellow name badges are a direct result of listening to our patients and acting on their feedback. The badge clearly states every frontline employee’s name and their job title, to ensure patients and visitors know who they are talking to. We have also rolled out the #hellomynameis campaign where we encourage staff who have patient contact to introduce themselves.

A prime example of ‘together we respect’ is the Our Stars staff awards event which I was delighted to attend last October. More than 300 members of staff, from all specialities across our three hospitals, turned out to honour, celebrate and recognise the stars of our organisation - those

people who go above and beyond in their role on a daily basis.

It was humbling to see the many teams and individuals who have gone the extra mile in helping to make a difference. For the first time we also had a patient’s choice award which saw more than 200 nominations received from the public, each of them full of praise for our staff.

Looking to the vision of ‘together we deliver’ I am spoilt for choice as our staff have embraced the concept of delivering forward thinking healthcare services. A shining example of ground-breaking work we have undertaken as a Trust is our WebV clinical portal which we are all incredibly proud of. This is a unique in-house computer system which digitally provides real time paperless information about patients on every ward. At a glance staff can see how many patients are on a ward, how poorly they are, when they last had their observations taken and if they are due for discharge. It also alerts staff for tasks that require immediate attention, such as a patient’s observations being due, whether they are due a hydration and nutrition assessment, as well as an overview of risk flags for each patient.

We have also this year encouraged our staff to have more of a say in delivering innovative healthcare

and services and have launched our very own version of Dragons Den. A selection of executive and non-executive directors act as Dragons with staff pitching their ideas for investment. So far we have seen the launch of PUG (pressure ulcer guide) mirrors being rolled out to frontline staff, together with the patenting of a new concept - a pressure ulcer wheel which provides a unique, visual guide to help nursing staff recognise and treat pressure ulcers.

Ideas have also been generated through our SHINE quality and improvement network which encourages staff to suggest and implement innovative ideas.

This year we have also seen significant investment in new services and refurbishment works. These have included:

• £2.49million project to create a cardiology day case unit at Grimsby hospital. This work will bring together all outpatient and day case cardiology services in one place

• £84,500 on improvements to maternity care for women at Grimsby, Scunthorpe and Goole hospitals

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• £630,000 refurbishment project on B3 (colorectal and gastrointestinal) at Grimsby which has seen new ensuite and bidet facilities

• £592,000 refurbishment of the intensive care unit at Scunthorpe hospital

• The development of a new ambulatory care service, together with improvements to the emergency centre at Scunthorpe hospital.

We have also continued working closely with our local health community and commissioners on shaping sustainable services for the future through Healthy Lives, Healthy Futures (HLHF). This is a review of the healthcare services across North and North East Lincolnshire and is linked to similar programmes within the East Riding of Yorkshire and East Lindsey. The sustainability programme aims to ensure that health and care systems are in place which provide safe, high quality and affordable services for the future.

The first phase of HLHF has been completed following public consultation which will see 24/7 hyperacute stroke services centralised at Scunthorpe hospital

and ear, nose and throat (ENT) services being centralised at Grimsby hospital. This work is ongoing and I know we will see more changes in the future.

Lastly, I would like to thank staff across the organisation who have continued to show tremendous determination, innovation and commitment in the past year. We are all focused on providing high standards of care within both our hospital and community based services and ensuring our patients, their safety and wellbeing is at the heart of everything we do.

It is extremely pleasing to note that some of our staff have been recognised for their excellence and innovation at a number of prestigious award ceremonies in the last year. To name but a few they include:

• The WebV team picked up the Medipex innovation award at the Yorkshire and Humber NHS innovation awards for the WebV clinical portal

• Trust senior infection control nurse Viv Duncanson won the practitioner of the year award at the Infection Prevention Society awards

• The facilities team walked away with three national awards during 2014/2015 having won the workforce efficiency category at the Health Service Journal value in healthcare awards with their hospital support assistant project. This saw the introduction of a new multi-skilled job role at the Trust combining ward caterer, ward domestic and ward support roles. The facilities team also won at the Hospital Estates and Facilities Management Association Awards where they picked up team of the year and project manager of the year.

Karen Jackson

Chief executive


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About the TrustNorthern Lincolnshire and Goole NHS Foundation Trust employs in the region of 6,500 staff across Scunthorpe General Hospital, Diana Princess of Wales Hospital in Grimsby and Goole and District Hospital. We also provide community services in North and North East Lincolnshire.

With a total of nearly 850 beds across the three hospitals, our core business is delivering a full range of emergency secondary health care services as well as a comprehensive range of planned services.

The Trust was originally established as a combined hospital Trust on April 1 2001, and achieved Foundation status on May 1 2007. It was formed by the merger of North East Lincolnshire NHS Trust and Scunthorpe and Goole Hospitals NHS Trust and operates all NHS hospitals in Scunthorpe, Grimsby and Goole.

In April 2011 the Trust became a combined hospital and community services Trust (for North Lincolnshire) under the Government’s Transforming Community Services plan. As a result of this the name of the Trust, whilst illustrating the geographical spread of the organisation, was changed during 2013 to reflect the Trust did not just operate hospitals in the region.

As a Foundation Trust we have more freedom to act than a traditional NHS trust, although we are still closely regulated and must comply with the same strict quality measures as non-foundation trusts.

As well as being an acute trust, we are also a teaching hospital working in partnership with the Hull York Medical School and Sheffield Medical School providing comprehensive undergraduate

teaching for year three, four and five medical students. We also have strong links with other universities in the region and with the Yorkshire and Humber Deanery.

We provide acute hospital services and community services to a population of more than 350,000 people across North and North East Lincolnshire and the East Riding of Yorkshire.

We care about quality and safety and are committed to being open and transparent with our patients and local community about how we are doing. Our performance can be measured through a variety of indicators, from infection and mortality rates to inspection results, patient feedback and the numbers of falls and pressure ulcers on our wards. Details of which are all contained in this report.

For latest news from Northern Lincolnshire and Goole NHS Foundation Trust visit our website at: www.nlg.nhs.uk

Our hospitals

Scunthorpe General HospitalCliff GardensScunthorpeNorth LincolnshireDN15 7BH

Telephone – (01724) 282282Email: [email protected]

Grimsby’s Diana Princess of Wales HospitalScartho RoadGrimsbyNorth East LincolnshireDN33 2BA

Telephone: (01472) 874111Email: [email protected]

Goole and District HospitalWoodland Avenue, GooleEast Riding of YorkshireDN14 6RXTelephone: (01405) 720720Email: [email protected]

Follow the Trust on Twitter: @NHSNLaG @GooleHospital @GrismbyHospital @ScunnyHospital

Follow the Trust on Facebook: /NHSNLaG /GrimsbyHospital /ScunnyHospital

/GooleHospital

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The Trust’s vision and values

The Trust launched its new vision and values in September 2013, which aims to strengthen our commitment to putting patients first.

Our vision of ‘Together we care, we respect, we deliver’ was created with input from more than 400 staff members to reflect their shared values, ideals and principles. It embodies our purpose and describes how and where we will focus our energies.

For patients its sets out what they can expect from the Trust at every step of their journey; whether that is on the phone, in writing or face-to-face. It says we care about more than just the treatment they receive, that we will respect them and will endeavour to deliver safe, compassionate, individualised healthcare services through working with them, when they need us most.

For staff it represents a set of standards and ideals for them to work by with a renewed emphasis on teamwork. By everybody getting involved and looking at how we deliver our services we can improve the quality of our patients’ care.

For our commissioners it says who we are and what we stand for. It signals to them that we place the patient at the fore of our activities and service developments. It tells


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Our values:

Together we care we care about quality and patient safety

we care about positive experiences for patients, carers and staff … and we care about doing the right thing, each time, every time

Together we respect We respect the dignity and individuality of each person in our care

we respect the professionalism, diversity and skills of each person in our team … and we respect the dedication and commitment of those delivering healthcare

Together we deliver we strive to deliver first-class services through listening, learning, and empowering

We aim to deliver forward thinking healthcare services that set us apart from the rest … and we will deliver safe, compassionate services to exceed our patients’ expectations.

them that we recognise our greatest asset is our staff and that our successes are determined by the dedication and skills of our teams.

Importantly it tells them that we care and are determined to deliver the best services we possibly can, each time, every time.

The vision and values have been endorsed by Trust Board members, who signed a public pledge to commit themselves to managing and delivering services in line with them.

The vision and values commit our staff to working in a collaborative

holistic style, placing patients at the very forefront of everything we do, either through our actions or the decisions we make. It also acknowledges that to do this we have to do it together, as a single team.

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Our servicesMedicine

Emergency centre (A&E) Minor injuries unit

Cardiology, coronary care unit

Diabetes, endocrinology

Respiratory, rheumatology, neurology Rheumatology only

Gastroenterology

Oncology, haematology

Rehabilitation medicine

Dermatology

Immunology

Acute medicine

Stroke services

Surgery

Colorectal/Lower and upper GI

General surgery

Marisco

Day case surgery

Breast

ENT

Outpatient Outpatient - Louth, Marisco

Ophthalmology

Head and neck

Vascular surgery outpatient clinics

Urology

Brigg Marisco

Trauma and orthopaedic surgery

Orthopaedic surgery only Marisco

Maxillo-facial and oral surgery Outpatient only

Pain

ITU and HDU

Women’s and children

Maternity and gynaecology

Neonatal services

Paediatrics Outpatients only

DiagnosticsPharmacy, audiology, ultrasound, medical engineering

General radiology, CT and MRI

Breast diagnostics, nuclear medicine and medical illustration

Physiological measurements, Limited service

Community and therapy

Community dental

Rehabilitation medicine service

Adult nursing - planned (district nursing)

Community specialist nursing

Rapid response (unplanned care)

Children’s nursing – health visiting, school nursing, family nurse partnership

Family nurse partnership

Nutrition and dietetics

Occupational therapy

Physiotherapy

Podiatry

Speech and language therapy

Community equipment service, wheelchair service

Clinical psychology

Key:

Scunthorpe General Hospital

Diana, Princess of Wales Hospital

Goole and District Hospital

Community North Lincolnshire

Community North East Lincolnshire

Visiting consultants also provide: plastic surgery; nephrology; cardio-thoracic; specialist paediatrics and clinical genetics.


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Strategic reportThe principal activity of the Trust during 2014/5 has been the provision of acute and community healthcare services and a range of clinical and non-clinical support services.

Operating within the healthcare service industry, the organisation serves a population of approximately 400,000 people across North Lincolnshire, North East Lincolnshire and the surrounding areas of Lincolnshire and East Riding of Yorkshire.

While the Trust is recognised by its three hospital sites, the Trust delivers a diverse portfolio of outreach and community based services. To deliver quality services which meet the needs of the population the Trust has a diverse workforce of 6,500 employees who deliver services to patients and their families both within the 850 bed base across the three sites and in locations within or closer to their own home. The Trust service portfolio generates an annual turnover of circa £330million.

The culture created within the Trust places the quality of care for our patients and their families at the heart of service delivery. The staff within the Trust deliver services ensuring continued improvement across the three key aspects of patient safety, clinical effectiveness and patient experience ensuring quality of care is at the heart of service delivery.

The Trust submitted its five year Strategic Direction to Monitor in June 2014. With quality at the fore, the core strategic principles of the Trust are:

i. To deliver services efficiently without impacting adversely on the quality of care. The Trust has a robust internal five year sustainability programme of efficiency improvements, structured intensively in the early

years. This will deliver optimum efficiency across the whole of the Trust cost base, and support the redesign process

ii. Working together across the health and care spectrum provides the greatest opportunity to control demand, alleviating the cost pressures arising from demand growth. Integration improves the quality of care provided by removing organizational boundaries, enabling clinical teams to work seamlessly across the patient journey

iii. Wider transformation where needed to improve patient care or to deliver more efficient and effective services.

To enable delivery of the core principles above, the Trust refined and strengthen the following strategic enablers:

• The Trust continues to develop a true patient first workforce whose services are delivered through a single, engaged and empowered team that has a voice and strives for uniqueness, innovation, quality and safety

• The IM&T strategy builds upon the innovative culture of system development the Trust continues to achieve. Harnessing the strengthening reputation and developing skills base, the strategic goal is to develop a local IM&T solution which meets the service needs and enables the secure sharing of information across the patient journey, removing organisational barriers

• Delivery of truly integrated service provision is reliant upon

the workforce of Northern Lincolnshire being able to work as a multi-disciplinary team regardless of where the patient is. With prime clinical space at a premium, maximum utilisation of the estate is key to deliver value. The strategy aims to enable service provision to be delivered in the most clinically appropriate locations regardless of organisational ownership.

The Trust and wider health and care economy in Northern Lincolnshire is facing their largest challenge to date, delivering quality care while meeting increasing demand and delivering the financial challenge. This is not a challenge unique to Northern Lincolnshire.

Organisations within Northern Lincolnshire recognise that this challenge cannot be delivered by one organisation in isolation and the Healthy Lives, Healthy Futures programme is the critical vehicle to drive integration and transformation. Working together as a health and care economy with a redesigned allocation framework will drive service transformation.

The Trust has declared a second consecutive year in deficit, and predicts further deterioration in 2015/16. The combination of restricted income flows, set through a tariff which has been progressively reduced in real terms over a number of years, and increased service demand levels and inflationary pressures have driven the majority of acute providers towards financial distress.

The Trust has not sacrificed care quality or services, and will continue to protect the improvements made in frontline services. There can be no trade-off between financial balance and patient safety.

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DirectorOther senior

managersEmployees Total

Male 8 64 1165 1237

Female 7 137 5053 5197

Total 15 201 6218 6434

*Senior managers have been classified as staff band 8 or above.

The Trust has in 2014/15 struggled to secure the income levels it set out in its plans, and where income has been secured, it has been tied to increased levels of activity and service, with the linked costs of delivery offsetting any gain. Though community wide planning work has taken major steps forward in the latter part of the year, there is still much to do.

The Trust has managed to deliver more than £10million of savings and cost mitigation in year, but this fell short of the target level set at the start of the year. Major improvements have been made to support delivery of projects, and the tail end of the year saw material improvements. The Trust has set a very challenging savings target of over £15million in 2015/16, building on this progress.

However, expenditure control will not come close to closing the current resource imbalance. The Trust will pursue an active and ambitious programme of savings projects in 2015/16 and beyond, but this can only be part of the solution.

The joint working arrangements of the Healthy Lives, Healthy Futures project will need to deliver transformational change to control the growth in activity levels and support reconfiguration of services. This work has started to move at a greater pace in year, but this is a long term project.

Even under the best forecast, these measures cannot balance available resources for the local health community and the costs of service delivery. Therefore, the Trust has started the process of application for central support in 2015/16, on behalf of the local health economy, and in consultation with Monitor. This is seen as a necessary step while local transformation work and clarity over national funding arrangements allow for longer term sustainability to be established.

The financial accounts, which can be found later in this report, have been prepared under a direction issue by Monitor under the National Health Service Act 2006.

Environmental mattersThe Trust recognises its corporate social responsibilities (CSR) with respect to the environment and is reducing its carbon footprint through a range of initiatives. It has invested £2.34million in 2014/15 with a further £3.65million investment committed in 2015/16 to further improve the Trust’s energy-savings as part of a contract with British Gas. Further information about ongoing work is detailed in the sustainability report.

Trust employeesThe ability to recruit and retain a workforce sufficient in terms of skills and volume to meet the demand both now and in the future is critical to the delivery of sustainable services. Workforce issues were a source of pressure for the Trust during 2014/15, as for many other organisations. There are national shortages of skilled clinical staff, and isolated Trusts such as ours struggle more than most to recruit. With vacancies covered by locum and agency staff at increased rates, the pressure on expenditure was significantly increased in year.

This is a critical area for action, and also a critical risk in 2015/16.

The Trust recognises that a workplace where individuals feel valued and respected supports retention of skilled staff and increases our attractiveness to potential recruits. The Trust aims to ensure people can reach their

full potential within their job roles and has a coaching and mentoring programme providing additional support and advice for people.

The Trust has continued its commitment to employee involvement and has continued to develop its Shine network during the year. A team of designated volunteer staff members are on hand to help people develop ideas for service improvements and development within their work area. As part of Shine, the concept of a dragons den forum has continued which allows staff to ‘pitch’ ideas to ask for money to develop and implement schemes and changes.

Recognition of the hard work, dedication and innovation of staff is also important to the Trust and there were two key events in 2014 which praised individuals and teams. The chief nurse’s Best Practice day allowed staff to showcase good practice and innovative ideas with colleagues across the organisation with inspirational poster and PowerPoint presentations.

The Trust also held its annual ‘Our Stars’ awards which attracted more than 300 people and celebrated the achievements of our staff.

Below is a breakdown of the number of males and females employed by the Trust as of March 31 2015:


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Going ConcernThe full Annual Report emphasises that the Trust remains technically a going concern, and the accounts are prepared on this basis. However, the necessity of external support in 2015/16 and the Monitor Licence Conditions are such that they highlight longer term concerns over sustainability. This is now an issue across much of the acute sector. This is reflected in the external auditor’s report. Please refer to note 1.1 of the accounts.

The strategic report has been approved by the directors of the Trust and signed by the Accounting Office.

Karen Jackson, chief executive

May 22 2015

Directors’ reportThe directors’ report is prepared in accordance with relevant sections of the Companies Act 2006, the Large and Medium-sized Companies and Groups Regulations, and additional disclosure required by the FReM and Monitor.

The report includes the following:

• Information about the composition of the Board of Directors during 2014/2015

• Equality and diversity

• Future developments at the Trust

• Information and involvement of employees

• Directors’ statement on the annual report

• Snapshot look at activity during 2014/2015.

Trust BoardThe Trust is headed by a Board of Directors with responsibilities for the exercise of the powers and the performance of the NHS Foundation Trust. The following people have served as directors on the Board during 2014/2015:

Current chairman and non-executive directors• Dr Jim Whittingham – chairman

– appointed July 2010 and his term of office ends in July 2016 – voting executive

• Alan Bell – non-executive director – appointed August 2010 and his term of office ends 2016

• Neil Gammon – deputy chairman/senior independent director - appointed August 2010 and his current term of office ends in 2016

• Linda Jackson – non-executive – appointed September 2014

and her term of office ends in September 2015

• Anne Shaw – non-executive – appointed August 2013 and her term of office ends August 2015.

• Stan Shreeve – non-executive – appointed in 2012 and his term of office ends in June 2015.

Current executive directors• Karen Jackson – chief executive

– was appointed in September 2010 – voting executive

• Wendy Booth – director of performance assurance and Trust secretary – appointed August 2013

• Pam Clipson – director of strategy and planning – appointed June 2014

• Dr Karen Dunderdale – chief nurse and deputy chief executive – appointed as chief nurse in 2011 and deputy chief executive in March 2014 – voting executive

• Karen Griffiths – chief operating officer – appointed in April 2014 – voting executive

• Marcus Hassall – director of finance – appointed in August 2014 – voting executive

• Jug Johal – director of estates and facilities – appointed in August 2014

• Dr Neil Pease – director of organisational development and workforce – appointed in October 2011

• Dr Lawrence Roberts – acting medical director – appointed March 2015 – voting executive

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Previous non-executives and executive directorsPhilip Jackson – non-executive between 2004 and September 2014

Mike Rocke – director of finance from 2010 to July 2014

Dr Mark Withers – medical director – January 2014 to March 2015– voting executive

The biographies of our Board of Directors are detailed later in the annual report.

Regulatory ratingsThe risk rating system:Monitor governs the Trust ratings based on systems set out in their Risk Assessment Framework. They use a combination of a continuity of service risk rating, based on key financial performance indicators, and governance risk rating, based on compliance with a set list of performance indicators and targets, to assess Trust compliance with core duties set out in their Terms of Authorisation. Plan submissions and in-year performance are evaluated against these measures to grade Trusts on compliance and risk of non-compliance.

Where Trusts do not remain complaint with the target levels set for either rating, they will be taken through an escalation process by Monitor, who will make their own assessment as to the appropriate actions to take. Monitor may judge the Trust to be in breach of its Terms of Authorisation, and sanction intervention which may include removal of the Trust Board.

Continuity of Service Risk Rating:During 2013/2014 Monitor revised the risk assessment framework to Continuity of Service Risk rating (CoSRR). This has more of a focus on liquidity and debt servicing capability. The new system also rates on a scale of one to four, one being the highest risk, and four lowest risk.

Governance risk rating:The governance risk rating uses a RAG (red, amber, green) rating system, based on a system of penalty points for failing to remain compliant with a set of core performance indicators. Grading runs through the following range – red, amber red, amber green, green. A red rating would normally trigger Monitor intervention.

Monitor will also in certain circumstances apply a ‘override rating’ where they judge that the point system alone does not adequately reflect the extent of risk. Any override rating remains in place until removed by Monitor. The Trust entered 2014/15 with an existing override rating of red.

Q1 2014/15

Q2 2014/15

Q3 2014/15

Q4 2014/15

Underlying rating Green Green Green Green

Override rating Red Red Red Red

During October 2014 Monitor issued a compliance certificate in respect of the Trust’s Enforcement Undertakings in respect of quality, in view of Monitor’s plan to work with the Trust to understand its financial situation an overriding rating of red remains in place.

However, in April 2015, the Trust was formally found to be in breach of its Licence, specifically conditions CoS3(1)(a) and (b), CoS3(2)(c), and FT4(5)(a),(d), and (f). The Trust will therefore retain the red Monitor governance rating, although Monitor has confirmed, and the Enforcement Undertakings which have been agreed, reinforce that this position relates to the financial position / wider system sustainability and not to any concerns regarding the Trust’s leadership and governance systems and processes.


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For further information about the Trust’s governance please refer to the annual governance statement on page 98 and the Quality Account for 2014/2015.

2014/15 Annual plan Q1 Q2 Q3 Q4

Continuity of service rating3

3 3 3 2

Governance rating Red Red Red Red

2013/14 Annual plan Q1 Q2 Q3 Q4

Under the Compliance FrameworkFinancial risk rating

33 3

Governance risk rating Red Red Red Red

Under the risk assessment frameworkContinuity of service rating

44 3

Governance rating Red Red Red Red

Future developments at the TrustThe Trust published its five year strategic direction in June 2014. This followed an extensive review of the Trust’s present and forecasted future prospects where the Trust concluded that it did not consider the current configuration of services to be either clinically or financially sustainable in the medium to long term. In coming to this view the Trust has consistently stated that the sustainability agenda is a challenge for the whole health economy and cannot be resolved by a single organisation.

The Trust is presently participating in a detailed review of services. Further information on this is contained within the planning and strategy directorate report on page 64.

Research and development activitiesThe Trust has a total of 87 studies open within the Trust, taking place at Scunthorpe and Grimsby hospital. Of these 15 are commercial (industry sponsored), 66 are adopted onto the NIHR (National Institute for Health Research) portfolio and the remaining six academic studies account for the other studies which are currently open.

Across the Trust there are currently 22 studies being set up and are at various stages. These include a mix of portfolio, academic and commercial studies as follows:

• Six oncology studies

• Two haematology studies

• Two in-house (student) studies

• Four ‘no local researcher’ studies

• Two rheumatology studies

• Two stroke studies

• Two management studies

• One physiotherapy study

• One breast surgical study.

Current recruitment figures for portfolio adopted studies show that between April 2014 and January 2015, the Trust recruited 1,306 patients into studies. This is marginally below the target set for us by the Clinical Research Network (CRN): Yorkshire and the Humber. The annual target is 2,200 patients.

Reproductive Health and Children is the highest recruiting area within this Trust, although it has to be noted that this is mainly due to one study called BaBY which has now closed to recruitment.

Further detailed information about research and development activity can be found in the Quality Account.

Equality and diversity The Trust is committed to promoting equality, diversity and human rights, being an inclusive employer by ensuring we meet the aims of the Public Sector Equality Duty (PSED) and operates within an equal opportunities policy framework.

Our policies are applied consistently to ensure fair and open recruitment of people with disabilities, as well as ensuring that staff with disabilities can access appropriate training and development, promotional opportunities and flexible working arrangements.

In line with legislation we always make reasonable adjustments and offer appropriate training for colleagues or job applicants with disabilities, which also includes support mechanisms, if required, through the Trust’s occupational health and wellbeing department.

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Information and involvement of employeesThe Trust involves employees in decision making as appropriate and aims to ensure the workforce has a common awareness of issues and matters affecting the organisation. Formal mechanisms to ensure they are informed and involved include:

• Monthly chief executive ‘open door’ days where individuals or groups can raise specific concerns or talk about issues important to them

• Monthly chief executive cascade

• ‘An audience with Karen’ is a quarterly event where the chief executive meets staff and provides a personal update as to what is happening within the Trust

• Director walkabouts

• A range of corporate communications including a weekly email bulletin, bulletins on the intranet, bi-monthly staff/members magazine, all-staff emails

• Involvement of staff governors on the Council of Governors

• Healthy Lives, Healthy Future roadshows

The Trust is also keen to ensure employees are involved in the Trust’s performance and there are several ways this is achieved, including:

• Personal appraisal development reviews (PADRs) are a useful tool for involving employees in the Trust’s performance as the paperwork is linked to the organisation’s vision and values

• The publication of performance assurance newsletters/bulletins on the Trust’s intranet (the Hub) and internal updates

• Group specific quality and safety days inform, and report on Trust performance

• Learning the lessons newsletter

• The Hub is used to keep people updated on latest Trust developments and performance

• The monthly chief executive’s cascade is delivered to managers and filtered down to staff on the shop floor. Key messages are also published in the weekly email bulletin which goes out to all staff

• Mock Care Quality Commission (CQC) visits and director visits feedback to staff on the performance of specific areas.

Political and charitable donationsThe Trust has not made any political or charitable donations. It continues to benefit from charitable donations and legacies. The Trust is grateful for all donors, individual fundraisers and fundraising organisations. The Trust is Corporate Trustee of the charity, Northern Lincolnshire and Goole NHS Foundation Trust Charitable Funds. This charity provides some equipment to the Trust, and also funding to improve patient experience and funding to enhance the staff skills and hospital environment.

Directors’ statementUnder the NHS Act 2006, Monitor has directed Northern Lincolnshire and Goole NHS Foundation Trust to prepare, for each financial year, a statement of accounts in the form and on the basis set out in the Accounts Direction. The directors are responsible for preparing the accounts on an accrual basis, which gives a true and fair view of the state of affairs of the Trust and of its income and expenditure, total recognised gains and losses and cash flows for the financial year.

In preparing the accounts, the directors are required to comply with the requirements of Monitor’s Foundation Trust Annual Reporting Manual 2014/2015 and in particular to:

• Observe the Accounts Direction issued by Monitor, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis

• Make judgements and estimates on a reasonable basis

• State whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual have been followed, and disclose and explain any material departures in the financial statements

• Ensure that the use of public funds complies with the relevant legislation, delegated authorities and guidance

• Prepare the financial statement on a going concern basis.


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The directors are responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS Foundation Trust and to enable him/her to ensure that the accounts comply with requirements outlined in the above mentioned Act. The directors are also responsible for safeguarding the assets of the NHS Foundation Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities.

As far as each director is aware, there is no relevant audit information of which the NHS Foundation’s Trust’s auditor is unaware.

The directors have taken all the steps they ought to as a director in order to make themselves aware of any relevant audit information and to establish that the NHS Foundation Trust’s auditor is aware of that information.

The directors consider that the annual report and the accounts taken as a whole, are fair, balanced and understandable and provide the necessary information for patients, regulators and other stakeholders to assess the NHS Foundation Trust’s performance, business model and strategy.

Each individual who is a director of the Trust Board has approved the directors’ report and as far as they are aware there is no relevant audit information of which the NHS Foundation Trust’s auditor’s is unaware. All directors have taken all the steps they ought to have taken as a director in order to make themselves aware of any relevant audit information and to establish that the NHS Foundation Trust’s auditor is aware of that information.

Declaration of interests of the Board of DirectorsThe Board of Directors undertakes an annual review of its Register of Declared Interests. The Trust register, which gives full details of all the relevant commercial and other relevant interests of directors, can be viewed on the Trust website at: http://www.nlg.nhs.uk/content/uploads/2014/12/NLG15025-Annual-Review-of-Register-of-Directors-Interest.pdf

Activity during 2014/2015Here is a snapshot of activity across the Trust from April 1 2015 to March 31 2015:

Total number of A&E attendances144,996

Outpatients400,295 of which

124,947 for new patients and

275,321 were review patients

Elective (planned) and day case spells60,475

Non elective spells (emergency)47,841

Total number of births4,633

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Review of the year


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Medicine groupThe medicine group provides a comprehensive range of services to patients in the following specialities: emergency medicine, acute medicine, cardiology, diabetes and endocrinology, elderly care, gastroenterology, stroke, dermatology, haematology, immunology, neurology and rheumatology. As well as inpatient services, it also provides outpatient services in a range of community and hospital settings.

In the last 12 months the group has made significant improvements for patients in a number of different areas including:

Stroke careIn October 2014 the Healthy Lives, Healthy Futures programme decided that hyperacute stroke services should continue to be provided at Scunthorpe hospital. The service had been provided at both Grimsby and Scunthorpe hospitals prior to November 2013, when it was consolidated onto the one site. The change means that local stroke patients will go to Scunthorpe hospital for up to the first 72 hours of their care. After this, if they need further treatment and monitoring they will receive this at a hospital nearer their home.

This decision followed the stroke service receiving a clean bill of health

from a team of independent external clinical reviewers who scrutinised the units’ processes, policies and patient pathways. The peer review team concluded that services were safe and sustainable and that significant improvements had been made since the previous visit in 2012, especially around the consolidation of the hyperacute stroke service. Particular praise was given for the creation of a team of stroke responders whose role it is to ensure patients flow through the early diagnostics and tests smoothly. Recognition was also given to the introduction of seven-day working in diagnostics which means patients have more access to CT and MRI scans.

Urgent, emergency careThe group has continued to look at new ways of working in emergency care in order to try to meet the

challenges of a year-on-year increase in the number of people coming through the doors of the emergency care centres at both Scunthorpe and Grimsby hospitals.

Work got underway in February on a £157,000 scheme to expand the major triage area of the emergency centre at Scunthorpe hospital. The work will increase the number of major triage bays from eight to 13 which will help during busy periods as more patients will be able to be seen. In addition to the additional five major triage bays, work was also be carried out to create an enhanced specialist drug preparation area for staff and a separate paediatric waiting area.

Work also started in January 2015 on a new ambulatory emergency care service at Scunthorpe hospital. The £148,000 project will see acute medical patients assessed, treated and discharged on the same day eliminating the need for them to be admitted to an inpatient bed. The aim is to reduce the number of emergency medical admissions and ensure low risk patients received the appropriate treatment in the right place and are discharged back to the comfort of their own home.

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The group was pleased with the results of the Care Quality Commission’s patient survey on accident and emergency departments which showed patients were happy with the care and treatment they received. The organisation overall scored ‘about the same’ as most other Trusts in the survey and scored ‘better’ on the length of time patients were in the department.

Minor injuries unit, GooleIn conjunction with East Riding Clinical Commissioning Group and East Midlands Ambulance Service (EMAS) the group has worked with staff at Goole MIU to ensure its continued sustainability and to ensure it continues to deliver safe, high quality and appropriate care for residents of Goole. The unit provides services for patients with minor injury and minor illness. It has ‘walk in’ open access and is staffed by medics, experienced emergency nurse practitioners and general nursing staff. The team are committed to providing a high quality service and continue to undertake extensive training and assessment of their skills.

CardiologyIn 2014 cardiology services saw the start of a £2.49million project to create a cardiology day case unit at Grimsby hospital. Work started in November and it is anticipated it will be completed in the summer of 2015. The development will bring all outpatient and day case cardiology services at the hospital together in one place. The facility will also have a dedicated cardiac catheterisation laboratory.

A £872,805 replacement programme also saw new equipment purchased for the catheterisation laboratory (cath lab) at Scunthorpe hospital. The new hi-tech equipment will enable clinicians to develop and expand the angioplasty service to allow more patients to be seen.

The cardiology service also now provides services for patients with heart failure or irregular heart rhythms

who need implants. Cardiologists started to provide cardiac resynchronisation therapy devices (CRT) and implantable cardioverter defibrillators (ICD) at Grimsby hospital. Patients previously had to travel to other hospitals for these treatments.

High dependency unit, Grimsby hospital Work was undertaken to expand the high dependency unit (HDU) and to relocate the respiratory ward at Grimsby hospital with an investment of £690,000. The HDU, which had four beds, gained an extra three and the respiratory ward was relocated from ward C2 to C5. The relocation of the respiratory ward nearer to HDU means those patients who require more intensive support have quick and easy access as respiratory patients are the highest users of the HDU.

New staff join the medical teamA number of new consultants have been recruited to posts across the medical group over the last 12 months. These have included:

• Lead palliative care practitioner at Scunthorpe hospital

• New gastroenterologist at Scunthorpe hospital with a special interest in inflammatory bowel disease and people with special needs

• Two new consultants in emergency care at Grimsby hospital

• A new consultant in diabetes and endocrinology at Scunthorpe hospital

• A new cardiologist at Scunthorpe hospital.

A new manager – associate chief operating officer – has also been appointed to lead the medicine group. A head of nursing based on the Grimsby hospital site has also been appointed to ensure that each of the main hospitals has a senior nurse presence within

the hospital ensuring high quality patient care is maintained.

For the first time medicine has recruited an epilepsy nurse specialist, which was also a first for Grimsby hospital. The post has been funded by Epilepsy Action for one year and then North East Lincolnshire Clinical Commissioning Group has agreed to continue funding for the following three years.

The nurse provides outpatient clinics at the hospital alongside consultant clinics for patients under the care of the consultant neurologist. In the future it is hoped to roll out community clinics in three GP practices.

Looking to the futureOver the coming months we will see the opening of the new cardiology facilities on both main hospital sites adding much needed capacity and state-of-the-art facilities. Additionally we will also see the opening of the new ambulatory care unit and the accident and emergency development on the Scunthorpe hospital site, helping to improve patient flow through the hospital.

The appointment of a Parkinson’s specialist nurse for Scunthorpe hospital has been agreed and it is expected that an appointment will be made in the spring of 2015. A concerted effort to encourage patients who attend hospital to stop smoking will be made over the coming year in a joint initiative with the respiratory unit, pharmacy and primary care. This will see awareness sessions, group and individual advice being promoted on both hospital sites and the appointment of a healthcare assistant to help support the work.


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Outpatient activityTotal New Review

Outpatient appointments 226,917 71,365 155,552

Outpatient attendances with a procedure 77,473 26,676 50,797

Inpatient activityTotal Day Case Inpatient Emergency

Inpatient activity 43,989 29,529 4,861 9,599

Trust Local peer group

Day-case rate: 85.9 per cent 79.1 per cent

Average length of stay 4.3 days 4.4 days

Elective average length of stay 2.9 days -

Emergency average length of stay 4.9 days -

Emergency readmissions within 30 days 4.1 per cent 4.7 per cent

Theatre activityElective theatre operations 17,087

Emergency/urgent theatre operation 1,450

Surgery and critical care group The group provides care within the following specialties across the three hospital sites:

• General surgery

• Breast surgery

• Colorectal surgery

• Upper gastrointestinal surgery

• Trauma and orthopaedics

• Urology

• Ear, nose and throat (ENT)

• Ophthalmology

• Maxillo facial services

• Orthodontics

• Anaesthetics and chronic pain

• Critical care.

Regular outpatient services are also provided across a number of community and primary care settings.

Performance against key targetsIn 2014/15 the specialties delivered:

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Patient careIn the last 12 months the group has made significant improvement for patients in a number of different areas including:

With the appointment last year of a urology consultant with a special interest in female continence, we have been able to develop a multi-disciplinary team focus for patients jointly with our colorectal surgeon and gynaecology consultant colleagues.

We have been able to increase the number of medical staff participating on a rota out of hours providing more capacity for ward reviews and emergency assessments.

We took part in the National Complicated Acute Diverticulitis (CADS) audit at both Grimsby and Scunthorpe, led by our consultant colorectal surgeons. It was a multicentre prospective audit of variation in clinical practice and its influence on immediate and short term patient outcomes, and is due to be published in 2015/2016. This national audit will provide landmark data on the national incidence, management pathways, and patient outcomes that will help to inform development of national guidelines for this common surgical emergency that has significant implications for patients.

2014/2015 saw the retirement of Mr Henry Pearson, a general surgeon with a special interest in bowel surgery, who had worked at the Trust for 27 years, with a 40 year career in the NHS. Mr Pearson was a well-known consultant, not just for his work in the hospital, but also through his various fundraising events through his love of cycling, and he has left a legacy of demonstrating what achievements can be made in developing services with positive action. Mr Pearson’s post is currently being recruited to.

The group has also participated in the National Emergency Laparotomy Audit which aims to look at the structure, process and outcome measures for the quality of care received by patients undergoing an emergency laparotomy. Although data collection is continuing, preliminary analysis of data collected so far has led to the development of a new emergency surgery pathway which includes patient risk scoring for mortality in order to ensure resources are in place for high risk patients.

This year the NCEPOD (National Confidential Enquiry into Patient Outcome and Death) undertook a study to identify the remedial factors in the quality of care provided to patients treated for acute pancreatitis which the Trust participated in and a national report will be published in 2016.

In line with the group’s commitment to developing its own staff, and also in offering opportunities for potential staff of the future, the orthoptic department at Grimsby hospital saw its first intake of first year orthoptic undergraduate students from Liverpool University, with a plan to expand this to Sheffield students (the only other university offering the degree course in orthoptics) as required.

We have enhanced the opportunities for women to undergo oncoplastic breast surgery following major surgery locally, with increased capacity from visiting consultants. This has built on the excellent care already delivered by our existing oncoplastic surgeon.

For the first time ever members of the public were given the unique opportunity of witnessing live orthopaedic surgery at the Trust. Goole hospital opened its doors, and its theatres, to the glare of interested members of public and health professionals. The aim of the event was to

showcase the types of orthopaedic treatment that is available at the hospital.

A new one-stop service has been launched at Goole for patients with suspected colorectal cancer to help speed up diagnosis. The normal journey for patients is they are seen within two weeks of referral from their GP in an outpatient clinic. A decision will then be made whether they need a colonoscopy or sigmoidoscopy and they are referred for the tests which could take another two weeks. The new service means for those patients where it is appropriate, they are booked into a clinic within two weeks and are seen by the consultant and have their endoscope examination on the same day.

We are the first group across the Trust to launch a dedicated quality and safety day which is held every other month with the objective of bringing consultant clinicians, registrars, junior doctors and specialist nurses together. The main aim is to focus on how the group can improve care for patients. The event promotes the importance of patient safety and allows shared experiences and learning.

Our death rates for patients undergoing bowel cancer surgery are well below the national average. Out of all the patients diagnosed with bowel cancer at the Trust between April 1 2010 and March 31 2013 there were 11 patients who died within 90 days of their major resection. That gives a post-operative mortality rate for the Trust of 2.98 per cent which is well below the five per cent national average.


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The figures were published last year by NHS Choices. The rates are for deaths in the 90 days post-surgery, so although aligned to the surgeon performing the surgery it’s also a reflection on the care given after surgery by staff on the intensive care unit, high observation unit and the wards.

The group has reviewed its provision of critical care across the two main site hospitals, and has developed plans for integrating the service through medicine and surgery, working with the multi-disciplinary team to improve the pathways of care delivery for the critically ill patients. This work has both short and long term aims, with short term plans being implemented currently and the longer term being reviewed in the context of the organisation’s long term vision.

Surgery and critical care received a large number of patient compliments over 2014/2015. Ward 25 at Scunthorpe hospital was awarded the Patient’s Choice award, voted by the patients and their families as part of the Trust’s Our Star awards in 2014. This is evidence that the focus on compassionate care is continuing within the group.

InvestmentsWe have seen a number of investments – new builds and refurbishments – get underway during 2014/2015. These have included:

• Grimsby’s B3 ward – this was a £630,000 refurbishment which saw new ensuite facilities installed in each bay, the addition of bidets to the unit, a new nurses’ station and single side room, as well as new flooring, windows and decoration. The existing treatment room was also refurbished. The former Bottoms Up appeal donated £160,000 towards the scheme

• The intensive care unit at Scunthorpe hospital had a makeover thanks to a £592,000 project which saw state-of-the-art pendants installed at each patient bedside, as well as new ceilings, flooring, a revamped medicine preparation area and a new isolation cubicle.

New staff join the surgical and critical care teamA number of new consultants have been recruited to posts across the surgical and critical medical group over the last 12 months. These have included:

• Trustwide consultant urologist with a special interest in female urology and stone disease

• Trauma and orthopaedic consultant with a special interest in lower limb, foot and ankle surgery at Scunthorpe and Goole hospitals

• Oral and maxillofacial consultant with a specialist interest in head and neck surgery

• Colorectal consultant with an interest in keyhole and open surgery for colorectal cancer, inflammatory bowel disease, diverticular diseases and functional bowel diseases such as constipation, diarrhoea, irritable bowel disease, rectal prolapses and faecal incontinence

• Four new consultant anaesthetists.

Look to the future:

Looking forward to 2015/2016 the group is continuing its focus on clinically led development of specialties that enables continued improvements in care that is sustainable for the local population, both improving patient access to specialist care, and enhances opportunity for recruitment of staff.

A review of development opportunities for roles across the multi-disciplinary teams in areas such as unregistered nursing opportunities to extend their scope, and opportunities for specialist nurses to work more closely with medical teams, are being explored to compliment this.

In order to do this, opportunity for efficiency is a focus for the group to ensure it is enabling its skilled workforce to perform at the best of their ability with both processes in theatres, outpatients and administration forming a focus.

Recruitment will also continue overseas for both nursing and medical staff to help to address the gaps in training posts coming from the medical deanery and the nursing colleges.

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Women and children groupThe group provides a range of inpatient, outpatient and community services. These include maternity, gynaecology, neonatal and paediatric services across all three of the Trust’s hospitals.

2014/2015 has been a busy year for the service delivering excellent care, working closely with patients, service users and commissioners to respond to the needs of the population. Austerity in the NHS provided the opportunity for the service to consolidate and focus on areas that matter most ensuring appropriate staffing levels and meeting essential quality standards consistently.

The year also saw the appointment of a new general manager Ashy Shanker for the group who with renewed enthusiasm, along with the team of the following clinical leaders has started further improvements to the services: Mr Franz Ndumbe, consultant in obstetrics and gynaecology and acting associate medical director; Mr Manohar Mahadeva, consultant in obstetrics and gynaecology and clinical lead for

obstetrics across all sites; Dr Sandeep Kapoor, consultant in paediatrics and clinical lead for acute paediatrics across all sites; Dr Omobolaji Wilson, consultant in paediatrics and clinical lead for community paediatrics across all sites; Julie Dixon, head of midwifery and assistant general manager; Amanda Jackson, head of children’s nursing and assistant general manager.

In 2014/15 the group made strides in the following areas:

CNST accreditationMaternity services achieved the Clinical Negligence Scheme for Trusts (CNST) level 2 in 2014 which demonstrates the quality and level of care being delivered in obstetric, maternity and neonatal

services ensuring that the Trust is complaint with national standards. During the two-day inspection by the NHS Litigation Authority (NHSLA) the assessment team looked at more than 400 medical records, as well as undertaking spot checks on the wards to look at care in progress.

Winners of the Royal College of Midwives normality awardThe group was nominated for two awards as the maternity service had been hard at work ensuring it provides a high quality,


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patient focused service for local pregnant women.

The clinicians and nurses had been jointly working to promote a ‘normal’ and natural birth experience wherever possible. At a luncheon in London the team from Scunthorpe hospital won the prestigious normality award. Caesarean section rates at the hospital are now among the lowest in the country and more and more women are choosing to have a natural delivery after having had a caesarean section in the past. The supervisor of midwives team was shortlisted in their category around the work they had done to reduce the Trust’s stillbirth rate.

Improving the environmentThe group was successful in bidding for part of a £10million Department of Health fund initiative. The group received £84,500 to spend on improvements to maternity care settings. The areas improved were on ward 26 at Scunthorpe hospital, the home-from-home unit at Goole hospital and the honeysuckle, jasmine, holly and blueberry wards at Grimsby hospital all receiving a slice of the money.

In Scunthorpe a new spacious and relaxing assessment room on ward 26 with ensuite facilities was created. This is used for women who have been referred by their GP or community midwife for an urgent assessment but don’t need to be admitted to the ward. At

Grimsby hospital a mobile variotrac and telemetry, which is specialist monitoring equipment, was purchased which has being used for women who are classed as having ‘high-risk pregnancies’ to allow them to have a pool birth and have some type of normality while still being monitored. The Goole home-from-home unit received a new birthing couch, birthing ball and mat.

New nurse-led clinic for young people with constipationA new nurse-led clinic for children and young people suffering with constipation was launched at Grimsby hospital providing help, advice and education for patients and their families. The service sees children aged up to 16 who have been referred by a consultant paediatrician with functional constipation. The service is provided by advanced nurse practitioners and a paediatric specialist nurse with advice and supervision provided by a consultant paediatrician. The aim of the clinic is to encourage and empower children and families to confidently manage their condition and ultimately avoid unnecessary admission to hospital. The emphasis of the clinic is on education and support. The service follows the appropriate NICE guidance, operating weekly and also offering home visits and telephone support for families. Early evaluation from patients and their families is very positive.

New service launched at Goole hospitalThe new termination of pregnancy service was launched at Goole hospital in February 2015. It provides medical terminations for women with pregnancies under nine weeks. The new service means women no longer have to travel to other

providers such as Hull, Doncaster or Scunthorpe. As this is in a small compact area partners or friends are encouraged to remain with the women to give extra support.

Tenth anniversary of the purpose-built maternity unit at Grimsby hospitalJuly 2014 saw the 10th anniversary since midwifery services in Grimsby moved from the former maternity hospital in Second Avenue, to the purpose-built family services department which stands within the hospital grounds. The celebrations begun on Sunday July 20 2014 – the exact date when the move took place a decade ago – and women who gave birth on this day were given an extra present for them and their baby by midwives, funded by the hospital League of Friends.

The staff also organised a drop-in birthday party inviting women who gave birth in July 2004 to attend, along with maternity staff who have since left or retired. The chief executive of the Royal College of Midwives, Cathy Warwick, also attended the celebrations.

Improvements to paediatric community teams at Scunthorpe and GrimsbyThe paediatric community teams in North and North East Lincolnshire have received additional staff to help support children and young people in the community setting. The aim of the children’s community nursing service is to ensure that children and young people remain as independent as possible, enabling them to enjoy the best possible quality of life without having to be admitted to hospital.

The team support children and young people in the community

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setting so that unnecessary hospital admissions and prolonged lengths of stay are avoided. The emphasis is also on empowering children and young people to be able to manage their own long-term conditions with support while receiving timely nursing support and advice at home or within a community setting where necessary.

The service provides care for children with long-term conditions, acute and short-term conditions, children with disabilities and complex conditions, and neonates. In addition the teams work closely with staff at St Andrew’s Hospice in Grimsby to provide tailored care packages for children with life-limiting and life-threatening illness, including those requiring palliative and end-of-life care.

Looking forward to the next 12 monthsNewborn hearing screeningFrom June 2015 the model for newborn screening will change in North Lincolnshire from a primarily community-based service to a hospital model. Currently in North Lincolnshire babies on the neonatal unit are screened in hospital while babies requiring ‘normal’ care are screened in the community setting. A change to funding has resulted in the need for a hospital-based model to be developed and it is anticipated that this will be in place from June 2015. This will result in all babies born in North Lincolnshire receiving hearing screening in hospital by a dedicated team of screeners. The model will mirror the excellent service already in place within North East Lincolnshire.

Paediatric assessment services for children in A&E at Scunthorpe hospitalA multi-disciplinary working party has been established to develop a business case to enhance the provision of assessment services for children attending A&E at Scunthorpe hospital. This will focus on a dedicated area for children, away from the adult setting, which is staffed by a dedicated paediatric team. It is anticipated that children would be assessed in a more timely manner if seen by a dedicated team and inappropriate admissions to the inpatient ward will be reduced.

Stillbirth working partyThe group has worked together to reduce the number of stillbirths as in 2013 the Trust had been an outlier in the Yorkshire and Humber Region. The medical and midwifery teams have worked together to reduce the number by reviewing themes and putting in interventions to help this reduction ie the use of customised growth charts to better identify babies that are not growing properly, the introduction of a leaflet promoting ‘counting the movements’ to help women know the signs if baby is compromised and the introduction of carbon monoxide monitoring at every antenatal appointment for all pregnant women who smoke. This is one of the major themes that smoking in pregnancy is a contributing factor. The number of stillbirths for 2014 has been significantly reduced and the group will continue this valuable work. This year will see the Trust being a pilot for the NHS

England project the stillbirth bundle. With this work the group will also concentrate on the aftercare care that is given to bereaved women and their families and look to the provision of a bereavement room at Scunthorpe hospital.

Integrated workingFor 2015 the group is moving forward with work on central delivery suite and integrating the coordinator team more with coordinators at Grimsby. This rotation is designed to enhance and strengthen this important role. In addition the service is redesigning the model of care to ensure where possible continuity of care is provided by the midwifery team through the journey of labour, delivery and post-delivery care. This will also see an increase in the number of midwives to national best practice standards to ensure safe and excellent quality care for the population we serve.

UNICEF breastfeeding friendly initiative The group took its responsibilities to promote breastfeeding seriously and worked with the wider community of health visitors and children’s centres to achieve the UNICEF baby friendly initiative level 2.The final assessment process is planned for July 2015 and the team is preparing and hoping for success.


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Community and therapy group The group provides a wide range of community and therapy services across North and North East Lincolnshire, including school nursing, health visiting, physiotherapy, psychology, podiatry and specialist dental services.

Staff work across a range of settings including community clinics, people’s homes, schools, leisure centres, care homes and in the hospital to name but a few. Community nursing and therapy services staff work with people of all ages. They recognise the importance of people being able to achieve and maintain their independence and health as far as possible

Community dental serviceDental teams are based in Scunthorpe’s Ironstone Centre and Ashby Clinic, as well as in St Hughs Avenue and Cromwell Road in North East Lincolnshire. In addition to providing treatment for those patients who have difficulty accessing treatment elsewhere, another remit of the service is to

monitor and improve the dental health of the local population.

The service also takes referrals from dentists, nurses, social workers and other related professionals and offers dental care to children with high levels of dental problems, people with special needs and the elderly, as well as wheelchair users and bariatric patients.

Over the last 12 months the service has introduced a texting service to remind patients about their appointment dates and times. This uses a functionality of the Software of Excellence system used for record keeping and clinic management. The text messaging was started in December and early indications suggest that the ‘failure to attend’ rate has reduced as a result.

The oral health promotion team has been working closely with Public

Health England in order to ensure that health promotion programmes are evidence based and targets groups within communities with high levels of dental disease. Resource boxes are available to local schools as well as an e-learning package which children and teachers can use. A ‘Making Every Contact Count’ (MECC) e-learning package has been written which will be accessible to the local general dental practitioners

PsychologyThe psychology service provides psychological care to adults, their families and carers in a variety of settings across the Trust’s three hospitals including outpatient, community, and inpatient settings. The department consists of clinical and health psychologists specialising in health, oncology, stroke and neuropsychology. Referrals are accepted from consultants, specialist nurses and hospital-based therapists.

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It works collaboratively with multi-disciplinary teams in the management of patients’ psychological assessment and therapy, and to offer advice and consultation on the patients’ psychological care to non-psychologists colleagues and to non-professional carers. The team also provides teaching and training to other Trust professionals in the management of health and neuropsychological needs including stroke patients.

During the last 12 months the team has introduced an emotional needs referral pathway into Scunthorpe’s Lindsey Lodge Hospice which has seen an increase in patients being able to access psychological care at the hospice. It has also introduced mood and capacity pathways for stroke patients and has been working collaboratively with the stroke multi-disciplinary team.

The team presented to the North and North East Lincolnshire Cancer Survivorship Conference and received excellent feedback locally and interest from NHS England to use the presentation nationally.

The department has collaborated with the MS specialist nurse and provided psychological care to MS support groups. This is a new and innovative way of newly diagnosed patients being able to access psychology.

In the coming year the team plans to deliver similar psychological support into the Parkinson’s and epilepsy support groups.

Adult therapy servicesTherapy services provide care to patients both in hospital and in the community. There are four types of teams in total which are made up of speech and language therapists, physiotherapists, occupational therapists, podiatry and orthotics, and nutrition and dietetics.

Notable achievements during the year include:In North East Lincolnshire there has been a ground-breaking project working with commissioners and service providers in the development of the Assisted Living Centre (ALC). This was due to be opened at the end of April 2015 and will provide the supply of equipment over seven days to support people within the community and facilitate discharge from hospital. It will also provide clinical guidance and access to equipment for those who wish to self-purchase. The unit will facilitate closer joint working between the equipment store and wheelchair services. There has been a successful consultation with administrative, technical and clinical staff within the ALC to work extended hours, including Saturdays and up to 6pm, increasing choice of access to services.

The speech and language therapy review was completed which resulted in an investment of £70,000 to ensure a more sustainable service is delivered. As a service it has worked hard to ensure processes and ways of working are mirrored across site, providing cross-site support and expertise. The extra investment has resulted in the appointment of dysphagia assistants who work across the speech and language therapy and the nutrition and dietetics service to manage patients with eating, drinking and swallowing disorders.

There has been continued partnership working in the North East Lincolnshire therapy teams to review patient pathways, which has enabled closer joint working between disciplines and analysis of the patient journey. This has included work with therapists in Care Plus to ensure a smoother journey for patients with clarity of care as they are discharged from one team into another.

A piece of work has also been undertaken cross-site and across disciplines looking at planning and initiation of job plans of all clinicians. This has provided increased clarity of roles and highlighted expected levels of activity.

The service has also been accredited as a supplier for musculoskeletal outpatients physiotherapy in North East Lincolnshire within a competitive market following a significant piece of work to reduce waiting times and improve processes. The approval of a PGD for soft tissue and joint injection means that the physiotherapist working in the orthopaedic triage clinic at Goole will be able to do joint injections as part of the extended scope of practice.

Allied health professional reporting is now in place in North East Lincolnshire which is providing detailed information on services. As an aspect of this, all therapy teams are producing, evaluating and reporting on outcomes gained from interventions made.

Following the introduction of the Malnutrition Universal Screening Tool (MUST) in the acute setting last year the nutrition and dietetics team have rolled out training into the community in North and North East Lincolnshire. The MUST tool is a five-step screening tool to identify adults who are at risk of malnutrition or are obese and includes management guidelines which can be used to develop a care plan.

The community stroke team have been collaborating with Bradford University and have been selected as a research pilot site to look at


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using empowerment and self-management for improving long term stroke care in the community (LoTS -2-Care). The project is funded for one year.

The use of an electronic referral system between therapists has also been initiated which will allow for improved speed of referrals. This has the potential to be rolled out to other referrers. This supports the drive to pull therapeutic records into paperless systems, increasing the level of information for GPs and clarity of care.

This year has seen the development of the therapy services to support the hyper-acute stroke services at SGH. Robust handover and discharge documentation is now in place to ensure safe and effective transfer and discharge of patients.

Following the successful trial “The perfect week” for frail elderly services which therapy played a key role, investment has now been agreed to provide these services on a permanent basis.

Family nurse partnership (FNP), school nursing and health visitingThe FNP team received a request from the national unit of the Department of Health to share its learning nationally so that other family nurses/community practitioners could benefit from sharing the lessons it had learned. A media production company travelled to Scunthorpe from London to make a short film that will be used nationally.

The school nurses in North Lincolnshire gave more than 2,000 teenagers the nasal flu vaccine this year. They were one of 13 teams across the country taking part in a pilot of the vaccine and achieved the highest rate of immunisation out of

six teams within the North Yorkshire and Humber area, achieving 70 per cent uptake. The pilot took place to help determine the best approach to implementing the programme, which will eventually see all children from the age of two to 17 offered the vaccine.

During nutrition and hydration week the health visitors educated parents providing integrated training (children’s centre staff, midwives, babies, health visitors, students health care professionals) about the importance of vitamin D in our diets, especially in at risk groups as per NICE guidance [PH56] November 2014. Two training sessions were also held and information has also been produced and added to the new birth red book for information.

The service achieved stage two of the Baby Friendly Initiative assessment passing on every criteria, following a visit from UNICEF inspectors to North and North East Lincolnshire in January 2015.

Kathryn Deighton, team leader for health visitors in North Lincolnshire, has been successful in her application to be a Fellow of the Institute of Health Visiting.

Integrated teams in North Lincolnshire communityCommunity nursing, therapy and social care continue to work in localities within integrated health and social care teams, playing an important part in the prevention of unnecessary hospital admissions by supporting in particular the vulnerable and frail elderly to remain in their own home or care home. Links with Humberside Fire and Rescue’s community safety team has seen home safety visits undertaken and risk assessments undertaken of vulnerable people’s homes. All patients who require air flow mattresses are informed of fire risks and smoking and fire prevention checks offered including fire retardant bedding, metal bins provided rather than using plastic waste bins. The fire safety service has carried out training in each locality base for the integrated teams.

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Children’s therapy teamThe children’s therapy team in North Lincolnshire has undertaken a review of the service they deliver to special schools, consulting closely with parents and teachers about how to work more effectively together. This has resulted in some ‘quick wins’ for improving communication, together with longer term projects involving ‘whole school’ approaches such as the correct positioning of children with physical disabilities in the classroom to help them stay well, socialise, learn and participate to the best of their ability.

A new service level agreement has also been established in 2014/2015 which will enable the team to deliver more occupational therapy support for special schools. The expertise of the team was also ‘bought in’ by one local school to help it develop a sensory service for children whose behaviour and wellbeing may be affected by over-sensitivity or under-sensitivity to their environment, which is often found in children with autism.

The team has also delivered a broad range of training for local schools and continues to be a partner in the local Teaching School Alliance, which promotes teaching and improving standards across the locality.

In North East Lincolnshire the team has gone ‘paper light’ which has improved efficiency and governance of record keeping and communication between agencies. It is now also offering electronic referrals which is supporting ease of access and referral.

During the last 12 months, it has seen an extension of its service level agreement with the local authority (LA) for children’s centres and school outreach posts and there is ongoing joint working with the LA.

Therapists have also devised a new

tool to help treat children with speech and language difficulties. The outcome web is used to identify goals for the child or young person to work towards and is used at the start and end of their therapy as a measure of their progress.

The team has maintained its four-week wait for assessment and 18 week referral to treatment targets despite experiencing significant staffing issues during the year. They have been successful in recruiting to a hard to reach post within paediatric physiotherapy and have been able to retain at risk staff through deployment within the team.

Work is continuing with North East Lincolnshire Clinical Commissioning Group to review children’s therapy across the patch and this should be completed by October 2015.

Intermediate care services in North LincolnshireA new state-of-the-art intermediate care facility was opened at the Sir John Mason House in Winterton in March 2015. This integrated health and social care facility has 30 ensuite rooms and helps people regain their independence and return home after a hospital stay through rehabilitation and reablement support.

Social care staff, therapists, nurses and GPs all work closely together to ensure that these people receive the services they need after an illness or receiving medical treatment.

There is a wide range of modern facilities such as bariatric beds and furniture and specialist adaptations. These include a range of assistive technologies that will be identified as appropriate for individual needs. People have the opportunity to relearn daily living skills to allow them to return to the life they had before becoming unwell. Also based at the centre is the community support team that coordinate staff providing rehabilitation and reablement in people’s homes.

Macmillan palliative care serviceThe community Macmillan end of life coordinator has been instrumental in driving forward the quality of care for patients who are near or at the end of life.

An advanced care plan has been developed and is being rolled out across both acute and community services to ensure that the conversation about patients’ preferences are discussed and implemented in a timely manner ensuring patients’ wishes are met where possible to die in their preferred place of care.

This role is supported by the expansion of the Macmillan health care team who deliver personal care to patients who are at the end of life in their own homes.


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Looking to the future

We expect the coming year will be a time to develop our services further with a range of commissioners and other partners. NHS England’s Operating Framework for 2014/5 – 2018/19 “Everyone Counts: Planning for Patients” sets out the strategic direction:

“Delivering care in a way which is integrated around the individual patient is essential to a new way of working which truly puts the patient at the heart of what we do. Our early focus will be the integration of care around the most frail.”

The Better Care Fund: Revised Guidance states:“Unplanned admissions are the biggest driver of cost in the health service that the BCF can affect. As such, Ministers are clear that plans will need to be revisited to demonstrate clearly how they will reduce total emergency admissions, as a clear indicator of the effectiveness of local health and care services in working better together to support people’s health and independence in the community”

The strategic aims of the Trust and wider providers are closely aligned with the expected outcomes of this development.

During 2015/2016 the group is expanding and developing two community based schemes which will deliver care within patients’ own homes wherever it is safe to do

so. The Better Care Fund has been implemented in the context of an ageing population and an increasing number of people who have one or more long-term conditions.

These two factors mean that the needs of patients and service users increasingly cut across multiple health and social care services. Increasing demand and financial pressures mean there is a need to focus on prevention, reducing the demand for services and making the most efficient and effective use of health and social care resources.

Emergency admissions account for more than 70 per cent of hospital bed days.

Factors associated with increased rates of admission include age, social deprivation, morbidity levels, living in an urban area, ethnicity and environmental factors.

A lack of alternative options frequently leads to patients being admitted to hospital when it is not clinically justified. It is vital that there is capacity for rapid responses in the community that offer an alternative to a hospital stay.

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Diagnostics, therapeutics and central operations group

Over the past 12 months the group has experienced very high growth in demand for CT and MRI diagnostics. It has successfully recruited an additional consultant radiologist and a plan to recruit radiographers is also on track.

Scunthorpe endoscopy department experienced a high turnover of nursing staff due to people leaving the area. It was supported in the interim with staff from Goole but all posts have now been recruited to.

This follows an overall increase in demand for diagnostic services and the need for them to be more accessible so they contribute towards improved diagnosis in the

community and reduced length of stay in hospital.

Even with the high demand for the services, the group continues to be effective in supporting the Trust with timely diagnostics and other support services.

General radiologyWork started in January 2015 on the construction of a new catheter laboratory at Scunthorpe hospital and it was expected the first patient would be seen in May 2015. While the construction and installation work was under way,

the department converted one of the other rooms, using a mobile machine, into a temporary cardiac facility to the benefit of local patients.

The now well established shift system continues to provide a robust 24 hour, seven day a week service. It has also enabled radiographers in the general department (after training) to undertake CT scans on stroke patients in order to maintain the stroke pathway. These radiographers are also undertaking increasing numbers of CT heads on trauma patients, so expediting their treatment, while maintaining

Diagnostic services, pharmacy and central operations are collectively known as the directorate of diagnostics, therapeutics and central operations services group. It provides a range of services including general radiology, ultrasound (obstetric and non-obstetric), CT, MRI, audiology, physiological measurements, medical illustration, medical engineering, nuclear medicine, breast diagnostics, pharmacy, endoscopy, outpatients, the cancer team and health records.


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the workflow in the general department.

The teams are also offering early morning and evening appointments to increasing numbers of primary care patients.

The Trust is currently building a cardiology day case unit at Grimsby hospital which will house a cardiac catheter laboratory. The lab will be staffed by the specialist radiographers currently working in the special procedures suite in radiology. This project is due for completion in October/November 2015.

The general radiology service continues to provide a solid grounding for radiographers wishing to progress into other modalities or areas of expertise such as CT, MRI and ultrasound, thus encouraging the recruitment and retention of radiographers. Throughout 2014/2015, the team has maintained its close links with local colleges and institutions offering work experience to students and generally promoting the image of radiology and the Trust by attending careers fairs and other functions.

There have been some challenges recently when trying to recruit to vacant radiographer posts due to the lack of qualified staff in the UK. This problem has been overcome by recruiting staff from Portugal. This has proved a successful venture with three Portuguese radiographers already working in the Trust and a further three expected in the near future.

General radiology is continuing to prove that it is a valuable training ground for all other imaging modalities with recruitment of radiographers from general into CT/MRI and ultrasound. Several staff are now working across modalities alternating between cross-sectional imaging and general radiology giving greater flexibly to the service and giving increased job satisfaction.

Ultrasound2014/2015 has been a very challenging year for maintaining the service due to vacant posts being difficult to fill versus an increase in demand. There is a national shortage of sonographers and locum staff have been sought to help. The team continues to be cohesive and supportive working together to support cross-site working and flexing skill mix to work in areas of greatest requirement, particularly in vascular and musculoskeletal (MSK) ultrasound.

The seven day service is fully operational and the challenge to maintain these staffing levels has been met. Our policy to “grow our own” sonographers with the ongoing recruitment and training plan for students is continuing and the department is actively recruiting students again for the new academic year.

The extended community services at Mablethorpe and Louth are still being well received and are currently working to maximum capacity. The community service at Barton is still popular with patients wanting their appointment at a location closer to home.

As part of the stroke service review, ongoing training and support from Hull has taken place and an external audit/peer review has been completed by a consultant radiologist from Leeds and two representatives from the Society of Vascular Technologists of Great Britain and Ireland. Valuable feedback has been received providing advice and encouragement for further improvement of the service. An action plan has been developed as a

result of the peer reviews and work is continuing to complete this with constant improvements to service quality being achieved.

Two new one-stop services have been established at Goole hospital in conjunction with the women and children’s group for medical termination of pregnancy clinics and hysteroscopy clinics. These allow the Trust to capture patients from a wider region increasing revenue to the Trust and providing a greater patient choice for location of service.

CT and MRICT and MRI at Scunthorpe and Grimsby hospitals are offering seven-day service, minimum 13 hours, and up to 15 hours per day. An extensive recruitment drive and training programme has been ongoing for staff for both modalities on both sites.

As a response to the stroke thrombolysis relocation, radiographers are now onsite at Scunthorpe hospital 24/7 to provide immediate access for CT heads for stroke patients. The stroke scanning targets are being successfully achieved. At Grimsby, the current scanner, although it does not have the clinical ability to perform specialist examinations, is reliable.

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A risk assessment on the Grimsby MRI scanner has been undertaken and the risks are being appropriately managed. In some instances patients are asked to have their scan at Scunthorpe to ensure quality of care.

New trauma scanning standards have been introduced and the group has successfully achieved these. This was confirmed at the Trust’s recent Trauma Peer Review.

The radiographer-led CT colon service at Grimsby has been well supported by radiologists and training of radiographers to perform this procedure continues. The CT department at the hospital continues to offer direct access to patients from clinics whenever possible and this has been well received by patients and clinicians.

The local MRI prostate service is now well established and showing savings of up to £20,000 per month when compared with doing the same number of patients at Hull. This also saves patients having to travel to the North Bank for scans.

Mobile scanners are routinely in use on a weekly basis on all three hospital sites to accommodate the ever increasing workload and they have been instrumental in preventing six week breaches. At

Scunthorpe, the Blue Sky Imaging Suite is continuing to be well used. A plan for sustainability of MRI and CT imaging is being drawn up encompassing partnership working where appropriate.

Work is ongoing to support the new ambulatory care unit at Scunthorpe hospital which opened in the spring of 2015, with endeavours to provide CT scans within 90 minutes for patients with suspected pulmonary embolus, facilitating early discharge to the hospital at home team, and freeing up beds for patients who need them.

Medical engineeringThe radiation protection quality assurance service developed in collaboration with Hull and East Yorkshire Hospitals NHS Trust’s medical physics department has seen further growth this year. NLaG engineers now carry out x-ray dose and image quality tests on the complete range of diagnostic imaging equipment.

The department has worked in collaboration with Path Links and procurement to replace hospital based blood gas analysers across the whole of Lincolnshire under a managed service agreement. This will further involve the department in supporting this equipment for the

duration of agreement.

The in-house service developed for testing and verification of decontamination equipment to meet HTM compliance has been expanded to cover all outreach based decontamination equipment used by community dental and podiatry services. The decontamination equipment service has also expanded to include some endoscopy decontamination equipment with further expansion planned.

The team at Grimsby hospital has developed a new anaesthetics maintenance service which has been established in partnership with GE Medical. This was developed following the introduction of a new fleet of anaesthetic machines across all theatres and will complement the service already provided at Scunthorpe hospital.

The wheelchair service is currently working with the community equipment service to develop a combined assisted living centre in Grimsby in collaboration with North East Lincolnshire Clinical Commissioning Group.


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AudiologyThe demand on the audiology service over the last year has continued to increase due to a greater acceptance of hearing aids and an increasing elderly population. The average monthly number of procedures carried out has increased on last year and to cope with this increased demand, the team is increasing staffing levels and further increasing the number of community clinics.

This year the team has added an outreach clinic at Scotter and increased the number of sessions at some of its established outreach clinics.

The department has replaced its complete fleet of audiometry equipment with the latest specification instruments in a move to improve the quality of testing, reliability and efficiency across the service. This has been done at the same time as updating the electronic patient management system to the latest version.

Physiological measurementsDespite challenges with recruitment and staffing levels, the team has performed very well demonstrating its ability to flex across speciality and cross cover different modalities.

A bank clinical physiologist has been recruited which has enabled the team to keep waiting times to a minimum and ensure greater flexibility and sustainability. Within the neurophysiology modality two student clinical physiologists have been appointed to supplement the existing staff and to allow the staff to expand the service in the future.

There has been investment in equipment with some new evoked potential kit being used to provide

additional visual and auditory evoked potential tests.

The team has an on-site consultant clinical neurophysiologist clinic which is supported by visiting consultant neurophysiologists from London and Birmingham. These have expanded to 15 hours alternate weekends. As well as supporting students to gain wider experience this has enabled the team to provide this service locally for our patients instead of them having to travel to other Trusts.

Remote reporting with neurophysiology colleagues has been instigated to enable greater access for our team of consultant neurophysiologists and clinical physiologists to be able to report remotely from home. This offers increased turnaround time reports for our clinicians and patients.

Nuclear medicineNuclear medicine has had a busy year with a significant increase in the more complex investigations which involve higher costs in both pharmaceuticals and staff time.

The team’s supernumerary trainee qualified in the summer, gaining a distinction in the IPEM training program and a first class honours degree in clinical technology. He has now been made a substantive member of staff, filling a vacant post.

Medical illustrationThe department has expanded from 1.5 whole time equivalent (WTE) staff to two WTE enabling the ophthalmology clinics to be supported at Goole and Scunthorpe hospitals.

Breast diagnosticsThe breast unit has had another busy year with activity again increasing month on month. The surgical team has undergone a period of change which has resulted in them working closely with the radiology team to change workflows to ensure the two-week wait continues to be met.

Tomosynthesis has been well received locally with BBC Radio Humberside broadcasting an interview describing its use.

The Trust is working with the Hull hospitals Trust to employ a joint breast radiologist post across sites due to radiologist vacancies in both Trusts.

Training continues with a trainee ultrasonographer awaiting final confirmation of a pass. An advanced practitioner has nearly completed her stereotactic biopsy MSc module with a further advanced practitioner completing her MSc in breast imaging.

The Pink Rose charitable fund has purchased a new ultrasound machine.

Pharmacy and medicines managementIn the past 12 months the Trust’s pharmacy and medicines management services has continued to develop which has generated

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local, national and international interest and publicity.

In 2014 the team started a project to replace all the locks on medicines cupboards with a state-of-the-art electromechanical locking system – ABLOY CLIQ. The project was implemented by the lead nurses in medicines management and to date approximately 40 wards now have the system; an investment of £150,000 over two years. This replaces the traditional bulky bunch of keys which is shared by all the nurses on the ward with an ‘intelligent’ key allocated to each nurse.

The system improves medicines security and saves nurses’ time as they no longer have to find the ward medicines cupboard keys. The time saving is considerable and equates to nearly four hours extra nursing time every day on each ward that has the system. The project was shortlisted in the HSJ Patient Safety and Care Awards 2014 and the project team members attended the elegant award ceremony in London.

The system has also featured twice on BBC’s local Look North news programme, and the manufacturer is actively promoting the system nationally and internationally using the BBC coverage and other videos made in our hospitals and featuring our staff.

We have had visits from a number of NHS Trusts to look at this innovative work. Another 20 wards will get the

system in 2015/16.

Pharmacy continues to use technology to increase the efficiency and effectiveness of its clinical services. eMedicines Management is now fully integrated into the

pharmacy operations. This Trust initiative has gained national and

international interest with people from as far as Malaysia coming to visit the department to view the system in practice.

The use of the system has led to a significant reduction in turnaround time for dispensed inpatient medicines and has reduced the number of errors occurring in the dispensing process. This work has been presented by one of our principal technicians at a number of national conferences and resulted in her nomination for Hospital Pharmacy Technician of the Year, where she was runner-up.

Similarly the Trust’s work with electronic prescribing has seen visits to Northern Lincolnshire from a number of Trusts and NHS Scotland to see what we have done.

The Trust’s partnership with Lloyds Pharmacy continues to deliver a high quality and cost effective patient-focused service. During the last 12 months we have been working closely with them to develop some new services which will deliver some selected high cost medicines directly to patients’ homes.

Proposals to provide pharmacy services seven days a week have now been supported. Extensive consultation with staff has taken place and the extended service was due to commence after Easter 2015. Pharmacists and pharmacy technicians will be visiting wards on a Saturday and Sunday ensuring

patients admitted during the weekend have all their regular medicines and new prescriptions correctly prescribed. The dispensary will supply any medicines those inpatients may require.

The safe use of medicines is the main focus of the pharmacy and medicines management services. Last year the Trust appointed a senior pharmacist to undertake the new role of medication safety officer. This is part of a national agenda to improve the reporting and learning from medication incidents.

Following the promotion of one of our assistant chief pharmacists and the retirement of the other, the pharmacy management team has undergone significant change with new post holders being recruited. The opportunity was taken to change the structure to give pharmacy more capacity to develop and deliver improved services. This will ensure more efficient and cost effective delivery of services to the Trust along with the introduction of fresh ideas to the department. Work has already begun on departmental development and on improving our staff engagement and satisfaction. Doctors and nurses are to rollout the electronic prescribing system across the whole Trust.

Health recordsThe health records department covers the Trust’s three hospitals with numerous libraries at each of the sites. The health records manager has the overall responsibility for ensuring that all records are available for all attendance


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and that the department complies with both national and local policies. Regular audits are undertaken to ensure that appropriate case record tracking is in place.

Recently the medico legal team has been centralised on the Scunthorpe hospital site which makes it easier to ensure the targets are delivered. Medico legal includes the following areas:

• Subject access requests for both patient/relatives and solicitors – these requests have to be completed within 40 days

• Police/coroner requests – immediate once request received

• Safeguarding children and looked after children requests maximum 14 days from request.

The health records departments at Scunthorpe and Grimsby hospitals have continued to maintain a 24/7 service 365 days per week and are responsible for putting on the admissions, discharges and transfers. They are also responsible for retrieving health records for emergency admissions.

The department continues to work on the electronic patient record (EPR) project, with the pilot areas being dermatology, immunology, ENT and gynaecology. The department is also looking at a scanning strategy to support this rollout.

Endoscopy The Trust has an endoscopy unit on each of its hospital sites – Grimsby, Scunthorpe and Goole. A range of endoscopic procedures are offered including: gastroscopy, colonoscopy, flexible sigmoidoscopy, endoscopic retrograde cholangiopancreatography (ERCP), bronchoscopy, cystoscopy and percutaneous endoscopic gastrostomy (PEG).

The Grimsby and Scunthorpe endoscopy units are accredited by JAG (Joint Accreditation Group) which enables the Trust, as a non-cancer centre, to be part of the National Bowel Screening Programme. The host of this national programme within our region is Hull and East Yorkshire Hospitals NHS Trust with whom we have a close working relationship. The Trust has dedicated colonoscopy lists for these patients as per JAG standards. Scunthorpe will have its planned five yearly JAG visit in 2015.

For all three units we continue to pass our six-monthly GRS (Global Rating Scale) assessment. Goole endoscopy unit is not currently JAG accredited but work is underway to strive towards this standard.

A paper to consult with staff regarding a move to seven-day working was due to be published in April 2015. The rationale is for the Trust to offer endoscopy procedures every day which will help respond to demand in elective activity as well as emergency activity (upper GI bleeds) as well as being part of the national strategy and complying with the national clinical standards.

Work is underway planning a new endoscopy unit for Scunthorpe hospital. The project is split into two phases; phase one being the construction of a new purpose-built decontamination unit intended to be completed by end of June 2015. Phase two is a whole new endoscopy unit which will be planned and constructed within the financial year in 2016/17.

Outpatients The Trust delivers an outpatient service at all three hospital sites for a wide range of specialities. At our Grimsby and Scunthorpe hospital sites a bleeper system is now in place. This enables patients, once they have booked in for their clinic appointment, to be offered the opportunity of visiting the restaurant/cafeteria when experiencing times of high clinic demand and we have patients waiting longer then we would like. Patients can be bleeped to return to the department as their time with the clinician/nurse becomes available. This has been well received by patients. In addition to the bleeper system at Scunthorpe, there is also a new vending machine in the ophthalmology outpatient area for those patients who are less mobile.

We are undertaking pieces of work linked to the Trust’s sustainability programme to ensure our patients have choice of appointment times, that they experience as few cancellations as possible and that we reduce the number of patients not attending without prior notice. This will help to ensure all clinic slots are used

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effectively and that the requirement for additional sessions is kept to a minimum.

Work has been undertaken at our Grimsby site to split outpatients into four colour-coded zones which makes it easier for patients to navigate their way around. By putting clinics in colour-coded zones we are now able to send appointment letters to patients detailing which zone they need to attend. New directional signage has also been installed which co-ordinates with the four colour-coded zones.

The Grimsby dermatology outpatient service has been relocated into premises in the community. This was a three stage process and is now complete. One session of minor operations has been relocated to main theatres within the hospital but is still staffed and supported by outpatients.

Improvements are currently being made to Goole outpatients with a room being adapted to provide TVLO light treatment for dermatology patients so light treatment can be offered locally rather than patients having to travel.

Cancer servicesPerformance on cancer waiting times for the past year has been maintained and as a Trust we have continued to achieve the national cancer targets on the whole. Cancer performance continues to be a challenge with a noticeable increase in two week wait GP referrals.

The Trust has robust processes within cancer services, the groups and Hull and East Yorkshire Hospitals NHS Trust, which are reinforced and monitored on a daily basis.

All of the cancer data is collected through the Trust’s electronic cancer register. The quality and quantity of data collected continues to improve significantly on a year by year basis.

This is evidenced in the published national clinical cancer audits within lung, bowel, head and neck and upper GI. In addition a new national clinical cancer audit has been implemented which focuses on prostate cancer with the first publication due the middle of 2015.

Over the last financial year the Trust continues to fulfil the contractual requirement to submit data on a monthly basis to Cancer Services and Outcomes Dataset (COSD). Recently the Trust has received a letter from Public Health England thanking the Trust’s cancer services and clinical teams for its continuing support for the excellent ongoing improvement in the completeness, quality and timeliness of cancer data being captured and reported.

There have been two national Be Clear on Cancer Campaigns over the last year within urology (bladder and kidney) and upper GI. Despite the Trust noticing a slight increase in demand it has been able to maintain its achievement of the national cancer targets.


We are looking forward to the new endoscopy unit at Scunthorpe taking shape over the next 18 months to two years. And we are undertaking work to strengthen and formalise endoscopy with seven-day working and out-of-hours services.

We are joining the East Midlands collaboration work to look at networking radiologists and reporting radiographers to strengthen our services and ensure sustainability. We are also planning to rollout more radiographer reporting of plain film x-ray to support our consultant radiologists and patients, ensuring quicker turnaround times for x-ray reporting.

We are working on developing a home reporting kit for radiologists and are almost ready to trial this across the Grimsby and Scunthorpe sites. This will offer radiologists more flexibility with home working and improved work-life balances while supporting the Trust in securing additional reporting capacity.

The introduction of an outpatient room booking system in conjunction with the Web V IT team will allow for better capacity planning and use of the outpatient clinics. The groups are closely involved in this scheme and are really positive about the benefits that the introduction of this system will bring.


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Path Links NHS pathology serviceThis year has been particularly challenging for Path Links in balancing the delivery of both operational and regulatory compliance objectives.

As a component of the long term ‘Reshaping Pathology’ Plan, our decision to create a single blood science directorate, combining haematology, chemical pathology and immunology, led to a temporary suspension of our accreditation status while internal quality process issues were addressed.

After successfully re-establishing full accreditation status in July 2014 we have since been preparing for a re-inspection of the entire service to the new, and more stringent, ISO15189 standards in 2015. In meeting the ISO challenge, quality management arrangements have accordingly been strengthened with clinically led revised structures and successful recruitment to expand the Path Links quality and governance team.

Despite this, it is recognised that the transition to ISO is a particularly difficult challenge given that it represents a major departure from the previous accreditation standards and that there is limited knowledge and experience of its application at a local and national level.

In continuing the work to complete the Path Links ‘Reshaping Pathology’ Plan, this year saw:

• Implementation of Agenda for Change ‘out of hours’ terms and conditions across the entire service and transition from on-call arrangements to full 24/7 shift work patterns in microbiology

• Blood science laboratories developing further with continued progress on biomedical scientist bi-disciplinary training and the appointment of additional

biomedical assistant staff to support multi-disciplinary working arrangements including out of hours

• In cellular pathology, implementation of a programme to deliver biomedical scientist dissection thereby ultimately releasing consultant pathologist staffing resource from this activity.

Recruitment to clinical posts continues to be a challenge with national shortages making recruitment difficult. While every effort is being made to fill key clinical vacancies, alternative strategies are being explored including, for example, extended roles for BMS reporting in histopathology, and flexible work locations to offer greater choice to prospective applicants. Looking ahead, the age profile of the existing clinical workforce presents a significant recruitment challenge over the next three to five years necessitating detailed planning and further evaluation and development of appropriate strategies.

The year has also seen significant changes as a result of a number of major equipment replacement schemes. Following a detailed and lengthy procurement and evaluation exercise, Path Links has successfully awarded contracts to replace all haematology, clinical chemistry and immunoassay, urinalysis, and molecular analytical equipment. With full implementation of the new analytical platforms across all Path Links laboratory sites to be complete by July 2015, the service will achieve long term quality and operational benefits from modern state of the art systems while simultaneously

achieving cost reductions in excess of £1million per annum.

Looking toward the next procurement phase, an initial assessment of digital imaging and reporting in histopathology has been conducted. We are now working to trial and purchase a digital solution for our centralised service. Replacing microscopic examination of glass slides, digital imaging has the potential to provide significant productivity, capacity and quality benefits, improving diagnostic precision and, importantly, enhancing patient safety. As an early adopter of this cutting-edge technology, uniquely in combination with existing ‘lean’ process expertise and bespoke IT systems capability, Path Links has the potential to be at the forefront of service transformation at a national and international level.

Underpinning the move to digital will require expanded IT capabilities and functionality to ensure maximum benefit is achieved both within Path Links and across the Trust for clinical users of the service. Accordingly, we are currently evaluating the most appropriate use and application of existing resource and exploring the potential benefits of an internally developed pathology IT system as part of the WebV suite of products.

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Medical directorThe medical director’s directorate is responsible for the medical workforce across all three hospitals including doctors in training, permanent medical staff and consultants.

Clinical leadership has been a key feature over the past 12 months with a new structure put in place to strengthen the team and ensure Board-level decisions are communicated effectively and efficiently to the frontline medical staff.

Five assistant medical director (AMD) posts were created focusing on women and children, surgery and critical care, medicine, community and therapy and Path Links. The AMDs work in a ‘triumvirate’ with the head of nursing, head of midwifery and the general manager to ensure an overview of each group. Furthermore clinical leaders were appointed to oversee specific clinical specialties. Each of them underwent a clinical leadership programme through Sheffield Hallam University.

In December 2014 two deputy medical directors were appointed to provide additional support to the medical director focusing principally on the mortality position of the organisation, which has been a key factor for the directorate. Their role has also seen them liaising with the General Medical Council (GMC) and the National Clinical Advisory Service (NCAS). Further devolved responsibilities included a review of the appraisal system and remediation.

The Trust moved into the ‘as expected’ range for its mortality rates in 2013 and further improvements have continued throughout the year with work continuing, not just within the organisation but also the wider health community. The Trust has identified the top six disease groups contributing to the mortality position and work is ongoing in these specific groups to understand the causes. A considerable contribution to the SHMI

is deaths occurring outside of the hospital within 30 days of discharge. A lead palliative care practitioner post has been appointed to help strengthen end of life care provision, and the Trust is looking to appoint additional palliative care clinicians.

The directorate has continued to enhance and develop the revalidation process which doctors undergo annually. The directorate ensures clinicians have a robust revalidation in a timely manner and plans for the future include additional support for validators to help them with this process. The directorate has ensured that 95 per cent of permanent medical staff are in date for an annual appraisal. A revalidation officer was recruited on a temporary basis which was an integral step in securing this performance and this post has been permanent.

Work is focusing on medical staffing and a workstream has been established looking at specific areas including rota management and control, job planning, capacity and demand planning, recruitment and retention and policy revisions. It is recognised that some specialities are hard to recruit to due to a national shortage of clinicians, such as emergency medicine, but the Trust has had some success in this area with the appointment of two new consultants at Grimsby hospital emergency care centre. The organisation has also recruited a number of orthopaedic doctors from Bulgaria who are expected to join the Trust in 2015.

Handovers were identified in the Keogh review as an area requiring improvement and

we now use our Web V system to help with this. Each ward has an electronic board which shows medical and nursing staff both occupancy and acuity. It also reminds staff when observations are due and provides up-to-date information on the patient’s care and treatment. This is being used in handovers, as well as proving a vital ‘at a glance’ look at patients.

The medical director has also started to look at how to better communicate with the medical workforce and has created a junior doctor forum, as well as a specialist and associate specialist doctor meetings.

As part of the Healthy Lives, Healthy Futures review of healthcare services the directorate has developed links with the medical director for the commissioners in North and North East Lincolnshire. Clinical engagement has been sought on the direction of travel for the programme which aims to provide sustainable and affordable care for the future.

Deputy medical director and Trust professional lead for allied health professionals Bryony Simpson was awarded an MBE for her service to speech and language services.

Deputy medical director Mr Lawrence Roberts has also been appointed as a Care Quality Commission specialist advisor and he has been given a seat on the Senate Assembly, which provides expertise and advice to commissioners planning on service reconfiguration.


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Chief nurse directorateThe chief nurse directorate provides direction in the Trust’s key priority areas of quality and patient experience. The chief nurse leads on discussions relating to the national nursing agenda and works in conjunction with the heads of nursing/midwifery and senior nurses in the organisation to impact on nursing and midwifery generally and within the organisation across both acute and community settings.

The Chief Nurse Strategy continues to develop a nursing and midwifery culture that places quality at the heart of everything we do, where we deliver a positive patient experience and improved outcomes. The principles of the strategy include:

• Improve patient safety

• Ensure a positive patient experience

• Enhance professionalism

• Improve clinical leadership close to the patient.

A number of initiatives have been progressed over 2014/2015 and

positive feedback has been received. The senior nursing team has hosted visits from a variety of individuals and groups including colleagues from the clinical commissioning groups and scrutiny committees that have learned more about the nursing care and services provided. We were pleased to have a visit from Lord Willis, as part of his commissioned review into the shape of caring and nurse education and we also hosted Dr Peter Carter from the Royal College of Nursing, who spent time with staff and patients on our wards at Grimsby.

Patient safetyInfection prevention and controlProgress continues to be made in the reduction of avoidable MRSA bacteraemia cases with the limit still set at zero. We have seen one case this year. We have also continued to work to reduce the number of patients affected by Clostridium difficile. Our target for the year is to have no more than 33 cases, and as of March 31 2015 we reported 20 cases.

Our senior infection control nurse Viv Duncanson received a national accolade this year when she walked away with the ‘practitioner of the year’ award from the Infection Prevention Society awards. As well as leading on strategies to reduce infections across the Trust’s three hospitals in Grimsby, Scunthorpe and Goole Viv and her team have also introduced infection control

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awards to acknowledge the high standards of infection control practice that ward staff have achieved, launched campaigns that focus on good practice and have injected fun and innovative ways to educate staff such as their own version of Blockbusters, ‘bacteria busters’.

Compliance with infection prevention mandatory training has achieved 90 per cent at the end of the year. The standards as highlighted in the C. difficile CQUIN, which largely included training, have been met. The team has this year received backing from the Trust’s dragons den scheme to hire a training device for three months to take infection prevention training to staff as giving clinical staff time away from the ward environment to train in a classroom can be a challenge. SID, which stands for successful innovative demonstration, is a mobile training unit which uses video-measurement technology to teach and evaluate hand hygiene techniques in real-time and a fun way. Staff wash their hands virtually in front of SID which tracks their movements and lets them know whether they are doing it correctly. The unit then uses a quiz style method to test them on other aspects of infection prevention as part of their mandatory training.

SafeguardingThe safeguarding team within the Trust encompasses the specialist services of child protection, adult protection, looked after children’s health service, Safeguarding liaison, PREVENT (a home office initiative aimed at identifying groups or individuals who are vulnerable to being exploited) and the team dealing with sudden unexpected deaths in children (SUDIC). Over the last year the team has also taken on the remit for advising professionals within the Trust in relation to the Mental Capacity Act (MCA) and the

Deprivation of Liberty Safeguards (DOLS).

The last year has been one of continuing change and development within the team and the safeguarding arena and there have been and continue to be key changes in guidance and legislation impacting on the services of the team.

The safeguarding team has continued to provide training at levels one, two and three in line with national standards, provide expert advice and support and supervision to staff groups within the Trust, and has developed and updated policies in relation to safeguarding, child protection supervision and children attending secondary care who are subject to a child protection plan or are looked after. The named midwife component of the team has further developed over the past 12 months and allowed for greater support and supervision of midwifery professionals and earlier identification of support. Audit has taken place in several areas and has assisted in strengthening child protection systems. A flagging system continues to be strengthened in areas such as accident and emergency (children on child protection plans, children in care and victims of domestic violence). This flagging system will be rolled out into other electronic systems within the Trust such as WebV.

Adult protection remains an area of rapid growth and development and will continue to be so with the introduction of statutory legislation in April 2015. The Safeguarding Adults Forum continues to meet every eight weeks and maintains the focus for adult safeguarding within the Trust. The agenda has standing items such as feedback from the Local Safeguarding Adult Boards (LSAB) for which NLaG covers three, the uptake of training,

the further development of the safeguarding adults policy and other related guidance. It also discusses individual cases from which all members can learn, recognising good practice as well as learning lessons when things go wrong. Over the last 12 months the forum has also taken up the remit for MCA/DOLS which is another area of rapid growth within the hospital setting.

The looked-after children health teams continue to deal with increased workload brought about by more children entering the care system and it is envisaged that this increase will continue over the next year. The teams continue to work with our partners to assist them in fulfilling their roles and responsibilities to meet the health needs of looked-after children both in and out of the local areas. The team in North East Lincolnshire has recently taken on increased staffing to cope with the increased demand and now also provides all initial health assessment for children coming into care.

A paediatric liaison nurse role has changed to become a safeguarding liaison service and now combines the roles of paediatric liaison and SUDIC. The service continues to strengthen and ensures effective information sharing between hospital and community and it also identifies child protection and significant health issues in families who access these services. The role is now established across the trust at both Scunthorpe and Grimsby hospitals. Liaison at Goole hospital is provided by a specialist nurse within the team.


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The liaison service is also involved in auditing attendances and assists in providing a greater insight into the children who attend the Trust.

The SUDIC component has gone from strength to strength and is well used by bereaved families. Following the death of any child between 0-17 years, the family is contacted by one of the nurses and support is offered and families signposted with regards to their future needs as required. This can be as simple as helping the family understand the post-mortem process, or more detailed support spread over several weeks. Bereavement-related books are provided for children and support with creating memories is also available.

Nutrition and hydrationApples are helping ensure patients receive vital malnutrition screening when they are admitted to hospital. The digital, colour-coded apples are part of the WebV system and show staff at a glance the nutritional status of every patient on their ward. It also flashes a prompt when another Malnutrition Universal Screening Tool (MUST) assessment is due. A comprehensive snack list has now been introduced at our hospitals which malnourished patients are encouraged to use. We have also introduced red trays on wards which clearly identify those patients who require assistance at mealtimes or those patients where we need to monitor their nutritional intake. A wide range of innovative activities was promoted during nutrition and hydration week in March 2015.

Pressure ulcersThe Trust has actively been focused on reducing hospital acquired pressure ulcers. The Pressure Ulcer Group reviews all incidents of pressure damage, identifying the themes and ensuring lessons learned are disseminated across all areas. Pressure ulcer education continues to ensure there is an increased focus on prevention of pressure damage. The matrons work closely with the team of tissue viability nurses to ensure there is a reduction in the incidence of hospital acquired pressure ulcers. The tissue viability nurses have been working hard to ensure the appropriate and sufficient replacement of specialised mattresses across the Trust. An innovative pressure ulcer grading wheel has also been designed as an educational tool and is being rolled out along with pocket mirrors to aid skin inspection.

FallsFalls incidents continue to reduce and are monitored by the lead quality matron and a full investigation takes place for any repeat fall or a fall that leads to moderate or severe injury. Individual wards receive their falls information (taken from the falls incident report). These are displayed in ward areas along with falls prevention posters. The matrons work hard to ensure there is sufficient provision of appropriate equipment available within the ward areas to reduce the risk of falls. Mandatory training for the Trust in terms of falls prevention for end of December 2014 was 92 per cent. This was achieved through a combination of online, face-to-face and work booklet training. A number of low-level beds have been purchased.

Patient experience

The Patient Experience Group continues to review results from local and national surveys and from other patient feedback mechanisms, monitoring required actions on an over-arching action plan. The patient experience practitioner has been instrumental in supporting the continued implementation and further rollout of the national Family and Friends Test question. Patient stories are heard by the Trust Board each month to improve quality of care and the patient experience.

On the back of patient comments we have introduced a new badge for our frontline staff so that people can easily identify who is caring for them. The badges are bright yellow with large black writing which makes them clear and easy to read for everyone, including people with visual impairments. They feature the staff member’s name and job title so patients and their relatives are clear about who they are talking to and who is treating them.

We are also piloting a new red badge on the medical wards with the words ‘shift leader’ on it which is worn by the nurse in charge on each shift. This is so people can easily identity the senior nurse on the ward.

DementiaWe are continuing to focus on how we can improve our care and services for dementia patients coming through our doors. This year we have seen the introduction of a new alert on our WebV system. WebV screens allow staff to see at a glance the numbers of patients on each ward, what their names are, which consultant they are under the care of and if they have any specific health needs such as are they are at risk of falls or are in isolation for infection control purposes. In April 2014, a new alert

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was developed that pops up on the screen in a red box to notify staff when a patient is due a dementia screening assessment. We also continue to decorate environments in a dementia friendly way with the support of the Alzheimer’s Society and Dementia Friends. This year we saw the opening of two dementia-friendly side rooms on our trauma and orthopaedic wards at Scunthorpe hospital.

Learning disabilityThe matrons continue to work closely with the learning disability specialist nurses across the health community to improve the care of patients with a learning disability. Patients are also asked for their feedback in order to influence further service developments. Training days and workshops involving service users are in place to raise awareness of living with a learning disability.

ChaplaincyA new addition has been welcomed to the team this year, bringing the number of chaplains at the Trust to three. They have continued to offer ward visits, bereavement support, chapel services and various events throughout the year including baby loss memorial services and carol services at Christmas.

The lead chaplain has also been working closely with his chaplaincy colleagues at Hull and East Yorkshire Hospitals NHS Trust and the University of Hull in providing a teaching package for student nurses. The team has successfully provided placements for students to spend time with the chaplaincy team and is planning on delivering lectures and tutorials at the university.

Voluntary servicesVoluntary services provide a range of important extra services which are not strictly essential to health care, but which can make an enormous difference to the patient’s well-being. Patients feeling isolated in the unfamiliar and professional hospital environment may be greatly comforted to see a volunteer willing to come and help in their free time. However, this contribution can only be used effectively if there is a clear understanding of the volunteer’s role in each particular situation. Volunteers and the Trust abide to a Code of Practice and Volunteers Charter. There are approximately 550 Trust registered volunteers who give their time to our hospitals for varying periods of time each week. Voluntary organisations such as the League of Friends, Hospital Radio and Royal Voluntary Service (RVS) contribute to the welfare of hospital patients and are greatly valued. Our volunteers adopt a number of different roles including helping on wards and guiding patients and visitors between departments. They also form a vital part of our PLACE environment self-assessment teams.

ProfessionalismResearch and developmentThe research and development department offers a central corporate function within the Trust and takes an organisational-level lead in ensuring that research is conducted and managed to high scientific, ethical and financial standards.

Services are delivered from two offices based at the Scunthorpe and Grimsby sites and is led and managed by the head of research and professional development supported by a team of 11 research nurses, two data coordinators and a projects coordinator.

The department currently supports a range of research projects including:

• National Institute of Health Research (NIHR) portfolio adopted research

• Non-portfolio research

• Commercially sponsored studies

• Academic and in-house research studies.

The team of nurses and data coordinators help to deliver research within our Trust in the following ways:

• By identifying patients suitable for research studies. Involvement is entirely voluntary and never undertaken without formal written consent from the volunteers


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• By supporting the investigators in delivering the research studies on a day-by-day basis, including seeing patients in clinics and at home where required

• Following-up of the patients involved in the studies once the actual treatment stage has been completed. This can be for a number of years in some studies

• Collecting the data that contributes to the results of studies. This then goes onto changing practices and treatments in the future.

The department is dedicated to supporting and furthering research, development and innovation within the Trust. The department provides assistance and guidance on how to:

• Check whether projects are research, service evaluation or audit

• Help and advice on protocol development, study design, data management and analysis

• Assist in the setup of a study

• Coordinate a submission to the Research Ethics Committee (REC) and where necessary Medicines and Healthcare Products Regulatory Agency (MHRA) to facilitate approvals

• Undertake the necessary NHS Trust approval process on behalf of Northern Lincolnshire and Goole NHS Foundation Trust.

Clinical educationDuring the last 12 months, a number of secondments were supported for a new clinical practice educator post. The aim was to deliver ward-based clinical education to frontline clinical nursing staff, supporting newly qualified nursing staff to consolidate their nurse education and develop sound clinical skills to deliver high

quality, safe effective care. This has been so successful that following a review of the roles they have been further developed and a permanent team appointed.

LeadershipStandardised nursing shiftsWe have introduced standardised shifts for nurses as part of our continued focus on improving safe, quality patient care. The move followed consultation with staff about the standardisation of rotational nursing shift patterns, breaks, and contracts. As a result of this, the Trust has implemented a new system of long days and short shifts and an extended night shift. The move has given us greater flexibility to match staffing availability to patient need, as well as ensuring there is protected time for handovers and protected management time for ward sisters and charge nurses.

Staffing levels available for people to viewWe have introduced two new ways for people to view our nurse staffing levels, on dedicated boards on our wards as well as on our website. Our ward boards not only show how many staff we have and should have on the wards, they show what we are doing if we have fallen short on that shift. We also publish data on a monthly basis to the Trust Board and on our website showing how many registered nurses/midwives and healthcare staff we planned over the month versus how many were actually on shift. The information on our website can be found at: www.nlg.nhs.uk/about/how-we-are-doing/nurse-staffing-levels

Recruitment and retentionSenior nurses have been working closely with colleagues in the directorate of organisational development and workforce on a number of initiatives to match recruitment to the needs of wards and departments. This has included a degree of overseas recruitment in Spain and Portugal and these nurses have been well received. It is also essential that we continue to develop retention strategies supported by education and development/career progression opportunities that make NLaG the employer of choice.


We are looking forward to continuing to drive high standards of care across the organisation. A key focus for the next 12 months is the development of the professional development team to deliver clinical skills training at ward level. This will be essential so that we can be assured that each new member of staff that comes to work within the organisation is equipped and supported to deliver patient care “the NLaG way”.

We will be further rolling out electronic patient records that will contribute to effective and accurate record-keeping and continuity of care.

Our annual Best Practice Day on May 12 continues to be well attended each year with many positive examples of best practice being shared so that innovation can be adopted by other areas. Our Best Practice Day 2015 will focus on “working together”, “doing things differently” and shining a spotlight on best practice.

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Organisational development and workforce

A dedicated team ensures that the OD and workforce strategy is taken forward and work continues to focus on engagement, generating high performing teams, embedding the behaviours found within the Trust’s vision and values and developing the desired leadership and management style.

The dedicated centralised recruitment team continues to take strides forward in embracing and implementing new and contemporary recruitment practices. This is strengthened by the newly created workforce planning function that supports the business planning cycle and, through delivery of the interim workforce plan, are delivering solutions to known local and national workforce issues.

Equality The promotion of equality is more than just a statement about how the Trust will meet statutory requirements and go beyond, it is an

integral part of the way we conduct our business.

The Trust strategy sets out how we continue to develop and promote equality and diversity in respect of all the protected characteristics within the Equality Act (2010) into our policy development, employment practices and the provision of our services to our patients and the wider public and health communities.

We are proud of the professionalism of our staff and the foundations that we have already put into place to eliminate all forms of discrimination. We recognise as an organisation that there is still more work to be done in a way that is fair and accessible for all. The Trust is committed to ensuring we meet and go beyond the spirit of the Equality Act. It is committed to shaping its services around the needs of patients and striving to eliminate inequalities in patient experiences and health outcomes.

As a Foundation Trust we are committed to growing our membership and strive to ensure our membership reflects the diversity of staff and the local communities we serve.

During 2014 the equality strategy and associated objectives continue to develop.

These objectives are:

• Raise awareness and promote equality among all staff

• Train and develop staff

• Meet statutory duties as required in the Equality Act , national legislation and guidance

• Identify gaps in service provision and promote equality so that everyone has equal access

• Develop our membership to

During 2014/2015 the organisational development and workforce directorate continued to see changes in the way in which it provides services and support to the Trust.


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ensure it is representative of the people we serve, particularly focusing on ensuring a diverse membership that provides opportunities for black and minority ethnic (BME) groups

• Record and monitor key indicators of performance against statutory requirements

• Establishing a rolling action plan to promote, implement and develop the equality agenda throughout the organisation

• Challenge and address working practices and identify and celebrate good working practices

• Develop our workforce to ensure it is representative of the people we serve at all levels of the organisation

• Ensure policies and procedures are non-discriminatory

• Ensure fair and equitable access to training and development opportunities

• Plan and provide services across the whole population we serve paying particular attention to their equality needs

• Promote dignity and respect for all our patients

• Promote equality in everything we do, paying particular attention to the service delivery for our patients.

Sickness absenceThe Trust continues to manage sickness through agreed and robust policies and procedures. Training of our sickness absence policy is delivered to our line managers with our occupational health team supporting sickness monitoring, staff and managers.

Recruitment and workforce teamSince the formation of the centralised recruitment and workforce team in 2013 the Trust has seen an unprecedented increase in recruitment activities compared to previous years. As such the Trust has invested in an automated vacancy management system which is due to go live in quarter two of 2015/16. This system, Trac, will significantly reduce the length of time it takes to recruit, in turn reducing vacancy backfill costs and improving two-way communications between candidates and the Trust.

In an increasingly competitive recruitment market competition is fierce. Consequently the Trust is endeavoring to position itself as a ‘rewarding employer’ to stay one step ahead of the competition. The process of recruitment has changed significantly in the past year. The recruitment teams have embraced this challenge and now actively promote and source candidates with social media platforms alongside the more traditional methods. The Trust has also adopted a new and innovative networking approach to tackle the problems in sourcing candidates which has seen the introduction of a structured overseas recruitment programme in addition to local campaigns for both medical and nursing positions.

The Trust’s geographical location continues to cause recruitment difficulties for certain hard to recruit-to posts. This coupled with the increase in establishments has resulted in the Trust continuing to have difficulties in attracting the highest caliber of candidates with attributes aligned to the Trust’s visions and values.

Nurse recruitment The recruitment team actively targets both the local and UK markets. A number of career events have been held locally and planned nationally in order to appoint newly qualified and experienced nurses. The recruitment team works closely with the chief nurse to ensure a consistent approach to nurse recruitment and continued support once the appointed staff start with the Trust.

A large number of nurses have also successfully been recruited from within Europe with further recruitment planned in 2015/2016. The Trust continues to development relationships with several European universities from which future recruitment exercises and appointments can be made.

Staff sickness absence12 months 2014/2015

12 months2013/2014

12 months2012/2013

9 months2012/2013

2011/2012 2010/2011

Days lost (long term) 56,412 50,776 55,536 38,336 44,042 44,425

Days lost (short term) 29,937 25,628 26,986 22,046 27,828 30,256

Total days lost 83,349 76,404 82,522 60,382 71,870 74,681

Total staff years 228 209 226 221 197 205

Average working days lost 19 19 19 18 17 19

Total staff employed in period 7,135 7,044 6,839 6,833 6,770 6,571

Total staff with absence in period 4,385 3,919 4,379 3,354 4,120 3,904

Total staff without absence in period 2,750 3,125 2,460 3,479 2,650 2,667

Percentage of staff with no sick leave 38.55% 44.36% 35.97% 50.91% 39.14% 40.59%

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Medical recruitment Members of the recruitment teams have attended a number of national medical career fairs to build brand exposure and to target specific professions. The Trust continues to work in partnership with the Deanery to help improve the fill rate for our training positions. Mirroring the overseas nurse recruitment, a targeted approach is being taken to overseas medical recruitment. The Trust now works in partnership with an external contractor and has planned recruitment activities throughout Europe and further afield throughout 2015/16.

ApprenticesThe Trust continues to invest in the future workforce of tomorrow by supporting a high number of local apprentices within the organisation. In 2014/2015 a total of 28 apprentices have been recruited throughout the organisation with a high percentage completing their qualifications and gaining employment. The Trust continues to work in close partnership with all the further education providers in the area to provide the best opportunities and training available. Work is planned in 2015/2016 for a centralised work experience scheme and a re-launch of the organisation’s award winning employability scheme.

Workforce planning The Trust has identified a number of core work streams as part of its workforce plan which focuses on those skills and specialities that are hardest to recruit to. This work has included the development and implementation of additional advanced clinical practitioners, including the creation of nurse consultants across a range of specialities. This aims to address concerns relating to the aging

nursing workforce and supply of future nurses, and the introduction of the ‘Calderdale Framework’ methodology to assist with role redesign to meet patient needs and service expectations. Finally, the plan is taking innovative steps to form partnership relationships with universities to sponsor students through a range of allied health professional degree courses and, in doing so, secure a highly skilled future workforce.

As important as recruiting the right staff is, the workforce team is also focusing on how the Trust retains the skills of the workforce that it already employs. As such, resource and efforts are being injected into understanding the needs of the workforce, and exit interview data is being used to ensure it stays one step ahead in adapting to its staff needs.

Finally during 2015/16 the workforce team is charged with the development and enactment of a Talent Management Strategy.

Staff surveyThe Trust’s staff survey results for 2014, as in previous years, shows that staff work in a safe working environment that is predominantly free from harassment, bullying or abuse from patients or their colleagues. It also shows that staff feel their individual and collective roles make a real difference to patients and they are satisfied with the quality of the care they and the Trust delivers. This is considered a major achievement since these indicators featured within the bottom five ranked scores in the previous year’s survey results.

Detailed performance – NHS staff survey

Response rate

2014/15 2013/14 Trust improvement/ deteriorationTrust

National average

TrustNational average

30% 45% 37% 49% -7%

Top four ranking scores2014/15 2013/14 Trust

improvement/ deteriorationTrust

National average


Percentage of staff experiencing harassment, bullying or abuse from patients relatives or the

public in last 12 months10% 14% 23% 29% +13%

Percentage of staff experiencing physical violence from staff in last 12 months

1% 3% 2% 2% +1%

Percentage of staff agreeing that their role makes a difference to patients

93% 91% 86% 91% +7%

Percentage of staff feeling satisfied with the quality of work and patient care they are able

to deliver83% 77% 77% 78% +6%

Bottom four ranking scores2014/15 2013/14 Trust

improvement/ deteriorationTrust

National Average

TrustNational Average

Percentage of staff able to contribute towards improvements at work

61% 68% 65% 67% -4%

Effective team working3.64

indicator3.74

indicator3.71

indicator3.73

indicator-0.7

indicator

Percentage of staff reporting errors, near misses or incidents witnessed in the last month

87% 90% 74% 84% +13%

Percentage of staff having well-structured appraisals in the last 12 months

30% 38% 30% 38% No change


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Focusing on the concerns emerging from the survey the Trust aims to focus on three main areas: the quality and content of appraisals; increasing the impact of listening to patients and staff voice in improving services and the reporting of incidents.

The Trust has action plans and monitoring tools in place to address the issues relating to appraisals. Since the staff survey the current appraisal rate holds at c.93 per cent for the workforce. This work continues to be supported by dedicated training courses for staff and managers with the delivery of appraisals monitored centrally within the Trust. This work not only aims to ensure all staff receive an appraisal but that the structure and quality of the appraisal is meaningful.

The patient and staff voice has become a key workstream and quality indicator through the newly created Patient and Staff Experience Group, which is a sub-group of the Quality and Patient Experience Committee, which seeks to implement initiatives that improve the patient experience and working lives of staff through listening to their collective experiences and service improvement ideas.

Concerns relating to effective teams is already a feature of programmes which strive to equip leaders with the skills to manage through an inclusive collaborative style (see training and development section below). Work also continues through the Trust’s risk management department to encourage staff to come forward and report incidents, and for managers to feedback to staff on the outcome of the investigated incident.

Postgraduate medical and dental education (PGM/DE)Postgraduate medical/dental education (PGM/DE) is committed to the principle of ensuring the highest quality of postgraduate medical and dental education is delivered in the Trust. Medical education continues to keep abreast of the many national changes in medical education that have an impact on both the Trust and PGME, ensuring that the delivery of education and training remains at the standards set by various bodies including the General Medical Council (GMC), Health Education England and the various royal colleges.

The feedback received from the 2014 annual quality management visit from Health Education, Yorkshire and the Humber reported that training is being delivered to a high standard in many areas of the Trust, although a number of conditions and recommendations were made for post approval and a significant amount of work has been undertaken to meet those conditions and recommendations.

A number of conferences, seminars and courses which are open to external candidates were held in 2014, with many more planned for 2015.

The team continues to work on engagement of the Trust’s consultant body in respect of their own training as educational supervisors and their contribution within the department of medical education and regularly facilitate educational supervisor training courses. It also continues to support the speciality and associate specialist doctors within the organisation with their continuing professional development.

Work is continuing within the Trust to meet the requirements of the clinical skills and simulation strategy in which doctors are given the

opportunity to develop and improve their clinical and practical skills in clinical skills labs and simulated patient environments before undertaking the procedure on patients. Accommodation at both Grimsby and Scunthorpe hospitals has been identified to house clinical/simulation training and work was completed at the Grimsby site in March 2014, with work due to commence at the Scunthorpe site in 2015. Funding to support these projects was a result of a successful bid to Health Education, Yorkshire and the Humber.

Library servicesTrust Library Services has continually striven to provide a comprehensive service for users that is available from their desktop as far as is possible. For the second year, the service has subscribed to the clinical decision support service – UpToDate – and to date, nearly 16,000 topic reviews in UpToDate have been used within the Trust to support evidence-based practice. Supplementing this, the library service has extended the number of document delivery requests each employee of the Trust can ask for free of charge per annum, and also continues to provide a mediated search service for any user that requests this service. Training is also provided in the use of NHS Evidence and is tailored to suit individual trainees in relation to their clinical specialty. The feedback from such training sessions has been consistently high over the last two years.

As far as more traditional library services are concerned, the team updates the book stock annually and actively responds to all book purchase requests. The library service also administers all OpenAthens account for the Trust, ensuring that Trust staff have easy access to NHS purchased clinical databases and e-journals, and is very pro-active where users experience difficulties with their accounts.

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In December 2014, the Trust library service learned that it had achieved 100 per cent in the Library and Quality Assurance Framework (LQAF) for the second year in succession.

Undergraduate medical educationThe Trust continues to welcome and host students from both Hull York Medical School (HYMS) and Sheffield Medical School. Third, fourth and fifth year students from both schools attend placements in Grimsby and Scunthorpe hospitals and HYMS students are also taught in GP practices across the Trust’s locality.

The Trust typically hosts 60 HYMS students on each site and up to 12 Sheffield students at any one time with very positive feedback received regarding the Trust’s ‘very committed clinical education tutors’.

October 2014 saw the GMC review of undergraduate and (some) postgraduate courses. Report findings included:

“Medical students with whom we met felt the support they received within the Trust was good. Students appeared confident that they could approach the student liaison officer with any issues and/or concerns … Those students with whom we met described a good level of supervision during clinical placements.”

Training and developmentMandatory trainingThe Trust has met the target of 95 per cent compliance set for mandatory training for the year. The increase in compliance ensures the Trust has staff who have the skills and knowledge to deliver safe effective care. The organisation has consistently been one of the highest users of the national e-learning

programme over the last year as well as developing alternative mediums such as work booklets to give staff flexibility to complete their training.

AppraisalThere has been an increase in appraisal uptake and the documentation framework has been refreshed, this now includes the vision and values behaviour statements to enable individuals to be appraised against behaviours and performance. The feedback on the document has been positive and gives structure to the process. The performance and behaviours matrix allows managers to identify talented staff to ensure they are given opportunities to develop their skills and knowledge to reach the next step of their career.

Leadership developmentOver the last six months ward mangers have completed the Together We Lead, Together We Shine development programme. This has focused on leadership skills to develop their own personal leadership skills and support their teams around them to deliver high quality patient care. Twenty five managers have completed the programme across the organisation which has built on their own leadership and resilience skills to enable them to be better prepared to lead their teams. In addition to this, the Trust’s clinical leads have participated in a clinical leads programme which was developed in partnership with Sheffield Hallam University. Each of the leads undertook an improvement project in their own area during the programme.

Support staffThe Trust is committed to the Talent for Care agenda which aims to enable staff in bands one to four to get in, get on and go further with their careers in the NHS. Over the year staff have completed QCF qualifications, apprenticeships, access courses, foundation degrees as well as in-house training and development. The course fees are supported by Health Education Yorkshire and the Humber Local Education Training Board funding and further funding has been pledged over the next year which will enable the Trust to provide support staff with training and education opportunities to enable them to go further in their career choice. The Trust was awarded employer of the year for the provider of apprenticeships for Yorkshire and the Humber in March this year.

Communications and marketingThe communications and marketing team has had another busy year in delivering internal communications, public relations and marketing activities and dealing with media enquiries and requests.

The team of four has issued 303 news releases between April 1 2014 and March 31 2015 and dealt with nearly 700 media enquiries. This has resulted in 802 pieces of positive coverage in the media, an increase of 68 on last year, and 249 pieces of mixed/neutral coverage, an increase of 22.


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This compares with 174 pieces of negative coverage, which is a reduction of 247 from the previous year. This means that 86 per cent of media coverage for the year was positive/neutral, compared to just 14 per cent negative. Coverage could be a newspaper article, radio bulletin, TV piece or an article in a trade magazine.

As well as collating responses to media enquiries, the team has organised interviews and media briefings with executives, frontline staff and patients. The team always takes every opportunity to maximise positive news and works with the media to support their requests in a timely manner.

The team has also continued to use social media to share news and information, retweet other people’s and organisations’ information and to respond to specific questions and concerns from members of the public. As at March 31 2015 the Trust had a total of 2,862 followers on Twitter across all four of its main accounts, and the team had posted 4,926 in the year. This compares to 1,449 followers in 2013/2014 and 2,298 tweets posted by the team. The Trust also had a total of 4,769 likes across its Facebook pages,

which compares to 1,798 in the previous financial year. The viral nature of social media can have a powerful impact as a piece of information or photo can be shared among thousands of people very quickly and this is something that is being harnessed by the team.

Work has continued throughout the year to further develop and enhance the Trust’s website to ensure it is easy to navigate and provides people with the latest information they require. Updates have included a new Patient Advice and Liaison (PALS) form so patients can log their concerns, compliments, suggestions and requests for information direct to the team. The form categorises the query, so for instance it could be a concern about admission, discharge and transfer arrangements of confidentiality or attitude of staff so that staff don’t have categorise them saving them time. Patients can now also cancel their outpatient appointment via a new form which has been launched on the website.

On average there are 1,341 visits to our website every day and of these 558 are unique visits. We have also had an amazing 1,031,929 page views on our site in the last 12 months. The number of visitors to the website has almost doubled

in the space of a year from 17,165 in April 2014 compared to 30,262 in March 2015. What is pleasing to note is that the number of ‘returning’ people visiting the site has seen a steady increase from 51.5 per cent in 2012, 59.4 per cent in 2013 and 59.8 per cent in 2014.

The top three pages that people visit are the home page, the staff portal and vacancies. What is remarkable is the explosion in people accessing the website via mobile devices. Combined, tablets and mobiles have been the primary way to access the website for the last 12 months. In November 2014, visits via a mobile accounted for two of three users. To place further emphasis on this, twice as many people accessed the website through an iPhone (43 per cent) than all desktop devices combined (22.5 per cent). The website can be accessed at www.nlg.nhs.uk

In addition to this, the team produces a bi-monthly staff and member magazine, a weekly email bulletin which is sent to all staff, monthly GP newsletters for each main locality served by the Trust – North Lincolnshire, North East Lincolnshire and East Riding of Yorkshire – and ad hoc communication newsletters. The team has also delivered a variety of marketing communication campaigns, including the launch of a comprehensive guide to services available at Goole hospital which was delivered to all homes and GP practices in the Goole area to encourage more referrals into Goole services. It is closely involved in the area-wide communications and engagement work for the Healthy Lives, Healthy Futures programme.

Income generation is also on the communication department’s agenda, with a number of new advertising channels being created to support both the Trust’s own messages as well as those of paying customers.

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Directorate of estates and facilitiesThe directorate is responsible for estates maintenance, capital building projects, property management, waste management, sustainability, catering, portering, post, linen, cleaning, transport, car parking, and security services.

EstatesEnergy performance contract (EPC)During 2014/15 the estates department has continued to work through the construction phase of the EPC. This has involved the installation of photovoltaic (PV) cells at Goole and Grimsby hospitals, a combined heat and power (CHP) unit at Grimsby hospital and both internal and external lighting replacement across all sites with more than 7,000 fittings and lamps with energy efficient technology. The construction phase is due to be completed in June 2015. The estates department will continue to develop a staff energy awareness campaign and British Gas has, and will, offer energy companies obligation (ECO) funding for staff, patients and public to get free cavity wall

was delivered by in-house operations and project estates teams

• Fire compliance works at Grimsby hospital which included the lobbying of the main stairwell

• Road resurfacing programme at Grimsby hospital

• Upgrade to the ventilation in the restaurant at Scunthorpe hospital

• Installation of a new generator at Scunthorpe hospital to provide continuous electrical supplies to the MRI to support the hyper-acute stroke service

and loft insulation. Further details of this contract can be found in the sustainability report.

Back log maintenance (BLM)BLM is capital investment in the building and equipment in the estate to ensure the Trust remains compliant in Health and Safety and legislation.

The estates department has delivered backlog maintenance worth £1.5million including:

• Upgrade of ward B3 at Grimsby hospital, to include windows, fire compliance, nurse call, flooring and water infrastructure. While the ward was being upgraded for engineering services it was decided to install ensuite facilities in the bays. All of this


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• Upgrade of engineering plant and equipment at Scunthorpe hospital

• Flat roof replacement at Goole hospital.

• Land sale and north-side reconfiguration

The team has been working in close partnership with consultants and North East Lincolnshire planning department to gain outline planning permission for a housing development on the greenfield site at the south-side of the Grimsby site. Running in parallel with this application the estates team has gained approval to rationalise the north-side of the Grimsby site, this will involve the demolition of some of the buildings and major refurbishment of the remaining buildings.

Purchase of residential accommodation at Scunthorpe hospitalThe team has led the purchase of the accommodation blocks at the Scunthorpe site. This has included operationalising the management of the accommodation with Northern Lincolnshire and Goole NHS Foundation Trust.

Clinical transformational schemesThe estates and capital teams have assisted the Trust to deliver the following clinical transformational schemes:

• Assisted Living Centre at Grimsby

• Refurbishment of ward C5 respiratory at Grimsby hospital to include an acute respiratory care unit

• Full refurbishment of the intensive care unit at Scunthorpe hospital.

Facilities servicesHospital support assistant (HSA)The launch of the HSA project has increased cleaning, catering and patient equipment cleaning cover to 13 hours per day, seven days a week. This is an increase of 10 hours per ward per week. Quality audit testing has shown that the high standards of ward cleaning have either been maintained or improved since the introduction of the hospital support assistants.

Time released for nurses is now focused on patients who require assistance and the increase in cover for evenings and weekends by the new role is supporting wards in many other ways not previously identified as part of the aims and objectives of the project. In addition, the development and implementation of the HSA role has reduced the recurrent pay spend by £467,000 per annum, a saving which is being reinvested back into patient care.

Phase two of the project will begin in April 2015 and will look to improve cleaning standards in non-clinical areas.

PorteringThe directorate formed a project team to design, develop and implement a new model of providing portering services to the wards and departments. The project team looked at developing a role which would provide equity across the organisation. The drivers for change were:

• To ensure patient-focused services were in place

• To meet changing demands from wards

• To ensure the services were providing value for money and cost improvements

• Staff were maintaining their skills and competencies.

The team is using the Trust’s cutting-edge WebV clinical portal task management system, which is automatically allocating tasks and provides prioritisation, diversion and acknowledgement, improving patient flow.

Retail cateringA tendering exercise for retail and catering services is currently underway. The project aims to improve facilities for staff, visitors and patients.

Car parking guidanceFollowing the Department of Health announcement regarding current guidance on NHS patient, visitor and staff car parking principles, the Trust has maintained strong links with the Healthcare Special Interest Group within the British Parking Association (BPA). The Trust has also provided significant input to the Healthcare Car Parking Charter. A review of the revised standards provides continued assurance that the Trust remains compliant with BPA legislation

Food and hydrationThe Department of Health recommends that NHS hospitals develop and maintain a food and drink strategy aimed at establishing good practice, improving nutritional content of meals and identifying (and solving) clinical nutritional problems. The Trust has developed a sub catering group which focuses on standards relating to the food and meal service for patients.

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Hydration stationsA £95,000 investment has seen the Trust roll out new ‘hydration stations’ across its Scunthorpe, Grimsby and Goole hospitals. The upgrade to these new trolleys means patients are now offered a tea or coffee at their bedside seven times a day, or as requested. The trolleys are also used during the breakfast service providing patients with cereals, toast, fruit juice and/or a hot drink. The improvement to the stations is a vital part of patient care to keep people well hydrated throughout their stay in hospital.

Estates and facilities compliancePremises assurance model (PAM)As the Trust has moved away from using Health Assure, the estates and facilities team has restructured and now has a specific estates and facilities compliance department. It is now embarking on the use of the

premises assurance model (PAM) to provide overall assurance of estates

and facilities compliance.

The 2014 NHS PAM represents a refreshed and updated version of the previous model that is more comprehensive incorporating ‘hard’ and ‘soft’ estates and facilities management services. It

is consistent, aligned with post-Francis regulatory

requirements and supports the longterm financial

sustainability of the NHS. The NHS PAM supports the NHS Constitution pledge: “to provide services from a clean and safe environment that is fit for purpose based on national best practice” and the current regulatory requirements to ensure that “service users are protected against risks associated with unsafe and unsuitable premises”.

The main benefits of the NHS PAM are to:

• Allow NHS organisations to demonstrate to their patients, commissioners and regulators that robust systems are in place to assure that their premises and associated services are safe

• Provide a consistent basis to measure compliance against legislation and guidance

• Allow NHS organisations to compare how efficiently they are using their premises

• Prioritise investment decisions to raise standards in the most advantageous way.

The NHS PAM is a tool which allows NHS organisations to better understand the efficiency, effectiveness and level of safety with which they manage their estate and

how that links to patient experience. The NHS PAM has two distinct but complimentary parts:

• Self-assessment question: supporting quality and compliance

• Metrics: supporting efficiency of the estate and facilities.

The previous lack of overall assurance has resulted in this indicator being changed from green in the last report to amber in this edition of the Trust Assurance Framework (TAF). Plans are now in place to update this system to provide overall assurance in the future.


The directorate of estates and facilities over the next 12 months will focus on delivery of some major projects to support the reconfiguration of clinical services as part of the Healthy Lives, Healthy Futures review.

In addition, a project to release surplus land at Grimsby hospital for residential redevelopment is nearing completion.

Following the purchase of on-site accommodation at Scunthorpe hospital, a major refurbishment programme is due to start in the summer of 2015.

A strategic estates and facilities review across the whole health community will be undertaken over the next 12 months.


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Sustainability reportSustainability has become increasingly important as the impact of people’s lifestyles and business choices are changing the world in which we live. In order for the Trust to fulfil its responsibilities in the role it plays, it has the following sustainability mission statement which is located in its sustainable development management plan (SDMP):

“The Trust is committed to long-term sustainability, it also recognises its corporate responsibility both as one of the largest employers in the local economy and as an emitter of carbon into the local environment. It seeks to use this position to engage, inform, persuade and influence staff, visitors, patients and contractors to reduce the emissions of carbon.”

As a part of the NHS, it is the Trust’s duty to contribute towards the level of ambition set in 2014 of reducing the carbon footprint in the NHS, public health and social care system by 34 per cent (from a 1990 baseline). This is equivalent to a 28 per cent reduction from a 2013 baseline by 2020. It is the Trust’s aim to supersede this target by reducing carbon remissions by 25 per cent by 2016 using 2007/08 as the baseline year.

In order to embed sustainability within the Trust’s business it is important to explain where in its processes and procedures it features. It currently considers sustainability in its travel and suppliers’ impact but not in procurement for environment or social impact.

Climate change brings new challenges to the Trust both in direct affects to the healthcare estate, but also to patient health. Examples of recent years include the effects of heat waves, extreme temperatures and prolonged periods of cold, floods, droughts etc. The organisation has identified the need for the development of a Trust Board approved plan for future climate change risks affecting our area.

PerformanceSince the 2007 baseline year, the NHS has undergone a significant restructuring process and this is still ongoing. Therefore in order to provide some organisational context, the following table may help to explain how both the Trust and its performance on sustainability has changed over time.

In 2009 the Trust’s Carbon Reduction Strategy outlined an ambition to reduce the carbon footprint of the NHS by 10 per cent (from a 2007 baseline) by 2015. We have supported this ambition as follows:

EnergyThe Trust has spent £3,225,824.00 on energy in 2014/15, which is a 14.1 per cent decrease on energy spend from 2013/2014. This reduction is attributable to a reduction in the consumption of gas and electricity. One of the reasons for this was an increase in weather temperature during the financial year. Comparing

2013/2014 to 2014/2015 this has resulted in the Trust emitting around 10 per cent less carbon. It is also worth noting that one per cent of our electricity comes from renewable sources.

The energy performance contract between the Trust and British Gas has seen the installation of some energy efficient projects during 2014/15. This has included roof mounted solar photovoltaic panels installed at Grimsby and Goole hospitals to generate renewable electricity for onsite and for export to the grid. Additionally an air handling unit has been installed in the kitchens at Grimsby hospital and improvements have made to the thermal insulation and in the efficiency of the boilers and pump replacements.

Work is also nearing completion on the installation of a combined heat and power system at Grimsby hospital which will meet the majority of the hospital’s demand for electricity and at the same time generate heat in the form of steam and hot water. An extensive high efficiency internal lighting replacement programme is almost complete at Scunthorpe hospital and is currently in progress at Grimsby hospital

Resource 2012/13 2013/14 2014/15

GasUse (kWh) 33,790,570 32,470,283 23,559,266

tCO2e 6,905.10298 6,888.245836 4,942.80476

OilUse (kWh) 18,896 33,342 82,532

tCO2e 6.0249896 10.6477677 26.4118415

CoalUse (kWh) 3,931,457 3,544,150 5,803,531

tCO2e 1447.090693 1295.883006 2126.50291

ElectricityUse (kWh) 18,427,806 18,654,683 15,717,738

tCO2e 10518.77594 10444.94356 9734.46668

Total Energy CO2e 18,876.9946 18,639.72017 16,830.1862

Total Energy Spend £3,732,947 £3,755,578. £3,225,824

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WasteThe Trust’s overall waste tonnage has increased by seven per cent during 2014/2015. However further improvements to the segregation of clinical waste has increased the amount of waste treated by autoclave. Compared with 2013/2014 this has brought about a 50 per cent reduction in waste disposed of by incineration. Future waste projects for the forthcoming year include glass recycling and food waste disposal.

Waste 2012/13 2013/14 2013/14

Recycling(tonnes) 150 187 160

tCO2e 3.15 3.93 3.36

Re-use(tonnes) 0 0 0

tCO2e 0 0 0

Compost(tonnes) 0 0 0

tCO2e 0 0 0

WEEE(tonnes) 15 14 14

tCO2e 0.32 0.29 0.29

High Temp recovery

(tonnes) 0 0 0

tCO2e 0 0 0

High Temp disposal

(tonnes) 237 143 72

tCO2e 52.14 31.46 15.84

Non-burn disposal

(tonnes) 390 435 561

tCO2e 8.19 9.14 11.78

Landfill(tonnes) 747 585 667.23

tCO2e 182.58 142.98 163.08

Total Waste (tonnes) 1539 1364 1474

% Recycled or Re-used 10% 14% 11%

Total Waste tCO2e 246.38 187.80 194.36

Water 2012/13 2013/14 2013/14

Mainsm3 193048 172836 152512

tCO2e 176 157 139

Water & Sewage Spend £374,906 £359,503 £343,284

WaterYear on year water consumption continues to decrease, particularly during 2014/15 at Grimsby hospital which has resulted overall in a four per cent reduction in cost.

Finite resource use - Water

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Recycling

WEEE

High temp disposal

Non-burn disposal

Land�ll

2014/152013/142012/13

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ght (

tonn

es)

Waste breakdown

0

5k

10k

15k

20k

Coal

Electricity

Oil

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14/1513/1412/13

Carbon emissions - Energy use

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on (t

CO2 e)

000

s


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Performance assurance directorateThe directorate is responsible for claims and legal services, clinical audit, document control, emergency planning, health and safety, patient advice and liaison services and complaints. It is also responsible for ensuring incidents are logged, investigated and lessons learned are fed back to the appropriate staff. The directorate also leads on risk and governance, and providing quality reports for the organisation.

Health and safetyThe centralised electronic risk assessment system now has more than 2,000 activity risk assessments. In total there are nearly 2,800 assessments on the system which have generated over 630 actions of which only 11 have not yet been completed. Actions that do arise from risk assessments are monitored by the system and administrator to ensure they are addressed and not left outstanding or overdue.

The migration of the system onto a new version has increased its flexibility. The Trust structure is now being mapped onto the risk assessments meaning that in some

instances assessments which

are on the system for each site can now be merged and assigned to the directorate/group involved. This will reduce duplication and allow users looking for a particular assessment to use the system filters more effectively and locate assessments quicker. Also the new version allows the development of bespoke assessments, inspection checklists and also walkthroughs so more assessments can be placed on the system. It can now be made available on tablets and smart phones with an offline function (allowing assessments to be completed even where there is no internet connection).

The 2014/2015 period also saw the completion of the replacement of

old beds with new electric profiling beds and a total of 548 new beds have now been placed in the Trust. This includes paediatric profiling beds and also new traction kits and integral IV poles. In addition a number of ultra-low profiling beds have also been purchased. These are ideal for patients where there is a risk of them falling from the bed as they can be lowered to just above floor level (approximately 85mm from floor level). Work in 2015/2016 will focus on the intensive care beds and bariatric beds.

The research in using electronic tagging of equipment (such as bariatric beds) identified a technical problem which has meant that electronic tagging has not been able to be progressed as envisaged. However, the concept is still being investigated using the wireless network infrastructure.

Fire safety management and education continues to progress and in 2014/2015 more staff

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received training than ever before including the training of fire wardens. This training is in keeping with the objective of having sufficient staff trained as fire wardens for all areas who are able to assist with any fire activations. In addition more involvement in projects (refurbishment and new build) has resulted in a greater assurance that appropriate fire safety arrangements are in place. Also the Trust has developed closer working relationships with the local authorities and their building control departments and Humberside Fire and Rescue Services (HFRS) to tackle areas of non- compliance identified from joint audits with HFRS. These audits and information from internal reviews of existing fire assessments have resulted in comprehensive fire action plans being developed and shared with HFRS showing progress and when work is scheduled to be completed.

Further work in 2015/2016 will progress the continuing development of a positive safety culture to improve patient care and treatment as well as looking at external safety management certification schemes.

ClaimsWe have seen a slight increase in the number of clinical claims received in 2014/2015 in comparison to the previous year. There has also been a slight increase in the number of non-clinical claims received during the financial year.

Any potential new claim is reviewed and information used within the risk and governance team, working with the audit facilitators and complaints facilitators, and discussed within the relevant group governance meetings to identify actions which can be implemented. Information from settled claims is also shared to consider any lessons to learn, and further work is being undertaken to review claims early in the process.

The NHS Litigation Authority standards were removed from April 2014 and the scheme changed to contributions based on the claims history of Trusts, based over the previous five years.

ComplaintsThe Trust has seen an increase in the number of formal complaints and patient advice and liaison service (PALS) concerns during 2014/15 possibly as a result of the Keogh Review which took place during the previous year. This resulted in an upwards trend in the number of ‘net open’ complaints (ie the number of new complaints received less the closed complaints) over a substantial part of the year. Additional resources were identified to assist with the reduction in the backlog. As a result of reviewing the way complaints are dealt with the complaints facilitators have aligned with the clinical groups and are now working with the risk and governance facilitators and the quality and audit facilitators to ensure that lessons are being learned and action plans arising from complaints are being implemented. We have introduced a dedicated complaints manager (currently a secondment post) to further improve the monitoring of complaints and progress responses within agreed timescales. All of these actions have resulted in a reduction in the ‘net open’ complaints during the latter part of the year.

In addition training for those dealing with complaints within the Trust has been provided and externally accredited training has been completed during 2014/15 to further improve the way the Trust deals with complaints and the quality of the response to complainants.

Weekly monitoring of open complaints has also been implemented as part of

the drive to ensure complainants are contacted on a regular basis to inform them of the current stage of their complaint. Where potential delays are identified, which could affect the agreed response dates, contact is also made with the complainant to agree any revised response date where appropriate.

Risk managementThe central team of risk and governance facilitators, each working to an operational group, has key responsibilities for supporting the organisation in its risk management and governance arrangements.

The Trust has in place a range of mechanisms for reporting incidents and raising concerns and has an online incident reporting system. This allows staff to easily report incidents which also results in quicker investigations and actions by the organisation. We have successfully implemented and embedded the national framework for investigating serious incidents, and have been commended for this work by regional commissioners.

A number of mechanisms have been developed and strengthened with renewed focus on feedback directly to individuals. Work continues to raise awareness on obtaining feedback from incidents which are reported. We also provide feedback via regular analysis reports, newsletters, use of the intranet, screen saver technologies and via local directorate governance group meetings.


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There is significant emphasis on learning lessons and ‘closing the loop’ following incidents, complaints and claims. Our learning lessons review group includes multi-professional membership and continues to meet bi-monthly with a specific focus to provide robust and ongoing assurance that lessons are being shared and disseminated following adverse incidents, complaints and claims, actions and progress is monitored via a formal action plan reviewed and monitored by our Trust Governance and Assurance Committee.

We deliver a range of training programmes to further strengthen the organisation’s risk management arrangements, focusing on investigations and learning from incidents, complaints and claims. Key to this is ensuring staff have access to appropriate training, advice and support to enable proactive management of risk. We have delivered root cause analysis (RCA) training to all staff involved in incident investigations to ensure consistency for investigations of incidents, complaints and claims.

The Trust has continued to embed training and support for Consent to Examination or Treatment and the Mental Capacity Act and Deprivation of Liberty Safeguards, and the Mental Health Act with the launch of a series of e-learning programmes to support the flexible training arrangements needed for our healthcare professionals. We have also held workshops for staff which have provided more indepth training for the requirements of the Deprivation of Liberty Safeguards.

We have continued developing and maintaining the Trust’s risk register, with continued review and monitoring of the Trust’s risk register confirm or challenge group, to ensure that risks are appropriately graded. This enables appropriate prioritisation/ranking of risks on the risk register, and in turn ensures that

investment decisions target the most significant risk issues. In addition, the quarterly non-executive director review and challenge process provides assurance to the Trust Board that risks of all kinds are being appropriately identified, assessed and managed. A number of risk prevention work programmes have also been developed and this work will continue in 2015/2016.

Information governanceThe risk and governance service is responsible for ensuring the Trust operates within the legislative framework for information governance, together with appropriate confidentiality standards as defined within the Caldicott principles. The Trust’s Information Governance Committee, which reports to the Trust Governance and Assurance Committee, is responsible for monitoring and reporting on the organisation’s compliance with the legislative requirements in respect of information governance.

The risk and governance team supports various work programmes which support the organisation in ensuring the required standards are met. The Trust has declared compliance at level two across the 45 requirements in the information governance toolkit during 2014/2015.

Document controlThe Trust has continued to bring policies, procedures and protocols into its document control system. This means more documents are now developed and reviewed to ensure good governance arrangements are embedded within the routine work of the Trust. The expansion of Sharepoint and its use as the Trust’s intranet (the Hub) ensures that all controlled documents are visible in a central location.

Closer monitoring of documents which are due for review has also resulted in reviews and updates being undertaken when required and this process is regularly reported at the Trust’s Governance and Assurance Committee (TGAC).

Quality assuranceQuality targets continue to be monitored using the Trust’s monthly quality and mortality reports, both of which are used by the Quality and Patient Experience Committee (QPEC) and the Mortality Performance and Assurance Committee (MPAC) to guide progress against the organisation’s quality priorities. These reports are also available to the public following sign off by the Trust Board. For more detailed information please refer to the Quality Account section of this report, which outlines performance over the 2014/2015 year with these priorities and outlines the priorities for 2015/2016 and the rationale for these choices.

Another initiative to help the Trust meet its aspirations to provide high quality care is the quality network called Together We Shine. It is designed to help staff:

• Share

• Help

• Integrate/innovate

• Nurture

• Empower.

The network is an umbrella term for lots of different support functions including seeking out new innovative ideas from staff using a Dragons Den event. Quality mentors, staff who have received specialist training in quality improvement, are on hand to provide face-to-face advice and support. They are clearly identifiable to staff as they wear bright orange ID badges and lanyards. Other resources include an intranet site, ideas and suggestions log. During 2014/15 the SHINE network was able to

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run its first quality training course which resulted in the training and graduation of more staff as quality mentors. From working with the national NHS Improving Quality (NHSIQ) team and local experts it is hoped that during 2015/16, the SHINE training programme can be up scaled allowing for more opportunities for staff to access and understand quality improvement methodologies and techniques. Following this, and as a result of networking with other NHS Trusts, the SHINE quality mentor role will be reviewed and a determination of how this role can become even more active and supporting of frontline staff, particularly in view of the challenges to balance cost, quality, efficiency and effectiveness.

MortalityThe Trust’s performance against the Summary Hospital Mortality Indicator (SHMI) has demonstrated significant improvements during 2014/2015 with the organisation being ranked ‘as expected’ according to the official national SHMI. This demonstrates the results of a lot of work undertaken to understand areas where further improvement was necessary. This work is continuing into 2015/2016 with a refreshed approach to the improvement groups that have been operating to give them greater access to the information that sits behind this indicator and providing more targeted focus to those areas with the highest mortality according to the crude mortality (calculated simply as number of deaths/number of admissions x 100). This new and revised approach is being led by the medical director’s office and is overseen for assurance purposes by the Trust’s Mortality Performance and Assurance Committee. For more information on mortality and the latest information available to the Trust, please refer to the Quality Account section of this report.

Quality dashboardsAs part of the work to compile different quality indicators into one place quality dashboards have been developed for a large number of wards. The quality dashboards have been fully embedded into the organisation and are proving an extremely useful tool for ensuring wards are engaged with the quality and governance agenda. They have also enabled the Trust to focus on specific indicators that are falling below threshold as well as identifying wards that are dipping. This work is innovative and will remain a priority for 2015/2016.

National Institute for Health and Clinical Excellence (NICE)The Trust has set itself a significant target to improve the review and implementation of NICE guidance to ensure that where relevant the quality and standard of care is further improved. During 2014/15, significant improvements were seen in terms of the Trust’s understood and declared compliance against NICE guidelines. This priority work continues for 2015/2016 with the intention to understand compliance against published recommendations. As this becomes more manageable, a number of other NICE related quality assurance systems will be prioritised and focused on to ensure the Trust has a good understanding and that this filters down to operational groups. Areas for attention include: quality standards; other new types of NICE guidance not seen before

now and more focused attention on guidelines where we have declared partial compliance. We need to systematically understand how partial is partial compliance, and we need to work with teams to ensure that these areas are on their risk registers and being actively monitored.

Clinical auditThe Trust has maintained a detailed and comprehensive programme of clinical audit and this work is detailed within the Quality Account report section.


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Directorate of strategy and planning The directorate formed in 2014 in order to place a specific focus on the development of the Trust’s longer term clinical strategy and the agreement of the overarching commissioning framework with the Trust’s commissioners which will allow the clinical strategy to be delivered.

The directorate leads the development and the operational management of the Trust’s investment programme, interfacing with the Trust’s clinical groups in order to ensure that investment plans are consistent with, and drive forward, the clinical strategy.

It also leads the Trust’s systems development, information technology, informatics, clinical coding and a range of other key management functions which support the Trust’s frontline clinical operations. The directorate is responsible for ensuring the day-to-day delivery of a robust, secure and timely Information Management and Technology (IM&T) service while ensuring IM&T is at the fore of the decision-making process

emphasising the strategic enablers deliverable by an innovative IM&T team.

Strategy and planningThe Trust published its five year strategic direction in June 2014. This followed an extensive review of the Trust’s present and forecasted future prospects where the Trust concluded that it did not consider the current configuration of services to be either clinically or financially sustainable in the medium to long term. In coming to this view the Trust has consistently stated that the sustainability agenda is a challenge for the whole health economy and cannot be resolved by a single organisation.

The Trust is participating in a detailed review of services which the directorate plays a key co-ordinating function identifying where there is both clinical and non-clinical benefit which may arise from:

• Developing pathways straight into a tertiary centre

• Integrating with other health and care organisations

• Wider scale system change across all organisations within the health community delivering efficiencies through integration of pathways.

The Trust’s key ethos throughout the review process is that it should be clinically led and managerially supported and is primarily focused on achieving the following key aims:

• Quality of care provided is maintained or improved

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• Explore service developments which provide the person with the confidence and support to remain within their place of residence where appropriate

• Clear ownership of the person/patient throughout their pathway

• Where acute care is needed there is a clear ‘decision to admit’

• Discharge planning commences as soon as the decision is made to enter inpatient care

• Services are available seven days where there is a clinical need

• Proposed changes take into account the whole patient journey thus delivering true transformation and avoiding a shift between providers

• The reconfigured services are both clinically and financially sustainable

• Common systems are developed across provision aiding a seamless care journey eg development of registers for specific groups of patients where care plans can be access where needed.

This review has been a core focus of the directorate during the course of 2014/2015 and forms a significant part of the overall Healthy Lives, Healthy Futures cross-community clinical review which all constituents of the local health community participate in. It is anticipated that the review will set out its key conclusions and future recommendations in the early stages of 2015/2016. The directorate will continue to play a vital role in both the formation of the final recommendations and the implementation process which will follow on from this.

While the delivery of the longer term strategic plan was a significant part of the directorate’s agenda during the financial year it also

played a significant part in the development of a number of key clinical developments which have either been implemented during the course of 2014/2015 or form part of the directorate’s planning agenda for the forthcoming year:

• Assisted Living Centre – this project relocates the five-day community equipment service into a refurbished location operating a multi-organisational service across seven days. With its expanded footprint, the new service provides a demonstration facility enabling people to try the equipment before delivery into their own home

• Cardiology – the cardiology day case unit is due to open in the summer of 2015. This project co-locates delivery of Grimsby hospital’s cardiology team into the one area and enables repatriation of services locally. The project is also a key enabler to the wider reconfiguration of the site

• Critical care – working alongside frontline teams, the Trust has in place a strategy for the future provision of critical care services. The strategy delivers a critical care service which meets the quality requirements expected from a general hospital service.

The directorate has also acted as the main co-ordinating and delivery point for a number of individual service reviews which act as key future enablers for the delivery of the longer term clinical service strategy under the auspices of the Healthy Lives, Healthy Futures review including but not exclusively:

• Home from Home – in partnership with NAViGO, North East Lincolnshire mental health provider, the Trust is supporting

the development of a home from home service. This is a service which will provide care for people with confusion of any cause and who also have a health need. The Home from Home team will provide care in the most appropriate location for the person’s health and care needs, whether that is within the Home from Home unit close to acute consultants or within the person’s place of residence

• Advanced community care – one of the most fundamental changes in the needs of the population is an increase in people attending hospital with multiple conditions. Working with health and care parties across all organisations, the advanced community care team focus on supporting people with long-term conditions to manage their conditions as far as possible within their own home. The teams are led by a GP and include health and care professionals across secondary and community services therefore ensuring the right care is accessed at the right time to suit the need of the person.

All of the above is underpinned by the strengthened contracting processes ensuring robust communications with key commissioners and comprehensive monitoring and delivery of activity and associated income.


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Systems developmentThe directorate is supporting frontline clinical delivery with some innovative and transformational development within clinical IT systems. This programme of work is centred on the Trust’s continued development of its WebV systems platform which forms part of the backbone for the Trust’s Electronic Patient Record (EPR).

Significant development work has been undertaken and is nearing completion for key functionality within EPR which will be delivered to priority areas in early 2015/2016.

The software will be supported with continued investment and deployment of mobile devices enhancing access to records and clinical tools at the point of care.

The WebV system team was awarded the Medipex and Yorkshire and Humber AHSN NHS Innovation Award 2014.

There is a strong integration agenda in relation to effective communication between IT systems both internally and externally. Within the Trust, individual departmental systems continue to be maintained and enhanced, offering the ability

to integrate specialist clinical data into the main EPR where appropriate. Externally, there are continuing strategic challenges around the sharing of clinical data within the local health community, which can be supported by the development of appropriate tools and technologies. The Trust has been further developing its relationships with local providers, primary care and commissioning support services with work underway to support timely and appropriate bi-directional access to clinical records held by respective providers.

Information technologyInformation technology is playing a significant role in supporting the delivery of safe, high quality and efficient patient care as we see increasing use of technology in all areas of the Trust.

The drive toward full electronic patient records continues at a pace and this is driving the continued investment in IT equipment and infrastructure to ensure fast, reliable and continuous access to IT systems and services 24 hours a day. Some of the investments within information technology this year include:

• Increased electronic storage and back-up capacity

• Updated equipment and further rollout of wireless networking

• Rollout of mobile devices

• Implementation of unified communication system

• Windows XP to Windows 7 migration

• Upgrade to call centre management systems

• Virtual server farm hardware replacement

• Upgraded internal paging system

• Upgraded network edge switches.

Information technology is driving change within the Trust by offering the tools and systems to provide new ways of working, new ways of communicating and new ways of recording and retrieving data. Mobile devices are growing in use so that data can be view whenever it is needed, wherever it is needed. Unified communications is providing the ability for healthcare professionals to communicate by video and voice messaging with

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the ability to view and collaborate on live data with colleagues, other healthcare organisations in remote locations and in the near future, possibly patients.

InformaticsThe team is working with local and national reporting requirements providing support to the Trust’s growing requirements for information, ensuring that operational groups have accurate reports to both understand patient activity and enable the management of patients along their pathway. Work has included:

• Utilisation of benchmarking information to identify outlying areas of performance

• Provision of summary management information to support operational needs and service improvement projects

• Ensuring that SUS data sets are provided in line with National Timetable to support the Trust’s income

• Mandated national returns are accurate and submitted in line with deadlines

• Provision of ad hoc reporting in line with changing operational requirements

• Continuing to develop and improve management information reports

• Monitoring data quality across key Trust’s systems and engaging with operational groups to provide support in improving the data quality agenda.

Clinical codingThe Trust’s experienced coding team is committed to continuing the improvement of coding through clinical engagement with key lead clinicians. The key aim is to ensure that clinical documentation fully represents patient episodes of care. The team undertake internal and external coding audits following Health Social Care Information Centre audit methodology. The team works with clinicians to support the Mortality Performance and Assurance Committee, reporting and demonstrating the Trust’s performance against peers.

Having a team with an external aspect enables a more comprehensive knowledge base to be applied locally adding to the quality of service provided.

Developmental agenda for 2015/2016 and beyondWithin its inaugural year the directorate has faced a number of challenges and developed both its team and processes to ensure maintained and/or improved service delivery. The directorate will continue to evolve to enable and deliver a proactive, customer focused strategy and planning service.

The Trust is continuing its programme of transformation and the directorate will continue to develop relationships with both internal and external stakeholders to ensure efficient and effective service delivery across all its service portfolio.


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How the Trust is run

Board of DirectorsThe Board of Directors operates according to the highest corporate governance standards. It has collective responsibility for all aspects of the performance of the Trust, including financial performance, clinical and service quality, management and governance. The Board is legally accountable for the services provided by the Trust and the key responsibilities include:

the Trust and its staff in accordance with NHS values and accepted standards of behaviour in public life including selflessness, integrity, objectivity, accountability, openness, honesty and leadership (The Nolan Principles).

The Board has resolved that certain powers and decisions may only be exercised or made by the Board in formal sessions. These powers and decisions, and those of the Trust’s Council of Governors, are set out in the Scheme of Delegation and Trust Devolution Policy which can be found at: http://www.nlg.nhs.uk/content/uploads/2014/02/NLG14074-Scheme-of-Delegation-feb14.pdf

The Board of Directors comprises five voting executive directors, four non-voting executive directors and five non-executive directors. The five executive directors with voting rights are the chief executive, chief nurse, medical director, director of finance and chief operating officer. The senior independent director is non-executive Neil Gammon. The Trust Board meets in public on a monthly basis and met on 12 occasions during 2014/15.

The Board is of sufficient size and the balance of skills and experience is appropriate for the requirement of the business and the future direction of the Trust. Arrangements are in place to enable the appropriate review of the Board’s balance, completeness and appropriateness to the requirements of the Trust.

Development of the Board Development of the Board is essential in ensuring that it is functional, relationships are constructive, healthy and challenging, in making sure it has control of the business of the organisation and that it has robust plans in place for the future.

The Board is developed in a number of ways including ‘time out sessions’, board briefings and development days. The main areas covered have been on strategy and planning around the sustainability review.

In accordance with the requirements of good corporate governance and in order to ensure their continuing effectiveness, the Board undertakes a formal and rigorous annual evaluation of its own performance and that of its sub-committees.

An assessment tool has been developed to evaluate the performance of the Trust Board across the whole range of its activities, including strategy and operational performance. The outcomes from this process complements the forward plan self-certification assurance process and also informs both the Board’s annual work programme and the Board Development Programme. The evaluation exercise is an annual event. The results of the evaluation exercise are reported to the Council of Governors.

The Board underwent a restructure in 2014 to ensure it encompasses the experience, skills and expertise needed to ensure compliance with the Code of Governance and to provide the necessary direction and leadership required to face

• Setting the strategic direction (having taken into consideration the views of the Council of Governors)

• Ensuring that adequate systems and processes are maintained to deliver the Trust’s Annual Plan

• Ensuring its services provide safe care for patients

• Ensuring robust governance arrangements are in place supported by an effective assurance framework that supports sound systems of internal control

• Ensuring rigorous performance management which ensures the Trust continues to achieve its local and national targets

• Seeking continuous improvement and innovation

• Measures and monitors the Trust’s effectiveness and efficiency

• Ensuring the Trust, at all times, is compliant with its Licence, as issued by the sector regulator Monitor

• Exercising the powers of the Trust established under statute, as described within the Trust’s Constitution available at http://www.nlg.nhs.uk/content/uploads/2013/10/TrustConstitution2015.pdf

The Board of Directors is also responsible for establishing the values and standards of conduct for

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the challenges in 2014/2015 and beyond. The restructure saw the directorate of clinical and quality assurance renamed as the performance assurance directorate. The move was to consolidate all of the elements of performance in one directorate thereby further strengthening these arrangements. In addition to this, the directorate of strategy and planning was created to bring together contracting and planning to ensure a cohesive and streamlined approach for the future. The new structure became operational from June 1 2014.

The Trust has commissioned relevant external reviews of its governance arrangements including reviews by KPMG of quality governance, clinical leadership and board assurance in support of the forward planning and self-certification process. Review of aspects of the Trust’s governance arrangements has been a key feature of the 2014/15 Internal Audit Programme following the appointment of the new internal auditors.

In respect of quality governance, at re-review by KPMG the Trust’s overall score was three, a reduction on the previous score of six, calculated in October 2013, reflecting the “progress made with implementation of the original 21 recommendations and the sustainability of the Trust’s processes”. A review of the quality governance arrangements at individual clinical group level was also completed during the latter part of 2014/15 and the report received for comment in April 2015. The outcome from this review will inform the Trust’s governance and assurance plans and arrangements for 2015/16.

For further information about the Trust’s governance please refer to the annual governance statement on page 98 and the Quality Account for 2014/2015.

How the Trust Board and Council of Governors interactThe Board works closely with the Trust’s Council of Governors. The Foundation Trust chairman is also the chairman of the Council of Governors and is supported at every meeting of the Council of Governors by the chief executive or deputy chief executive. The chairman works closely with the lead governor to review all relevant matters. The chairman, chief executive, Trust secretary and membership manager meet before each meeting of the Council of Governors to set the agenda and review key issues.

The non-executive and executive directors of the Board attend the

Council of Governors as observers and take part in open discussions that form part of each meeting. Executive directors or their deputies, and non-executive directors, are assigned to and are integral members of the each of the Council of Governors’ sub-groups – steering group, quality review group, membership working group and training working group. Participation in each quarterly sub-group meeting ensures an understanding of the views of the governors and subsequently members of the public.

Details of the attendance of executive directors at the Council of Governor meetings can be found in the Council of Governors section.


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Trust Board of Directors - Non-executive directorsAll of the non-executive directors fulfil the criteria for independence as specified in the Code of Governance.

Dr Jim Whittingham ChairmanJim heads up both our Board of Directors and Council of Governors. He was born and brought up in Scunthorpe and studied at the University of Sheffield where he was awarded a PhD in soil microbiology. He has an Honorary Doctorate from the University of Lincoln. After finishing his PhD he worked in IT in vehicle leasing before joining the University of Humberside in Hull where he undertook a wide range of management roles including in finance, HR, registry, student services, and IT before being pro vice chancellor. In this role he took a leading post on the establishment of the University of Lincoln and the development of the city’s Brayford Pool campus. Jim left the university in 2008 and moved into interim management.

Jim was appointed chairman of the Trust in July 2010 and his current term of office ends in July 2016.

Alan Bell Non-executive director/chairman of the Remuneration CommitteeAlan is a graduate of Durham University with electrical engineering qualifications acquired while working for BICC Plc (now Balfour Beatty) after university. His business achievements include his time as marketing director and then managing director of Hepworth Industrial Plastics where he pioneered the development of uPvc windows in the UK. He is also responsible for the introduction of external gas and electricity meter boxes in British houses, made out of GRP. Another milestone was when he took a significant personal shareholding in a Scottish chipboard and MDF business whose fortunes he transformed in three years to the extent that it is now a world leader in particleboard and fibreboard technology.

Alan was appointed to the Board in August 2010 and his term of office ends 2016.

Neil Gammon Non-executive director/ deputy chairman/senior independent director During a 37-year career in the engineer branch of the Royal Air Force, Neil served in a dozen UK locations and in Germany and Saudi Arabia. His final post saw him commanding Royal Air Force Cosford and the Defence College of Aeronautical Engineering, where he was responsible for training aeronautical engineers for the three armed services. He left the Royal Air Force in 2009 and settled in Ashby cum Fenby. Neil has an Honorary Doctorate of Business Administration from the University of Lincoln, and he was appointed an independent member of Humberside Police Authority in May 2010. Neil retains Royal Air Force links through his presidency of both the Grimsby and Cleethorpes Branches of the Royal Air Forces Association and Number 866 (Immingham) Squadron of the Air Training Corps.

Neil joined the Board in August 2010 and his term of office ends in 2016. He was appointed deputy chairman 2012.

Philip Jackson Non-executive directorPhilip joined the Board in 2004 and he resigned on September 30, 2014.

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Linda Jackson Non-executive directorLinda Jackson is from Cleethorpes and studied hotel, catering and institutional management at Grimsby College before graduating with a Diploma in Management from the University of Reading. Her career in facilities management began in London where she secured a position of trainee manager for ISS Facility Services who provide facilities services across the NHS.

Linda quickly worked her way up the ranks to hold positions including regional director providing facilities services across NHS organisations in the capital and became board director at the age of 38. In her last 10 years in the private sector she undertook a transformational change role responsible for implementing the company’s new business and initiatives nationally within the NHS. She was appointed to the Board on September 30 2014 and her term of office ends on September 29 2015.

Anne Shaw Non-executive directorAnne is from the East Riding of Yorkshire but began her professional career as a staff nurse working in the accident and emergency department at John Radcliffe Hospital, Oxford. It wasn’t long before she decided to move closer to home working as a staff nurse and ward sister in Hull. Her career took a different route when she moved to teaching nurses which opened new doors for her as she joined The Open University, teaching within the health and social care department for about a decade. Over the years Anne has also been a secondary school governor, a public sector director for the Doncaster Learning and Skills Partnership and Director of Aim Higher Humber. Anne also brings previous experience as a non-executive director having worked with Hull and East Yorkshire Community Mental Health and Learning Disability NHS Trust for seven years.

Anne joined the Board on August 12 2013 and her term of office is until August 11 2015.

Stan Shreeve Non-executive directorA semi-retired businessman and qualified accountant with experience at board level as chief executive, chief finance officer and non-executive director in both the public and private sectors. He has experience of evaluating, funding, integrating and reorganising businesses, often in a turnaround situation. He has worked with venture capitalists and financial situations raising more than £200million in structured finances. He has a wealth of experience of financial controls and the generation of cash from working capital. He also has experience of pan-European management and reorganisation within a culturally diverse business.

Stan joined the Board 2012 and his term of office ends on June 7 2015.


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Trust Board of Directors - Executive directors

Karen Jackson Chief executiveAs chief executive Karen is responsible for providing strategic direction and leadership. She started her career in the NHS at Leeds Teaching Hospital as chief financial accountant then assistant director. She went onto work as deputy director of finance at Sheffield Teaching Hospitals before moving to Northern Lincolnshire and Goole Hospitals NHS Foundation Trust in August 2008 when she took up the position as director of finance, information and performance. She spent two years in this role before being appointed to the chief executive post in September 2010. Karen has a degree in genetics and is a qualified chartered accountant. In her spare time she is involved with a number of NHS charities.

Wendy Booth Director of performance assurance and Trust secretaryWendy specialises in governance and risk management and is the lead for our complaints, legal, risk and quality assurance teams as well as our Foundation Trust office. She was appointed to her role in August 2012, having previously held the posts of head of governance and Trust secretary, assistant director of risk management and Trust risk manager. Prior to that she worked in a variety of administrative/general management roles before moving into, and specialising in, governance/risk management. Her title changed in July 2014 from director of clinical and quality assurance to her current one.

Pam ClipsonDirector of strategy and planningPam has been with the Trust since starting out as an apprentice straight from school in 1995. She has held a number of roles in the finance directorate since then, most recently as assistant director of finance and performance, leading the Trust’s planning, contracting and information functions. She was appointed as director of strategy and planning on June 13 2014.

Dr Karen DunderdaleChief nurse/deputy chief executiveKaren is our lead nurse and was born and brought up in Scunthorpe. She qualified as a nurse in 1991 and worked on a general medical ward before moving to coronary care. She became a cardiac nurse specialist developing cardiac rehabilitation and heart failure. She has a PhD in quality of life in chronic heart failure from York University and has contributed substantially to the development of cardiac nursing within the region.

Karen held the position of assistant director of nursing focusing on the Grimsby hospital site before becoming the chief nurse in 2011. She took on the additional role of deputy chief executive from March 7 2014.

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Karen GriffithsChief operating officerKaren has 33 years’ experience of working in the NHS, beginning her career as a student nurse at Scunthorpe hospital in 1981. She went on to train as a midwife and has held a number of clinical and managerial posts across the Trust. Her role carries a responsibility for the management of the wards, diagnostic and other clinical services, departments and support facilities. She was appointed as chief operating officer on April 16 2014.

Marcus HassellDirector of financeMarcus was previously deputy director of finance at the Trust for three years, and has been at the Trust in a variety of finance roles since joining the previous Grimsby Health NHS Trust back in 1995. Marcus has spent his working career in NHS finance, having started as a finance trainee in Bradford. He was appointed as director of finance on August 1 2014.

Jug JohalDirector of facilitiesJug joined the NHS in 2006 after working his way up from transport administrator to group operation manager in a private logistics firm. He has worked in a number of roles at the Trust including transport manager and general manager for hotel services before being appointed to director of facilities in August 2014. He is also chair of the British Parking Association Healthcare Special Interest Group. He was appointed as director of facilities on August 14 2014.

Dr Neil PeaseDirector of organisational development and workforceNeil heads up our recruitment, HR, training and development, organisational development and communications and marketing functions. He has worked in the NHS for nearly 20 years including as a porter and healthcare assistant. After obtaining a degree in sports medicine he moved into medical education, where he pioneered the use of clinical simulation in palliative care education. Neil holds a Professional Doctorate from Sheffield Hallam University on the subject of organisational development. Neil was appointed as director of organisational development and workforce at the Trust in October 2011. In January 2014, he also took on the role of interim director of facilities.


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Mr Lawrence RobertsActing medical director Mr Roberts has a wealth of experience having graduated from Charring Cross Medical School before being commissioned into the Royal Navy as a medical student on a short service commission. He worked as a ship’s medical officer and on an air-sea rescue squadron and was also attached to the Royal Marines. He then trained as a GP during his time in the Royal Navy before transferring to the Army where he trained in obstetrics and gynaecology at a military hospital in Aldershot. He also worked as a perinatal training fellow at the University College of London and became a consultant in 1994. He went on to take up the post of Command Consultant in Obstetrics and Gynaecology (British Army of the Rhine) and was promoted to lieutenant-colonel before being made redundant in 1996. He then joined Scunthorpe hospital as a consultant, and has held various posts including clinical lead, clinical director, associate medical director, deputy medical director and more recently acting medical director as of March 2 2015.

Mike RockeDirector of finance – 2010 to September 30 1214Mike led IT, planning and financial teams including procurement and payroll. He was appointed as a director in November 2010 and stepped down as director with effect from July 31 2014 but continued to be employed by the Trust in a project management role before retiring on September 30 2014. With effect from November 1 2014 Mike has been employed in a part-time project management role but no longer holds a Board position.

Dr Mark WithersMedical directorA consultant anaesthetist by background Mark joined us in January 2014 from Rotherham NHS Foundation Trust having held the position of deputy medical director and director of medical workforce. He has a special interest in intensive care and a career-long interest in medical management. He also holds the position of deputy director for revalidation at NHS England North of England and Independent Secondary Care Doctor for Nottingham City CCG. Mark was medical director with the Trust between January 6 2014 and March 1 2015.

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Non-executive directorsThe Appointments and Remuneration Committee identifies suitable candidates to fill non-executive director vacancies as they arise (this is carried out by advertisement and open competition).

The committee evaluates the skills of candidates against the description of capabilities required and makes a recommendation on the appointment to the Council of Governors.

Candidates for non-executive director positions are required to provide the Council of Governors with details of their other significant commitments, with a broad indication of the time involved, and also to provide an undertaking that they will have sufficient time to fulfil their role. Additionally, the Trust constitution specifies that non-executive directors must be members of the Trust and so candidates must live within one of the specified public constituencies.

It is only the Council of Governors that has the authority to appoint non-executive directors. In making such appointments, however, the council must have regard to the recommendations of the Appointments and Remuneration Committee, the other commitments of candidates, and the views of the Board of Directors on the qualifications, skills and experience required for the position.

The normal term of office of a non-executive director is three years. Removal of a non-executive director, other than at the end of a term of office, requires the approval of three-quarters of the Council of Governors.

The process for the appointment of a chairman is essentially the same as for other non-executive directors. There are, however, two further eligibility criteria to be taken into account:

• No individual who is simultaneously a chairman of another NHS Foundation Trust can be appointed as chairman

• On appointment, the chairman must meet the criteria for independence as specified in the Trust Constitution.

Independence of non-executive directorsThe Board of Directors undertakes an annual review of the independence of its non-executive directors. The Board determines whether each director is independent in character and judgment and whether there are relationships or circumstances which are likely to affect, or could appear to affect, the director’s judgment.

The following non-executive directors are considered to be independent:

• Dr Jim Whittingham

• Alan Bell

• Neil Gammon

• Philip Jackson

• Linda Jackson

• Anne Shaw

• Stan Shreeve.

Challenge rolesAs part of their roles as non-executive directors they have specific challenge roles which they use to seek assurances from the executive directors that the Trust is delivering sustained or improved services. The areas of specific challenge include:

• Food and catering

• Patient communication

• Appointments and signage

• Complaints

• Pressure ulcers

• Falls and dementia

• Nutrition and hydration

• Mortality rates

• Medical staffing

• Nurse agency controls

• End of life care.

Declaration of interests of the Board of DirectorsThe Board of Directors undertakes an annual review of its Register of Declared Interests. The Trust register, which gives full details of all the relevant commercial and other relevant interests of directors, can be viewed on the Trust website at: http://www.nlg.nhs.uk/content/uploads/2014/12/NLG15025-Annual-Review-of-Register-of-Directors-Interest.pdf

Statement of compliance with the NHS Foundation Trust Code of GovernanceNorthern Lincolnshire and Goole NHS Foundation Trust has applied the principles of the NHS Foundation Trust Code of Governance on a comply or explain basis. The NHS Foundation Trust Code of Governance, most recently revised in July 2014, is based on the principles of the UK Corporate Governance Code issued in 2012.


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Directors’ attendance at Trust Board meetings

Title Name Atte

ndan

ce

19.4

.14

27.5

.14

24.6

.14

29.7

.14

26.8

.14

30.9

.14

28.1

0.14

25.1

1.14

16.1

2.14

27.1

.15

24.2

.15

24.3

.15

ChairmanDr Jim Whittingham

12/12 P P P P P P P P P P P P

Chief executive Karen Jackson 10/12 P P A P A P P P P P P P

Director of performance assurance and Trust secretary

Wendy Booth 11/12 P P P A P P P P P P P P

Director of strategy and planning *appointed 13.6.14

Pam Clipson 7/10 n/a n/a P P P P A A A P P P

Chief nurseDr Karen Dunderdale

10/12 P P P P P P A P P P P A

Chief operating officer Karen Griffiths 11/12 P P P P P P P P A P P P

Director of finance *appointed 1.8.14

Marcus Hassall 6/8 n/a n/a n/a n/a A P P P P P A P

Director of finance *resigned 31.7.14

Mike Rocke 3/4 P P A P n/a n/a n/a n/a n/a n/a n/a n/a

Director of facilities *appointed 14.8.14

Jug Johal 4/8 n/a n/a n/a n/a A P P A A P P A

Director of organisational development and workforce Dr Neil Pease 8/12 A P P P A P A P P P A P

Medical director Dr Mark Withers 5/12 P A A A P P A P P A A A

Non-executive director Alan Bell 12/12 P P P P P P P P P P P P

Non-executive director Neil Gammon 12/12 P P P P P P P P P P P P

Non-executive director *appointed 30.9.14 Linda Jackson 6/7 n/a n/a n/a n/a n/a P P P P A P P

Non-executive director Anne Shaw 11/12 P P P P P P P P A P P P

Non-executive director Stan Shreeve 11/12 P P P P P P P P P P P A

Non-executive director *resigned 30.9.14 Philip Jackson 5/6 A P P P P n/a n/a n/a n/a n/a n/a n/a

Table Key: P = Present; A = Absent

Committees of the Board of DirectorsThe Board of Directors has established a number of committees to support it in discharging its responsibilities. In addition to meeting the statutory requirements of having an Audit Committee and a Remuneration Committee, the Trust has also established a Resources Committee, Trust Governance and Assurance Committee, Quality Patient Experience Committee, Mortality Performance Committee and Charitable Funds Committee.

Minutes of the sub-committees are presented to the Trust Board and a front cover sheet highlights issues for the Board to note and items for escalation. The Trust Board sub-committees are as follows:

Trust Audit Committee The Audit Committee is a standing committee formally established by the Trust Board. The Audit Committee’s remit is to ensure that effective internal controls and systems are in place, and compliance with law, guidance and codes of conduct. It also oversees the establishment and maintenance of an effective system of internal control that supports the achievement of the organisation’s objectives and monitors the integrity of the financial statements of the Trust.

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The committee, which meets six times per annum, is appointed by the Board from among the non-executive directors of the Trust and consists of three members. There is cross membership with other standing committees. Minutes of Audit Committee meetings are submitted to the Resources Committee, Trust Governance and Assurance Committee, Quality and Patient Experience Committee and the Trust Board.

The Trust has an internal audit function. Following a formal competitive mini-tendering exercise in early 2014 the Trust awarded its internal audit contract to KPMG for an initial period of three years, with the option to extend for a further year. The new service commenced on the June 1 2014. Internal audit’s role is to provide an independent and objective opinion to the chief executive, the Audit Committee and the Board on the degree to which risk management, control and governance arrangements support the effective operation of the Trust. The head of internal audit produces an annual audit opinion on the effectiveness of the system of internal control. The head of internal audit and/or the internal audit manager for the Trust will normally attend Audit Committee meetings and has a right of access to all Audit Committee members, the chairman and chief executive of the Trust. The head of internal audit is accountable to the director of finance.

The Trust’s external auditor is PwC, who were appointed in 2012 following a mini-tendering exercise. Representatives of the Audit Committee acted as advisors to the Council of Governors in relation to the tendering exercise, and the Council of Governors convened a sub-committee to oversee the process and make a recommendation to the full Council of Governors. The external audit contract was awarded for a period

of three years with the option for a one year extension. The value of external audit services is disclosed in the Trust’s financial statements at note six. The February 2015 Audit Committee meeting considered the issue of the external auditors re-appointment for a further one year extension option (in line with the original contract award) and made a formal recommendation regarding this to the Council of Governors who considered the recommendation at their formal meeting in May 2015. The Audit Committee assessed the effectiveness of its external auditor by completing the annual PwC client satisfaction survey and by holding a private discussion (without either external or internal audit present) at the end of one of its Audit Committee meetings to review the performance of PwC in discharging its external auditor duties. PwC also provides non-audit services to the Trust. It is important that the independence of our external auditors in reporting to governors, non-executive directors and Northern Lincolnshire and Goole NHS Foundation Trust is not, or does not appear to be, compromised in terms of the objectivity of their opinion on the financial statements of the Trust. Equally the Trust should not be deprived of expertise where it is needed. The Trust has therefore devised a formal policy for the engagement of the external auditor for non-audit work to ensure that their objectivity and independence are safeguarded. The value of non-audit services is disclosed in the Trust’s financial statements at note 6.

During 2014/15 the Audit Committee received the final audit reports and the annual report for 2013/14 from its former internal auditor provider. Most notably, one of the final reports related to a ‘no assurance’ rating in relation to the issue of agency nurse staffing for which a detailed action plan with executive director

responsibilities for implementation was agreed. This action plan has now been through implementation, and has significantly improved control processes. The committee continued to receive progress updates in relation to the issue of medical staff job plans. Previous audit work had identified that the process for the Trust as a whole was not operating effectively and required significant improvement to ensure a robust job planning process going forward. Progress remains ongoing and further updates will be provided to the Audit Committee as part of the routine follow up process. Reports were also received from the new internal auditors (KPMG) relating to areas of work on the refreshed and agreed internal audit plan for 2014/15. There were no ‘no assurance’ reports issued during 2014/15.

The committee also received and reviewed the draft financial statements and the audited accounts, as well as the Annual Governance Statement. Due to the financial position of the Trust at the end of 2014/15 one of the significant issues given full consideration by the Audit Committee as part of the accounts preparation process was the Trust’s ability to continue as a going concern. The Audit Committee considered this in detail and note 1.1 of the financial statements refer to the accounts being prepared on a going concern basis, which the Audit Committee agreed was appropriate.

As part of the committee’s regular review of its own governance arrangements it


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conducted a self-assessment workshop in December 2014, in line with the latest NHS Audit Committee Handbook (HFMA, 2014). A thorough review of its formal terms of reference was also undertaken, and a revised terms of reference document was approved by the Board in order to ensure that they remain up to date and fit for purpose.

Attendance at the Audit Committee during 2014/2015 is as follows:

Members Role April 2014

May 2014

August 2014

Oct 2014

Dec 2014

Feb 2015

Attendance

Stan Shreeve NED – chairman P P P P P P 100%

Neil Gammon NED P P A P A P 67%

Anne Shaw NED P P P P*1 n/a n/a 100%

Linda Jackson NED n/a n/a n/a P*2 P P 100%

Attendees

Alan Bell NED P A P P P P 83% *3

Mike Rocke Director of finance P P A *4 n/a n/a n/a 67%

Marcus Hassall Director of finance P P P P*5 P P 100%

Wendy BoothDirector of performance assurance

A P A *6 P P A *6 50%

Head of compliance/LCFS P P P P A*7 P 83%

Internal audit P A P P P P 83%

External audit P P P P P P 100%

Notes: Table Key: P = Present; A = Absent; A* = Absence covered by deputy

1 Anne Shaw – NED – last meeting as formal Audit Committee member

2 Linda Jackson – NED – attended October meeting but not formal Audit Committee member until December meeting

3 Alan Bell – NED – not a formal Audit Committee member

4 Mike Rocke – director of finance – final meeting as director/ Marcus Hassall, deputy director of finance, in attendance

5 Marcus Hassall – director of finance – first official meeting as director

6 Kathryn Helley, deputy director of performance assurance, in attendance

7 Nicki Foley, assistant head of compliance and LCFS, in attendance

Remuneration CommitteeThe Board of Directors has established a Remuneration Committee. Its responsibilities include consideration of matters pertinent to the nomination, remuneration and associated terms of service for executive directors (including the chief executive), maters associated with the nomination of the non-executive directors and remuneration of senior managers/clinical leaders.

The committee is comprised of three non-executives. Other people attending meetings as required include the chairman, the chief executive, the director of organisational development and workforce, the director of finance and the Trust secretary. Between April 1 2014 and March 31 2015, the remuneration committee met four times.

The chief executive attends the committee in relation to discussions about Board composition, succession planning, remuneration and performance of executive directors. She also has in place a suitable framework for the appraisal of the performance of each executive director, and the she reports to the committee on her assessment of performance of each director. The chief executive was not present during discussions relating to her own performance, remuneration and terms of service. The director of organisation development and workforce, Trust secretary and director of finance attend meetings to offer guidance and advice, but they withdrew from any meetings when discussions about their own performance, remuneration and terms of service were held.

The director of organisational development and workforce will also be responsible for advising the committee on the appointment of any external independent consultants in respect of executive director remuneration more generally and where such advice is felt necessary by the committee, bearing in mind any conflict of interest.

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The committee is responsible for the following:

• Developing, refining and periodically reviewing the executive remuneration strategy including pension rights pursued by the Trust for the purpose of ensuring that the organisation is able to attract, retain and motivate executive directors of the quality required for the successful operation of the Trust. Development and review of the strategy will include consideration of where to position the Trust relative to other NHS Foundation Trusts and comparable organisations, ensuring that relevant benchmarking information is available and that there is no increase in pay without corresponding improvements in performance and being sensitive to pay increases elsewhere in the Trust

• For those staff (eg chief executive and executive directors) on local pay and terms and conditions of service, to determine remuneration and terms and conditions through a formal and transparent procedure and to review those arrangements at the agreed intervals

• For executive directors (including the chief executive) employed on locally determined spot salaries (ie where no incremental scales apply) to ensure that at the agreed intervals, those salaries and remuneration packages are benchmarked against the remuneration paid in comparable organisations. In support of this periodic review, the director of organisational development and workforce will provide appropriate benchmarking information in order to provide a comparative analysis of remuneration packages.

For full details of the remuneration committee (including attendance at meetings) please see the renumeration report.

Resources Committee gives detailed consideration to the Trust’s workforce, finance, IM&T and estates and facilities issues and, in turn, provides assurance that the Trust has in place the necessary controls to manage its risk exposure in these areas and, where this may not be the case, to make recommendations for action. The following sub-groups report to the Resources Committee: Workforce Review Group, Strategy and Planning (including IM&T) Group, Finance (including Commercial Ventures) Group and Estates and Facilities Group. It is chaired by a non-executive director and its minutes are submitted to the Trust Board, Audit Committee, Trust Governance and Assurance Committee and the Quality and Patient Experience Committee, as well as ‘highlight’ reports to the Trust Board.

Trust Governance and Assurance Committee oversees the development of the Trust’s governance strategy and arrangements. It also provides assurance to the Trust Board that the Trust has in place the necessary controls to manage its risk exposure, meet statutory and other governance requirements and achieve its principal objectives. It meets every other month and is chaired by a non-executive director. Minutes are submitted to the Trust Board and the Resources Committee.

Quality Patient Experience Committee ensures the Trust has in place a co-ordinated and effective approach to understanding the experience of patients who use our services and ensuring that appropriate actions are taken where gaps are identified. It meets monthly and is chaired by a non-executive director. ‘Highlight’ or exception reports are submitted to the Trust Board as required and the Resource Committee.

Mortality Performance Committee oversees all of the work streams identified in the mortality action plan. It meets monthly and is chaired by Trust chairman Dr Jim Whittingham. Minutes are submitted to the Quality and Patient Experience Committee and the Trust Board.

Charitable Funds Committee oversees the management of the Trust’s charitable funds within defined policies and procedures. It meets quarterly and is chaired by the Trust chairman Dr Jim Whittingham. Minutes of the meeting are submitted to the Trust Board.


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Remuneration report

IntroductionIn company law a senior manager is defined as ‘those persons in senior positions having authority or responsibility for direction or controlling the major activities of the foundation trust’.

The Annual Reporting Manual indicates that this means those who influence the decisions of the Trust as a whole rather than the decisions of individual directorates or services. For the purpose of this remuneration report the description ‘senior managers’ will refer to the executive directors and the non-executive directors holding positions on the Board of Directors.

The remuneration report contains details of senior managers’ remuneration and pensions. It also sets out further information about the appointment of those senior managers (where these have occurred during 2014/15) as required by Monitor’s Code of Governance. The narrative and figures in this report relate to those individuals who have held office as a senior manager of the Trust during 2014/15.

The information in this section is not subject to audit by our external auditors, however they will read the narrative to ensure it is consistent with their knowledge of the Trust. The auditable section is on page 85.

Annual statement on remunerationRemuneration Committee – executive director’s remunerationWith regard to executive directors, the overarching policy of the Remuneration Committee is to follow the guidance given by the Department of Health in determining pay and terms of service.

The key decisions made on senior managers’ remuneration in 2014/15 were as follows:

In making these decisions the committee looked at a number of remuneration comparisons these included: the NHS Board Room Pay Report 2014, as well as market testing with local providers including Hull, York, Doncaster and Bassetlaw and Lincoln. It was concluded from this that the remuneration levels for the Trust are appropriate.

None of the changes made during 2014/15 were deemed to be major or substantial.

Remuneration Committee – non-executive directors remunerationThe overarching policy for the remuneration of the non-executive directors is to award levels of remuneration in line with other comparable NHS foundation trusts, using benchmarked figures from a number of sources.

• The Remuneration Committee made its carefully considered decisions concerning the remuneration of the chief executive and executive directors and there were no substantial changes to policy or approach

• There was some structural change in the portfolios of certain posts during the course of the year and affected posts were subject to further job evaluation

• As a result of a consideration of the job evaluation scores, the internal relativities, benchmarking and market considerations, in addition to the Trust’s financial position, the pay awarded to other staff groups and the wider NHS environment, the committee took a view on the remuneration of each member of the executive team individually

• Overall, increases were awarded to three posts out of a total of nine, together with two temporary retention premiums. Five posts were either new or revised, or a new appointment had been made. These changes were made to take into account internal relativities, the need to retain key post-holders, taking into account the market benchmarking. Retention premiums are payable on a temporary basis and not rolled into base pay. They are awarded where there is a concern that the post is hard to recruit to, particularly bearing in mind the portfolio and the level of skills and experience required; and/or where the post is falling behind market benchmarks. It is fixed at a point which maintains the salary at an appropriate level compared to benchmarked market competitors.

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Non-executive directors’ pay is determined by the Appointments and Remuneration Committee (ARC), a sub-committee of the Council of Governors. The Monitor Code of Governance echoes the general principles concerning probity and transparency which apply to executive directors, and also sets out some additional principles:

• Levels of remuneration should reflect the time commitment and responsibilities of their roles (D.1.2)

• The Council of Governors should

consult external professional advisors to market-test remuneration levels for the Chair and other NEDs once every three years and when they intend to make a material change to their remuneration (D.2.3).

A review of the chair and non-executive directors’ remuneration was carried out in 2014/15. The Council of Governors received a paper which set out the legal and regulatory framework and asked them to consider a Principles Framework for determination of

remuneration before making any decisions on pay. The Council was provided with benchmarked information from other Trusts identifying remuneration levels and time commitments. The ARC met on December 3 2014 and the following attended: Paul Grinnell, Ian Davey, John Frost, Harold Edwards, Max Withrington, Jim Whittingham, Katherine Helley and Neil Pease.

The work of the ARC is in line with the requirements of paragraph 18(2) of Schedule 7 of the Health and Social Care Act 2006.

Annual report on remunerationThe Remuneration Committee is a sub-committee of the Board and was established in accordance with the Trust Constitution and Monitor’s NHS Foundation Trust Code of Governance (July 2014) for the purpose of setting the remuneration of executive directors of the Board and those reporting directly to the chief executive.

The committee is accountable to and reports directly to the Trust Board. Its key objective is to ensure that remuneration packages are sufficient to attract, retain and motivate executive directors of the quality required for the successful operation of the Trust, while avoiding paying excessively for this purpose. Remuneration includes pay, all contractual terms and conditions, pensions and redundancy or settlement entitlements.

The committee also has delegated responsibility for recommending and monitoring the level and structure of remuneration for senior management. The definition of senior management for this purpose will include the first layer of management below board level (see Monitor Code of Governance D.2.2).

The committee is comprised of three non-executives. Other people attend meetings or parts of meetings by invitation as required for specialist advice including the chair, the chief executive, the director

of organisational development and workforce, the director of finance and the Trust secretary. However, in accordance with Monitor’s Code of Governance, no director is involved in deciding his or her remuneration (para D.2.a.)

Between April 1 2014 and March 31 2015, the Remuneration Committee met four times. The table right, illustrates the attendees and their attendance.

Advice to the committeeExternal advice to the Remuneration Committee was provided from two sources, which are detailed below:

The Hay Group. The Hay Group provided job evaluation and remuneration benchmarking from their NHS executive director pay database. They were contracted by the Remuneration Committee to assist in the implementation of the Trust’s Remuneration Strategy, agreed

Name TitleDate of attendance

Alan Bell Chairman

10.7.1431.7.1416.12.1411.2.15

Stan Shreeve Non-executive director

10.7.1431.7.1516.12.1411.2.15

Neil Gammon Non-executive director

10.7.1431.7.1416.12.1411.2.15

Dr Jim Whittingham

Chairman of the Trust Board

31.7.1411.2.15

Dr Neil PeaseDirector of organisation development and workforce

10.7.1431.7.1416.12.1511.2.15

Sarah Mainprize

Head of communications and marketing

11.2.15

Sue MillerIndependent external advisor

10.7.14

Wendy Jones Minute taker 11.2.15

Claire Mason Minute taker 31.7.14


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in 2013/14, which requires formal and independent job evaluation of the chief executive and executive director roles. This provides clarity of job size and relativities which facilitates decision-making on remuneration and enables the Remuneration Committee to minimise risks of equal pay and equal value claims. It also contributes to the transparency of the methods for awarding pay and for the pay decisions themselves and mirrors the Agenda for Change process for other staff. The Hay Group was selected on the advice of Sue Miller Consulting Ltd (see below) as there are very few proprietary job evaluation systems on the market which apply to posts of this seniority and are ‘analytical’ (having a clear and objective underlying methodology to job evaluation). In addition, the Hay Group has a remuneration database of executive posts in the NHS.

In 2014/15, the Hay Group was paid £3,000 for these services which included carrying out job evaluations and writing reports on their findings, together with the addition of benchmarking information.

Sue Miller Consulting Ltd. Sue Miller is an independent HR consultant who provided advice to the Remuneration Committee on the pay and remuneration for the chief executive and executive directors, and non-executive directors. The committee contracts with this company to ensure that advice is independent and objective, as required by the Code of Governance, and to avoid any potential conflict of interest arising from advice being given internally. Ms Miller provided an analysis using the Hay information, to provide proposals to the committee in line with the Trust’s Reward Strategy, ensuring that all elements of the strategy were considered. This company was selected by the then RATS

Committee in 2013/14 from a shortlist provided by the consultancy arm of the Trust’s solicitors at the time, DACBeachcroft, because Sue Miller was considered to have the relevant skills and experience in remuneration and on the provision of advice at Board level, including other Remuneration Committees.

Ms Miller was paid £9,581.65 in 2014/15 for her services, which included the analysis of information, writing of reports and attendance at the Remuneration Committee in relation to executive pay, and the analysis of information and writing of reports for the Appointments and Remuneration Committee for non-executive pay.

Components of the remuneration of executive team and the Trust’s Remuneration StrategyThe Trust agreed a new Reward Strategy in the year 2013/14 which was created in line with a Principles Framework previously agreed; the legal and regulatory framework and good practice. The strategy was designed to take the following issues into account:

• The importance of addressing historical anomalies

• Internal relativities and equal pay between members of the executive team

• Internal relativities in relation to staff on AfC bands reporting in to executive team members

• The positioning of individuals on or below the pay ranges for the posts

• Consideration of the appropriate external market benchmarking information

• The application of the Principles Framework in practice

• The ability to and mechanism for progressing through a scale

• The transparency of decision-making and communication processes.

This was considered to meet the Trust’s strategic objectives through a range of means as set out in the Principles Framework:

• The Trust’s competitive position in attracting, appointing and retaining candidates of the highest calibre from the national market

• The Trust’s competitive position in retaining candidates of the highest calibre from the national market

• The reputation of the Board and the Trust in terms of internal equity

• The reputation of the Board and the Trust in terms of external equity within the Public Sector

• The proposals made by the committee are affordable

• The Executive’s performance/objectives are clearly being achieved and worked through.

Due to historical anomalies in relation to pay and some lack of clarity as to how pay was determined for executive directors, one of the key priorities was to create a scheme which was clear and transparent, and which was both fair and transparent. The Remuneration Committee were advised on a range of approaches and methods with different strategic impact, including different forms of performance-related pay, but this was not considered appropriate at that time. A system was therefore established based on the following elements:

• Job Evaluation to establish job size, enable a consideration of internal relativities and provide assurance – as far as possible – concerning equal pay and equal value

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• Benchmarking against relevant NHS Trusts, and other sectors if appropriate, to assess the market worth of posts, taken from either one or two sources: the Hay Group Database and the IDS NHS Boardroom Survey or the Foundation Trust Network Executive Pay Survey

• A consideration of internal relativities between executive members and also between them and their direct reports on Agenda for Change terms and conditions

• There was a pre-existing contractual agreement for a lease car which was considered necessary due to the geographical location of the Trust’s sites and those of stakeholders and partners, as well as being a retention measure

• Salaries are spot ie not on a range, and there is no performance-related pay

• There is a slightly different approach in alternate years – in year one a fuller review of job descriptions and wider benchmarking; in year two, an annual market review of salaries against relevant NHS benchmarks only.

Affected staff were consulted by being able to comment on the strategy in the previous year when it was proposed; and additional discussions and consultation took place with the external advisor in 2014/15 due to changes in roles and responsibilities.

There are no future policy changes planned in the remuneration of the executive team.

The table to the right sets out the appointment dates of the senior manager, the end dates of their contract and the period of notice they have to provide.

The post of medical director is currently being recruited to. Mr Roberts is applying for the substantive post. If unsuccessful the term will end on commencement of the successful applicant in the role.

Post Contract

Chief executiveKaren Jackson

Appointed: September 2010End date: indefinite termNotice period: three months

Chief operating officerKaren Griffiths

Appointed: April 2014End date: indefinite termNotice period: three months

Director of organisational development and workforceNeil Pease

Appointed: October 2011End date: indefinite termNotice period: three months

Chief nurse and deputy chief executiveDr Karen Dunderdale

Appointed chief nurse: May 2011Appointed as deputy CEO: March 2014End date: indefinite term.Notice period: three months

Medical directorDr Mark Withers

Appointed: January 2014End date: March 2015Notice period: three months

Acting medical directorMr Lawrence Roberts

Appointed: March 2015End date: *Notice period: three months

Director of financeMarcus Hassall

Appointed: August 2014End date: indefinite term.Notice period: three months

Director of performance and assuranceWendy Booth


Director of strategy and planningPam Clipson

Appointed: June 2014End date: indefinite term.Notice period: three months

Director of facilitiesJug Johal


Remuneration of the chairman and non-executivesName Salary 2014/15 Salary 2013/2014

Jim Whittingham £40,000 £40,000

Alan Bell £12,500 £11,573

Anne Shaw £12,500 £11,573

Linda Jackson * £12,500 £11,573

Philip Jackson ** £12,500 £11,573

Neil Gammon £12,500 £11,573

Stan Shreeve

£12,500

£2,426 for chair of Audit Committee

£11,573

£2,426 for chair of Audit Committee

Notes:

The remuneration of the chairman and the non-executives for 2014/15, applied from April 1 2014, was as follows:

*Pro-rata, part year only. Appointed September 30 2014

**Mr Jackson resigned from the Trust on September 30 2014

There were no off-payroll arrangements during 2014/15. This would be discretionary as there is no contractual obligation to pay this.


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Directors’ expensesTen directors claimed expenses during 2014/2015 totalling £10,000 to the nearest £100. In addition to this, four non-executives claimed expenses totalling £5,886.

Senior managers’ remuneration policyAll executive directors have a permanent contract and their appointments are not time limited and the period for serving notice is three months. The remuneration for executive directors does not include any performance-related bonuses and none of the executives receive personal pension contributions other than their entitlement under the NHS Pension Scheme.

The tenure (length) of employment for non-executive directors is set out in the Trust’s constitution and is three years for the chair and non-executive directors, and then subject to re-appointment. Any term beyond six years is subject to rigorous review by the Council of Governors and non-executive directors serving beyond this are subject to an annual reappointment.

No new components were added within the remuneration packages during 2014/15 and they are consistent with the previous financial year.

There is currently no provision within the remuneration policy for payment for loss of office in senior managers’ contracts and no payments have been made during 2014/15. There is a clause in the senior managers’ contract which enables the Trust to reclaim relocation monies if the individual leaves within an agreed period of their appointment, none have been claimed during 2014/15.

There has been no formal consultation regarding senior managers’ remuneration policy but this is something that the committee will consider in the next financial year.

Remuneration component Policy

Base pay Base pay is determined through job evaluation, market benchmarking and internal relativities and is used to attract and reward the right calibre of leadership to deliver the Trust’s short and long-term objectives

Lease car Offered to any member of staff via salary sacrifice

Pension Set at national rates of contribution

Temporary retention premium

A retention premium is paid to reflect the nature of the individual contribution of the post-holder and encourage retention in the face of a difficult recruitment market.

Additional incentive payment for deputy CEO role

This is paid as an additional incentive for the deputy chief executive role

Base pay for consultant post Any doctor working at consultant level receives base pay as part of the consultant contract

Additional programmed activities

Specifically related to doctors and the consultant contract

Clinical excellence award Any consultant can apply for clinical excellence awards in recognition of clinical excellence in practice

On-call payment In relation to executive pay the only board member who could receive remuneration for on call would be the medical director as part of a consultant contract

Remuneration for all other staff Agenda for Change, the nationally introduced pay reform for the NHS which was introduced in October 2004, covers all directly employed staff, except very senior managers and those covered by the Doctors Dentists Pay Review Body. For all local pay arrangements not determined by Agenda for Change, pay increases were consistent with Agenda for Change increases. A robust system of appraisal and personal development planning has been adopted for all staff.

A different approach is adopted in relation to the Trust Executive because all other staff are on national terms and conditions and Executive Team members’ remuneration is determined locally. Agenda for Change staff have clear incremental progression, some performance related, and medical and dental staff are on a separate contractual arrangement which also allows for incremental progression and the award of substantial additional payments for clinical excellence. They are also able to benefit from an annual cost of living award, if this is agreed. It was not felt appropriate for executive team members to be on an incremental scale unless this involved performance-related assessments. The priority was to provide a simple, clear and transparent model which provided an equity of approach and took into account the markets in which such senior posts are operating. Salaries are inclusive and there is no additional cost of living award. Strategically, this strategy is designed to enable the Trust to recruit and retain the level of skills and expertise we cannot effectively function without.

The remuneration policy for senior managers is determined independently to that for employees of the Trust.

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Audited directors' remuneration 2014/152014/15 2013/14

Name and TitleSalary

(bands of £5,000)£000's

Pension Related benefit

(bands of £2,500)£000's

Benefits in kind £00's

Total(bands of £5,000)

Salary (bands of £5,000)£000's

Pension Related benefit

(bands of £2,500)£000's

Benefits in kind £00's

Total(bands of £5,000)

Dr J Whittingham Chairman £35 - £40 - - £35 - £40 £35 - £40 - - £35 - £40

Mrs K Jackson 1 Chief Executive £180 - £185 £20.0 - £22.5 20 £205 - £210 £180 - £185 £45.0 - £47.5 14 £230 - £235

Dr K Dunderdale 1Chief Nurse & Deputy Chief Executive

(appointed Deputy Chief Executive 01/04/14)£130 - £135 £185.0 - £187.5 5 £315 - £320 £100- £105 £147.5 - £150.0 0 £255 - £260

Mrs K Griffiths 1 Chief Operating Officer (appointed 01/04/14) £115 -£120 £207.5 - £210.0 27 £330 - £335 - - - -

Ms A Smithson Chief Operating Officer & Deputy Chief Executive (resigned 31/03/14)

- - - - £130 - £135 £190.0 £192.5 22 £325 - £330

Mr L Roberts 1 Acting Medical Director (apointed 01/03/2015) £5 - £10 £2.5 - £5.0 2 £15 -£20 - - - -

Dr M Withers 1,3Medical Director (appointed on 06/01/2014

and resigned 28/02/2015))£145-£150 £210.0 - £212.5 63 £355 - £360 £35- £40 £22.5 - 25.0 16 £60 - £65

Professor C Sewell Acting Medical Director (01/08/2013 to 05/01/2014)

- - - - £5- £10 £2.5 - £5.0 - £5 - £10

Dr E Scott 4 Medical Director (resigned 31/07/2013) - - - - £45- £50 £35.0 £37.5 - £80 - £85

Mrs W Booth 1,2Director of Performance Assurance & Trust

Secretary £105- £110 £227.5 - £230.0 25 £340 - £345 £90- £95 - 20 £95 - £100

Mr M Hassall 1 Director of Finance (appointed 01/08/2014) £70-£75 £65.0 - £67.5 18 £135 - £140 - - -

Mrs P Clipson 2Director of Strategy & Planning (appointed

13/06/2014) £80- £85 £240.0 - £242.5 7 £320 - £325 - - -

Mr M Rocke 1Director of Finance & Business Support

(resigned 31/07/2014)£40- £45 £25.0 - £27.5 3 £70 - £75 £115- £120 £172.5 - £175.0 2 £290 - £295

Mr J Johal 1Director of Estates & Facilities (appointed

14/08/2014)£55 -£60 £92.5 - £95.0 48 £150 - £155 - - - -

Mr N Myhill Director of Facilities Management (resigned 16/02/2014)

- - - - £75- £80 - £75 - £80

Dr N Pease 1Director of Organizational Development &

Workforce£120 - £125 £22.5 -£25.0 40 £145 - £150 £105- £110 £82.5 - £85.0 17 £195 - £200

Mr P Wisher Director of Diagnostics & Therapeutics (resigned 30/09/2013)

- - - £ 60 - £65 - 15 £60 - £65

Mr A Bell Non Executive Director £10 - £15 - - £10 - £15 £10 - £15 - - £10 - £15

Mr N Gammon Non Executive Director £10 - £15 - - £10 - £15 £10 - £15 - - £10 - £15

Cllr P Jackson Non Executive Director (resigned 30/09/2014) £5 - £10 - - £5 - £10 £10 - £15 - - £10 - £15

Mrs L Jackson Non Executive Director (appointed 30/09/2014)

£5 - £10 - - £5 - £10 - - - -

Mrs A Shaw Non Executive Director (appointed 12/08/2013)

£10 - £15 - - £10 - £15 £5 - £10 - - £5 - £10

Mr S Shreeve Non Executive Director £10 - £15 - - £10 - £15 £10 - £15 - - £10 - £15

Mrs M Wilson Non Executive Director (resigned 31/07/2013) - - - - £0- £5 - - £0- £5

£000 £000 £000 £000 Gross remuneration including national insurance and pension contributions 1,456 258 1,365 106

Band of Highest Paid Director's Total Remuneration (£000) £180-£185 £180-£185Median Remuneration (£000) £22 5 £23 5

Ratio 8.3 6 8.1 6

Notes:

1 - Benefit in kind relates to Lease Cars2 - Benefit in kind relates to Computers3 - Dr M Withers is seconded to another NHS Trust4 - Dr E Scott is presently seconded to Public Health England5 - The median remuneration is the middle item salary when the annualised salaries of all members of

staff including agency and seconded staff, (excluding bank staff and he highest paid director) are arranged in descending order.

6 - The ratio is obtained by dividing the highest paid directors salary by the median salary.


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The chairman and non-executive directors do not receive pensionable remuneration; therefore there are entries in respect of pensions for the chairman and the non-executive directors.

Cash equivalent transfer valuesA cash equivalent transfer value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member’s accrued benefits and any contingent spouse’s pension payable from the scheme. A CETV is a payment by a pension scheme or arrangement to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme.

The pension figures shown relate to the benefits that the individual has

accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which disclosure applied. The CETV figures and the other pension details include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme.

They also include any additional pension benefit accrued to the member as a result of purchasing additional years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries.

The basis of CETV calculations are based in the Department of Work and Pensions regulations which came into force on October 13 2008.

This year the CETVs shows reduction in real term in most cases due to not having any inflation factors applied.

Real increase in CETVThis reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another scheme or arrangement) and uses common market valuation factors for the start and end of the period. No inflation factors have been applied this financial year as per the guidance from NHS Pensions Agency.

Karen Jackson Chief executive

May 22 2015

Audited Pension Benefits 2014/15

Name and Title

Real

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£'000 £'000 £'000 £'000 £'000 £'000 £'000

Mrs K Jackson Chief Executive 0.0 - 2.5 5.0 - 7.5 40 - 45 130 - 135 766 689 58

Dr K Dunderdale Chief Nurse & Deputy Chief Executive 7.5 - 10.0 25.0 - 27.5 40 - 45 130 - 135 698 529 156

Mrs K Griffiths Chief Operating Officer 7.5 - 10.0 27.5 - 30.0 40 - 45 130 - 135 826 611 199

Mr L Roberts Medical Director (Part year) 2.5 - 5.0 7.5 - 10.0 30 - 35 100 - 105 261 230 2

Dr M Withers Medical Director (Part year) 10.0 12.5 30.0 - 32.5 45 - 50 145 - 150 473 691 (217)

Ms W Booth Director of Performance Assurance & Trust Secretary 10.0 - 12.5 30.0 - 32.5 40 - 45 120 -125 685 478 194

Mr M Hassall Director of Finance (Part year) 2.5 - 5.0 7.5 - 10.0 25 -30 85 - 90 467 369 59

Mr M Rocke Director of Finance & Business Support (Part year) 0.0 - 2.5 2.5 - 5.0 55 -60 145 - 150 - 1,052 (360)

Mr J Johal Director of Estates & Facilities (Part year) 2.5 - 5.0 12.5 - 15.0 10 - 15 35 - 40 163 67 59

Dr N Pease Director of Organisational Development & Workforce 0.0 - 2.5 5.0 - 7.5 15 -20 50 -55 267 228 33

Mrs P Clipson Director of Strategy & Planning (Part year) 10.0 - 12.5 32.5 - 35.0 25 -30 80 - 85 335 164 133

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Council of GovernorsOne of the key differences in the management arrangements of a Foundation Trust is that the Board of Directors is no longer accountable to the Department of Health, but to the local communities it serves. In practice, it is the Council of Governors which acts as proxy for the community and it is an important part of the role of the governors to ensure that the Board of Directors does not breach the organisation’s terms of authorisation as a Foundation Trust.

There are at least four meetings of the Council of Governors annually and all of these are held in public. In addition there are several working groups including steering, membership, training and local involvement network groups.

Responsibilities of the Council of Governors include:

• Provide a response when consulted by the Board of Directors

• Appointment and dismissal of the chairman and other non-executive directors

• Setting the salary and conditions of employment of the chairman and non-executive directors

• Appointment of, and if appropriate, removal of the Trust’s external financial auditors

• Acceptance of the Trust’s Annual Accounts and the Auditor’s Report on them and the Annual Report

• To approve the appointment of the chief executive. However, the Council of Governors will not appoint the chief executive.

The Trust chief executive and the other Trust executive directors are appointed by a committee consisting of the non-executive directors, the chairman and the

chief executive (except when a chief executive is being appointed).

The non-executive directors, including the chairman, are appointed by the Council of Governors. In making these appointments, however, the council has to apply certain criteria for eligibility and also to take account of the Trust Board as to the particular skills required.

The Trust has an Appointments and Remuneration Committee for the appointment of non-executive directors (including the chairman, deputy chairman and senior independent director). The committee has delegated authority to consider


88

these appointments on behalf of the Council of Governors, and provide advice and recommendations to the full council in respect of these matters. The committee also periodically reviews the process to be followed for the appointment of the chairman, deputy chairman, senior independent director and non-executive directors, including the means by which views will be obtained from the Trust Board on the qualifications, skills and experience required for each position when considering potential candidates.

The committee also, on an annual basis, reviews the remuneration of non-executive directors in the context of changes to the cost of living. It also reviews no more than every two years the remuneration of non-executive directors with reference to remuneration levels in comparable organisations. It also considers and make recommendations to the Council of Governors for the re-appointment of the lead governor.

The committee is made up of seven governors elected by the Council and is chaired by the lead governor of the Council of Governors. It meets quarterly at a minimum.

The Trust is locally accountable to its members through the Council of Governors (CoG) which represents the interests of the members, members of the public and partner organisations. Governors exercise statutory duties and hold the non-executive directors (NEDs) of the Trust Board to account, who in turn hold the directors to account for the performance of the Trust. Governors are encouraged to act in the best interests of the Trust and are bound to adhere to its vision and values and code of conduct.

Key statutory duties of the governors are to:

• Appoint, and if appropriate, remove the chair and NEDs

• Set the terms and conditions of NEDs

• Approve the appointment of future chief executives

• Appoint or remove the Trust’s external auditor

• Consider the annual accounts, any report from the auditor on them and the annual report

• Be consulted by the Board of Directors on the forward plans for the Trust.

Governors are the link between our members and the general public (determining their needs/views on the delivery of services) and the directors who make decisions about the services (hold responsibility for delivery). Governors are responsible for conveying information from the Board of Directors to members about affordability, service plans and health improvement initiatives. In this way the population served by the Foundation Trust (FT) will be directly involved in its governance.

The Trust’s Council of Governors has 26 elected and nominated governors as follows:

• 15 public governors – they are elected by public members

• Four staff governors – they are elected by staff members

• Seven nominated governors – they are nominated by partner organisations.

The Trust lead governor is Paul Grinell, a public governor for North Lincolnshire.

Governors serve a term of office for up to three years at the end of which time they are able to offer themselves for re-election/re-nomination (serving for a maximum of nine years in total). However, governors cease to hold office if they no longer:

• Live in the area of their constituency (for public governors)

• Work for our Trust (for staff governors)

• Are supported in office by the organisation that they represent (for nominated governors).

The Board of Directors and the CoG enjoy a strong, effective and developing working relationship. Both are chaired by the Trust chairman who acts as a link between the two and each are kept informed of the other’s progress through various means which include:

• Attendance of the Board of Directors at the CoG

• Individual NEDs attendance at CoG sub-groups

• Board highlight reports delivered at the CoG

• Board papers circulated to governors on a monthly basis

• Exchange of meeting minutes

• Planned governor and NED briefings

• Informal updates via the chairman.

It should be noted that governors’ participation in Trust business consists of much more than purely attendance at formal meetings. Throughout 2014/15 governors have taken part in a range of activities including:

• Serving on committees and working groups

• Hosting members’ events

• Hosting governor drop-in sessions at each site

• Hosting local governor and member forums

• Undertaking ward review visits

• Undertaking PLACE assessments

• Participating in membership recruitment activities

• Supporting governor election roadshows

• Supporting Trust award ceremonies

89

• Serving “afternoon tea” as part of nutrition and hydration awareness week

• Participating in staff health and wellbeing events.

Governors also canvass the opinion of the members and the public on the Trust’s forward plan, and they communicate these views to the Board of Directors. The Trust

*Clinical Commissioning Groups

– North East and North Lincolnshire

**Local Authorities (LA)

- East Riding of Yorkshire, Lincolnshire, North East and North Lincolnshire

7 Appointed stakeholder governors

Clinical comissioning

groups*2

Local Authority**

4(shared seats

over 4 LAs)

Hull York Medical School

1

Chairman

Board of DirectorsFocus on services

Non executive directors

Always majority to executive

directors

Executive directors

Plus chief executive

Trust management

team

Council of Governors

(26) Focus on

communities

15 Elected public governors from the following public constituencies

East & West Lindsey

2

Goole & Howdenshire

3

North Lincolnshire

5

North East Lincolnshire

5

4 Elected staff governors from staff constituency

undertakes the initial consultation and engagement on the forward plan with governors via the governor and NED briefings. Governors then engage with members through various channels including the quarterly governor and member forums (for appointed and elected governors). Governors are able to feedback through various mechanisms including the CoG

(where the forward plan is on the agenda at appropriate times throughout the year), and where the Trust’s full executive team/board members sit.

The Trust has in place a longstanding Council of Governors engagement policy. This describes how any disagreements between the Council of Governors and the Board of Directors will be resolved.

Composition of the Trust’s Council of GovernorsThe composition of the CoG, as detailed in the Trust Constitution, is demonstrated in the diagram below, which details the public and staff constituencies, and the governor representation on the CoG:

Work continues through the Governor Steering Group and CoG to ensure all nominated stakeholder governors are identified within partner organisations to fill current vacancies.

Governor elections 2014In accordance with the Model Rules for Election there were two governor elections in 2014. The staff governor elections held in July 2014 resulted in four newly elected governors: Dr Makani Hemadri, Louise Salt, Mr Sid Goel and Antony Whyte. The annual governor elections held in November 2014 resulted in one uncontested seat for North East Lincolnshire, Liz Stones,

who was re-elected and one newly elected governor for the North Lincolnshire constituency, Beryl Allison.

Detailed reports of the elections are available on the Trust website www.nlg.nhs.uk

All governors who have served during the 2014/15 year are listed in the next section with the dates of their terms of office.

Where a governor’s term has ended during the year the reason is given in parenthesis.


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Attendance at Governor Meetings 2014/15Council of Governors Term of office began Term of office ends 30-Apr 18-Jun 23-Jul 11-Sep 11-Nov 29-Jan Total Other Meetings

Mrs Sheila Fisher 23/11/2006 03/12/2015 P A P P P A 4 of 6 0 of 4Miss Iona Scott 31/10/2013 30/10/2016 P A A A A A 1 of 6 N/A

Mrs Susan Diack 08/02/2011 30/10/2016 P P A P P P 5 of 6 8 of 16Mr John Frost 25/04/2013 24/04/2016 A P P A P A 3 of 6 N/AMr Roy Taylor 23/11/2011 03/12/2015 P P P P P P 6 of 6 2 of 7

Miss Helen Blow - resigned 03/12/2012 07/12/2015 P A P A A 2 of 5 2 of 3Mr Ian Davey 03/12/2012 02/12/2015 A P P P A P 4 of 6 N/AMr Jeff Shaw 23/11/2008 30/10/2016 A A P A A A 1 of 6 4 of 5Mrs Esther Smith 31/10/2013 30/10/2016 A A P A A A 1 of 6 2 of 9Ms Liz Stones - re-elected 23/11/2011 22/11/2017 P A A P A P 3 of 6 N/A

Mrs Kath Allen - was not re-elected 03/12/2012 21/11/2014 P P P P P 5 of 5 6 of 6Mrs Beryl Allison - newly elected 21/11/2014 21/11/2017 P 1 of 1 N/AMrs Maureen Dobson 28/11/2007 30/10/2016 P P P P P P 6 of 6 11 of 11Mr Harold Edwards 23/11/2011 03/12/2015 P P P P P P 6 of 6 10 of 13Mr Paul Grinell (Lead Governor) 04/11/2009 03/12/2015 P P P P P P 6 of 6 8 of 8Mr Max Withrington 31/10/2013 30/10/2016 P P P A P P 5 of 6 3 of 4

Mr Sid Goel - newly elected 28/07/2014 28/07/2017 A P A P 2 of 4 N/ADr Makani Hemadri - newly elected 28/07/2014 28/07/2017 P A P A 2 of 4 N/AMrs Louise Salt - newly elected 28/07/2014 28/07/2017 P P A P 3 of 4 N/AMs Jen Smith - resigned 03/12/2012 24/06/2014 A A 2 of 2 N/AMr Tony Whyte - newly elected 28/07/2014 28/07/2017 P P P P 4 of 4 1 of 1

No representative since 06/05/2010 A A A A A A 0 of 6 N/A

Mrs Caroline Briggs 12/02/2014 11/02/2017 P A A A P A 2 of 6 N/A

Mrs Julie Taylor Clark - resigned 22/10/2014 02/02/2015 A 0 of 1 N/AMrs Michelle Barnard - Interim cover 02/02/2015 22/10/2017 P 1 of 1 N/A

Cllr Rob Waltham 19/03/2012 18/03/2015 A A A A A A 0 of 6 N/A

Vacancy N/A

Vacancy N/A

Vacancy N/A30-Apr 18-Jun 23-Jul 11-Sep 11-Nov 29-Jan Total Other meetings

Directors TitleDr Jim Whittingham Chairman P P A P P P 5 of 6 N/AKaren Jackson Chief Executive P A A P P P 4 of 6 N/AKaren Griffiths Chief Operating Officer P P P P P A* 5 of 6 N/ADr Mark Withers Medical Director A A* A A A* P 1 of 6 N/AMike Rocke D irec to r o f F inanc e, P lanning & P erfo rmanc e P P P 3 of 3 N/AMarcus Hassall Director of Finance P P P 3 of 3 N/ADr Karen Dunderdale Chief Nurse, Deputy Chief Executive A A* P P A* P 3 of 6 N/ADr Neil Pease Director of OD & Workforce A P A A A A* 1 of 6 N/AWendy Booth Direc tor of P erf ormanc e A ssuranc e and Trust S ec retary P P P P A* P 5 of 6 N/AJug Johal Director of Estates & Facilities A P P 2 of 3 N/APam Clipson Director of Strategy & Planning P A A P P 3 of 5 N/A

Non-executive DirectorsAlan W Bell P P P P P P 6 of 6 N/ANeil Gammon Deputy Chairman P P P A P P 5 of 6 N/ALinda Jackson P P 2 of 2 N/APhilip Jackson P A P P 3 of 4 N/AAnne Shaw A A P P P 3 of 5 N/AStan Shreeve P P P P P P 6 of 6 N/A

P PresentA AbsentA* Deputy covered for Director absence

Goole & Howdenshire Council

East & West Lindsey Council

Nominated Governors - APPOINTEDHull York Medical School

North Lincolnshire Clinical Commissioning Group

North East Lincolnshire Clinical Commissioning Group

North Lincolnshire Council

North East Lincolnshire Council

Staff Governors - ELECTED

Public Governors - ELECTEDEast & West Lindsey

Goole & Howdenshire


North Lincolnshire

91

Attendance at meetingsIndividual governors’ attendance at the formal meetings of the CoG and other meetings during the 2014/15 year are detailed left. There have been six formal meetings of the CoG (including the annual members’ meeting) during 2014/15, and other meetings attended include the following CoG sub-groups:

• Membership Working Group

• Quality Review Group

• Steering Group

• Steering Group and Healthwatch Group

• Training Working Group

• Appointments and Remuneration Committee.

In addition to the above sub-groups, governors attend governor and member forums held quarterly across all three sites.

It should be noted that the information given with regard to attendance at meetings is relevant only to the meetings that have taken place during each of the governors’ term of office. This is in respect of Mrs Allen, Mrs Allison, Ms Barnard, Miss Blow, Mr Goel, Dr Hemadri, Mrs Salt, Mrs Taylor-Clark, and Mr Whyte.

Declaration of interestsAll governors are required to comply with the Trust’s code of conduct and declare any material, commercial, political or other interests which may result in a potential conflict of interest in their governor role. The Trust maintains a register of these which can be viewed by appointment at the membership office, Modular building, Scunthorpe General Hospital. Alternatively, the electronic version of the register is available on the Trust’s website at: http://www.nlg.nhs.uk/content/uploads/2015/03/Register-of-Governors-Interests-2015.pdf

Governor expenses 2014/2015Although governors receive no payment for their role, a number were paid expenses to reimburse their travel costs incurred while attending meetings and events at the Trust, which amounted to £3,277.22. For comparison, the total figure for the previous period (2013/2014) was £3,140.66.

Governor training and developmentVarious governor and NED briefings have been delivered during 2014/15 as part of the governor training and development programme which help them to assist in their engagement role with members and the public. These have included:

• Holding to account and effective questioning

• Healthy Lives, Healthy Futures – sustainability review update

• Remuneration Committee

• Forward plan

• Morale barometer

• Staffing levels and shift patterns

• Patient experience (including Friends and Family Test)

• Sustainable services update

• Quality priorities 2015/16

• Never Events

• Nursing shift patterns

• Electronic patient record and Web V demonstration

• Providing governor buddy system from more experienced governors

• Completing governor skills set questionnaire to identify developmental needs, which produces the CoG skills profile

• Participate in the annual review of the CoG.

In addition to these formal sessions, monthly one-to-ones and group governor sessions are available with the Trust chairman.

Trust membershipThe Trust’s membership consists of both public and staff constituencies with the public constituency being made up of public members (who have the ability to vote for and elect public governors), and the staff constituency being made up of staff members (who have the ability to elect staff governors).

Public constituencyBecoming a public member of the Trust is voluntary and free of charge and open to anyone aged 16 or above, who lives in an area specified below as an area for a public constituency (subject to the additional grounds for eligibility or disqualification of members described in annex 8 of the Trust Constitution).

The public constituencies are divided into four main areas as detailed in the table on page 92, together with details of the relevant electoral wards.


92

Name of the public constituency

Area of the public constituency by electoral wardsMinimum number of members

Number of governors to

be elected

North Lincolnshire

The wards of:Ashby; Axholme Central; Axholme North; Axholme South; Barton; Bottesford; Brigg and Wolds; Broughton and Appleby; Brumby; Burringham and Gunness; Burton upon Stather andWinterton; Crosby and Park; Ferry; Frodingham; Kingsway/Lincoln Gardens; Ridge; Town.

500 5


The wards of:Croft Baker; East Marsh; Freshney; Haverstoe; Heneage; Humberston and New Waltham; Immingham; Park; Scartho; Sidney; South; Sussex; Waltham; West Marsh; Wolds; Yarborough.

500 5

Goole and Howdenshire

The wards of:Goole North; Goole South; Howden; Howdenshire; Snaith, Airmyn and Rawcliffe and Marshlands.

200 3

East Lindsey The wards of:Binbrook; Grimoldby; Holton Le Clay; Legbourne; Louth North Holme; Louth Priory; Louth St Marys; Louth St Michaels; Louth Trinity; Ludford; Mablethorpe Central; Mablethorpe East; Mablethorpe North; Mablethorpe South; Marsh Chapel; North Somercotes; North Thoresby; Skidbrook with Saltfleet Haven; Sutton on Sea North; Sutton on Sea South; Tetney; Trusthorpe; Withern with Stain. 200 2

West Lindsey The wards of:Caistor; Gainsborough East; Gainsborough North; Gainsborough South West; Hemswell; Kelsey; Scotter; Thonock; Waddingham and Spital; Wold View; Yarborough.

Staff constituencyStaff membership is open to individuals who are employed by the Trust under a contract of employment provided that:

He or she is employed by the Trust under a contract of employment which has no fixed term or has a fixed term of at least 12 months; or

He or she has been continuously employed by the Trust under a contract of employment for at least 12 months.

All qualifying members of staff are automatically invited to become members of the Trust, but are able to opt out if they wish to do so. Individuals who exercise functions for the purposes of the Trust, otherwise than under a contract of employment, may become members of the staff constituency provided such individuals have exercised those functions continuously for a period of at least 12 months.

Current membershipAs at March 12 2015, the Trust had a membership of 11,948. The number of new members for the period of 2014/2015, including staff members was 1,058. The number of members leaving was 941, again, including staff.

This is an overall increase of 117 members. The tables left provide a detailed breakdown:

Figures as at March 12 2015

Total membership overviewAge group – public

membersNo. % Pop*

Public members 5,253 0 to 16 0 0.00% 1.57%

Staff members 6,695 17 to 21 454 8.64% 7.15%

(no DOB) 22 + 4,799 91.36% 91.28%

Total members 11,948 (Not stated) n/a n/a

Total 5,253 100% 100%

* Persons under the age of 16 have been excluded from the calculation of population percentages as they are not eligible for Trust membership.

Breakdown by constituencyConstituency Male Female Not stated Total

Goole and Howdenshire

177 247 3 427


679 1,472 2,151

North Lincolnshire 759 1,301 2,060

East and West Lindsey 228 373 601

Staff 1,257 5,438 14 6,709

Total 3,100 8,831 17 11,948

93

Foundation Trust

Membership Public

Breakdown by socio-economic groupings

Socio-economic groupings (derived from IMD scores above)

Class Number % Pop* %

A,B 2,340 44.55% 43,359 14.83%

C1 514 9.79% 72,864 24.93%

C2 802 15.28% 80,098 27.40%

D,E 1,598 30.43% 95,976 32.84%

*Data for population aged 16-64A Higher managerial, administrative, professional B Intermediate managerial, administrative, professional C1 Supervisory, clerical, junior managerial C2 Skilled manual workers D Semi-skilled and unskilled manual workers E Casual labourers, pensioners, unemployed.

Breakdown by ethnicityEthnicity – public members No. % Pop %

White 4,927 93.81% 372,737 97.62%

Mixed 18 0.34% 1,854 0.48%

Asian or Asian British 87 1.66% 5,529 1.48%

Black or Black British 18 0.34% 882 0.22%

Other 0 0% 786 0.20%

Not stated 202 3.85% 0 0%

The current Trust membership generally reflects the demographic of the population served, and is representative for the majority of categories. Membership recruitment events will be undertaken in 2015/16, some of which will target various groups to further ensure representative membership (eg 16-year-olds through schools and colleges etc).

Membership strategyThe governance structure for Foundation Trusts is explained in the membership strategy, which was rewritten in 2013. This document outlines the:

• Significance of membership for Foundation Trust

• The Trust constituencies (as referenced under the CoG section)

• Communication with members

• Member benefits

• Member recruitment

• Member engagement.

The membership strategy is reviewed and updated by the governors’ Membership Working Group. The full document is available at the following link:

www.nlg.nhs.uk/content/uploads/2014/01/NLG13394-Membership-Strategy.pdf

People living in the constituencies that are served by the Trust can become members, as well as staff who work at the Trust (see above). It is the members who elect the governors who sit on the Council Governors and represent members’ interests in the running of the organisation. In this way members are given a say in the management and provision of services at the Trust. Members are able to engage in establishing the direction of services provision and ensure that hospital services more accurately reflect the needs and expectations of local people (patient-led NHS service).

The diagram below demonstrates this relationship:

All Foundation Trusts have a duty to engage with their local communities and encourage local people to become members of the organisation (ensuring that membership is representative of the communities that they serve). By this method, Foundation Trusts provide greater accountability to patients, service users, local people and NHS staff with the overriding principle being that Trust members have a sense of ownership over the services that they provide.

As governors are elected/appointed by public and staff members they are accountable to those members. In turn, the NEDs are accountable to the governors; this chain of interlocking relationships drives the performance of the organisation and is the mechanism of local accountability.

Governors face both directions. On the one hand they are the link between the local community and its needs and views on the delivery of services, and the directors making the decisions about services and the responsibility for delivery. On the other hand governors need to transmit information from the Board of Directors to the local community about affordability and other constraints.


94

The governors, therefore, at all times link the community and the Trust, and the success of a Foundation Trust very much lies in the success of the governors role in linking the Trust to the community.

Key priorities of the strategy• Membership community –

to uphold our membership community by addressing natural attrition and membership profile short-fallings with member recruitment

• Membership engagement – to develop and implement best practice engagement methods with our members

• Governor development – to support the developing and evolving role of our governors.

Public constituenciesAs detailed below the Trust has a membership community made up of public and staff members aged 16 years and over who live in the area. The public constituencies are defined on the basis of one or more local government electoral areas and comprise of patients, carers and members of the public and aims to be representative of the communities of the Trust. In the table below are the Trust’s public constituencies and the minimum number of members required, together with the number of governor seats per constituency as per the Trust Constitution:

ConstituencyMinimum number of

membersNumber of governors

to be elected

East and West Lindsey 200 2

Goole and Howdenshire 200 3

North East Lincolnshire 500 5

North Lincolnshire 500 5

Staff constituencyThe staff constituency is made up from staff. The Trust can allow people who have carried out functions for the Trust but are not employed by the Trust, ie volunteers, academic staff, nurses and doctors who are employed by a recruitment agency to become members. However to be eligible they must have carried out these functions at the Trust for at least 12 months.

Membership and eligibilityThe Trust has nearly 12,000 members, over 5,000 of which are public members. Eligibility for public membership of the public constituency includes:

• Anyone from the community aged 16 years or over

• Anyone from the community who is interested in the Trust, including local residents, patients, carers and volunteers.

The Trust also currently has more than 6,000 staff members with people being automatically invited to become a member (subject to certain eligibility conditions outlined above), however, staff are free to ‘opt out’ if they prefer. Staff are not eligible to be a member if they have been dismissed as an NHS employee within the last two years or have been involved in a serious incident of violence against a member of staff or registered volunteer, at any of the Trust’s facilities, within the last five years.

As with public members, staff members can also become more involved in the work of the Trust through its CoG with staff members voting for staff governors during the election process.

Becoming a memberMembership to the public constituency is through application to the Foundation Trust membership office, by the following methods:

Website: www.nlg.nhs.uk/about/membership/join/

Telephone: (01724) 387946

Email:

[email protected]

Levels of member engagementSome members will choose to have a very active membership, while others will choose to only receive a newsletter. The level of engagement is up to the individual, and they can choose their level of engagement with the Trust, as demonstrated opposite.

Engaging and communicating with membersAs a Trust we aim to ensure effective two-way communication and appropriate engagement with our members via a combination of Trust and governor managed formal and informal communications.

A ‘welcome pack’ is the first step for our new members and assists with the initial communications, guidance and support.

The membership office maintains regular contact with members using a variety of methods, including:

• Trust website with a designated section for members

• Members’ Portal – a specialist tool for member engagement

95

• Email – for newsletters, invites to meetings and volunteer opportunities

• Face-to-face through members’ events

• Face-to-face through informal governor drop-ins at each site

• Face-to-face through governor and members’ forums

• E-newsletter produced bi-monthly (joint staff and members’ newsletter)

• Twitter and Facebook

• News releases for local media.

There are various opportunities for members to become more involved with the Trust, below are some examples:

• Attending quarterly governor and members’ forums

• Trust promotional members’ events

• Helping to recruit new members

• Voting in governor elections

• Standing for election as a governor

• Fundraising activities

• Participating in surveys

• Participating in consultations on Trust plans

• Joining the Trust’s volunteer services.

Membership Working Group The group consists of governors, Healthwatch representatives, a NED and a representative from the communications and marketing team. The membership manager also sits on the group and leads in implementing member involvement and engagement. The group is also responsible for monitoring the size and composition of the membership to ensure that it continues to be representative of the population served by the Trust and in accordance with the Monitor Compliance Framework. Member recruitment also falls within this group’s remit.

Contact with governorsMembers who wish to discuss issues with individual governors should make contact in the first instance with the membership office. This can be done:

• By telephoning 01724 387946

• By emailing to [email protected]

• By writing to:

Foundation Trust Membership Office,

Modular Building FREEPOST – RRYL – SZKA – SYAU, Scunthorpe General Hospital, Cliff Gardens, Scunthorpe. North Lincolnshire DN15 7BH

The levels of engagementLevel one • as little as:• Receiving newsletters and regular updates• Receiving invites for members’ events and meeting• Receiving voting papers for the governor elections.

Level two • as above and a little more:• Participating in surveys and questionnaires• Attending members’ events• Attending and participating in the quarterly

governor and member meetings• Voting for a governor to represent them in the

election process.•

Level three • as per levels one and two, plus:• Standing for election as a governor• Attending Council of Governor meetings.

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3


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Membership recruitment 2014/2015The Trust has a duty to ensure it engages with its local communities and encourages local people to become members, ensuring that membership is representative of the communities that it serves. The focus this year has been on maintaining membership rather than a large recruitment drive, and greater engagement with current members. This has been achieved with an overall increase in membership. The following are examples of some of the membership recruitment initiatives carried out:

• Members’ portal now available for all Trust members

• Regular updates on the Trust website

• Senior managers meet with community/volunteer groups on request

• Encouraged staff to inform family/friends and people within their local communities about becoming a member

• Membership posters and application forms forwarded to each Trust group/directorate and reception areas

• Production of combined staff and members’ newsletters for existing members with details of how to become a member for family and friends

• Promotional “Become a member” materials established and made available at events

• Poster campaigns.

To further engage with staff members regular articles are submitted to the directorate team brief and weekly staff bulletin. Regular updates are also provided to operational managers’ groups and the Trust Board with additional departmental updates.

Membership database managementMembership office staff ensure that the membership database, which is located on the members’ portal, is accurate, secure, reflects the Trust’s constitution and is resilient enough to support governance arrangements and elections.

This database administration includes:

• Ensuring the database is up-to-date by managing changes of details such as the prompt deletion of deceased members, changes of address are accurate and complete to reduce the risks of mailing to deceased persons

• Preparation of appropriate data extracts for specific member groups as required by the Trust, for any activities being undertaken such as consultation on key areas of interest identified, targeted communications

• Utilising these data extracts to interrogate the membership data and establish the demographics of our members, ensuring that they are representative of our local population.


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Annual governance statement 2014/15

1. Scope of responsibility

As accounting officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the Northern Lincolnshire and Goole NHS Foundation Trust’s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the Northern Lincolnshire and Goole NHS Foundation Trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum.

2. The purpose of the system of internal control

The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of the Northern Lincolnshire and Goole NHS Foundation Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in Northern Lincolnshire and Goole NHS Foundation Trust for the year ended March 31 2015 and up to the date of approval of the annual report and accounts.

3. Capacity to handle risk Leadership and accountabilityThe existing organisational management structure illustrates the Trust’s commitment to effective governance and quality governance including risk management processes. A directorate of clinical and quality assurance was created on Monday September 17 2012 following an extensive consultation exercise. (The directorate’s name was changed to performance assurance in 2014, reflecting changes to the executive director structure and responsibilities).

The key aims of the proposal to introduce the directorate were as follows:

• To continue to raise the profile of governance by ensuring governance (and quality governance) and assurance remain on an equal footing with other organisational priorities

• To ensure that governance, quality and safety are seen as the responsibility of all staff who, in discharging those responsibilities, have access to, and support from, an appropriately skilled and responsive governance support team

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• To ensure that the Trust’s governance, quality and infection control resource is targeted in the right place at the right time with an emphasis on outcomes rather than process and improved quality and safety

• To ensure that during a period of inevitable increased emphasis on cost effectiveness in healthcare, that this is not at the expense of reduced quality or poor governance in our organisation. A devolved management structure describes lines of accountability at appropriate levels with clear clinical and managerial leadership roles being defined.

In line with the principles of devolution within the Northern Lincolnshire and Goole NHS Foundation Trust, and in accordance with the Scheme of Delegation, responsibility for the management/control and funding of a particular risk rests with the directorate/group concerned. However, where action to control a particular risk falls outside the control / responsibility of that domain, where local control measures are considered to be potentially inadequate or require significant financial investment or the risk is ‘significant’ and simply cannot be dealt with at that level, such issues are escalated to the Trust Governance & Assurance Committee, Executive Team or Trust Board for a decision to be made.

Supporting this devolved structure are central non clinical directorates – including as above the directorate of performance assurance. These directorates have a nucleus of experienced and appropriately qualified staff to lead support and advice staff at all levels across the organisation with the identification and management of risk.

Directors individually and collectively have responsibility for providing assurance to the Trust Board on the controls in place to mitigate risks to

compliance with the Trust’s licence. The sub-committees of the Trust Board in turn have responsibility for providing assurance in respect of the effectiveness of those controls. A system of ‘highlight’ reports to the Trust Board is in place to highlight any risks to compliance. A review and strengthening of the Board sub-committees was undertaken during 2014/15 in particular to create a new Resources Committee with a key focus on workforce issues.

The effectiveness of the Trust’s governance structures continued to be tested during 2014/15 via internal and external testing including internally via the Annual Internal Audit Programme and externally via the follow-up reviews of the Trust’s overarching quality governance and clinical leadership arrangements undertaken by KPMG and via the re-visit by the CQC Chief Inspector of Hospitals CQC in April 2014. In respect of quality governance, at re-review the Trust’s overall score was three, a reduction on the previous score of six, calculated in October 2013, reflecting the “progress made with implementation of the original 21 recommendations and the sustainability of the Trust’s processes”. A review of the quality governance arrangements at individual clinical group level was also completed during the latter part of 2014/15 and the report received for comment in April 2015. The outcome from this review will inform the Trust’s governance and assurance plans and arrangements for 2015/16.

Training Through the provision of a comprehensive mandatory training programme which includes governance and risk management awareness – with training sessions being delivered both centrally and within individual directorates/groups and

engaging internal and external trainers, and through individual personal development, staff are trained and equipped to identify and manage risk in a manner appropriate to their authority, duties and experience.

The governance and risk management training programme is reviewed annually by the directorate of performance assurance to ensure that it remains responsive to the needs of Trust staff. There is regular reinforcement of the requirements of the Trust’s Mandatory Training Policy and Training Needs Analysis (which as above includes elements of governance and risk management training) and the duty of staff to complete training deemed mandatory for their role and non-compliance is a feature of the Trust’s ‘Zero Tolerance’ Framework. A key focus during 2014/15 was on ensuring an increase in compliance with mandatory training and appraisal requirements and the Trust met the year end targets set.

Control mechanisms including ‘Learning Lessons’ A single IT Risk Management System (Datix) is in place which links all key risk elements (including incident reporting, complaints / PALS and claims management) and which, in turn, informs the Trust’s Risk Register (which is also held on Datix). Lessons learned when things go wrong are shared throughout the organisation via a range of mechanisms including safety alerts, ‘learning lessons’ newsletters,


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governance forums and via the dedicated ‘Learning Lessons’ Review Group, which was implemented to ensure that lessons learned following incidents/complaints and PALS and claims are effective and are widely disseminated. Further mechanisms for ensuring the sharing of transferrable lessons – as well as good practice – continued to be explored. A key success in this regard during 2014/15 has been the development of the Group Quality and Safety Days which bring together multi-disciplinary teams to discuss quality and safety issues and ensure the sharing of transferrable lessons from incidents, complaints and claims. The surgery and critical care group has led the way with this development. However, plans are in place to ensure these days are replicated and embedded in all clinical Groups during 2015/16.

The Trust Board routinely considers specific risk issues and receives minutes from Board sub-committees including the Audit Committee, Trust Governance and Assurance Committee and the Quality and Patient Experience Committee. The Trust Governance and Assurance Committee, on behalf of the Trust Board, routinely receives information on Serious Untoward Incidents (SUIs) including lessons identified and learnt. The Trust is also a member of and provides assurance to commissioners on its arrangements for investigating and learning from SUIs via a community-wide SUI Collaborative Group.

The Trust actively encourages networking and has strong links with relevant central bodies, eg National Health Service Litigation Authority (NHSLA), Health and

Safety Executive (HSE), and acts on recommendations/alerts from these bodies as appropriate.

The Trust continues to develop its relationship with the CQC – escalating risks/concerns in respect of patient safety/quality as they occur, together with the actions taken or proposed, and in order to provide assurance that the Trust Board has appropriate oversight of its quality governance/patient safety risks. Quarterly relationship meetings are held.

The Trust also routinely considers and acts upon the recommendations of relevant national high level enquiries (eg Mid Staffordshire/Francis, etc) through the use and monitoring of robust action plans.

4. The risk and control frameworkThe management of riskThe Trust has in place a Risk Management Strategy which is reviewed by the Trust Board annually.

The Northern Lincolnshire and Goole NHS Foundation Trust is committed to the management of risk (both clinical and non-clinical) in order to improve the quality of care; provide a safe environment for the benefit of patients, staff and visitors by reducing and, where possible, eliminating the risk of loss, harm or damage; and protecting its assets and reputation. This is achieved through a process of identification, analysis, evaluation, control, elimination and transfer of risk.

The Trust’s Risk Management Strategy is an integral part of the Trust’s approach to continuous

quality improvement and is intended to support the Trust in delivering the key objectives within the Quality Strategy as well as ensuring compliance with external standards, duties and legislative requirements.

Risks are identified routinely from a range of reactive and pro-active and internal and external sources including workplace risk assessments, analysis of incidents, complaints/PALS, claims, external safety alerts and other standards, targets and indicators etc. These are appropriately graded and ranked and included on the Trust’s Risk Register. A Risk Register – ‘Confirm or Challenge’ Group is in place to review and monitor risks added to the Risk Register and quarterly reports from the Risk Register are submitted to the Trust Governance and Assurance Committee and Trust Board. The Trust has also identified a non-executive director to lead the challenge in respect of the Risk

Register and to report to and provide assurance or escalate risk issues to the Board as part of the submission of the quarterly Risk Register reports. The Trust recognises that, as risks can change and new risks can emerge over time, the review and updating of risks on the risk register is an ongoing, dynamic process.

Risk Management is embedded in the activity of the organisation by virtue of robust organisational and committee structures. Of fundamental importance is the Trust’s commitment to the ongoing development of a ‘fair blame’ culture, where incident reporting is openly and actively encouraged and the focus when things go wrong is on ‘what went wrong, not who went wrong’, and a progressively ‘risk aware’ workforce. The Trust also has in place long standing ‘speaking out’ and safeguarding policies and procedures. These arrangements ensure that staff can raise issues of

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concern regarding care and safety – outside of the line management relationship where this is felt to be required.

The Trust agrees annual governance/risk management objectives/Key Performance Indicators (KPIs), which are shared through the business planning and performance management frameworks. Business Planning and Service Development proposals do not proceed without an appropriate assessment of and therefore recognition/acceptance of the risks involved and the involvement of the relevant risk management, health and safety and fire expertise.

The Trust also has in place an Assurance Framework, which is designed to assist the Trust in the control of risk. The Framework incorporates and provides a comprehensive evidence base of compliance against a raft of internal and external standards, targets and requirements including CQC registration requirements, Information Governance Toolkit Standards, Safety Alerts etc. Assurance to the Trust Board on compliance with these requirements is provided via quarterly Trust Assurance Framework reports and is supported by a robust Internal Audit Programme. The quarterly Trust Assurance Framework report routinely captures, and the Trust Board considers, the information held by the CQC about the Trust which is contained within the CQC Intelligent Monitoring Reports.

The Trust currently holds Level 2 Accreditation in respect the NHSLA Risk Management Standards for Acute Trusts and was awarded Level 2 Accreditation in respect of the CNST Maternity Standards following assessment in March 2014. Whilst formal assessment against these standards are no longer undertaken by the NHSLA, the Trust continues to refer to these standards as good practice.

The Trust also has in place a range of mechanisms for managing and monitoring risks in respect of quality including:

• The Trust has in place a Quality Strategy which has been endorsed by the Trust Board. The Trust Board also agrees annual quality objectives

• The Trust has in place a Quality and Patient Experience Committee (a sub-committee of the Board) which meets monthly and is chaired by a non-executive director. The Quality and Patient Experience Committee is responsible for monitoring performance against the agreed annual quality objectives. The minutes of the Quality and Patient Experience Committee are submitted to the Trust Board

• The Trust has published Annual Quality Accounts in 2008/09, 2009/10, 2010/11, 2011/12, 2012/13, 2013/14 and has prepared its 2014/15 Quality Account

• A Quality Report, which reports progress against the above-mentioned key quality objectives in year is prepared and submitted monthly to the Quality and Patient Experience Committee and the Trust Board. This monthly report in turn informs the annual Quality Account. The submission of this monthly report ensures that the Trust Board focuses on quality in the same way that it has historically considered finance and performance

• The Trust has in place arrangements and monitoring processes to ensure ongoing compliance with other service accreditation standards eg bowel screening, colposcopy, cancer, CPA, MHRA (for blood

products) and HTA licences for mortuary and post mortems etc

• The Trust Governance and Assurance Committee monitors performance with NICE guidance implementation and minutes of that committee are submitted to the Trust Board. Compliance with NICE guidance is also monitored, internally via the performance review process and externally via the Commissioner Quality Contract Group

• The medical director has the lead for mortality. The Mortality Performance and Assurance Committee, a sub-committee of the Trust Board chaired by the Trust’s chairman, monitors mortality and morbidity statistics and provides a monthly update to the Trust Board. While historically, mortality information was included on a quarterly basis within the monthly Quality Report, a separate monthly Mortality Report has been in place since 2012 and is submitted to the Mortality Performance Committee, the Quality and Patient Experience Committee and the Trust Board. The Quality and Patient Experience Committee retains a challenge/assurance role. A refresh of these arrangements was undertaken during 2014/15 not least to ensure the required level of clinical engagement

• Ward standards have been introduced and are monitored via a programme of unannounced ward reviews


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• A programme of announced and unannounced (executive and non-executive) director visits is also in place to all wards and departments – clinical and non-clinical – in order to ensure that there is ‘Board to Ward’ oversight and ownership of quality and safety issues. Director forums were also introduced during 2013. The purpose of these forums is to allow staff to raise concerns or showcase good practice directly with board members

• The Trust has identified non-executive directors to lead the challenge in respect of specific aspects of governance including HCAI, risk management and the risk register, mortality, falls, pressure ulcers and quality and patient experience and during 2013/14 in respect of complaints. These challenge roles are reviewed annually

• Within the revised management structure introduced in July 2011, the directorate of the chief nurse has responsibility for focusing on the quality of the patient experience and is the Board lead for quality and the patient experience

• A nursing dashboard is in place to monitor the nursing contribution to safety and quality

• The Trust routinely considers and acts upon the recommendations of national quality benchmarking exercises, eg national patient surveys

• The Trust acts upon patient feedback from complaints and concerns and from feedback from Patient and Public Involvement (PPI) representatives (eg HealthWatch)

• Patient Stories are presented to QPEC and the Trust Board monthly and actions and lessons learnt are widely shared.

CQC: Registration and essential standards of quality and safety During April 2014, the Trust received a visit by the CQC Chief Inspector of Hospitals. The outcome from the visit was that the Trust ‘requires improvement’. No significant concerns were identified and issues were not felt to be systemic and reflected the need for embedding of some of the actions put in place post-Keogh.

As at the end of March 2015, the Northern Lincolnshire and Goole Hospitals NHS Foundation is not fully compliant with the registration requirements of the Care Quality Commission (CQC). While the majority of actions are complete, some actions will not be completed until 2015/16 in accordance with the Trust’s Quality Development Plan (QDP). These timescales were agreed with the CQC and regular reports of progress against the Trust’s action plan are provided to the CQC. Any slippage and the mitigating actions are also outlined within the QDP. Re-inspection by the CQC is expected during Q1/Q2 of 2015/16.

Information governance (IG) and data security (including serious information governance incidents)The Trust continues to strengthen its arrangements for Information Governance and has the following arrangements in place:

• An Information Governance Steering Group, a sub-committee of the Trust Governance and Assurance Committee

• An Information Security Policy

• Compliance at Level 2 or above across all 45 requirements within the Information Governance Toolkit which has

been independently verified by Internal Audit and ‘significant assurance’ provided.

In respect of data security the following arrangements are in place:

• A security feature at login to the Trust network, giving guidance to users and requiring acceptance of ‘rules of use’

• IT policies which take account of updated national requirements

• A ‘best practice’ IT security awareness leaflet

• The encryption of all removable/portable devices including laptops, USB pens and CDs, specifically:

Laptop encryption has been completed on all laptops/clinical tablets

Encrypted USB pens have been allocated to staff

Support for the use of staff who own PDA devices has been removed, floppy drives have been blocked from use, no machines are purchased with floppy drives as standard and port blocking software has been implemented

CD/DVD writers are not issued as a standard piece of equipment. Where the use of these writers is required, the creation of data on these devices is covered by Trust policies

The creation of data on PACs CDs is governed by Trust policy and encryption ability is available. Tracking procedures are in place for CDs sent off site.

During 2014/15, the Trust reported one serious incident relating to a confidentiality breach. This incident was classified as Level 2 in the Information Governance Reporting Tool and was reported to the Information Commissioner’s Office (ICO). The ICO was satisfied with the Trust’s response to this incident. Lessons learnt were shared across the Trust.

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Patient and public involvement (PPI)The Trust ensures that public stakeholders are involved in understanding the risks which impact upon them by a variety of means: the principal amongst these being the operation of the Council of Governors and during 2012/13 the introduction of Board meetings held in public. The council meets at least five times per year in public and receives a comprehensive report on performance (and risks of non-delivery) on each occasion. These reports are published along with the rest of the council papers on the Trust internet site.

A PPI policy and procedure is also in place and reflects the requirements of the DOH guidance ‘Real Involvement’ and the comments from PPI representatives.

Additionally, the Trust engages actively with three OSCs and continues to collaborate closely with the three local HealthWatch organisations. A protocol for joint

working with Health Watch is in place and is reviewed annually and opportunities for joint working have been agreed.

The Trust’s comprehensive internet website provides the public with ready access to information across all areas of Trust activity and the organisation also uses its newsletter for members to inform the public of new developments and items of interest.

NHS Pension SchemeAs an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the scheme regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments in to the scheme are in accordance with the scheme rules, and that member pension scheme records are accurately updated in accordance with the timescales detailed in the regulations.

Equality, diversity and human rights Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with.

Carbon reduction The Trust has undertaken a review of its carbon emissions in line with the NHS Carbon Reduction Strategy and Climate Change Act. The Trust has a Carbon Trust approved Carbon Management Plan in place which sets out reduction delivery plans. The Trust’s Estates and Facilities Group oversees work to reduce emissions, ensures compliance with the Climate Change Act and how these impact on emergency preparedness. The group also ensures the Trust is compliant with the Carbon Reduction Commitment and Energy Performance Directive.

5. Review of economy, efficiency and effectiveness of the use of resources The Trust’s clinical activities are managed under a devolved management structure, governed by a Scheme of Delegation renewed and refreshed annually. The Trust has adjusted its clinical management structure to better support effective leadership of clinical services and ensure effective care, following a review commissioned from KPMG in 2013. This structure has been implemented through 2014/15, with the medical director supported by two part time deputy medical directors (who will continue to be engaged in clinical front line work),

and six associate medical directors (AMD), covering each clinical group. Each AMD will lead a team of clinical leads for individual service areas.

The finance directorate provides dedicated support to clinical groups and to non-clinical directorates through nominated business accountants. They support management teams in these areas.

Support to the clinical and non-clinical structure of the organisation on business planning, performance and information technology

support is provided by the new directorate of strategy and planning. This directorate was created in July 2014 as a result of the changes to management structures set out in the Fit for the Future Two document, in order to more closely link strategy development


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The Trust maintains a strong focus on performance management. All directorates and groups are explicitly made responsible for the delivery of financial and other performance targets through a system of performance agreements which are agreed and documented as part of the annual business planning cycle and monitored through a series of regular performance meetings chaired by the chief executive.

The Financial Framework adopted annually by the Trust Board contains an overarching assessment of the strategic planning climate within which the framework has been constructed and sets out the mechanisms by which the key risks emanating from the strategic context are to be managed. This assessment reflects both the national planning context and the local context; and recognises the financial planning context for the public sector as a whole; especially the expectation for significant efficiencies on an ongoing basis.

The Trust conducts a comprehensive review of the in-year progress of the Business and Financial Framework in the form of a Mid-Year Review report – any issues or emerging risks not previously identified within the original Framework are identified and mitigating actions recommended and actioned during this process.

The Trust Resources Committee provides assurance to the Trust Board as to the achievement of the Trust’s financial plan and priorities and, in addition, acts as the key forum for the scrutiny of the robustness and effectiveness of all cost efficiency opportunities. It interfaces with the other Trust Board committees and the Trust Executive Team and also has particular regard to the work of the Strategy and Planning Group, which sets the agenda and co-ordinates the process of business planning, specific business case development, and

capital programme management.

Compliance is further assured through quarterly monitoring and annual planning processes with auditors. The Trust is developing an improved internal audit programme, based on key business governance themes with new internal audit providers KPMG, designed to enhance focus on business governance process and support improved compliance.

The Trust, building upon the lessons learnt following the 2013 Keogh review process, understands that robust front line clinical services are the real purpose of the organisation, delivering effective quality outcomes for patients. The Trust is proactive and continuously reviews and realigns its structure where necessary, to allow it to adapt and respond to the rapidly changing business environment brought about by the changes in the economy, the NHS environment, competitive markets and patient pathway best practice.

The Trust has also enhanced its focus on workforce planning in order to secure a more consistent supply of appropriately skilled and qualified staff to carry out front line service delivery, specifically to review plans for future workforce numbers and to oversee implementation processes, working jointly with commissioners and other local provider organisations. In support of this work the Trust has developed an Organisational Development and Workforce Strategy which has been endorsed by the Trust Board.

Following the Keogh Review in June 2013, Monitor, the regulator of Foundation Trusts, found the Trust in breach of its licence (specifically the requirement to secure economy, efficiency and effectiveness) and in August 2013 the Trust was placed in ‘special measures’. Following the review process, and the visit of the CQC team to carry out a full

across the wider health economy with service planning in clinical service areas.

In order to further enhance the level of assurance in respect of economy, efficiency and effectiveness of resources, Trust Board commissioned in 2014 a review of all financial governance arrangements. This was undertaken in two stages. The first was carried out by KPMG, and concentrated on the compliance of systems with financial governance best practice. Positive assurance was received from this process, with a number of follow-up actions agreed.

The second stage was carried out by PwC, and looked more widely at underlying financial performance, in the context of the whole local health economy. The report on this stage proposed that the Trust adopt a more project based approach to savings delivery, given past performance in this area had fallen short of national savings and efficiency targets.

In response to this, the Trust established a new PMO-style approach to savings delivery. The Sustainability Programme Governance (SPG) Team was established in November 2014, with support from PwC and others, and has established a comprehensive programme of action, including 2014/15 rapid cost reduction measures, a refocused and comprehensively documented 2015/16 plan, and enhanced governance oversight arrangements. Some measure of progress was identified in quarter four of 2014/15, with significant further progress anticipated in 2015/16.

The Trust will also carry out a further follow on exercise to review and update all Trust Board policies which fall under the financial governance remit. This will build upon the normal annual review of the SFIs and Scheme of Delegation immediately following completion of the planning round for 2015/16.

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inspection, the specific ‘special measures’ sanction was removed in July 2014.

The Trust retained its Monitor red governance override for 2014/15 while the outstanding clinical leadership issues were addressed and following notification from Monitor of its intention to work with the Trust to understand its financial situation. On April 8 2015 and within the context of a wider sustainability gap across the local health economy, in which work is ongoing to address sustainability in the longer term, Monitor issued enforcement undertakings stating

that the Trust had not demonstrated that it has established and effectively implemented systems and/or processes to ensure compliance with its duty to operate economically, efficiently and effectively

While noting the above qualification, the Trust is satisfied that it otherwise has robust internal control mechanisms in place and these are subject to robust and regular internal and external review.

The processes and review work established by the Trust have been designed to supply corrective actions for any failures in delivery of services in an economic,

effective and efficient manner. The Financial Governance Review work undertaken in 2014 established an outline assessment of structural cost premium facing the Trust because of its configuration and also laid the foundations for a corrective savings programme addressing those issues within the Trust’s control. This work was used as the basis for the Trust’s Sustainability Programme for 2015/16, which was again subject to external review, covering both scale and content, through the involvement of the regulator, the Trust’s independent Improvement Director, and PwC as programme advisors.

6. Annual quality report

The directors of Northern Lincolnshire and Goole NHS Foundation Trust are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended) 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 in the NHS Foundation Trust Annual Reporting Manual.

The following arrangements are in place within Northern Lincolnshire and Goole Hospitals NHS Foundation Trust to assure the Board that the Quality Account presents a balanced view and that there are appropriate controls in place to ensure the accuracy of data:

Governance and leadership: • The Trust has appointed a

member of the Board, the chief nurse, to lead on quality. The chief nurse, supported by the

medical director and director of performance assurance, advises the Trust Board on all matters relating to the preparation of the Trust’s annual Quality Account

• The Trust’s director of strategy and planning is responsible for providing the information and performance data which informs the Annual Quality Account. An Information services manager, to whom this responsibility is delegated, is also in post

• The Trust’s director of performance assurance is responsible for ensuring that there are mechanisms in place for assuring the quality and accuracy of the performance data which informs the Annual Quality Account including external testing as appropriate. A head of performance, to whom this responsibility is delegated, is also in post.

• Policies and plans in ensuring quality of care provided:

• Policies and procedures are in place in relation to the capture and recording of patient data

• Clinical coding follows national guidelines in addition to a local policy, as per the Audit Commission’s guidelines.

Systems and processes: • Systems and processes are in

place for the audit and validation of performance data both centrally (through the data quality team) and at operational level. Weekly meetings are held to review waiting time data.


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People and skills: • All staff involved in collecting

and reporting on quality metrics are suitably trained and experienced

• All PAS users have to receive training before being issued a password, and individual user activity is auditable

• Clinical coding is regularly audited both internally and externally and audits also take place with individual clinicians.

Data use and reporting:• As above, monthly Quality

Reports, which outline the Trust’s performance against key quality objectives including benchmarking and comparative

data, and are the subject of discussion and challenge at every monthly Quality and Patient Experience Committee and Trust Board meeting, inform the annual Quality Account

• The Trust also considers and acts upon information received via the Dr Foster alerts and the CQC Intelligent Monitoring Reports and the information also informs the relevant Trust action plans eg mortality

In preparation for the requirement for a published audit opinion in the 2014/15 Quality Account, the purpose of which is to provide assurance on the arrangements in place to ensure Quality Accounts are fairly stated and in respect of the accuracy of the information and indicators within the report, audit

review will be undertaken. This will involve sample testing in respect of a number of mandated quality indicators including for 2014/15 the accuracy and reporting of waiting time data.

The report arising from the audit review, including any gaps in assurance and remedial actions required, will be agreed through the Trust’s Audit Committee and submitted internally to the Trust Board and Council of Governors and externally to Monitor. As with the 2013/14 remedial actions, the action plan will be monitored via the Quality and Patient Experience Committee.

The Trust Board also now receives quarterly data quality reports via the monthly Quality Report.

7. Review of effectiveness

As accounting officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, clinical audit and the executive managers and clinical leads within the Northern Lincolnshire and Goole NHS Foundation Trust who have responsibility for the development and maintenance of the internal control framework.

I have drawn on the content of the Annual Quality Report attached to this Annual Report and other performance information available to me.

My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised on the implications

of the result of my review of the effectiveness of the system of internal control by the Trust Board, the Audit Committee, the Trust Governance and Assurance Committee and the Quality and Patient Experience Committee and a plan to address weaknesses and ensure continuous improvement of the system is in place.

The head of internal audit provides me with an opinion on the overall arrangements for gaining assurance through the Assurance Framework and on the controls reviewed as part of the internal audit work (Appendix A refers). The Assurance Framework and the monthly performance reports provide me with evidence that the effectiveness of the controls in place to manage the risks to the organisation achieving its principal objectives have been reviewed.

Gaps in controlsThe following control issues arose during 2014/15:

Keogh and special measuresThe Trust was one of 14 included in the Keogh Review process because of higher than expected mortality rates. Arising from the Keogh Review Visit to the Trust in June 2013, and as part of their Enforcement Undertakings, the Trust was placed in ‘special measures’ by Monitor, the regulator of Foundation Trusts.

The Trust implemented all of the Keogh recommendations and following inspection by the CQC Chief Inspector of Hospitals in April 2014, and whilst some actions were required arising from that visit, the Trust was removed from ‘special measures’ in July 2014. In October 2014, Monitor issued compliance certificates which formally recognised the progress

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made. However, given Monitor’s notification of its intention to work with the Trust to understand its financial situation, the Trust retained its red governance override during 2014/15. As outlined in section 5 above, in April 2015, the Trust was formally found to be in breach of its Licence, specifically conditions CoS3(1)(a) and (b), CoS3(2)(c), and FT4(5)(a),(d), and (f), The Trust will therefore retain the red Monitor governance override, although Monitor has confirmed, and the Enforcement Undertakings which have been agreed, reinforce that this position relates to the financial position / wider system sustainability and not to any concerns regarding the Trust’s leadership and governance systems and processes.

In respect of internal sustainability, savings plans have been agreed for 2015/16. Risks to delivery will be identified and mitigating actions agreed via the programme governance arrangements in place.

In respect of wider system sustainability (Healthy Lives, Healthy Futures – HLHF), the NLaG CEO has been released part-time to lead on the delivery of the HLHF Sustainability Plan. The Trust Board has approved the appointment of a substantive deputy chief executive to support release of the NLaG chief executive to lead this work and to ensure no loss of leadership capacity at Executive Team/Board level.

CQC Chief Inspector of Hospitals VisitAs outlined in section four above, as at the end of March 2015, the Trust is not fully compliant with the registration requirements of the Care Quality Commission (CQC). An action plan is in place to address the compliance actions identified (some actions are not due to be completed until 2015/16 in accordance with the Trust’s QDP). Re-inspection by the CQC is expected during Q1/Q2 of 2015/16.

A&E performanceThe Trust breached its A&E target in quarters three and four. This reflects the considerable activity pressures locally and is also consistent with the position nationally. While the Trust aims to meet this target during 2015/16 and will take all actions within its control, there remains a risk to delivery due to factors/system issues outside the Trust’s control. A number of actions have already been taken and plans are in place including work with other local providers. Performance against all targets is monitored on an ongoing basis by the Trust Board as part of scrutiny of the monthly Performance Compliance reports.

Maintenance and review of the effectiveness of the system of internal control has been provided by comprehensive mechanisms already referred to in this statement. Further measures include:

• Regular reports to the Trust Board from the Trust’s Risk Register including NED review/challenge

• Regular risk management activity reports to the Trust Board covering incidents, complaints/PALS and claims analysis and including details of lessons learnt/changes in practice

• Receipt by the Trust Board of minutes/reports from key forums including the Audit Committee, Trust Governance and Assurance Committee, Mortality Performance Committee and the Quality and Patient Experience Committee

• The ongoing development of the Trust Assurance Framework

• Further independent external review by KPMG of the Trust’s board assurance and self-certification processes. While no significant control issues were identified arising from that review, some

actions were identified for further strengthening the Trust’s arrangements and these have been implemented during 2014/15

• Actions arising from the above review included the further refinement of the approach to self-certification at annual/forward plan to include consideration of assurances from the clinical audit process and the attendance of the head of quality at the annual Trust Board self-certification event. The Trust’s Annual Planning and Self Certification Protocol was also updated to reinforce the requirement to ensure that there is sufficient focus on the prospective nature of the self-certification process for service performance targets

• Review by KPMG during 2014/15 of the Trust’s response to the Keogh recommendations

• Consideration of a monthly Quality Report, allowing the Trust Board to monitor performance in respect of agreed quality objectives. The information contained within this monthly report, in turn, informs the Trust’s Annual Quality Account

• The provision and scrutiny of a monthly Performance Compliance Report to the Trust Board, which covers a combination of specific licence and key contractual obligations and including the identification of key risks to future performance and mitigating actions


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• The provision of the monthly Trading Report to the Trust Board. As with the Compliance Report this report includes the identification of key risks to future performance and mitigating actions

• A follow-up review by KPMG was also undertaken in March 2014 and confirmed that the Trust has made good progress with the implementation of the original recommendations and calculated the Trust’s score as being three this an improvement from the previous score of six. (Note: Monitor requires Foundation Trusts to self-assess against their Quality

Governance Framework and maintain performance of a score of 3.5 or less.)

• The completion and submission to the Trust Board in February 2013 of an initial gap analysis against the recommendations within the report of the Francis Inquiry and the updating of that analysis and the development of an action plan in March 2013. Monitoring of actions agreed arising from that process and the implementation of the agreed actions continued to occur via the Trust Governance and Assurance Committee with escalation to the Trust Board, as appropriate.

The validity of the Corporate Governance Statement has been provided to me by the relevant Board sub-committees – most notably the Trust Governance and Assurance Committee and the Audit Committee, both of whom have considered and commented on this statement, and by the external auditors.

All of the above measures serve to provide ongoing assurance to me, the Executive Team and the Trust Board of the effectiveness of the system of internal control.

8. Conclusion

In conclusion, where issues have been identified during 2014/15, action has been taken or action plans are in place to address the gaps in control identified. The Trust Board is satisfied that plans are adequate to ensure delivery of these targets or improvements during 2015/16. Where appropriate these action plans will be tested via relevant external scrutiny and review processes including the planned follow-up inspection by the CQC Chief Inspector of Hospitals during Q1/ Q2.

Karen Jackson Chief Executive

May 22 2015

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Appendix A

Head of internal audit opinion on the effectiveness of the system of internal control at Northern Llncolnshire & Goole NHS Foundation Trust for the year ended 31 March 2015Head of Internal Audit Opinion to Northern Lincolnshire & Goole NHS Foundation Trust


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Basis of opinion for the period April 1 2014 to March 31 2015

The purpose of our HoIA opinion is to contribute to the assurances available to the accountable officer and the Board which underpin the Board’s own assessment of the effectiveness of the system of internal control. This opinion will in turn assist the Board in the completion of its AGS, and may also be taken into account by other regulators to inform their own conclusions.

The opinion does not imply that the HoIA has covered all risks and assurances relating to the organisation. The opinion is substantially derived from the conduct of risk-based plans generated from a robust and Management-led Assurance Framework. As such it is one component that the Board takes into account in making its AGS.

OpinionOur opinion is set out as follows:

• Basis for the opinion

• Overall opinion; and

• Commentary.

The basis for forming our opinion is as follows:

• An assessment of the design and operation of the underpinning Assurance Framework and supporting processes

• An assessment of the range of individual assurances arising from our risk-based internal audit assignments that have been reported throughout the period. This assessment has taken account of the relative materiality of these areas; and

• An assessment of the process by which the Trust has assurance over its registration requirements of its regulators.

Our overall opinion for the period April 1 2014 to March 31 2015 is that:

Significant assurance with minor improvement opportunities can be given on the overall adequacy and effectiveness of the organisation’s framework of governance, risk management and control.

CommentaryThe commentary below provides the context for our opinion and together with the opinion should be read in its entirety.

Our internal audit service has been performed in accordance with KPMG’s internal audit methodology which conforms to Public Sector Internal Audit Standards. As a result, our work and deliverables are not designed or intended to comply with the International Auditing and Assurance Standards Board (IAASB), International Framework for Assurance Engagements (IFAE) or International Standard on Assurance Engagements (ISAE) 3000. PSIAS require that we comply with applicable ethical requirements, including independence requirements, and that we plan and perform our work to obtain sufficient, appropriate evidence on which to base our conclusion.

Roles and responsibilitiesThe Board is collectively accountable for maintaining a sound system of internal control and is responsible for putting in place arrangements for gaining assurance about the effectiveness of that overall system.

The Annual Governance Statement (AGS) is an annual statement by the Accountable Officer, on behalf of the Board, setting out:

• How the individual responsibilities of the accountable officer are discharged with regard to maintaining a sound system of internal control that supports the achievement of policies, aims and objectives

• The purpose of the system of internal control as evidenced by a description of the risk management and review processes, including the Assurance Framework process; and

• The conduct and results of the review of the effectiveness of the system of internal control including any disclosures of significant control failures together with assurances that actions are or will be taken where appropriate to address issues arising.

The Assurance Framework should bring together all of the evidence required to support the AGS.

The head of internal audit (HoIA) is required to provide an annual opinion in accordance with Public Sector Internal Audit Standards, based upon and limited to the work performed, on the overall adequacy and effectiveness of the organisation’s risk management, control and governance processes (ie the system of internal control). This is achieved through a risk-based programme of work, agreed with Management and approved by the Audit Committee, which can provide assurance, subject to the inherent limitations described below.

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Our opinion covers the period April 1 2014 to March 31 2015 inclusive, and is based on the 14 audits that we completed in this period.

The design and operation of the Assurance Framework and associated processes

Overall our review found that the Assurance Framework in place is founded on a systematic risk management process and does provide appropriate assurance to the Board.

The Assurance Framework does reflect the organisation’s key objectives and risks and is reviewed on a quarterly basis by the Board. It was reviewed by the Board on March 24 2015.

The range of individual opinions arising from risk-based audit assignments, contained within our risk-based plan that have been reported throughout the year.

We issued one ‘significant assurance’ and nine ‘significant assurance with minor improvement opportunities’ opinions in respect of our 2014/15 assignments. The ‘significant assurance’ opinion related to information governance and the nine ‘significant with minor improvement opportunities’ opinions related to our reviews of core financial systems, risk management and Board Assurance Framework, review of Board and sub-committee meetings, clinical governance, data quality, reference costs, safeguarding, officer’s expenses and working with partners.

We also issued four ‘partial’ and no ‘no’ assurance opinions in respect of our 2014/15 assignments. The four ‘partial’ assurance opinions related to workforce, procurement (estates and facilities), revalidation, and review of self-assessment against Monitor’s Well-Led Framework.

We raised 11 high risk recommendations relating to:

• Workforce – A report was issued by the previous Internal Auditors in September 2013 in relation to medical staffing – job plans, containing a total of six recommendations all with an implementation date of December 2013. This report has been followed up and while progress has been made, this is not in line with the dates agreed by management in the finalised report. The Trust is going through a team job planning exercise and now has a policy and paperwork to put the job plans onto. Some job plans have been completed and it is anticipated that further progress will be made before the year end

• The Trust agreed that it needs to increase the pace at which these plans are being developed so that all relevant plans are in place as soon as possible. The recommendation was accepted and this work stream is a key aspect of the financial turnaround programme currently being delivered

• Subsequent to receiving our audit report, the Trust’s response plan is demonstrating a strong impact as, per a recent report to the Audit Committee; at the end of 2014/15 90 per cent of staff now have job plans agreed or are in the process of being agreed.

• Procurement (estates and facilities) – The Trust’s Procurement Strategy was last formally approved in January 2007. While a new strategy was developed in summer 2014, it did not cover all areas of procurement systems and strategy that would provide a comprehensive plan for development moving forward. The Trust agreed to build on the work undertaken in 2014 to complete the process of renewal on the Procurement Strategy.

• Revalidation – Since the commencement of the revalidation process, 207 doctors have been revalidated. While this is adequate progress, a lack of emphasis on the importance of this process has prevented the Trust from progressing further. Our review of revalidation raised seven high risk recommendations relating to policy, staffing, appraisees, performance review process, systems and responding to agreed actions. Accepting there has been a high staff turnover in this area and there has been a loss of some corporate knowledge, the Trust has agreed to move these areas forward at the earliest convenience

• Review of Self-Assessment against Monitor’s Well Led Framework – The consolidated self-assessment against the requirements of the full Monitor Well Led review included a number of gaps. The Trust agreed to review the areas identified as being not covered in the self-assessment and ensure that these are addressed


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in order to meet the requirements of a formal, independent assessment against Monitor’s Well Led Framework. Our high priority recommendation does not suggest that governance is not effective, but it is important that the Trust is properly prepared for its Well Led review.

• Working with Partners (this report received significant assurance with minor improvement opportunities) – The Trust recognises the need to better understand its partnership working arrangements and the Director of Strategy and Planning has developed a Service Development Tracker (the Tracker) identifying the Trusts existing and proposed partnerships, including where relevant responsibilities lie, governance, financial and performance monitoring arrangements etc. The Trust agreed that the Tracker should be completed at the earliest opportunity, cascaded throughout the Executive Team and kept as a live document which should be updated as new partnership arrangements come into effect.

This does not prevent us from issuing significant assurance with minor improvement opportunities as the organisation has either implemented or is implementing the recommendations raised as a result of our work to address the issues identified.

KPMG LLP Chartered Accountants Leeds

13 May 2015

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Financial reviewMonitor has directed that foundation trusts’ financial statements should meet the accounting requirements of the NHS Foundation Trust Annual Reporting Manual (FT ARM), as agreed with HM Treasury.

Our financial statements have been prepared in accordance with the 2014/15 FT ARM and follow International Financial Reporting Standards (IFRS) and HM Treasury’s Financial Reporting Manual to the extent to which they are meaningful and appropriate to NHS foundation trusts. Accounting policies are applied consistently in dealing with items considered material in relation to the accounts.

The Trust reports a headline deficit of £21.07million for the year. This is the second consecutive year of deficit for the Trust, and reflects the significant financial stresses facing acute provider organisations across the NHS. These are forecast to continue into 2015/16.

This headline figure includes a number of balance sheet revaluation and review adjustments. When these are excluded, the Trust’s underlying

trading deficit for the year is £18.41million. This figure is the most appropriate for comparison with the planned deficit figure for the year of £5.94million.

The Trust’s forecasts at the start of 2014/15 had anticipated a challenging year – both in terms of securing sufficient income base from commissioners, and also in terms of controlling expenditure in the face of growing demand for services. Performance through the year has borne this out.

At the heart of the Trust’s financial position is a fundamental issue common to the majority of acute providers – income available from commissioners for hospital services has seen little or no increase, yet providers have had to accommodate both inflation pressures and also

the costs of treating increased numbers of patients. The Trust has no intention of allowing the safety of patient services to be compromised through ill-advised reductions in the resources available for frontline care, and has already made significant savings across other areas. Further work must continue to deliver further expenditure savings. However, the misalignment of income when compared with the costs of delivering the required level of services to an acceptable quality standard will remain a fundamental issue. This issue cannot be solved by the Trust alone.


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The Trust initially set a deficit plan after risk adjusting its income forecasts to reflect the planning priorities of key local clinical commissioning groups (CCGs). The Trust had hoped to secure a revised contractual settlement which would have replaced the activity based charging arrangements based on the national tariff. The Trust has also participated in wider community analysis that has suggested that the Trust’s multi-site configuration brings with it additional costs which cannot be accommodated within tariff. In the event, only partial success was achieved on this front.

The work carried out during the year has however helped in bringing the wider health economy closer for planning purposes. This is essential for the future sustainability of services.

Activity levels have continued to rise – a result of a population which is growing and ageing. Particular pressures have been felt in urgent care services, in demand for diagnostic procedures, and in the use of high cost drug treatments.

These are all areas with significant delivery costs to the Trust. Payment arrangements often do not recompense providers for the full costs of delivery in these areas, particularly where the staff and resources needed to deliver are available only at a premium.

The Trust has continued to add capacity to accommodate increased workload, opening beds and increasing staffing levels to support increased occupancy rates and the increased acuity of those patients being admitted. Diagnostic services have also been expanded to meet increased demand.

Workforce pressures have been a major contributory factor in the Trust’s financial position also. There are national shortages of staff across many key clinical areas, and the Trust’s geographical position

and configuration make it harder to recruit than in other parts of the country.

Difficulties in recruiting doctors are long standing, but major issues have also been faced this year to recruit sufficient registered nursing staff to support the required increases in capacity. The Trust cannot leave frontline understaffed and unsafe, and has had to cover the gaps with locum and agency staff – at a significant premium cost.

This has added a further significant pressure on expenditure levels. The accounting policies for pensions and other retirement benefits are set out in notes 1.6 and 9.7 to the accounts and the details of the senior employees’ remuneration can be found on page 85 of the remuneration report.

The Trust delivered £9.09million of its savings plan, and also delivered a further £0.99million of in year cost increase mitigation. The total of £10.08million represented just over three per cent of turnover.

However, the Trust target for the year was £13.25million. The net shortfall on delivery was a further component of the financial deficit.

The Trust has taken action in year to improve delivery of savings schemes, and with the advice of Monitor has established a significantly increased support team to help plan and deliver projects. This has had a marked impact in year, and has significantly improved the planning for next year.

The Trust held cash balances of £21.16million at the end of the March. Significant progress was made with local CCGs in the final quarter on cashflow and debtor improvements, and an agreement is in place to maintain the improved position achieved by March into next year.

The Trust holds loan funds remain set aside for specific business development purposes:

• Energy improvement investments (due to complete in 2015/16)

• Staff Accommodation improvements (due to continue into 2016/17)

• Reprovision and redevelopment of the Grimsby hospital site linked to the ongoing land sale project (due to complete in 2015/16).

Excluding loans funds held the underlying cash position is £5.51million.

The Trust has been in close contact with Monitor throughout the year, having identified well before the start of the year the likely difficulties that the organisation would face in 2014/15. This has generally been a positive process, with sharing of information and advice. The Trust was able to identify issues and take appropriate corrective action where it was empowered to do so. Nevertheless, Monitor has undertaken a thorough review of the Trust’s financial position. They have not identified any further significant actions that they would expect the Trust to undertake, and have stated that they do not have material concerns in respect of systems of financial governance or leadership. However, looking forward into 2015/16, the Trust forecasts a significant deficit, and that the local health economy will require external resource support. In these circumstances, Monitor had no option but to declare the Trust in breach of its licence in April 2015.

The Trust already has in place a short term recovery plan, and must deliver it. The Trust is confident it will do so. However, as Monitor have noted, the Trust cannot resolve its financial issues alone. The challenge is one for both the whole local health community and also system regulators.

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Revenue from Patient Care Activities 296.044

Other Operating Revenue 34.413

Reversal of Impairments 0.603

331.06

£ million

Clinical commissioning groups 293.7

Private patients/RTA etc 2.3

Education and training 10.2

Other income 24.8

331.0

Income and expenditureAs an NHS Foundation Trust we receive most of our income from service level agreements with our commissioners for services provided, based on the nationally/locally agreed tariff, For the year 2014/2015, the income details are given below:

Table 1

Clinical Commissioning Groups 293.7

Private patients/others 2.3

Education and training 10.2

Other income 24.8

7%

3%

1%

89%

Clinical Commissioning GroupsPrivate patients/othersEducation and trainingOther income

£ million

Services received from Other NHS Trusts/bodies 5.2

Medical pay 67.3

Nursing pay 70.7

Scientific/therapeutic/prof. tech. 38.3

Health care assistants-support staff 25.1

Other pay 33.8

Supplies and services 64.6

Establishment and premises 22.9

Depreciation and impairments 9.2

Other non pay 11.8

Total 348.9

3%3%

7%

19%

10%

7% 11%

20%

19%

1%

Services received from Other NHS Trusts/bodiesMedical payNursing payScientific/therapeutic/prof. tech.Health care assistants-support staffOther paySupplies and servicesEstablishment and premisesDepreciation and impairmentsOther non pay

£ million

Services received from Other NHS Trusts/bodies 5.2

Medical pay 67.3

Nursing pay 70.7

Scientific/therapeutic/prof. tech. 38.3

Health care assistants-support staff 25.1

Other pay 33.8

Supplies and services 64.6

Establishment and premises 22.9

Depreciation and impairments 9.2

Other non pay 11.8

Total 348.9

Public dividend capital 3.3

What we spend out income on:

The income from the provision of goods and services for the purposes of the health service in England is greater than the income from the provision of goods and services received for any other purpose.


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Looking ahead 2015/16:The same pressures facing acute services will continue into next year – income levels will either remain unchanged or be further reduced, yet demand on services will continue to increase, and inflationary pressures will push up underlying costs.

The Trust will have the same pressures. An ambitious savings programme is agreed, with significantly improved delivery support, and momentum already achieved in the latter part of last year – but even if delivered in full, it will not offset the impact of restricted income and increased pressures on expenditure. The underlying financial position will deteriorate, not improve, in 2015/16.

The Trust will not sacrifice service quality or safety in order to try to close this gap. The hard won improvements in services seen in the last two years cannot be reversed. Nor will the Trust be looking to restrict access to services for local people – waiting times and other access standards should and must be maintained.

The Trust could attempt to shift the cost burden onto commissioner organisations, through refusing to sign up to contract income levels which did not support real costs of delivery. However, through improved community planning, it is clear that the Commissioner’s funding allocations would not be sufficient to close the gap. And the interests of patients and the taxpayer would not be well served by such a confrontational strategy – local organisations need to be working together to solve the problems we face.

Though the Trust has a significant opening cash balance, a large proportion is pre-committed to upcoming essential capital developments, which will significantly improve the medium term financial position and longer term viability of the Trust and its services. It would be foolish to plan for short term gain at the expense of longer term sustainability.

This leaves the Trust in effect to bear the burden for the wider local health community. All current projections suggest that the Trust, and the local health economy as a whole, will require significant external financial support, starting from the middle of 2015/16.

The Trust has been working hard with other local organisations all year to develop an effective strategy for longer term financial stability, and has developed a three-part forward plan, which in many ways mirrors the “Five Year Forward View” published by new NHS England chief Simon Stevens:

First, the Trust must deliver all potential improvements in its own operating efficiency. This is reflected in the planned savings delivery target over five years of in excess of £40million. There is a limit to the pace at which such savings can be delivered. Nevertheless, the Trust has set the target high for 2015/16, with a target of over £15million savings in year.

Secondly, the whole health community will have to work together to support the redesign of pathways and service configurations to deliver more effective pathways and to reduce pressure of activity demand on services. This is a complex task, requiring a major transformation of planning processes, and the engagement of clinical staff from across all

service areas working together. This process is essential to longer term sustainability and viability of services, but it will take time. Through the Healthy Lives Healthy Futures project, major progress has been made in the last six months. We will start to deliver gains in 2015/16, but the greatest gains will take longer.

Finally, however, there remains an underlying gap between available resources over the next five years and the costs of delivering necessary services to acceptable standards. Nationally, Simon Stevens quantified this as £8billion by 2020. Current estimates put the local health community equivalent at around £30million over the same timeframe, even assuming strong delivery on the other elements of the sustainability agenda. Longer term resourcing arrangements nationally remain unclear – but there will need to be a national response to what is a problem across the sector.

For 2015/16, the Trust has discussed options with Monitor throughout 2014/15, and now has resolved to apply for central funding support as soon as it has submitted its plan to Monitor in May. This is not an action taken lightly by the Trust – but having reviewed the options, it is the only step that can be taken now to protect local services while longer term solutions are sought.

2015/16 will be an extremely challenging year. The Trust will simultaneously have to maintain effective services, deliver challenging efficiencies, and play a central role in the longer term work to be taken forward across the health community.

Marcus Hassall

Director of finance

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Independent auditors’ report to the Council of Governors of Northern Lincolnshire and Goole NHS Foundation Trust


118

119

Independent auditors’ report to the Council of Governors of Northern Lincolnshire and Goole NHS Foundation Trust

Report on the financial statements

Our opinion In our opinion, Northern Lincolnshire and Goole Group NHS Foundation Trust’s (“the Trust’s”) group financial statements and parent Trust’s financial statements (the “financial statements”):

• give a true and fair view of the state of the Group’s and of the Parent Trust’s affairs as at 31 March 2015 and of the Group’s income and expenditure and Group’s cash flows for the year then ended 31 March 2015; and

• have been properly prepared in accordance with the NHS Foundation Trust Annual Reporting Manual 2014/15.

Emphasis of matter – Going Concern In forming our opinion on the financial statements, which is not modified, we have considered the disclosures made in note 1 (Accounting Policies) concerning the Trust’s ability to continue as a going concern and the preparation of the financial statements on a going concern basis. Following the Trust reporting an £21.3m deficit in the year ended 31st March 2015, and the third successive year of a net outflow of cash, the Trust is currently developing plans for the continuity of its services. It anticipates that it will receive external financial support through Public Dividend Capital to ensure that it is able to meet its liabilities and provide ongoing healthcare services.

However, the extent and nature of any financial support, including whether such support will be forthcoming or sufficient is not yet certain. Therefore there is uncertainty around how the Trust will ensure that the continuity of services will be achieved. These conditions indicate the existence of material uncertainty, which may cast significant doubt about the Trust’s ability to continue as a going concern. The financial statements do not include the adjustments that would result if the Trust was unable to continue as a going concern.

What we have audited The Group’s and Trust’s financial statements comprise:

• the Consolidated and Parent Trust’s Statement of Financial Position as at 31 March 2015;

• the Consolidated Statement of Comprehensive Income for the year then ended;

• the Consolidated Statement of Cash Flows for the year then ended;

• the Consolidated Statement of Changes in Taxpayer’s Equity for the year then ended;

• the accounting policies; and

• the notes to the financial statements, which include other explanatory information.

Certain required disclosures have been presented elsewhere in the Annual Report, rather than in the notes to the financial statements. These are cross-referenced from the financial statements and are identified as audited.

The financial reporting framework that has been applied in the preparation of the financial statements is the NHS Foundation Trust Annual Reporting Manual 2014/15 issued by the Independent Regulator of NHS Foundation Trusts (“Monitor”).

Our audit approach - Overview

• Overall Group materiality: £6,609,140 which represents 2% of total revenue.

• The audit was conducted at the trusts Grimsby site, the Diana Princess of Wales Hospital, where the Trust’s finance function is based, and all three Hospital sites are in scope. The group all includes the Trust’s Charitable Funds, a fully-owned subsidiary.

• Going concern/financial sustainability; • Risk of fraud in revenue and expenditure recognition; and • Valuation of land and buildings


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Northern Lincolnshire and Goole NHS Foundation Trust context Northern Lincolnshire and Goole NHS Foundation Trust provides services to over 350,000 people. The Trust runs the following hospitals:

• Scunthorpe General Hospital • Grimsby’s Diana, Princess of Wales Hospital; and • Goole and District Hospital.

The Trust also provides community health services in North and North East Lincolnshire from a variety of locations.

The Trusts principal commissioners are North Lincolnshire Clinical Commissioning Group (CCG) and North East Lincolnshire Clinical Commissioning Group (CCG). The CCGs represents over 88% of the trusts revenue.

The Trust provides a full range of hospital services to the local community including emergency and intensive care, medical and surgical care, elderly care, paediatric and maternity care as well as diagnostic and clinical support.

The scope of our audit and our areas of focus We conducted our audit in accordance with International Standards on Auditing (UK and Ireland) (“ISAs (UK & Ireland)”).

We designed our audit by determining materiality and assessing the risks of material misstatement in the financial statements. In particular, we looked at where the directors made subjective judgements, for example in respect of significant accounting estimates that involved making assumptions and considering future events that are inherently uncertain. As in all of our audits, we also addressed the risk of management override of internal controls, including evaluating whether there was evidence of bias by the directors that represented a risk of material misstatement due to fraud.

The risks of material misstatement that had the greatest effect on our audit, including the allocation of our resources and effort, are identified as “areas of focus” in the table below. We have also set out how we tailored our audit to address these specific areas in order to provide an opinion on the financial statements as a whole, and any comments we make on the results of our procedures should be read in this context. This is not a complete list of all risks identified by our audit.

Area of focus How our audit addressed the area of focus

Going concern/financial sustainability As part of our audit work, we are required to consider the ongoing financial position of the Trust and the appropriateness of the going concern principle. The NHS Foundation Trust Annual Reporting Manual 2014/15 requires that the financial statements should be prepared on a going concern basis unless management either intends to apply to the Secretary of State for the dissolution of the NHS foundation trust without the transfer of the services to another entity, or has no realistic alternative but to do so. The Trust’s overall position at year end is a £21.3m deficit which was behind the originally planned deficit of £6m. The Trust’s cash balance is also behind plan and the budget for 2015/16 includes the need for external finance support through Public Dividend Capital in order for the Trust to remain solvent. The deterioration of the Trust’s financial position has led to Monitor placing a licence condition on the Trust. Monitor is also investigating the Trust’s in respect of financial governance and sustainability.

We have focused on reviewing the assumptions within and consequences of the Trust’s forecasted financial performance.

In considering the financial performance of the Trust we have:

- Obtained a list of material balances owing to and from other health bodies through the national balance agreement exercise at 31 March 2015 and assessed their recoverability by considering historic patterns;

- understood the Trust’s budget, cash flow forecasts and levels of reserves, and the impact of cash flow sensitivities on the Trust’s ability to meet its liabilities as they fall due; and

- challenged the assumptions behind the Trust’s financial forecasts by comparing them to Monitor forecasting guidelines, including the potential for further downsides.

The financial plan for 2015/16 indicates that the Trust will require external financial support in order to meet its liabilities and provide ongoing services. The nature of any financial support is not yet confirmed.

Therefore it is not clear at present how the continuity of the Trust’s services will be achieved. The Trust is currently working with its key commissioners as well as other locally based provider organisations to share financial planning information in order to build an integrated community wide financial plan.

As the Trust is dependent upon receiving additional financial support, and currently has no agreement for this, there is a material uncertainty, which may cast significant doubt about the Trust’s ability to continue as a going concern.

Risk of fraud in revenue and expenditure recognition Under ISA (UK&I) 240 there is a rebuttable presumption that there are risks of fraud in revenue recognition. There is a risk that the Trust could adopt accounting policies or treat income transactions in such a way as to lead to material misstatement in the reported revenue position. We extend this presumption to the recognition of expenditure in the

Revenue and expenditure We evaluated the accounting policy for income and expenditure recognition to ensure that it is consistent with the requirements of the NHS Annual Reporting Manual and noted no issues in this respect.

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Area of focus How our audit addressed the area of focus NHS We focused on this area because there is a heightened risk due to: • The significant majority of the Trust’s income (88%)

is received from Clinical Commissioning Groups and NHS England, which are in effect, related parties to the Trust. As such, there is an increased risk that this income could be fraudulently recognised, and this could result in: - material amounts of fictitious revenue being

recognised; and/or - material amounts of revenue being recorded in

the incorrect period. • the inherent complexities contractual arrangements

entered into by the Trust; and • The trust being under increasing financial pressure.

The deficit for the year is £21.3m, and whilst the trust is looking at ways to maximise revenue and reduce cost, there is an incentive for management to recognise as much revenue as possible in 2014/15 and defer expenditure to 2015/16.

We consider the key areas of focus are: • Recognition of revenue and expenditure; • Manipulation of journal postings; • Management estimates (revaluation of Plant, Property

and Equipment, accruals, provisions, deferred income, and bad debt provision).

For Clinical Commissioning Group income, we obtained and reconciled the income to a signed contract and correspondence between the Trust and the CCG. We also tested a sample of reconciling items to confirm they related to agreed contract variations. We tested a sample of revenue transactions recognised after the year end to confirm that the amount of revenue recognised was accurately and appropriately recognised in 2014/15. We tested a sample of transactions before and after the year-end, confirming that the cut off procedures had been appropriately applied, that transactions and the associated income or expenditure had been posted to the correct financial year. Intra- NHS balances We obtained the Trust’s mismatch reports received from Monitor, which identified balances (debtor, creditor, income or expenditure balances) that were disputed by the counterparty. We then checked that management had investigated all disputed amounts over the investigation threshold set by Monitor, namely £0.25m, and discussed with them the results of their investigation and the resolution. We also read correspondence with the counterparties, which validated these explanations. We then considered the impact, if any, that the remaining disputed amounts would have on the Trust’s financial statements and determined that there was no material impact. Journal postings We selected a sample of manual and automated journal transactions that had been recognised in both income and expenditure, focusing in particular, on those with a higher risk rating when considering the following factors:

• Materiality; and • Key word assessment, e.g. description includes “error”

We used data analysis techniques to identify a sample of journals that had higher risk characteristics. We traced these journal entries to the supporting documentation (for example, invoices, and cash receipts and payments). Recognition and measurement of estimates. We evaluated and tested management’s accounting estimates focusing on:

• Provisions; • Deferred revenue; and • Plant Property and Equipment valuation.

We evaluated and challenged the accounting estimates and the basis of their calculation by:

• Compared assumptions used by management in the calculation of their estimation against independent assumptions for reasonableness; and

• Tested the data used to calculate the estimate against source data.

From the testing performed we did not note any material issues. We also performed a ‘look back’ test to compare the estimate made at 31 March 2014 to the actual outturn in the year in order to test the Trust’s historical estimating accuracy. From this testing we have not identified any indication of material management bias.

Valuation of Land and Buildings We have focussed on this area because Property, Plant and equipment (“PPE”) represents the largest balance in the Trust’s statement of financial position. PPE is valued at

We obtained and read the relevant sections of the full valuation performed by the Trust’s Valuers. We have utilised our valuations expertise and evaluated and challenged the assumptions and methodology applied in the valuation


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Area of focus How our audit addressed the area of focus £138.4m. All property, plant and equipment assets are measured initially at cost with land and buildings being subsequently measured at fair value based on periodic valuations. The valuations are carried out by professionally qualified valuers in accordance with the Royal Institute of Chartered Surveyors (RICS) Appraisal and Valuation Manual, and performed with sufficient regularity to ensure that the carrying value is not materially different from fair value at the reporting date. A full valuation was undertaken during 2014/15 by the Trust’s valuation experts. This valuation has resulted in an impairment of the Land and Buildings balance of £2.6m. The valuation of Land and Buildings requires significant levels of judgement and technical expertise in choosing appropriate assumptions therefore our work has focussed on whether the valuer’s methodology, assumptions and underlying data, are appropriate and correctly applied.

exercise. We found the assumptions and methodology applied to be consistent and in line with our expectations.

We assessed the competence and objectivity of the Trust’s valuers by obtaining evidence of their qualifications, resources, objectivity and approach, which didn’t identify any issues”.

We tested the underlying data upon which the valuation was based back to floor plans for a sample of properties. We found the valuation to have been based on appropriate and up to date floor space data.

We tested a sample of new additions to land and buildings in the year to confirm they had been appropriately valued – this involved agreement back to supporting invoice.

We physically verified a sample of assets to confirm existence and in doing so assessed whether there was any indication of physical obsolescence which would indicate potential impairment.

We considered the disclosures in the financial statements and were satisfied that they appropriately reflected the valuation undertaken in the period

We reviewed whether the change in valuation was appropriately disclosed in the annual report and correctly reflected in management’s corresponding accounting entries.

How we tailored the audit scope We tailored the scope of our audit to ensure that we performed enough work to be able to give an opinion on the financial statements as a whole, taking into account the structure of the Group, the accounting processes and controls, and the environment in which the Group operates.

Materiality The scope of our audit was influenced by our application of materiality. We set certain quantitative thresholds for materiality. These, together with qualitative considerations, helped us to determine the scope of our audit and the nature, timing and extent of our audit procedures and to evaluate the effect of misstatements, both individually and on the financial statements as a whole.

Based on our professional judgement, consistent with last year, we determined materiality for the financial statements as a whole as follows:

Overall Group materiality £6,609,140 (2014: £6,380,941).

How we determined it 2% of revenue

Rationale for benchmark applied

We have applied this benchmark, which is a generally accepted measure when auditing not for profit organisations, because we believe this to the most appropriate financial measure of the performance of a Foundation Trust.

We agreed with the Audit Committee that we would report to them misstatements identified during our audit above £330,457 (2014: £321,135) as well as misstatements below that amount that, in our view, warranted reporting for qualitative reasons.

Other required reporting in accordance with the Audit Code for NHS foundation trusts The Audit Code for NHS Foundation Trusts requires us to report where we have not been able to satisfy ourselves that the NHS Foundation Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. The Trust was removed from special measures on 17th July 2014, however, the additional license condition issued on 6th August 2013, to the Board of Directors and the Council of Governors remains in place and Monitor is investigating financial governance and sustainability concerns at the trust, triggered by a deterioration in the trust’s financial position. On 8th April 2015, Monitor issued enforcement undertakings stating that the Trust has not demonstrated that it has established

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and effectively implemented systems and/or processes to ensure compliance with its duty to operate economically, efficiently and effectively. As a result of the matters discussed in the notice issued by Monitor and referred to above, we are unable to satisfy ourselves that Northern Lincolnshire and Goole NHS Foundation Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the year ended 31 March 2015. Opinions on other matters prescribed by the Audit Code for NHS foundation trusts In our opinion:

• the information given in the Strategic Report and the Directors’ Report for the financial year for which the financial statements are prepared is consistent with the financial statements; and

• the part of the Directors’ Remuneration Report to be audited has been properly prepared in accordance with the NHS Foundation Trust Annual Reporting Manual 2014/15.

Consistency of other information

Under the Audit Code for NHS foundation trusts we are required to report to you if, in our opinion:

• information in the Annual Report is: − materially inconsistent with the information in the audited financial statements; or − apparently materially incorrect based on, or materially inconsistent with, our

knowledge of the Trust acquired in the course of performing our audit; or − otherwise misleading.

We have no exceptions to report arising from this responsibility.

• the statement given by the directors on page 20, in accordance with provision C.1.1 of the NHS Foundation Trust Code of Governance, that they consider the Annual Report taken as a whole to be fair, balanced and understandable and provides the information necessary for members to assess the Group’s and Parent Trust’s performance, business model and strategy is materially inconsistent with our knowledge of the Group’s and Parent Trust acquired in the course of performing our audit.


• the section of the Annual Report on page 86, as required by provision C.3.9 of the NHS Foundation Trust Code of Governance, describing the work of the Audit Committee does not appropriately address matters communicated by us to the Audit Committee.


• the Annual Governance Statement does not meet the disclosure requirements set out in the NHS Foundation Trust Annual Reporting Manual 2014/15 or is misleading or inconsistent with information of which we are aware from our audit. We are not required to consider, nor have we considered, whether the Annual Governance Statement addresses all risks and controls or that risks are satisfactorily addressed by internal controls.

We have no exceptions to report arising from this responsibility

Quality report including economy, efficiency and effectiveness of resources

Responsibilities for the financial statements and the audit Our responsibilities and those of the directors As explained more fully in the Directors’ Responsibilities Statement, the directors are responsible for the preparation of the financial statements and for being satisfied that they give a true and fair view in accordance with the NHS Foundation Trust Annual Reporting Manual 2014/15.

Our responsibility is to audit and express an opinion on the financial statements in accordance with the National Health Service Act 2006, the Audit Code for NHS Foundation Trusts issued by Monitor and ISAs (UK & Ireland). Those standards require us to comply with the Auditing Practices Board’s Ethical Standards for Auditors.

Under the Audit Code for NHS Foundation Trusts we are required to report to you if, in our opinion:

• we have not been able to satisfy ourselves that the Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources.

We have qualified our certificate in this respect. See above

• we have qualified, on any aspect, our opinion on the Quality Report

We have no exceptions to report arising from this responsibility


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This report, including the opinions, has been prepared for and only for the Council of Governors of Northern Lincolnshire and Goole NHS Foundation Trust as a body in accordance with paragraph 24 of Schedule 7 of the National Health Service Act 2006 and for no other purpose. We do not, in giving these opinions, accept or assume responsibility for any other purpose or to any other person to whom this report is shown or into whose hands it may come save where expressly agreed by our prior consent in writing.

What an audit of financial statements involves An audit involves obtaining evidence about the amounts and disclosures in the financial statements sufficient to give reasonable assurance that the financial statements are free from material misstatement, whether caused by fraud or error. This includes an assessment of:

• whether the accounting policies are appropriate to the Group’s and Parent Trust’s circumstances and have been consistently applied and adequately disclosed;

• the reasonableness of significant accounting estimates made by the directors; and

• the overall presentation of the financial statements.

We primarily focus our work in these areas by assessing the directors’ judgements against available evidence, forming our own judgements, and evaluating the disclosures in the financial statements.

We test and examine information, using sampling and other auditing techniques, to the extent we consider necessary to provide a reasonable basis for us to draw conclusions. We obtain audit evidence through testing the effectiveness of controls, substantive procedures or a combination of both.

In addition, we read all the financial and non-financial information in the Annual Report to identify material inconsistencies with the audited financial statements and to identify any information that is apparently materially incorrect based on, or materially inconsistent with, the knowledge acquired by us in the course of performing the audit. If we become aware of any apparent material misstatements or inconsistencies we consider the implications for our report.

Certificate We certify that we have completed the audit of the financial statements in accordance with the requirements of Chapter 5 of Part 2 to the National Health Service Act 2006 and the Audit Code for NHS Foundation Trusts issued by Monitor. As reported above we are not able to conclude that that the Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources for the financial period.

Ian Looker (Senior Statutory Auditor) for and on behalf of PricewaterhouseCoopers LLP Chartered Accountants and Statutory Auditors Leeds 28th May 2015

(a) The maintenance and integrity of the Northern Lincolnshire and Goole Group NHS Foundation Trust website is the responsibility of the directors; the work carried out by the auditors does not involve consideration of these matters and, accordingly, the auditors accept no responsibility for any changes that may have occurred to the financial statements since they were initially presented on the website.

(b) Legislation in the United Kingdom governing the preparation and dissemination of financial statements may differ from legislation in other jurisdictions.

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The Trust annual accounts 2014/15

Foreword to the Accounts

Northern Lincolnshire and Goole NHS Foundation TrustThe Trust achieved Foundation Status in May 2007. These Accounts for the year ended 31st March 2015 have been prepared by Northern Lincolnshire and Goole NHS Foundation Trust in accordance with the paragraphs 24 and 25 of schedule 7 to the National Health Service Act 2006 in the form which the Independent Regulator of NHS Foundation Trusts (Monitor) has, with the approval of the Treasury directed.

Northern Lincolnshire and Goole NHS Foundation Trust’s Annual Report and Accounts are presented to Parliament pursuant to Schedule 7, paragraph 25(4) of the National Health Service Act 2006.

Signed

Date: May 22 2015



126

127

Northern Lincolnshire and Goole NHS Foundation TrustAnnual Accounts 2014/15Statement of the Chief Executive’s responsibilities as the accounting officer of Northern Lincolnshire and Goole NHS Foundation Trust

The NHS Act 2006 states that the Chief Executive is the accounting officer of the NHS Foundation Trust.

The relevant responsibilities of the accounting officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by Monitor.

Under the NHS Act 2006, Monitor has directed the Northern Lincolnshire and Goole NHS Foundation Trust to prepare for each financial year a statement of accounts in the form and on the basis set out in the Accounts Direction. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of Northern Lincolnshire and Goole NHS Foundation Trust and of its income andexpenditure, total recognised gains and losses and cash flows for the financial year.

In preparing the accounts, the Accounting Officer is required to comply with the requirements of the NHS Foundation Trust Annual Reporting Manual and in particular to:

• observe the Accounts Direction issued by Monitor, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis;

• make judgements and estimates on a reasonable basis;

• state whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual have been followed, and disclose and explain any material departures in the financial statements;

• ensure that the use of public funds complies with the relevant legislation, delegated authorities and guidance;

• and prepare the financial statements on a going concern basis.

The Accounting Officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS Foundation Trust and to enable him/her to ensure that the accounts comply with requirements outlined in the above mentioned Act.

The Accounting Officer is also responsible for safeguarding the assets of the NHS Foundation Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities

To the best of my knowledge and belief, I have properly discharged the responsibilities set out in Monitor’s

NHS Foundation Trust Accounting Officer Memorandum.

Signed

Date: May 22 2015



128

129

Consolidated statement of comprehensive income for the year ended March 31 20152014/15

£0002013/14

£000

Note

RevenueRevenue from patient care activities 4 296,044 284,275

Other operating revenue 5 34,413 34,822Operating Expenses 6 (346,449) (320,863)

Operating Deficit before Restructuring/ Impairments relating to Market Value changes (15,992) (1,766)

Restructuring costs (436) 0

Impairments of Property, Plant and Equipment 13 (2,031) (2,253)Reversal of previous Impairments of Property, Plant and Equipment 13 603 1,913

Operating deficit for the financial year (17,856) (2,106)

Finance costs:Finance Income 11 144 163

Finance costs 12 (346) (141)Public dividend capital dividends payable (3,318) (3,498)

Deficit for the financial year (21,376) (5,582)Share of Loss of Joint Ventures accounted for using equity method of accounting (43) (50)

Gain from Transfer by Absorption 0 0Movement in fair value of investment property and other investments 35 142 21

Deficit for the year (21,277) (5,611)

Other comprehensive income and expenditure -amounts that will not be reclassified subsequently to income and expenditure

Gain from Transfer by Modified Absorption from demising bodies 0 156Gains on revaluations on Property, Plant and Equipment 13 817 1,682

Losses on revaluations on Property, Plant and Equipment 13 (2,009) (1,258)

Total comprehensive income for the year (22,469) (5,031)

Allocation of (Losses)/Profits for the year: 2014/15 £000

2013/14 £000

(a) Deficit for the year attributable to:(i) owners of the parent. (21,277) (5,611)

Total (21,277) (5,611)(b) total comprehensive income for the year attributable to:

(i) owners of the parent. (22,469) (5,031)

Total (22,469) (5,031)

Breakdown of DeficitTrading Deficit (19,202) (5,152)

Restructuring costs (436) 0Impairments or previous impairments (1,428) (340)

Deficit after impairments (21,066) (5,492) Consolidation of Charity Net Expenditure (211) (119)

Retained Deficit (21,277) (5,611)

The notes on pages 133 to 145 form part of these accounts


130

Statement of financial position as at March 31 2015

31 March 2015

31 March 2015

31 March 2014

31 March 2014

Restated Group

£000

Restated Trust £000

Group £000

Trust £000Note

Non-current assetsIntangible assets 14 1,435 1,435 1,045 1,045

Property, plant and equipment 15 138,373 138,373 135,867 135,867

Other Investments 35 1,995 0 2,053 0

Trade and other receivables 18 15 15 18 18

Total non-current assets 141,818 139,823 138,983 136,930

Current assets

Inventories 17 2,685 2,685 2,741 2,741

Trade and other receivables 18 16,325 16,310 17,043 17,018

Cash and cash equivalents 20 21,177 21,156 26,633 26,504

Total current assets 40,187 40,151 46,417 46,263

Total assets 182,005 179,974 185,400 183,193

Current liabilities

Trade and other payables 22 (35,043) (34,960) (30,889) (30,841)

Borrowings 23 (1,807) (1,807) (220) (220)

Provisions 30 (4,105) (4,105) (2,930) (2,930)

Other liabilities 24 (1,307) (1,307) (2,963) (2,963)

Total current liabilities (42,262) (42,179) (37,002) (36,954)

Net current (liabilities)/assets (2,075) (2,028) 9,415 9,309

Total assets less current liabilities 139,743 137,795 148,398 146,239

Non-current liabilities

Trade and other payables 22 0 0 (34) (34)

Borrowings 23 (19,403) (19,403) (5,909) (5,909)

Provisions 30 (5,255) (5,255) (6,982) (6,982)

Total non-current liabilities (24,658) (24,658) (12,925) (12,925)

Total assets employed 115,085 113,137 135,473 133,314

Financed by taxpayers’ equity:

Public dividend capital 125,995 125,995 123,914 123,914

Income and expenditure reserve (25,885) (25,885) (4,819) (4,819)

Revaluation reserve 13,027 13,027 14,219 14,219

Charitable funds reserve 1,948 0 2,159 0

Total Taxpayers’ Equity 115,085 113,137 135,473 133,314

The financial statements on pages 129 to 169 were approved by the Audit Committee on behalf of the Foundation Trust Board and signed on its behalf by:

Signed

Date: 22 May 2015


131

2014/15 £000

2013/14 £000Cash flows from operating activities Note

Operating deficit from continuing operations * (17,856) (2,106)

Non- cash income and expense

Depreciation and amortisation 6 7,113 7,538

Impairments 6 2,031 2,253

Reversal of Impairments 5 (603) (1,913)

Decrease/(Increase) in inventories 17 56 (180)

Decrease/(Increase) in trade and other receivables 708 (5,615)

Increase in trade and other payables 2,809 332

(Decrease)/Increase in other liabilities (1,656) 1,146

Decrease in provisions 30 (608) (1,639)

NHS Charitable Funds - net adjustments for working capital movements, non-cash transactions and non-operating cash flows

45 (281)

Other Movements in operating cash flows (3) 93

Net cash used in operations (7,964) (372)

Cash flows from investing activitiesInterest received 11 65 83

Payments for property, plant and equipment (10,840) (8,776)

Proceeds from disposal of plant, property and equipment 228 420

Payments for intangible assets (747) (414)

NHS Charitable funds - net cash flows from investing activities 279 101

Net cash generated used in investing activities (11,015) (8,586)

Net cash used before financing (18,979) (8,958)

Cash flows from financing activities

PDC received 2,081 71

PDC dividend paid (3,350) (3,193)

Loans Received 15,301 5,721

Capital element of finance lease (219) (206)

Interest paid (264) (32)

Interest element of finance lease (26) (31)

Net cash generated from financing activities 13,523 2,330

Net decrease in cash and cash equivalents (5,456) (6,628)

Cash and cash equivalents at the beginning of the financial year 26,633 33,261

Cash and cash equivalents as at 31st March 2015 20 21,177 26,633

Consolidated statement of cash flows for the year ended March 31 2015

* Operating (deficit)/surplus from continuing operations 2014/15 £000

2013/14 £000

Operating deficit before restructuring/ impairments relating to market value changes

(15,992) (1,766)

Restructuring costs (436) 0Reversal of Impairments included within income 603 1,913

Impairments charged to expenses re revaluation of property, plant and equipment

(2,031) (2,253)

(17,856) (2,106)


132

Consolidated statement of changes in taxpayers’ equityPublic

Dividend Capital

(PDC)

Revaluation Reserve

Income and Expenditure

Reserve

Charitable Funds

Reserve

Total Taxpayers’ and other

equityNote £000 £000 £000 £000 £000

Balance at 31 March 2014 123,914 14,219 (4,819) 2,159 135,473Prior year adjustment 0 0 0 0 0

Taxpayers’ Equity at 1 April 2014 123,914 14,219 (4,819) 2,159 135,473

Changes in taxpayers’ equity for 2014/15Total Comprehensive Income for the year:

Retained (deficit)/surplus for the year 0 0 (21,819) 542 (21,277)Revaluation gains on Property plant and Equipment 0 817 0 0 817

Impairment losses on Property, plant and Equipment

0 (2,009) 0 0 (2,009)

Public Dividend Capital Received 2,081 0 0 0 2,081Other reserve movements - charitable funds

consolidation adjustment0 0 753 (753) 0

Balance at 31 March 2015 125,995 13,027 (25,885) 1,948 115,085

Public Dividend

Capital (PDC)

Revaluation Reserve

Income and Expenditure

Reserve

Charitable Funds

Reserve

Total Taxpayers’ and other

equity£000 £000 £000 £000 £000

Balance at 31 March 2013 123,843 12,171 2,141 2,278 140,433Prior year adjustment 0 1,518 (1,518) 0 0

Taxpayers’ Equity at 1 April 2013 restated 123,843 13,689 623 2,278 140,433

Changes in taxpayers’ equity for 2013/14Total Comprehensive Income for the year:

Retained surplus for the year 0 0 (6,024) 413 (5,611)Transfers by MODIFIED absorption: Gains on 1 April

transfers from demising bodies. 0 0 156 0 156

Transfers by MODIFIED absorption: transfers between reserves 0 106 (106) 0 0

Revaluation gains on Property, Plant and Equipment 0 1,682 0 0 1,682Impairment losses on Property, Plant and

Equipment 0 (1,258) 0 0 (1,258)

Public Dividend Capital Received 71 0 0 0 71Other reserve movements - charitable funds

consolidation adjustment 0 0 532 (532) 0

Balance at 31 March 2014 123,914 14,219 (4,819) 2,159 135,473

133

Notes to the accounts

1. Accounting Policies Monitor has directed that the financial statements of NHS Foundation Trusts shall meet the accounting requirements of the FT ARM which shall be agreed with HM Treasury. Consequently, the following financial statements have been prepared in accordance with the FT ARM 2014/15 issued by Monitor. The accounting policies contained in that manual follow International Financial Reporting Standards (IFRS) and HM Treasury’s Financial Reporting Manual (FReM) to the extent that they are meaningful and appropriate to NHS foundation trusts. The accounting policies have been applied consistently in dealing with items considered material in relation to the accounts.

1.1 Accounting convention These accounts have been prepared on a going concern basis, under the historical cost convention modified to account for the revaluation of land and buildings. Plant and equipment, Intangible assets, inventories and certain financial assets and financial liabilities have been reviewed to represent fair value as at 31st March 2015.

The accounting rules (IAS 1) require management to assess, as part of the accounts preparation process, the NHS Foundation Trust’s ability to continue as a going concern. In accordance with the NHS Foundation Trust’s Annual Reporting Manual the financial statements have been prepared on a going concern basis as we do not either intend to apply to the Secretary of State for the dissolution of the NHS Foundation Trust without the transfer of the services to another entity, or consider that this course of action will be necessary

We are also required to disclose material uncertainties in respect of events or conditions that cast doubt upon the going concern ability of the NHS Foundation Trust and these are disclosed below.

The Trust’s performance in-year showed a deficit of £21.066m. This is taken from a deficit of £19.202m less an impairment of £1.428m and restructuring costs of £0.436m. The Trust is forecasting a further significant operating deficit in 2015/16. The Trust’s operating and cash flow forecasts have identified the need for additional financial support to enable it to meet debts as they fall due over the foreseeable future, which is defined as a period of 12 months from the date these accounts are signed. An application for additional financial support will be made to Monitor at the end of June 2015.

We are putting recovery plans in place to enable the continuity of services and are seeking distress funding in the short term to ensure that liabilities can be met and services provided. The Trust has presented a financial plan to Monitor which indicates a further deficit for 2015/16 and consequent significant cash funding requirement to enable the Trust to meet its liabilities and to continue the provision of services.

At the point of finalising these financial statements we note the following 2015/16 future plans to be submitted to Monitor will require significant external cash funding. Whilst an application will be made for Public Dividend Capital following the finalisation of these financial statements at the end of June 2015, the level of funding to be received is as yet uncertain.

Having considered the material uncertainties and the Trust’s financial recovery plans and the likelihood of securing additional financial funding to support the financial operations, the directors have determined that it remains appropriate to prepare these accounts on a going concern basis.

The accounts do not include any adjustments that would result if Northern Lincolnshire and Goole NHS Foundation Trust was unable to continue as a going concern.

1.2 Consolidation 1.2.1 Subsidiaries The NHS Foundation Trust is the corporate trustee to Northern Lincolnshire & Goole NHS Foundation Trust Charitable Funds. The Foundation Trust has assessed its relationship to the charitable fund and determined it to be a subsidiary because the Foundation Trust has the power to govern the financial and operating policies of the charitable fund so as to obtain benefits from its activities for itself, its patients or its staff.


134

The charitable fund’s statutory accounts are prepared to 31 March in accordance with the UK Charities Statement of Recommended Practice (SORP) which is based on UK Generally Accepted Accounting Principles (UK GAAP). On consolidation, necessary adjustments are made to the charity’s assets, liabilities and transactions to;

• Recognise and measure them in accordance with the Foundation Trust’s accounting policies; and

• eliminate intra-group transactions, balanced, gains and losses.

Northern Lincolnshire and Goole NHS Foundation Trust charitable fund accounting policies:

a) Funds Structure Perpetuity Funds are funds which are to be used in accordance with specific restriction imposed by the donor. Where the restriction requires the gift to be invested to produce income but the capital cannot be spent, it is classed as a perpetuity fund.

Restricted funds are funds which are to be used in accordance with specific restrictions imposed by the donor. Where the restriction requires the gift to be invested to produce income but the trustees have the power to spend the capital, it is classed as expendable endowment.

Unrestricted income funds comprise those funds which the Trustee is free to use for any purpose in furtherance of the charitable objects. Unrestricted funds include designated funds, where the donor has made known their non-binding wishes or where the trustees, at their discretion, have created a fund for a specific purpose.

The charity does not have any perpetuity funds or expendable endowments

b) Incoming Resources All incoming resources are recognised once the charity has entitlement to the resources. Provided it is certain that the resources will be received and the monetary value of incoming resources can be measured with sufficient reliability.

c) Incoming Resources From Legacies Legacies are accounted for as incoming resources either upon receipt or where the receipt of the legacy is virtually certain; this will be once confirmation has been received from the representatives of the estate(s) that payment of

the legacy will be made or property transferred and once all conditions attached to the legacy have been fulfilled.

d) Gifts In Kind Assets given for distribution by the funds are included in the Statement of Financial Activities only when distributed.

In all cases the amount at which the gifts in kind are brought into account is either a reasonable estimate of their value to the funds or the amount actually realised.

e) VAT And TaxIrrecoverable VAT is charged against the category of resources expended for which it was incurred.

The Charity is a registered charity, and as such is entitled to certain tax exemptions on income and profits from investments, and surpluses on any trading activities carried on in furtherance of the charity’s primary objectives, if these profits and surpluses are applied solely for charitable purposes.

f) Allocation Of Overhead and Support CostsOverhead and support costs have been apportioned on an appropriate basis between all funds. The apportionment is in proportion to the quarterly aggregate balance on each of the funds and is distributed on a quarterly basis.

g) Fixed Asset InvestmentsInvestments are stated at market value as at the Statement of Financial Position date. The Statement of Comprehensive Income includes the net gains and losses arising on revaluation and disposals throughout the year.

The Common Investment Fund Units & Brewin Dolphin Limited portfolio are included in the statement of financial position at the closing dealing price at 31st March 2015.

h) Realised Gains & LossesAll gains and losses are taken to the Statement of Comprehensive Income as they arise. Realised gains and losses on investments are calculated as the difference between sales proceeds and opening market value (purchase date if later). Unrealised gains and losses are calculated as the difference between the market value at the year end and opening market value (or purchase date if later).

135

1.3 Joint Ventures The Foundation Trust has entered into a co-operation agreement with the Brain Injuries Rehabilitation Trust (BIRT) to form a separate entity Goole Neuro Rehabilitation Centre (GNRC) which operates from Ward 4 at Goole District Hospital. The Joint Venture provides both NHS care and care independent to the NHS but within an NHS location. The Commissioners, Social Services and other agencies commission services from the Joint venture and the Joint Venture is managed on a day to day basis by BIRT. The Joint Venture accesses support services and has access to NHS facilities from Northern Lincolnshire and Goole NHS Foundation Trust which are governed by appropriate Service Level Agreements. The Trust includes within its financial statements its share of the activities, assets and liabilities.

1.4 Critical Accounting Judgements and Key Sources of Estimation and Accuracy In the application of the Foundation Trust’s accounting policies, management is required to make judgements, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. The estimates and associated assumptions are based on historical experience and other factors that are considered to be relevant.

Actual results may differ from those estimates and the estimates and underlying assumptions are continually reviewed. Revisions to accounting estimates are recognised in the period in which the estimate is revised if the revision affects only that period or in the period of the revision and future periods if the revision affects both current and future periods.

The following are the key assumptions concerning the future, and other key sources of estimation uncertainty at the Statement of Financial Position date, that have a significant risk of causing a material adjustment to the carrying amounts of assets and liabilities.

a) Going Concern The accounting rules (IAS 1) require management to assess, as part of the accounts preparation process, the NHS Foundation Trust’s ability to continue as a going concern. Please refer to Accounting policy 1.1.

b) Property valuations and asset lives Valuations are undertaken by an independent external valuer. These values will therefore be subject to changes in market conditions and market values. The

asset lives are also estimated by the independent external valuer and are the subject of professional judgement.

c) Accruals Accruals included within the accounts are based on the best available information. This is applied in conjunction with historical experience and based on individual circumstances.

d) ProvisionsThe estimates of outcome and financial effect of provisions are determined by the judgement of the management of the Trust, supplemented by experience of similar transactions and, in some cases, reports of independent experts.

Uncertainties surrounding the amount to be recognised as a provision are dealt with by various means according to the circumstances. Where the provision being measured involves more than one outcome, the obligation is estimated by weighing all possible outcomes by their associated probabilities and the expected value of the outcome. Where there is a range of possible outcomes, and each point in the range is as likely as the other, the mid-point of the range is used.

Where a single outcome is being measured, the individual most likely outcome may be the best estimate of the liability. However, even in such a case, the Trust considers other possible outcomes.

The Foundation Trust has continued to develop plans to restructure both front line services and support functions in order to meet the changing service requirements set out by Commissioners and also to meet the ongoing requirement to deliver efficiency savings as mandated through the Operating Framework and tariff.

The Foundation Trust has set out an ongoing restructuring plan in order to respond to the market pressures facing the organisation through the current period of restricted income growth and increased competitive threat, and this has been updated during 2014/15.

The Foundation Trust has signed off planning assumptions going forward which will see a continued dependence on pay control in order to deliver a challenging Sustainability Programme.


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It is inevitable that this process will incorporate some measures which will result in non recurrent costs – redundancy and early retirement costs, and payments in line with the Foundation Trust pay protection policy. The projected total requirement to support committed sustainability plans made by 31st March 2015 derived on this basis is £2.846m. There has been a charge of £0.436m to the Foundation Trust during 2014/15.

Annual Leave accrualsThe Foundation Trust had written to all members of staff requesting details of their outstanding annual leave at the end of March 2015. The response from this survey was 32%. The value of the outstanding amount has been calculated based on the returns received back from staff and their average salary, then adjusted to cover groups of staff expected to have outstanding leave but had not returned the details. The Foundation Trust is carrying £0.448m.

1.5 IncomeIncome is accounted for applying the accruals convention. The income is shown gross except where administrative arrangements exists, whereby the associated income is netted off with the corresponding expenditure in accordance with the NHS Foundation Trust Financial Reporting Manual (FT ARM). In recognising income in the current financial year, the Trust has considered and followed IAS18

Income in respect of services provided is recognised when, and to the extent that, performance occurs and is measured at fair value of the consideration receivable. The main source of income for the Trust is contracts with commissioners in respect of healthcare services.

Where income has not been received prior to the year end, but the provision of a healthcare service has commenced, i.e. partially completed patient spells, then the income relating to the patient activity is accrued. The closing accrued income is estimated based on the number of days of incomplete spells at an average daily tariff adjusted to reflect the case mix.

Where income is received for a specific activity which is to be delivered in the following financial year, that income is deferred. Income from the sale of non-current assets is recognised only when all material conditions of sale have been met, and is measured as the sums due under the sale contract.

The Foundation Trust receives income under the NHS Injury Cost Recovery Scheme, designed to reclaim the cost of treating injured individuals to whom personal injury compensation has subsequently been paid e.g. by

an insurer. The Foundation Trust recognises the income when it receives notification from the Department of Work and Pension’s Compensation Recovery Unit that the individual has lodged a compensation claim. The income is measured at the agreed tariff for the treatments provided to the injured individual, less a provision for unsuccessful compensation claims and doubtful debts which is 6.1 % above the national recommended rate. This rate is based on local trends and experiences of recovery.

1.6 Expenditure1.6.1 Expenditure on Employee Benefits Short-term employee benefits Salaries, wages and employment-related payments are recognised in the period in which the service is received from employees. The cost of annual leave entitlement earned but not taken by employees at the end of the period is recognised in the financial statements to the extent that employees are permitted to carry-forward leave into the following period.

1.6.2 Pension costs NHS Pensions Scheme

Past and present employees are covered by the provisions of the NHS Pensions Scheme. Details of the benefits payable under these provisions can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions. The scheme is an unfunded, defined benefit scheme that covers NHS employers, General Practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. It is not possible for the NHS Foundation Trust to identify its share of the underlying scheme liabilities. Therefore, the scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS Body of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period.

Employer’s pension cost contributions are charged to operating expenses as and when they become due. Additional pension liabilities arising from early retirements are not funded by the scheme except where the retirement is due to ill-health. The full amount of the liability for the additional costs is charged to the operating expenses at the time the Foundation Trust commits itself to the retirement, regardless of the method of payment.

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1.6.3 Expenditure on Goods and ServicesExpenditure on goods and services is recognised when, and to the extent that they have been received, and is measured at the fair value of those goods and services. Expenditure is recognised in operating expenses except where it results in the creation of a non-current asset such as property, plant and equipment.

1.7 Property, plant and equipmentRecognitionProperty, plant and equipment is capitalised if:

• it is held for use in delivering services or for administrative purposes

• It is probable that future economic benefits will flow to, or service potential will be supplied to the Foundation Trust

• it is expected to be used for more than one financial year;

• the cost of the item can be measured reliably;

• and the item has a cost of at least £5,000; or

• collectively, a number of items have a cost of at least £5,000 and individually have a cost of more than £250, where the assets are functionally interdependent, they have broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or

• items form part of the initial equipping and setting-up cost of a new building, ward or unit irrespective of their individual or collective cost.

Where a large asset, for example a building, includes a number of components with significantly different asset lives, the components are treated as separate assets and depreciated over their own useful economic lives.

Borrowing costs associated with the construction of new assets are not capitalised.

ValuationAll property, plant and equipment are measured initially at cost, representing the cost directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended. All assets are measured subsequently at fair value.

Land and buildings used for the Foundation Trust’s services or for administrative purposes are stated in the Statement of Financial Position at their revalued amounts, being the fair value at the date of revaluation less any

subsequent accumulated depreciation and impairment losses.

Revaluations are performed by professional valuers every five years and in the intervening years by the use of appropriate indices or by interim valuation as necessary to ensure that carrying amounts are not materially different from those that would be determined at the end of the reporting period.

Fair values are determined as follows:

• Freehold Properties - Existing Use Value (EUV)

• Specialised buildings - Depreciated Replacement Cost (DRC) ~ Modern Equivalent Asset (MEA)

• Others - DRC ~ EUV

• Land - Modern Equivalent (MEA)

Useful Economic lives

For any new acquisition of property, plant and equipment, the following table details the useful economic lives for the main classes of assets and where applicable, sub categories within each

Main Assets Sub Category Life in Years

BuildingsStructural Up to

100 yrsEngineering

Plant, Machinery and Equipment 5 to 15 yrs

Furniture and Fittings 5 to 10 yrs

Vehicles / Transport Equipment Up to 7 yrs

IT Equipment Up to 5 yrs

Intangible Up to 10 yrs

During this financial year, valuations were carried out by DTZ Debenham Tie Leung Limited. The valuations are carried out in accordance with the current Valuation Standards and UK Valuation Standards contained within the Royal Institute of Chartered Surveyors (RICS) Valuation Standards – The Red Book, which are consistent with the agreed requirements of the Department of Health and HM Treasury. In accordance with the requirements of the Department of Health, the Modern Equivalent Asset (MEA) based valuations were undertaken in February 2015 with a valuation date of 31 March 2015.


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Property assets have been valued primarily by using the Depreciated Replacement Cost (DRC) approach. In accordance with VS6.6, the DRC will be subject to the prospect and viability of the continued occupation and use by the Foundation Trust. The Market Value for readily identifiable alternative uses would not be higher than the Existing Use.

Properties in the course of construction for service or administration purposes are carried at cost, less any impairment loss. Cost includes professional fees but not borrowing costs, which are recognised as expenses immediately, as allowed by IAS 23 for assets held at fair value. Assets are revalued and depreciation commences when they are brought into use.

The ultimate objective of the valuation is to place a value upon the asset. In this the value of the land in providing a modern equivalent facility was also considered. The modern equivalent may be located on a new site out of town, or be on a smaller site due to changes in the way services are provided. The site is valued based on the size of the modern equivalent, and not the actual site area occupied at present, which has given rise to reduction in the land values.

The results of these valuations have been incorporated into these financial statements.

Equipment assets are valued using appropriate indices (for 2014/15 no change) and predominantly the Depreciated Replacement Cost is assumed to be the fair value. Annually, an equipment review is also conducted by the department/directorate/equipment specialist and the life of the Equipment assets is reviewed in conjunction with the experts in the field (Medical Electronics/Suppliers/market intelligence). Assets in the course of construction are valued at current cost and they are revalued by professional valuers when they are brought into use or as part of the five or intervening years valuation whichever occurs first. These assets include any existing land or buildings under the control of a contractor.

Subsequent expenditureSubsequent expenditure relating to an item of property, plant and equipment is recognised as an increase in the carrying amount of the asset when it is probable that additional future economic benefits or service potential deriving from the cost incurred to replace a component of such item will flow to the enterprise and the cost of the item can be determined reliably.

Where a component of an asset is replaced, the cost of the replacement is capitalised if it meets the criteria for recognition above. The carrying amount of the part replaced is de-recognised. Other expenditure that does

not generate additional future economic benefits or service potential, such as repairs and maintenance, is charged to the Statement of Comprehensive Income in the period in which it is incurred.

DepreciationFreehold land, properties under construction, and assets held for sale are not depreciated.

Otherwise, depreciation and amortisation are charged to write off the costs or valuation of property, plant and equipment and intangible non-current assets, less any residual value, over their estimated useful lives, in a manner that reflects the consumption of economic benefits or service potential of the assets. The estimated useful life of an asset is the period over which the Foundation Trust expects to obtain economic benefits or service potential from the asset. This is specific to the Foundation Trust and may be shorter than the physical life of the asset itself. Estimated useful lives and residual values are reviewed each year end, with the effect of any changes recognised on a prospective basis. Assets held under finance leases are depreciated over their estimated useful lives.

Revaluation and ImpairmentsAt each reporting period end, the Foundation Trust checks whether there is any indication that any of its tangible or intangible non-current assets have suffered an impairment loss. If there is indication of an impairment loss, the recoverable amount of the asset is estimated to determine whether there has been a loss and, if so, its amount. Intangible assets not yet available for use are tested for impairment annually.

In accordance with the FT ARM, impairments that are due to a loss of economic benefits or service potential in the asset are charged to operating expenses. A compensating transfer is made from the revaluation reserve to the income and expenditure reserve of an amount equal to the lower of (i) the impairment charged to operating expenses; and (ii) the balance in the revaluation reserve attributable to that asset before the impairment.

An impairment arising from a loss of economic benefit or service potential is reversed when, and to the extent that, the circumstances that gave rise to the loss is reversed. Reversals are recognised in operating income to the extent that the asset is restored to the carrying amount it would have had if the impairment had never been recognised. Any remaining reversal is recognised in the revaluation reserve. Where, at the time of the original impairment, a transfer was made from the revaluation reserve to the income and expenditure reserve, an amount is transferred back to the revaluation reserve when the impairment reversal is recognised.

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Other impairments are treated as revaluation losses. Reversals of ‘other impairments’ are treated as revaluation gains.

Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income as an item under “Other Comprehensive Income”.

De-recognitionAssets intended for disposal, are reclassified as ‘Held for Sale’ once all of the following criteria are met:

• the asset is available for immediate sale in its present condition subject only to terms

• which are usual and customary for such sales;

• the sale must be highly probable i.e.:

• management are committed to a plan to sell the asset;

• an active programme has begun to find a buyer and complete the sale;

• the asset is being actively marketed at a reasonable price;

• the sale is expected to be completed within 12 months of the date of classification as “Held for Sale”; and

• the actions needed to complete the plan indicate it is unlikely that the plan will be dropped or significantly changed.

Following reclassification, the assets are measured at the lower of their existing carrying amount and their ‘fair value less costs to sell’. Depreciation ceases to be charged and the assets are not revalued, except where the ‘fair value less costs to sell’ falls below the carrying amount. Assets are de-recognised when all material sale contract conditions have been met.

Property, plant and equipment which is to be scrapped or demolished does not qualify for recognition as ‘Held for Sale’ and instead is retained as an operational asset and the asset’s economic life is adjusted. The asset is de-recognised when scrapping or demolition occurs.

1.8 Donated Assets Donated and grant funded property, plant and equipment assets are capitalised at their fair value on receipt. The donation/grant is credited to income at the same time, unless the donor imposes a condition that the future economic benefits embodied in the grant are to be consumed in a manner specified by the donor, in which case, the donation/grant is deferred within liabilities and is

carried forward to future financial years to the extent that the condition has not yet been met.

The donated and grant funded assets are subsequently accounted for in the same manner as other items of property, plant and equipment.

Within these financial statements, the Foundation Trust does not have any donations with conditions attached at this present moment in time

1.9 Intangible assets Recognition Intangible assets are non-monetary assets without physical substance, which are capable of sale separately from the rest of the Foundation Trust’s business or which arise from contractual or other legal rights. They are recognised only when it is probable that future economic benefits will flow to, or service potential be provided to, the Foundation Trust; where the cost of the asset can be measured reliably, and where the cost is at least £5,000.

Internally generated Intangible Assets Internally generated goodwill, brands, mastheads, publishing titles, customer lists and similar items are not capitalised as intangible assets.

Expenditure on research is not capitalised.

Expenditure on development is capitalised only where all of the following can be demonstrated:

• the project is technically feasible to the point of completion and will result in an intangible asset for sale or use;

• the Foundation Trust intends to complete the asset and sell or use it;

• the ability to sell or use the intangible asset;

• how the intangible asset will generate probable future economic benefits or service potential;

• the availability of adequate technical, financial and other resources to complete the intangible asset and sell or use it; and

• the ability to measure reliably the expenditure attributable to the intangible asset during its development.


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Software Intangible assets acquired separately are initially recognised at fair value. Software that is integral to the operating of hardware, for example an operating system, is capitalised as part of the relevant item of property, plant and equipment. Software that is not integral to the operation of hardware, for example application software, is capitalised as an intangible asset

MeasurementIntangible assets are recognised initially at cost, comprising all directly attributable costs needed to create, produce and prepare the asset to the point that it is capable of operating in the manner intended by management.

Subsequently intangible assets are measured at fair value. Increases in asset values arising from revaluations are recognised in the revaluation reserve, except where, and to the extent that, they reverse an impairment previously recognised in operating expenses, in which case they are recognised in operating income.

Decreases in asset values and impairments are charged to the revaluation reserve to the extent that there is an available balance for the asset concerned, and thereafter are charged to operating expenses. Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income as an item of ‘other comprehensive income’.

Intangible assets held for sale are measured at the lower of their carrying amount or ‘fair value less costs to sell’.

Amortisation

Intangible assets are amortised over their expected useful economic lives in a manner consistent with the consumption of economic or service delivery benefits.

Economic Lives of intangible Assets

Intangible assets - internally generated

Min. Life Years

Max. Life Years

Information technology 5 5

Intangible assets - purchased

Software 5 10

Licences & Trademarks 5 10

1.10 Government grantsGovernment grants are grants from Government bodies other than income from Clinical Commissioning Groups or NHS Trusts for the provision of services. Where a Government grant is used to fund revenue expenditure it is taken to the Statement of Comprehensive Income to

match that expenditure.

1.11 InventoriesInventories are valued at the lower of cost and net realisable value.

1.12 Private Finance Initiative (PFI) transactions At the 31st March 2015, the Foundation Trust did not have any PFI transactions

1.13 LeasesThe Trust as Lessee- Finance LeasesWhere substantially all risks and rewards of ownership of a leased asset are borne by the NHS Foundation Trust, the asset is recorded as property, plant and equipment and a corresponding liability is recorded. The value at which both are recognised is the lower of the fair value of the asset or the present value of the minimum lease payments, discounted using the interest rate implicit in the lease.

The asset and liability are recognised at the commencement of the lease. Thereafter the asset is accounted for as an item of property plant and equipment.

The annual rental is split between the repayment of the liability and a finance cost so as to achieve a constant rate of finance over the life of the lease. The annual finance cost is charged to Finance Costs in the Statement of Comprehensive Income. The lease liability, is de-recognised when the liability is discharged, cancelled or expires.

- Operating leasesOther leases are regarded as operating leases and the rentals are charged to operating expenses on a straight-line basis over the term of the lease. Operating lease incentives received are added to the lease rentals and charged to operating expenses over the life of the lease.

- Leases of land and buildingsWhere a lease is for land and buildings, the land component is separated from the building component and the classification for each is assessed separately.

The Foundation Trust as lessorThe Foundation Trust has made spaces available within the three sites to the local CCGs, Disability Trust etc. renewable on an annual basis. These are operating leases and the rental from these leases are recognised on a straight line basis within these financial statements.

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1.14 Cash and cash equivalentsCash is cash in hand and deposits with any financial institution repayable without penalty on notice of not more than 24 hours. Cash equivalents are investments that mature in 3 months or less from the date of acquisition and that are readily convertible to known amounts of cash with insignificant risk of change in value.

1.15 Clinical negligence costs The NHS Litigation Authority (NHSLA) operates a risk pooling scheme under which the NHS Foundation Trust pays an annual contribution to the NHSLA, which, in return, settles all clinical negligence claims. Although the NHSLA is administratively responsible for all clinical negligence cases, the legal liability remains with the NHS Foundation Trust. The total value of clinical negligence provisions carried by the NHSLA on behalf of the NHS Foundation Trust is disclosed at note 30, but is not recognised in the Trust’s accounts.

1.16 Non-clinical risk pooling

The NHS Foundation Trust participates in the Property Expenses Scheme and the Liabilities to Third Parties Scheme. Both are risk pooling schemes under which the Trust pays an annual contribution to the NHS Litigation Authority and in return receives assistance with the costs of claims arising. The annual membership contributions, and any ‘excesses’ payable in respect of particular claims are charged to operating expenses when the liability arises.

1.17 Provisions The NHS Foundation Trust provides for legal or constructive obligations that are of uncertain timing or amount at the Statement of Financial Position date on the basis of the best estimate of the expenditure required to settle the obligation. Where the effect of the time value of money is significant, the estimated risk-adjusted cash flows are discounted using HM Treasury’s discount rate of 1.30% in real terms for early retirement provisions and Injury Benefit provisions only.

When some or all of the economic benefits required to settle a provision are expected to be recovered from a third party, the receivable is recognised as an asset if it is virtually certain that reimbursements will be received and the amount of the receivable can be measured reliably.

Present obligations arising under onerous contracts are recognised and measured as a provision. An onerous contract is considered to exist where the Foundation Trust has a contract under which the unavoidable costs of meeting the obligations under the contract exceed the economic benefits expected to be received under it.

A restructuring provision is recognised when the Foundation Trust has developed a detailed formal plan for the restructuring and has raised a valid expectation in those affected that it will carry out the restructuring by starting to implement the plan or announcing its main features to those affected by it. The measurement of a restructuring provision includes only the direct expenditures arising from the restructuring, which are those amounts that are both necessarily entailed by the restructuring and not associated with on-going activities of the entity.

1.18 Sustainability and Carbon Reduction Commitment (CRC) The CRC scheme is a mandatory cap and trade scheme for non-transport CO2 emissions. The Foundation Trust has registered with the CRC scheme, and therefore, is required to surrender to the government an allowance for every tonne of CO2 emitted during the financial year. Accordingly, the Foundation Trust has recognised a liability (and related expense) in respect of this obligation for CO2 emissions.

The carrying amount of the liability at 31 March 2015 reflects the CO2 emissions that have been made during this financial year, less the allowances (if any) surrendered voluntarily during the financial year in respect of that financial year

The liability will be measured at the amount expected to be paid out at the rate of £16 per tonne allowance.

1.19 Contingencies Contingent assets (that is, assets arising from past events whose existence will only be confirmed by one or more future events not wholly within the entity’s control) are not recognised as assets, but are disclosed in note 32.2 where an inflow of economic benefits is probable.


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Contingent liabilities are not recognised, but are disclosed in note 32, unless the probability of a transfer of economic benefits is remote. Contingent liabilities are defined as:

• possible obligations arising from past events whose existence will be confirmed only by the occurrence of one or more uncertain future events not wholly within the entity’s control; or

• present obligations arising from past events but for which it is not probable that a transfer of economic benefits will arise or for which the amount of the obligation cannot be measured with sufficient reliability.

1.20 Public Dividend Capital Public Dividend Dapital (PDC) is a type of public sector equity finance based on the excess of assets over liabilities at the time of establishment of the predecessor NHS Trust. HM Treasury has determined that PDC is not a financial instrument within the meaning of IAS 32.

A charge, reflecting the cost of capital utilised by the NHS Foundation Trust, is payable as Public Dividend Capital dividend. The charge is calculated at the rate set by HM Treasury (currently 3.5%) on the average relevant net assets of the NHS Foundation Trust during the financial year. Relevant net assets are calculated as the value of all assets less the value of all liabilities, except for (i) donated assets, (ii) average daily cash balances held with the Government Banking Services (GBS), excluding cash balances held in GBS accounts that relate to a short-term working capital facility, and (iii) any PDC dividend balance receivable or payable. In accordance with the requirements laid down by the Department of Health (as the issuer of PDC), the dividend for the year is calculated on the actual average relevant net assets as set out in the “pre-audit” version of the annual accounts. The dividend thus calculated is not revised should any adjustment to net assets occur as a result of the audit of the annual accounts.

In 2013/14 only, net assets and liabilities transferring from bodies which ceased to exist on 1 April 2013 will be excluded from the calculation of net relevant assets used in the PDC dividend calculation for the year.

This includes, for example, transfers of assets from PCTs. The value of such assets will be excluded from the calculation of opening net relevant assets. The value of any such assets still held at the year end should be excluded from the calculation of closing net relevant assets.

The closing value may differ from that recognised on 1 April 2013 by virtue of depreciation, disposals, revaluation and impairment. This exemption will not apply from 2014/15 onwards.

This exemption is only available where the net assets transfer directly to the NHS Foundation Trust from an entity which demised on 1 April 2014.

1.21 Value Added TaxMost of the activities of the NHS Foundation Trust are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.

1.22 Corporation TaxThe NHS Foundation Trust has carried out a review of corporation tax liability of its non healthcare activities. At present, all activities are either ancillary to the Trust’s patient care activity or are below the de minimus level at which corporation tax is due. Therefore, the Trust has determined that it has no liability for corporation tax. Further guidance is awaited from Monitor, HM Treasury and the Inland Revenue

1.23 Foreign exchangeThe functional and presentation currencies of the Foundation Trust are sterling. A transaction which is denominated in a foreign currency is translated into the functional currency at the spot exchange rate on the date of the transaction.

The Foundation Trust does not have any assets or liabilities denominated in a foreign currency at the Statement of Financial Position date.

1.24 Third Party AssetsAssets belonging to third parties (such as money held on behalf of patients) are not recognised in the accounts since the NHS Foundation Trust has no beneficial interest in them. However, they are disclosed in a separate note (note 36) to the accounts in accordance with the requirements of HM Treasury’s Financial Reporting Manual.

1.25 Losses and Special PaymentsLosses and special payments are items that Parliament would not have contemplated when it agreed funds for the health service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way that individual cases are handled.

Losses and special payments are charged to the relevant functional headings in the Statement of Comprehensive

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Income on an accruals basis, including losses which would have been made good through insurance cover had NHS Trusts not been bearing their own risks (with insurance premiums then being included as normal revenue expenditure). However, note 38 is compiled directly from the losses and compensations register which is prepared on an accrual basis with the exception of provisions for any future losses.

1.26 Financial instruments - Financial Assets and Financial Liabilities

Recognition Financial assets and financial liabilities which arise from contracts for the purchase or sale of non-financial items (such as goods or services), which are entered into in accordance with the Foundation Trust’s normal purchase, sale or usage requirements, are recognised when, and to the extent which, performance occurs i.e. when receipt or delivery of the goods or services is made

Financial assets or financial liabilities in respect of assets acquired or disposed of through finance leases are recognised and measured in accordance with the accounting policy for leases described below.

Financial assets are recognised when the Trust becomes party to the financial instrument contract or, in the case of trade receivables, when the goods or services have been delivered. Financial assets are de-recognised when the contractual rights have expired or the asset has been transferred. All other financial assets and financial liabilities are recognised when the Foundation Trust becomes a party to the contractual provisions of the instrument.

De-recognition All financial assets are de-recognised when the rights to receive cash flows from the assets have expired or the Foundation Trust has transferred substantially all of the risks and rewards of ownership. Financial liabilities are de-recognised when the obligation is discharged, cancelled or expires.

Classification and Measurement Financial assets are classified into the following categories:

• financial assets at fair value through income and expenditure

• loans and receivables

• available for sale financial assets.

Financial liabilities are classified as

• fair value through income and expenditure or as

• other financial liabilities.

Financial assets and financial liabilities at fair value through Income and Expenditure

Financial assets and financial liabilities at “fair value through income and expenditure” are financial assets or financial liabilities held for trading. A financial asset or financial liability is classified in this category if acquired principally for the purpose of selling in the short-term. Derivatives are also categorised as held for trading unless they are designated as hedges. Derivatives which are embedded in other contracts but which are not “closely-related” to those contracts are separated-out from those contracts and measured in this category. Assets and liabilities in this category are classified as current assets and current liabilities.

These financial assets and financial liabilities are recognised initially at fair value, with transaction costs expensed in the Statement of Comprehensive Income . Subsequent movements in the fair value are recognised as gains and losses in the Statement of Comprehensive Income.

Loans and receivables Loans and receivables are non-derivative financial assets with fixed or determinable payments which are not quoted in an active market. They are included in current assets.

The Foundation Trust’s loans and receivables comprise of, cash and cash equivalents, NHS debtors, accrued income and “other receivables”

Loans and receivables are recognised initially at fair value, net of transactions costs, and are measured subsequently at amortised cost, using the effective interest method. The effective interest rate is the rate that discounts exactly estimated future cash payments/ receipts through the expected life of the financial asset or, when appropriate, a shorter period, to the net carrying amount of the financial asset.


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Interest on loans and receivables is calculated using the effective interest method and charged/credited to the Statement of Comprehensive Income.

Available for sale financial assets Available-for-sale financial assets are non-derivative financial assets which are either designated in this category or not classified in any of the other categories. They are included in long-term assets unless the Foundation Trust intends to dispose of them within 12 months of the date.

Available-for-sale financial assets are recognised initially at fair value, including transaction costs, and measured subsequently at fair value, with gains or losses recognised in reserves and reported in the Statement of Comprehensive Income as an item of “other comprehensive income”. When items classified as “available-for-sale” are sold or impaired, the accumulated fair value adjustments recognised are transferred from reserves and recognised in “Finance Costs” in the Statement of Comprehensive Income.

Other financial liabilitiesAll other financial liabilities are recognised initially at fair value, net of transaction costs incurred and measured subsequently at amortised cost using the effective interest method, except for loans from Department of Health, which are carried at historic cost. The effective interest rate is the rate that exactly discounts estimated future cash payments through the life of the asset, to the net carrying amount of the financial liability.

They are included in current liabilities except for amounts payable more than 12 months after the Statement of Financial Position date, which are classified as long-term liabilities.

Interest on financial liabilities carried at amortised cost is calculated using the effective interest method and charged to Finance Costs. Interest on financial liabilities taken out to finance property, plant and equipment or intangible assets is not capitalised as part of the cost of those assets.

The Foundation Trust has reviewed all its main contracts and any derivatives the contracts many have with other contracts are “closely-related” and therefore, does not warrant separate accounting or disclosure.

Determination of fair valueFor financial assets and financial liabilities carried at fair value, the carrying amounts are determined from using a number of appropriate techniques including quoted

market prices, independent professional appraisals, discounted cash flow analysis, and previous trends and experiences.

Impairment of financial assetsAt the end of the reporting period, the Foundation Trust assesses whether any financial assets, other than those held at ‘fair value through profit and loss’ are impaired. Financial assets are impaired and impairment losses recognised if there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset.

For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset’s carrying amount and the present value of the revised future cash flows discounted at the asset’s original effective interest rate. The loss is recognised in expenditure and the carrying amount of the asset is reduced directly/through a provision for impairment of receivables.

If, in a subsequent period, the amount of the impairment loss decreases and the decrease can be related objectively to an event occurring after the impairment was recognised, the previously recognised impairment loss is reversed through expenditure to the extent that the carrying amount of the receivable at the date of the impairment is reversed does not exceed what the amortised cost would have been had the impairment not been recognised.

The Foundation Trust has reviewed its income receivable from the Injury Recovery Unit on an annual basis taking into account local trends of recovery and appropriate top up provision has been made for irrecoverable debtors, over and above the proposed bad debts provision of 18.9% recommended by the Department of Health.

In line with the policy, the Foundation Trust has undertaken a review of all outstanding debts and suitable provisions are recognised within these statements for bad and doubtful debts.

1.27 Transfers of functions from other NHS bodies For functions that have been transferred to the Foundation Trust from another NHS body, the assets and liabilities transferred are recognised in the accounts as at the date of transfer. The assets and liabilities are not adjusted to fair value prior to recognition.

The net gain/loss corresponding to the net assets/

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liabilities transferred is recognised within income/expenses, but not within operating activities. In 2013/14, transfers recognised by an NHS Foundation Trust directly from a body which ceased to exist on 1st April 2013 were accounted for under modified absorption accounting. No new transactions will be accounted for using modified absorption principles in 2014/15.

In 2013/14 the net gain/loss corresponding to the net assets/liabilities transferred on 1st April 2013, is recognised within the income and expenditure reserve. There were no transfers during 2014/15.

For property plant and equipment assets and intangible assets, the Cost and Accumulated Depreciation/Amortisation balances from the transferring entity’s accounts are preserved on recognition in the Trust’s accounts. Where the transferring body recognised revaluation reserve balances attributable to the assets, the trust makes a transfer from its income and expenditure reserve to its revaluation reserve to maintain transparency within public sector accounts.

The following transactions are included as at 1st April 2013

£000’s

Net Book ValueLand 50Buildings 90

Info Technology 8Current Assets Prepayments 8Current Liabilities Trade Creditors (1)I&E Reserve (48)Revaluation Reserve (107)

1.28 Accounting Standards that have been issued but have not yet been adopted

The HM Treasury FReM/FT ARM does not require the following Standards and Interpretations to be applied in 2014/15. The application of the Standards as revised would not have a material impact on the accounts for 2014/15, were they applied in that year.

• IFRS 9 Financial Instruments - Assets & Liabilities. Under Consultation

• IFRS 13 Fair Value Measurement Adoption delayed by HM Treasury. To be adopted from 2015/16

• IAS 19 Employer Contributions to defined Benefit pension schemes. Effective from 2015/16

• IAS 21 Levies. EU adopted in June 2014 but not yet adopted by HM Treasury

• IAS 36 Recoverable amount disclosures. To be adopted from 2015/16


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2 Operating segments

The Foundation Trust’s major activity is healthcare and therefore is treated as a single segment.

The operating results of the Foundation Trust are reviewed monthly by the Foundation Trust’s chief operating decision maker which is the overall Foundation Trust Board and which includes non-executive directors. For 2014/15, the Board of Directors reviewed the financial position of the Foundation Trust as a whole in their decision making process.

The single segment of ‘Healthcare’ has therefore been identified consistent with the core principle of IFRS 8 which is to enable users of financial statements to evaluate the nature and financial effects of business activities and economic environments.

3. Income generation activitiesThe Foundation Trust undertakes certain activities with an aim of break even or achieving a small profit, which is then used to support patient care. Some of these activities are essential for providing the right level of service to the patients and visitors and the profit element, if any, is incidental to the service provision.

The following table provides details of activities for which gross income exceeded £1m.

i) Car Parking ServicesCar parking services is a managed service operated by ISS Mediclean.

The income is received by the Foundation Trust and is accounted for gross within the financial statements.

ii) Catering services across three sitesCatering income amounted to £0.75m (£0.7m 2013/14) during the year. However, the costs associated with the income generation form part of the costs of the total catering provision for patients, staff and visitors and are not separately identified.

Healthcare Total2014/15

£0002013/14

£0002014/15

£0002013/14

£000

Income 330,457 319,097 330,457 319,097

Deficit before impairments and Restructuring

23,141 5,951 23,141 5,951

Restructuring costs (436) 0 (436) 0

Impairment reversals relating to market value changes included in income

603 1,913 603 1,913

Impairments relating to market value changes charged to expenses (2,031) (2,253) (2,031) (2,253)

Retained Deficit 21,277 5,611 21,277 5,611

Segment net assets 115,085 135,473 115,085 135,473

2014/15 £000

2013/14 £000

Income 2,159 1,877

Direct costs (925) (895)

Surplus before indirect costs 1,234 982

Indirect Costs (898) (846)

Surplus / (Deficit) 336 136

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4. Revenue from patient care activities2014/15 2013/14

£000 £000

NHS Trusts 0 266

Clinical Commissioning Groups and NHS England 293,730 281,542 Notes to:

4. Revenue from patient care activities

* Injury cost recovery income is subject to a provision for impairment of receivables of 25%, which is 6.1% more than the recommended Department of Health rate, to reflect expected rates of collection based on historical trend.

Non-NHS: Private patients 921 798

Overseas patients (non-reciprocal) 140 153

Injury costs recovery* 842 1,203

Other 411 313

296,044 284,275

4.1. Income from Activities by Activity

2014/15 £000

2013/14 £000

Acute TrustsElective income 46,094 46,418

Notes to:

4.1. Income from Activities by Activity

* Other NHS Clinical income includes income from non-tariff services relating to activity such as Pathology, Radiology, Imaging,

Therapy, Community etc.

Non elective income 78,902 77,531

Outpatients income 43,444 45,655

A&E income 13,098 12,555

Other NHS Clinical income * 104,789 93,278

286,327 275,437

Private Patient Income 921 798

Other non protected Clinical income 8,796 8,040

296,044 284,275

Under the Terms of Authorisation, the Foundation Trust is required to provide mandatory services. The allocation of operating income between mandatory services and other services is given below

2014/15 £000

2013/14 £000

Mandatory services 286,232 274,853

Non mandatory services 9,812 9,422

296,044 284,275

The Foundation Trust experienced increased demand on services during the course of the year and the number of patients treated was higher in 2014/15.


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5. Other Operating Revenue 2014/15 £000

2013/14 £000

Education, training and research 10,229 9,388

NHS Charitable Funds: Incoming Resources excluding investment income

372 358

Non-Patient Care services to other bodies * 18,731 19,288

Other revenue ** 5,081 5,788

34,413 34,822

Impairment Reversals 603 1,913

Total Other Income 35,016 36,735

6. Operating Expenses 2014/15 £000

2013/14 £000

Services from other NHS Trusts (2,403) (1,280)

Services from other NHS bodies (284) 0

Services from Foundation Trusts (1,127) (2,186)

Purchase of healthcare from non NHS bodies (1,350) (1,100)

Non Executive Directors’ costs (112) (108)

Executive Directors’ costs (1,344) (1,257)

Staff costs (233,792) (216,817)

Supplies and services - clinical (60,009) (54,905)

Supplies and services - general (4,607) (4,239)

Establishment (4,000) (3,705)

Transport (1,875) (1,578)

Premises (17,036) (15,544)

Provision for impairment of receivables ( Bad Debts) 44 93

Depreciation and amortisation on tangible assets (6,751) (7,228)

Depreciation and amortisation on intangible assets (362) (310)

Consultancy fees * (1,654) (1,085)

Audit fees (72) (68)

Clinical negligence (6,622) (7,042)

Loss on disposal of Property plant and equipment (61) (80)

Other ** (3,032) (2,424)

Operating expenses before impairments/Restructuring (346,449) (320,863)

Impairments of property, plant and equipment *** (2,031) (2,253)

Restructuring costs **** (436) 0

Total Operating Expenses including technical items (348,916) (323,116)

Notes to:

5. Other Operating Revenue

* Non Patient Care Services to other bodies includes £9.7m (£9.7m 2013/14) income from United Lincolnshire Hospitals NHS Trust for Pathology services, £2.3m (£2.6m 2013/14) from other providers for Pathology Services, and £6.2m (£5.5m 2013/14) relates to other provider to provider agreements.

** Other revenue includes £2.16m (£1.877m 2013/14) for car parking, £0.75m (£0.713m 2013/14) for catering and £0.78m (£0.587m 2013/14) for staff accommodation.

Notes to:

6. Operating Expenses

* Consultancy fees includes £0.601m (£0.152m 2013/14 ) paid to the Trust’s external auditors in respect of other professional services

** Other costs include £0.35m (£0.37m 2013/14) of insurance costs, £0.81m (£0.69m 2013/14) training costs, £0.60m (£0.43m 2013/14) legal costs and early retirements benefit £0.15m (£0.22m 2013/14).

*** Impairment expenditure £2.031m (£2.253m for 2013/14) relates to the reduction in the Foundation Trust’s property assets that have been charged to the Statement of Comprehensive Income.

**** Restructuring costs in 2014/15 relate to the redundancy/restructuring cost expected to be incurred.

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7. Limitation on External Auditors Liability

The Auditors’ fee for this financial year is £0.098m (2013/14 £0.068m) which relates to the statutory audit and the consolidation of charitable funds accounts.

8. Operating leases8.1 As lesseeThe Foundation Trust ‘s operating leases predominantly relate to lease cars

8.2 Annual commitments under non-cancellable operating leases are:

8.3 As lessorThe Foundation Trust has made spaces available within the three sites to the local CCGs and the Disability Trust renewable on an annual basis. These are operating leases and the rental from these leases is recognised on a straight line basis within these financial statements.

2014/15 £000

2013/14 £000

Limit as per the Auditors’ engagement letter 1,000 1,000

Payments recognised as an expense 2014/15 £000

2013/14 £000

Minimum lease payments 620 676

620 676

Total future minimum lease payments 2014/15 £000

2013/14 £000

Payable:

Not later than one year 1,271 990

Between one and five years 1,042 326

Total 2,313 1,316


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9.1 Employee costs 2014/15 2013/14

TotalPermanently

Employed Other TotalPermanently

Employed Other

£000 £000 £000 £000 £000 £000

Salaries and wages 179,975 178,649 1,326 169,585 167,746 1,839

Social Security Costs 13,402 13,402 0 13,066 13,066 0

Employer contributions to NHS Pension scheme * 20,312 20,312 0 20,107 20,107 0

Agency/Contract Staff 21,447 0 21,447 15,316 0 15,316

Termination benefits 0 0 0 0 0 0

Employee benefits expense 235,136 212,363 22,773 218,074 200,919 17,155

* For more details on Pension costs, please refer to the note 9.7 on page 151

9.2 Monthly average number of people employed

2014/15 2013/14

TotalPermanently

Employed Other TotalPermanently

Employed Other

WTE WTE WTE WTE WTE WTE

Medical and dental 533 519 14 552 533 19

Administration and estates 1,171 1,171 0 1,154 1,154 0

Healthcare assistants and other support staff 1,068 1,068 0 1,017 1,017 0

Nursing, midwifery and health visiting staff 1,561 1,561 0 1,480 1,480 0

Scientific, therapeutic and technical staff 994 994 0 956 957 (1)

Agency and contract staff 171 0 171 129 0 129

Bank staff 116 0 116 93 0 93

Total 5,614 5,313 301 5,381 5,141 240

9.3 Retirements due to ill-healthDuring 2014/15 there were 17 (2013/14 11) early retirements from the Foundation Trust agreed on the grounds of ill-health. The estimated additional pension liabilities of these ill-health retirements will be £1.226m (2013/14 £0.543m). The cost of these ill-health retirements will be borne by the NHS Business Services Authority - Pensions Division.

9.4 Management costs2014/15

£0002013/14

£000

Management costs 11,835 11,252

Income 330,815 319,272

Management costs as a % of income 3.6% 3.5%

The above is excluding Charitable income and costs.

9. Employee costs and numbers

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9.5 Directors’ remuneration analysis2014/15

£0002013/14

£000

Executive and Non Executive Directors’ Salaries 1,172 1,098

National Insurance - Employers 136 127

Pension contributions - Employers 148 140

Total 1,456 1,365

9.6 Staff Termination and other exit packages(a) (b) (c) (d) (e)

Exit Package Cost Band - Excluding Directors Number of compulsory

redundancies 2014/15

Number of other

departures agreed

2014/15

Total number of exit

packages by cost band

2014/15

Total number of exit

packages 2013/14

< £10,000 2 0 2 5

£10,001 - £25,000 3 0 3 8

£25,001 - £50,000 1 0 1 4

£50,001 - £100,000 3 0 3 5

£100,001 - £150,000 3 0 3 2

Total Number of Exit Packages by type 12 0 12 24

Total Resource Cost £000 614 0 614 900

All the above payments have been made as per the NHS terms and conditions on termination of employees.

9.7 Pension costsPast and present employees are covered by the provisions of the NHS Pensions Scheme. Details of the benefits payable under these provisions can be found on the NHS Pensions website at www.nhsbsa.nhs.uk/pensions. The scheme is an unfunded, defined benefit scheme that covers NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State, in England and Wales. The scheme is not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, the scheme is accounted for as if it was a defined contribution scheme: the cost to the NHS Body of participating in the scheme is taken as equal to the contributions payable to the scheme for the accounting period.

In order that the defined benefit obligations recognised in the financial statements do not differ materially from those that would be determined at the reporting date by a formal actuarial valuation, the FReM requires that “the period between formal valuations shall be four years, with approximate assessments in intervening years”. An outline of these follows:

a) Accounting valuationA valuation of the scheme liability is carried out annually by the scheme actuary as at the end of the reporting period. This utilises an actuarial assessment for the previous accounting period in conjunction with updated membership and financial data for the current reporting period, and are accepted as providing suitably robust figures for financial reporting purposes. The valuation of the scheme liability as at 31 March 2015, is based on valuation data as 31 March 2013, updated to 31 March 2015 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS 19, relevant FReM interpretations, and the discount rate prescribed by HM Treasury have also been used.


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The latest assessment of the liabilities of the scheme is contained in the scheme actuary report, which forms part of the annual NHS Pension Scheme (England and Wales) Pension Accounts, published annually. These accounts can be viewed on the NHS Pensions website. Copies can also be obtained from The Stationery Office.

b) Full actuarial (funding) valuationThe purpose of this valuation is to assess the level of liability in respect of the benefits due under the scheme (taking into account its recent demographic experience), and to recommend the contribution rates.

The last published actuarial valuation undertaken for the NHS Pension Scheme was completed for the year ending 31 March 2004. Consequently, a formal actuarial valuation would have been due for the year ending 31 March 2008. However, formal actuarial valuations for unfunded public service schemes were suspended by HM Treasury on value for money grounds while consideration is given to recent changes to public service pensions, and while future scheme terms are developed as part of the reforms to public service pension provision due in 2015.

The Scheme Regulations were changed to allow contribution rates to be set by the Secretary of State for Health, with the consent of HM Treasury, and consideration of the advice of the Scheme Actuary and appropriate employee and employer representatives as deemed appropriate.

The next formal valuation to be used for funding purposes will be carried out at as at March 2012 and will be used to inform the contribution rates to be used from 1 April 2015.

c) Scheme provisionsThe NHS Pension Scheme provided defined benefits, which are summarised below. This list is an illustrative guide only, and is not intended to detail all the benefits provided by the Scheme or the specific conditions that must be met before these benefits can be obtained:

The Scheme is a “final salary” scheme. Annual pensions are normally based on 1/80th for the 1995 section and of the best of the last three years pensionable pay for each year of service, and 1/60th for the 2008 section of reckonable pay per year of membership. Members who are practitioners as defined by the Scheme Regulations have their annual pensions based upon total pensionable earnings over the relevant pensionable service.

With effect from 1 April 2008 members can choose to give up some of their annual pension for an additional tax free lump sum, up to a maximum amount permitted under HMRC rules. This new provision is known as “pension commutation”.

Annual increases are applied to pension payments at rates defined by the Pensions (Increase) Act 1971, and are based on changes in retail prices in the twelve months ending 30 September in the previous calendar year. From 2011-12 the Consumer Price Index (CPI) has been used and replaced the Retail Prices Index (RPI).

Early payment of a pension, with enhancement, is available to members of the scheme who are permanently incapable of fulfilling their duties effectively through illness or infirmity. A death gratuity of twice final year’s pensionable pay for death in service, and five times their annual pension for death after retirement is payable.

For early retirements other than those due to ill health the additional pension liabilities are not funded by the scheme. The full amount of the liability for the additional costs is charged to the employer.

Members can purchase additional service in the NHS Scheme and contribute to money purchase AVC’s run by the Scheme’s approved providers or by other Free Standing Additional Voluntary Contributions (FSAVC) providers.

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10. Better payment practice code10.1 Better payment practice code - measure of compliance

2014/15 2013/14

Number £000 Number £000

Total Non-NHS trade invoices paid in the year 71,693 123,889 71,264 106,388

Total Non NHS trade invoices paid within target 10,132 36,407 38,576 55,737

Percentage of Non-NHS trade invoices paid within target 14% 29% 54% 52%

Total NHS trade invoices paid in the year 3,644 16,055 3,618 16,541

Total NHS trade invoices paid within target 1,706 8,435 193 11,093

Percentage of NHS trade invoices paid within target 47% 53% 5% 67%

The Better Payment Practice Code (BPPC) requires the Foundation Trust to aim to pay all undisputed invoices by the due date or within 30 days of receipt of goods or a valid invoice, whichever is later.

The Foundation Trust aims to pay all its suppliers within the normal payment terms. During 2014/15 the Foundation Trust has actively managed its working capital balances to maximise cash. However, this has reduced the BPPC performance.

10.2 The Late Payment of Commercial Debts (Interest) Act 19982014/15

£0002013/14

£000

Compensation paid to cover debt recovery costs under this legislation £0 £0

11. Finance income 2014/15 £000

2013/14 £000

Foundation Trust Interest on loans and receivables 65 83

Charitable Funds Interest on loans and receivables 79 80

Total 144 163

12. Finance Costs 2014/15 £000

2013/14 £000

Interest on loans (264) (32)

Finance leases (26) (31)

Other finance costs - unwinding of discount on provisions (56) (78)

Total (346) (141)

13. Revaluation of assets (property, plant and equipment) - DTZ valuations summaryImpairments 2014/15

£0002013/14

£000

Impairments charged to Revaluation Reserve (2,009) (1,258)

Impairments charged to Statement of Comprehensive income (2,031) (2,253)

Total Impairments due to Market Changes (4,040) (3,511)

Revaluation gains 2014/15 £000

2013/14 £000

Revaluation gains credited to Revaluation Reserve 817 1,682

Revaluation gains relating to previous impairments credited to income

603 1,913

Total Revaluation gains due to Market Changes 1,420 3,595


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14. Intangible assetsGroup and Trust

Software, Licences and Trademarks

Software, Licences and Trademarks

£000 £000

31 March 2015 31 March 2014

Gross cost at 1 April restated 5,226 4,685

Additions purchased 747 414

Reclassifications 5 127

Disposals other than by sale 0 0

Gross cost at 31 March 5,978 5,226

Accumulated amortisation at 1 April 4,181 3,871

Disposals other than by sale 0 0

Charged during the year 362 310

Amortisation at 31 March 4,543 4,181

Net book valuePurchased 1,435 1,045

Total at 31 March 1,435 1,045

Intangible assets are depreciated over 5 to 10 year period on a straight line basis.

All intangible assets are purchased and they are not subject to indexation or revaluations.

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15. Property, plant and equipment

The Foundation Trust received Charitable Contributions of £0.332m during this financial year to support capital purchases. The assets purchased are predominantly medical equipment, in order to enhance patient care, funded from donations and legacies received by the Foundation Trust.

The Foundation Trust’s Property have been revalued on a Modern Equivalent Asset basis as at 31st March 2010 by the District Valuers in accordance with the Treasury’s guidelines. At the 31st March 2015, the Foundation Trust’s Valuers (DTZ) completed a revaluation of the Estate which resulted in a net downward valuation. The results of this valuation have been included in these financial statements.

The property asset lives are as stated in the revaluation by the Foundation Trust Valuers.

In line with the Foundation Trust’s Estates strategy and rationalisation program, and some of the non specialised building assets have been declared non-operational and these assets have been valued by the Foundation Trust Valuers to the land value. These are predominantly on the North side of Diana, Princess of Wales Hospital site and have been earmarked for demolition as per the Estates Strategy. The impairments relating to these assets are charged to the Statement of Comprehensive Income.

Basis of ValuationThe valuations have been carried out primarily on the basis of Market Value Existing Use using the depreciated replacement cost (DRC) methodology on a modern substitute basis. Non-operational property, including surplus land, has been valued to Market Value Alternate Use.

Unless otherwise stated, the assumption has been made that the properties valued will continue to be in the occupation of the Foundation Trust for the foreseeable future having regard to the prospect and viability of the continuance of that occupation.

Method of ValuationDepreciated Replacement Cost (DRC) is the method of valuation adopted for arriving at the value of specialised operational property for financial accounting purposes as recommended by UK GAAP, the Royal Institution of Chartered Surveyors and HM Treasury.

“DRC is based on an estimate of the Market Value for the existing use of the land, plus the current gross replacement (reproduction) costs of the improvements, less allowances for physical deterioration and all relevant forms of obsolescence and optimisation.”

Where the actual use of the property is so special that it proves impossible to categorise it in general market terms, land has been valued assuming the benefit of planning permission for development for a use, or a range of uses, prevailing in the vicinity of the actual site. In these circumstances, the Market Value for the Existing Use (MVEU) of the land has been arrived at having regard to the cost of purchasing a notional replacement site in the same locality that would be equally suitable for the existing use and of the same size, with normally the same physical and locational characteristics as the actual site, other than characteristics of the actual site that are irrelevant, or of no value, to the existing use.


156

Group and Trust

Land

Build

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£000 £000 £000 £000 £000 £000 £000 £000 £000 Cost or valuation at 31 March 2014 9,283 114,507 3,234 870 38,792 92 6,795 683 174,256

Additions purchased 588 2,801 1,372 4,361 1,655 41 977 21 11,816Additions leased 0 0 0 0 0 0 0 0 0

Additions donated 0 163 0 0 169 0 0 0 332Transfers by absorption 0 0 0 0 0 0 0 0 0

Revaluations 179 203 435 0 0 0 0 0 817Impairments (80) (563) (1,366) 0 0 0 0 0 (2,009)

Reclassifications 0 712 7 (749) 0 0 25 0 (5)Disposals (70) 0 (171) 0 (842) 0 0 0 (1,083)

At 31 March 2015 9,900 117,823 3,511 4,482 39,774 133 7,797 704 184,124

Accumulated Depreciation at 1 April 2014 (2) 4,839 124 0 28,188 64 4,702 474 38,389Disposals 0 0 (8) 0 (809) 0 0 0 (817)

Transfers by absorption 0 0 0 0 0 0 0 0 0Impairments 896 1,036 99 0 0 0 0 0 2,031

Reversal of Impairments 0 (603) 0 0 0 0 0 0 (603)Reclassifications 0 0 0 0 0 0 0 0 0

Charged during the year 0 2,281 68 0 3,545 9 784 64 6,751At 31 March 2015 894 7,553 283 0 30,924 73 5,486 538 45,751

Net book value Purchased 9,006 107,673 3,228 4,482 8,355 60 2,284 154 135,242

Donated 2,597 495 27 12 3,131Total at 31 March 2015 9,006 110,270 3,228 4,482 8,850 60 2,311 166 138,373

Owned 9,006 110,270 3,228 4,482 8,647 60 2,311 166 138,170Finance Leased 0 0 0 0 203 0 0 0 203

Total at 31 March 2015 9,006 110,270 3,228 4,482 8,850 60 2,311 166 138,373

Protected 9,006 110,270 0 0 0 0 0 0 119,276Un protected 0 0 3,228 4,482 8,850 60 2,311 166 19,097

Total at 31 March 2015 9,006 110,270 3,228 4,482 8,850 60 2,311 166 138,373

15. Property, plant and equipment

157

Group and Trust

Land

Build

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exclu

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£000 £000 £000 £000 £000 £000 £000 £000 £000 Cost or valuation at 31 March 2013 9,729 109,925 3,447 1,222 36,969 115 5,638 678 167,723

Additions purchased 0 2,973 0 786 2,451 0 959 5 7,174Additions leased 0 0 0 0 85 0 0 0 85

Additions donated 0 23 0 0 79 0 40 0 142Transfers by absorption 50 90 0 0 0 0 9 0 149

Revaluations 12 1,529 141 0 0 0 0 0 1,682Impairments (360) (889) (9) 0 0 0 0 0 (1,258)

Reclassifications 0 862 0 (1,138) 0 0 149 0 (127)Disposals (148) (6) (345) 0 (792) (23) 0 0 (1,314)

At 31 March 2014 9,283 114,507 3,234 870 38,792 92 6,795 683 174,256

Accumulated Depreciation at 1 April 2013 0 2,080 70 0 25,068 80 3,939 398 31,635Disposals 0 (6) (11) 0 (774) (23) 0 0 (814)

Transfers by absorption 0 0 0 0 0 0 0 0 0Impairments 0 2,253 0 0 0 0 0 0 2,253

Reversal of Impairments (2) (1,911) 0 0 0 0 0 0 (1,913)Reclassifications 0 0 0 0 0 0 0 0 0

Charged during the year 0 2,423 65 0 3,894 7 763 76 7,228At 31 March 2014 (2) 4,839 124 0 28,188 64 4,702 474 38,389

Net book value Purchased 9,285 106,675 3,110 870 9,819 28 2,086 187 132,060

Donated 0 2,993 0 0 785 0 7 22 3,807Total at 31 March 2014 9,285 109,668 3,110 870 10,604 28 2,093 209 135,867

Owned 9,285 109,668 3,110 870 10,197 28 2,093 209 135,460Finance Leased 0 0 0 0 407 0 0 0 407

Total at 31 March 2014 9,285 109,668 3,110 870 10,604 28 2,093 209 135,867

Protected 9,285 109,668 0 0 0 0 0 0 118,953Un protected 0 0 3,110 870 10,604 28 2,093 209 16,914

Total at 31 March 2014 9,285 109,668 3,110 870 10,604 28 2,093 209 135,867


158

Donated AssetsGroup and Trust Group and Trust

31 March 2015 31 March 2014

Build

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Plan

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£000 £000 £000 £000 £000 £000 £000 £000 £000 £000

Cost or valuation at 1 April 2,852 2,981 149 48 6,030 3,097 2,927 109 48 6,181

Additions purchased 163 169 0 0 332 23 79 40 0 142

Disposals 0 (89) 0 0 (89) (1) (25) 0 0 (26)

Impairments 0 0 0 0 0 (332) 0 0 0 (332)

Revaluation gains 26 0 0 0 26 65 0 0 0 65

At 31st March 3,041 3,061 149 48 6,299 2,852 2,981 149 48 6,030

Accumulated depreciation at 1st April 273 2,419 112 31 2,835 104 2,142 102 26 2,374

Disposals 0 (89) 0 0 (89) 0 (25) 0 0 (25)

Impairments 127 0 0 0 127 150 0 0 0 150

Revaluation (13) 0 0 0 (13) (39) 0 0 0 (39)

Charged during the year 57 236 10 5 308 58 302 10 5 375

At 31st March 444 2,566 122 36 3,168 273 2,419 112 31 2,835

Net Book Value at 31st March 2,597 495 27 12 3,131 2,579 562 37 17 3,195

Group and Trust Group and Trust

31 March 2015 31 March 2014

Plan

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tech

nolo

gy

Tota

l

£000 £000 £000 £000 £000 £000

Cost or valuation at 1 April 1,400 36 1,436 1,315 36 1,351

Additions purchased 0 0 0 85 0 85

At 31st March 1,400 36 1,436 1,400 36 1,436

Accumulated depreciation at 1st April 993 36 1,029 791 36 827

Disposals 0 0 0 0 0 0

Charged during the year 204 0 204 202 0 202

At 31st March 1,197 36 1,233 993 36 1,029

Net Book Value at 31st March 203 0 203 407 0 407

Assets held under Finance Lease

159

Net C

hang

e in V

alua

tion

(incre

ase)

Dec

reas

e

Char

ged t

o Exp

ense

s

Impa

irmen

t Rev

ersa

ls In

clude

d as I

ncom

e

Chan

ges t

o Rev

alua

tion

Rese

rves

Site Description £000 £000 £000 £000

Diana, Princess of Wales Hospitals, Grimsby Land and Buildings 2,958 1,654 (237) 1,541

Scunthorpe General Hospital Land and Buildings (465) 377 (353) (489)

Goole District Hospital Land and Buildings 127 0 (13) 140

Other Land and Buildings 0 0 0 0

Total 2,620 2,031 (603) 1,192

2014/15 - Property Valuations Summary by the DTZThe Foundation Trust Valuers (DTZ) completed a valuation of the Property Assets at 31st March 2015 and concluded that there were changes to the Value of Property Assets. The Foundation Trust identified that these changes are material and therefore, the results have been incorporated into these financial statements.

The outcome from the valuation was that, on all three sites, some of the assets suffered impairments whilst other assets had revaluation gains. The Foundation Trust continues to progress its Estates Strategy and Rationalisation programme. The approximate net impact of the Foundation Trust’s valuations are given below.

All the above changes relate to properties in the Foundation Trust’s main healthcare segment.

16. Capital commitments

Contracted capital commitments at 31 March 2015 not otherwise included in these financial statements

Group and Trust Group and Trust31 March 2015 31 March 2014

£000 £000

Property, plant and equipment 6,563 850Intangible assets 0 0

Total 6,563 850

17. Inventories17.1. Inventories

Group and Trust31 March 2015

£000


£000

Materials:-Drugs 925 746

Consumables 1,359 1,524Energy 79 115

Other 322 356Total 2,685 2,741

Of which held at net realisable value: 2,685 2,741

The Foundation Trust continues its policy on reducing stock and as far as possible follows Just in Time principles.


160

17.2 Inventories recognised in expensesGroup and Trust

31 March 2015£000


£000

Inventories recognised as an expense in the year * 37,164 34,283

Total 37,164 34,283

18. Trade and other receivables18.1 Trade and other receivables

Current

Group31 March 2015

£000

Trust31 March 2015

£000

Group31 March 2014

£000

Trust31 March 2014

£000NHS receivables 6,822 6,822 8,292 8,292

Other trade receivables * 6,136 6,121 5,550 5,525VAT net receivables 616 616 292 292

Provision for the impairment of receivables (786) (786) (890) (890)Prepayments other 3,537 3,537 3,799 3,799

Total 16,325 16,310 17,043 17,018

Non-current

Group31 March 2015

£000

Trust31 March 2015

£000

Group31 March 2014

£000

Trust31 March 2014

£000NHS receivables 0 0 0 0

Other trade receivables 15 15 18 18VAT net receivables 0 0 0 0

Provision for the impairment of receivables 0 0 0 0Prepayments other 0 0 0 0

Total 15 15 18 18

* Other trade receivables include £1.9m of Injury Cost Recovery receivables, £2.9m of other receivables.

18.2 Ageing of impaired receivables past their due date

Group31 March 2015

£000

Trust31 March 2015

£000

Restated 31 March 2014

Group£000

Restated31 March 2014

Trust£000

0 - 30 days 251 251 136 13630-60 Days 105 105 310 31060-90 days 106 106 315 315

90- 180 days 328 328 450 450Over 180 days 1,420 1,420 1,239 1,239

Total 2,210 2,210 2,450 2,450

Notes to:

17.2 Inventories recognised in expenses

* Inventories recognised in expenses is calculated using transactions from the purchase ledger on the appropriate expenditure areas.

161

18.3 Receivables past their due date but not impaired

Group31 March 2015

£000

Trust31 March 2015

£000

RestatedGroup

31 March 2014£000

RestatedTrust

31 March 2014£000

0 - 30 Days 596 596 681 68130-60 Days 302 302 1,461 1,46160-90 days 371 371 388 388

90- 180 days 943 943 701 701Over 180 days* 820 820 437 437

Total 3,032 3,032 3,668 3,668

19. Other current assets31 March 2015

£00031 March 2014

£000EU Emissions trading scheme allowances 0 0

Other assets 0 0Total 0 0

20. Cash and cash equivalentsGroup

31 March 2015£000

Trust31 March 2015

£000

Group31 March 2014

£000

Trust31 March 2014

£000Balance at 1 April 26,633 26,504 33,261 32,732

Net change in year (5,456) (5,348) (6,628) (6,228)

Balance at 31 March 21,177 21,156 26,633 26,504

Made up of:Cash with Government Banking Services 20,929 20,929 26,233 26,233

Commercial banks and cash in hand 248 227 400 271Cash and cash equivalents as in statement of financial position 21,177 21,156 26,633 26,504

Cash and cash equivalents as in statement of cash flows 21,177 21,156 26,633 26,504

21. Non-current assets held for saleAt the Statement of Financial Position date, the Foundation Trust does not have any assets held for sale.

Notes to:

18.3 Receivables past their due date but not impaired

* This relates to a number of outstanding invoices with other NHS suppliers which are overdue and the Foundation Trust is actively pursuing these debts.

Group31 March 2015

£000

Trust31 March 2015

£000

Group31 March 2014

£000

Trust31 March 2014

£000Balance at 1 April (890) (890) (997) (997)

(Increase) in provision in the year (210) (210) (446) (446)Amounts utilised 60 60 14 14

Unused amounts reversed 254 254 539 539Balance at 31 March (786) (786) (890) (890)

The provision for bad debt has been calculated following a detailed review of all outstanding invoices as at 31st March 2015. The departmental heads were involved in determining the potential bad debt values in view of the nature of the services provided and the possibility of potential receipts. The RTA provision for bad debt is 25% based on the recovery trend in the past years and the level of potential cancellations.

18.4 Provision for impairment of receivables


162

22. Trade and other payables

Current

Group31 March 2015

£000

Trust31 March 2015

£000

Group31 March 2014

£000

Trust31 March 2014

£000Notes to:

22. Trade and other payables

* NHS payables includes £2.87m for NHS Pension agency payments and PDC Dividend £0.09m.

** Other includes £0.45m for accrued annual leave, £0.12m for Clinical Excellence Awards and £0.48m Goole Neuro Rehabilitation Centre (GNRC).

NHS payables * (7,497) (7,497) (6,676) (6,676)Trade payables (6,808) (6,808) (5,174) (5,174)

Other trade payables - capital (2,816) (2,816) (1,508) (1,508)Tax and social security costs (4,406) (4,406) (4,388) (4,388)

Accruals (9,989) (9,989) (9,678) (9,678)Other ** (3,527) (3,444) (3,465) (3,417)

Total (35,043) (34,960) (30,889) (30,841)

Non-Current

Group31 March 2015

£000

Trust31 March 2015

£000

Group31 March 2014

£000

Trust31 March 2014

£000Other trade payables - revenue 0 0 (34) (34)

Total 0 0 (34) (34)

23. Borrowings Group and Trust Group and TrustNotes to:

23. Borrowings

* The above relates to payments due to suppliers in relation to the lease of medical and other equipment over the term of the lease.

Current Non-current31 March 2015

£00031 March 2014

£00031 March 2015

£00031 March 2014

£000Loans from independent trust financing facility (1,329) 0 (17,516) (3,850)

Loans from Department of Health (355) 0 (1,822) (1,871)Finance lease liabilities * (123) (220) (65) (188)

Total (1,807) (220) (19,403) (5,909)

24. Other liabilities Group and Trust Group and TrustCurrent Non-current

31 March 2015£000

31 March 2014£000

31 March 2014£000

31 March 2014£000

Other (Deferred Income) (1,307) (2,963) 0 0

Total (1,307) (2,963) 0 0

The £1.307m of deferred income in 2014/15 includes £0.17m clinical trials income and £1.0m relating to the sale of land at Diana Princess of Wales Hospital.

163

25. Finance lease obligationsThe Foundation Trust has some medical equipment under leasing arrangements. The table below shows the amounts payable under the terms of the lease for these equipment.

Amounts payable under finance leases:

There are no sub leases or contingent rents

26. Finance lease receivables (i.e. as lessor)The Foundation Trust has arrangements with other NHS and non NHS bodies whereby the Foundation Trust receives income for the premises rented to these bodies. These arrangements are covered by annual service level agreements and are normally for a term of one year, renewable at the end of each year by mutual agreement. This income is included within this year’s operating income shown in these financial statements. These arrangements are not classed as leases.

27. Finance lease commitmentsAs at the 31 March 2015, the Foundation Trust does not have any Finance Lease commitments.

28. Private Finance Initiative contractsThe Foundation Trust does not have any PFI schemes at the 31 March 2015

29. Other financial liabilitiesThe Foundation Trust does not have any other Financial Liabilities

Group and Trust

Minimum lease payments31 March 2015

£00031 March 2014

£000Within one year 131 241

Between one and five years 70 201

Less future finance charges (13) (34)

Present value of minimum lease payments 188 408

Included in: Current borrowings 123 220

Non-current borrowings 65 188

188 408


164

30. Provisions Group and TrustCurrent

Group and TrustNon-current

31 March 2015£000

31 March 2014£000

31 March 2015£000

31 March 2014£000

Pensions relating to other staff - retirement (289) (291) (2,404) (2,517)Legal claims (163) (191) 0 0

Restructurings & Redundancies (2,561) (1,650) (285) (1,908)Other (Demolition, Injury Benefit & Carbon Reduction Commitment) (1,092) (798) (2,566) (2,557)

Total (4,105) (2,930) (5,255) (6,982)

Group and Trust Tota

l

Pens

ions

relat

ing

to st

aff

Lega

l cla

ims

Redu

ndan

cies a

nd

Restr

uctu

rings

Othe

r

£000 £000 £000 £000 £000At 1 April 2014 (9,912) (2,808) (191) (3,558) (3,355)

Arising during the year (3,536) (147) (202) (2,552) (635)Used during the year 1,902 297 123 1,148 334

Reversed unused 2,242 0 107 2,116 19Unwinding of discount (56) (35) 0 0 (21)

(9,360) (2,693) (163) (2,846) (3,658)

Expected timing of cash flows:In the remainder of the spending review year to 31

March 2016(4,105) (289) (163) (2,561) (1,092)

Between 1 April 2016 and 31 March 2020 (2,757) (1,117) 0 (285) (1,355)From 1 April 2020 onwards (2,498) (1,287) 0 0 (1,211)

(9,360) (2,693) (163) (2,846) (3,658)

£62,967,000 is included in the provisions of the NHS Litigation Authority at 31/3/2015 (31/03/14 £57,286,000), as detailed below;

Group and Trust 31 March 2015£000

31 March 2014£000

Clinical Negligence Claims 58,605 52,505Employee Liabilities Scheme 4,362 4,781

62,967 57,286

Provision for retirement relates to pre 1995 premature pensions and the amount provided is based on the actual number of members of staff and their demographic and gender factor.

Provision for redundancies of £2.846m will be discharged as part of the workforce review process. The above provision has been made based on the Sustainability Plans agreed by the Foundation Trust Board.

Other provisions include demolition provision of £1.646m, £0.336m of Carbon Reduction Commitment provision and the balance relates to injury benefit relating to named individuals’ payments.

165

31 March 2015Loans and receivables

Restated31 March 2014

Loans and receivables

Group Trust Group Trust

£000 £000 £000 £000

Receivables 11,394 11,379 11,730 11,702

Cash and cash equivalent 21,177 21,156 26,633 26,504

Total at 31 March 32,571 32,535 38,363 38,206

33.2 Financial liabilities31 March 2015

Other Financial LiabilitiesRestated

31 March 2014Other Financial Liabilities

Notes to:

33.2 Financial liabilities

* Borrowing relates to loan from the Independent Trust Financing Facility (£18.845m) and The Department of Health (£2.177m)

** Other borrowings relates to Obligations under Finance Leases.

Group Trust Group Trust

£000 £000 £000 £000

Payables 38,433 38,350 36,476 36,428

Borrowings* 21,022 21,022 5,721 5,721

Other borrowings ** 188 188 408 408

Total at 31 March 59,643 59,560 42,605 42,557

31. Revaluation ReservesProperty Plant and equipment

£00031.1 Revaluation Reserve 2014/15Revaluation reserve at 1 April 2014 14,219

Total Comprehensive income for the year (1,192) Revaluation reserve at 31 March 2015 13,027

31.2 Revaluation Reserve 2013/14 Property Plant and equipment - Restated

£000Revaluation reserve at 1 April 2013 13,689

Total Comprehensive income for the year 424

Transfers to the income and expenditure account in respect of transfer from demising bodies 106Revaluation reserve at 31 March 2014 14,219

32. Contingencies32.1 Contingent liabilities

Group and Trust2014/15

£000

Group and Trust2013/14

£000

NHSLA notified EL/PL claims (97) (114)

Total (97) (114)

32.2 Contingent assetsThere are no contingent assets in the current financial year.

33. Financial Instruments33.1 Financial assets


166

33.3 Financial risk managementFinancial reporting standard IFRS 7 requires disclosure of the role that financial instruments have had during the year in creating or changing the risks a body faces in undertaking its activities. Because of the continuing service provider relationship that the Foundation Trust has with Clinical Commissioning Groups and the way those clinical commissioning groups are financed, the Foundation Trust is not exposed to the degree of financial risk faced by business entities. Also financial instruments play a much more limited role in creating or changing risk than would be typical of listed companies, to which the financial reporting standards mainly apply. The Foundation Trust has limited powers to borrow or invest surplus funds and financial assets and liabilities are generated by day-to-day operational activities rather than being held to change the risks facing the Foundation Trust in undertaking its activities.

The Foundation Trust’s treasury management operations are carried out by the Finance Directorate, within parameters defined formally within the Foundation Trust’s standing financial instructions and policies agreed by the Board of Directors. Foundation Trust treasury activity is subject to regular review by the Trust’s Resources Committee and the Foundation Trust’s internal auditors.

Currency riskThe Foundation Trust is principally a domestic organisation with the great majority of transactions, assets and liabilities being in the UK and sterling based. The Foundation Trust has no overseas operations. The Foundation Trust therefore has low exposure to currency rate fluctuations.

Interest rate riskThe Foundation Trust currently has borrowings of £21.022m of which £2.177m carries no interest charge. The remaining loans have an interest rate of 2.06% (£8.845m) and 2.39% (£10.0m).

Credit riskBecause the majority of the Foundation Trust’s income comes from contracts with other public sector bodies, the Foundation Trust has low exposure to credit risk. The maximum exposures as at 31 March 2015 are in receivables from customers, as disclosed in the Trade and other receivables note 18.1.

Liquidity riskThe Foundation Trust’s operating costs are incurred under contracts with Clinical Commissioning Groups, which are financed from resources voted annually by Parliament . The Foundation Trust funds its capital expenditure from internally generated funds and funds obtained from Department of Health or Independent Financing Facility loans. The Foundation Trust is not, therefore, exposed to significant liquidity risks.

34. Events after the reporting year

There are no post balance sheet events in the reporting year.

35. Related party transactions

During the year none of the Department of Health Ministers, Foundation Trust Board Members or members of the key management staff, or parties related to any of them, has undertaken any material transactions with Northern Lincolnshire and Goole NHS Foundation Trust.

The Department of Health is regarded as a related party. During the year, this Foundation Trust has had a significant number of material transactions with other entities for which the Department of Health is regarded as the parent department. These entities are:

NHS England, Clinical Commissioning Groups, NHS Trusts, NHS Foundation Trusts and NHS Litigation Authority.

In addition, the Foundation Trust has had a number of material transactions with other government departments and other central and local government bodies.

The Foundation Trust has also received revenue and capital payments from a number of charitable funds, the trustees of the charitable funds are also members of the NHS Foundation Trust Board.

167

Organisations 2014/15Income

£000

2014/15Expenditure

£000

31 March 2015

Receivables£000

31 March 2015

Payables£000

Department of Health 0 0 1,000 1,023Doncaster and Bassetlaw Hospitals NHS Foundation Trust 95 144 57 27

East Riding of Yorkshire Council 0 169 0 0Health Education England 9,243 37 111 37

Hull CCG 317 0 0 0Hull and East Yorkshire Hospitals NHS Trust 1,429 2,112 429 874

Humber NHS Foundation Trust 37 8 0 0Leeds Teaching Hospital NHS Trust 6 424 1 154

Lincolnshire Community Health Services NHS Trust 1,241 5 373 5Lincolnshire Council 101 0 0 0

Lincolnshire Partnership NHS Foundation Trust 197 0 24 0NHS Bassetlaw CCG 114 0 0 0

NHS Blood & Transplant 0 1,630 0 14NHS Doncaster CCG 930 0 0 49

NHS East Riding of Yorkshire CCG 18,805 16 79 16NHS England 24,280 62 585 32

NHS Hull Teaching CCG 0 0 49 0NHS Lincolnshire East CCG 26,718 0 764 0

NHS Lincolnshire West CCG 9,967 0 406 0NHS Litigation Authority 0 6,793 0 14

NHS North East Lincolnshire CCG 100,942 10 947 6NHS North Lincolnshire CCG 105,426 0 587 2,100

NHS Pension Scheme 21 20,312 0 2,873NHS Property Services 0 450 0 213

NHS South Lincolnshire CCG 933 0 78 0NHS South West Lincolnshire CCG 2,538 0 86 0

NHS Vale of York CCG 673 0 57 0NHS Wakefield CCG 210 0 47 0

North East Lincolnshire Council 230 883 5 0North Lincolnshire Council 880 791 241 44

Nottingham University Hospitals NHS Foundation Trust 101 144 79 22Peterborough & Stamford NHS Foundation Trust 25 199 9 12

Public Health England 0 238 0 0Rotherham Doncaster and South Humber Mental Health

NHS Foundation Trust128 175 64 28

Sheffield Children’s NHS Foundation Trust 39 259 8 82Sheffield Teaching Hospitals NHS Foundation Trust 702 353 178 198

United Lincolnshire Hospitals NHS Trust 7,408 1,024 48 459University Hospitals of Leicester 11 55 268 27

York Hospitals NHS Foundation Trust 8 16 1 13Other (Total) 1,894 879 487 219

Total Related Parties 315,649 37,188 7,068 8,541HM Revenue and Customs ( Taxes and Duties) 0 13,402 616 4,406

Other Government Departments 0 13,402 616 4,406

Comparatives 2013/14Total Related Parties 305,745 37,590 8,630 9,072

Other Government Departments 0 13,066 292 4,388


168

2014/15Expenditure

£000

2013/14Expenditure

£000

1. Short term employee benefits 0 0

2. Post employment benefits 0 0

3. Other long term benefits 0 0

2014/15£000

2013/14£000

Notes to:

Charitable Funds

* Expenditure includes £0.034m (£0.033m 2013/14) administration costs and £0.211m (£0.256m 2013/14) expenditure on medical equipment, staff training and development

Statement of Financial ActivitiesTotal Incoming Resources 451 438

Total Resources Expended * (804) (578)

Net (outgoing) resources before transfers (353) (140)

Gains on revaluation and disposal 142 21

Other fund movements 0 0

Net movement in funds (211) (119)

Statement of Financial positionInvestments 1,995 2,053

Cash 21 129

Other Current Assets 15 28

Current Liabilities (83) (51)

Total Charitable Funds 1,948 2,159

Restricted Charitable Funds 109 391

Unrestricted Charitable Funds 1,839 1,768

Total Charitable Funds 1,948 2,159

Key management PersonnelIn 2014/15, apart from what is shown within the Remuneration report, no other payment was made to key management personnel.

Charitable FundsThe Northern Lincolnshire and Goole NHS Foundation Trust Board is the Corporate Trustee of the NHS Charitable Funds and therefore, the Charitable Funds represents a subsidiary of the Foundation Trust on the basis that it:-

• has control over the NHS charitable fund (as determined by IAS 27 (revised)); and

• benefits from the NHS charitable fund.

From 2013/14 Northern Lincolnshire and Goole NHS Foundation Trust has consolidated the NHS charitable funds into its accounts.

For 2014/15, the financial position of the NHS Charitable Funds is as follows:-

169

Current receivables

£000

Non-current receivables

£000

Current payables

£000

Non-current payables

£000Balances with other Central Government Bodies 616 0 (7,279) 0

Balances with NHS Bodies 6,822 0 (5,624) 0Balances with Local Authorities 246 0 (44) 0

Intra Government balances 7,684 0 (12,947) 0Balances with bodies external to Government 8,641 15 (22,096) 0

At 31 March 2015 16,325 15 (35,043) 0

Balances with other Central Government Bodies 292 0 (6,784) 0Balances with NHS Bodies 8,292 0 (6,676) 0

Balances with Local Authorities 338 0 0 0Intra Government balances 8,922 0 (13,460) 0

Balances with bodies external to Government 8,121 18 (17,429) (34)At 31 March 2014 17,043 18 (30,889) (34)

36. Third Party AssetsThe Foundation Trust held £3,000 (2013/14 £17,000) cash and cash equivalents which relates to monies held by the NHS Foundation Trust on behalf of patients. This has been excluded from the cash and cash equivalents figure reported in the accounts.

37. Intra-Government and Other Balances

38. Losses and Special Payments

There were 242 (100 cases in 2013/14) cases of losses and special payments totalling £0.226m (£0.215m in 2013/14) paid during the year.

There were no cases exceeding £0.250million in this year and prior year.

2014/2015 ANNUAL QUALITY REPORT


2

Contents4 PART 1: Statement on quality from the chief executive of the Northern Lincolnshire and Goole NHS Foundation Trust

6 About Northern Lincolnshire and Goole NHS Foundation Trust

6 Executive summary of the key points from this year’s Quality Account

6 The Trust’s quality targets and priorities – driving continuous improvement

13 PART 2: Priorities for improvement, statements of assurance from the board and reporting against core indicators

13 2.1 Priorities for improvement: overview of the quality of care against 2013/14 quality priorities

15 2.1a Clinical effectiveness (CE)

16 CE1 – Mortality improvement – Summary Hospital Mortality Indicator (SHMI)

20 CE2 – National Early Warning Score (NEWS)

22 CE3 – Dementia

27 CE4 – National Institute for Health and Care Excellence (NICE) evidence-based practice

30 CE5 Transfer and discharge

35 2.1b Patient safety (PS)

36 PS1 MRSA bacteraemia incidence

37 PS2 C. difficile incidence

39 PS3 Safety Thermometer – increase in harm free care (community)

42 PS4 Increase in harm free care (acute)

51 PS5 Patient falls

52 PS6 Pressure ulcers

54 PS7 Nutrition

58 PS8 Hydration

61 2.1c Patient experience (PE)

62 PE1 Friends and Family Test

68 PE2 Complaints

71 PE3 Complaints – action plans agreed within timescales

73 PE4 Complaints

74 PE5 Pain management

75 PE6 Staff satisfaction: culture change and the morale barometer

79 2.1d: Quality priorities for 2015/16

81 The Trust’s quality targets & priorities – driving continuous improvement

82 2.2 Statements of assurance from the Board

2.2a Information on the review of services

2.2b Information on participation in clinical audits and national confidential enquires

89 2.2c Information on participation in clinical research

3

91 2.2d Information on the Trust’s use of the CQUIN framework

2.2e Information on Never Events

2.2f Information relating to the Trust’s registration with the Care Quality Commission

2.2g Information on quality of data

92 2.2h Information governance assessment report

2.2i Information on payment by results clinical coding audit

2.3 Trust performance against core indicators

93 2.3a: Summary Hospital-Level Mortality Indicator (SHMI)

100 2.3b: Patient Reported Outcome Measures (PROMS)

102 2.3c Readmissions to hospital

102 2.3d Personal needs of patients

104 2.3e Staff recommending Trust as a provider to friends and family

105 2.3f Risk assessed for venous thromboembolism

106 2.3g Clostridium difficile infection reported within the Trust

107 2.3h Patient safety incidents

109 2.3i Ambulance handover times

111 Part 3: Other information

An overview of the quality of care based on performance in 2013/14 against indicators

The Trust’s quality targets & priorities – driving continuous improvement

114 3.2 Performance against relevant indicators and performance thresholds

115 3.3 Information on staff survey report

116 3.4 Information on patient survey report

118 Annex 1: Statements from commissioners, local Healthwatch organisations and overview and scrutiny committees

Annex 1.1: Statements from Commissioners

119 Annex 1.2: Statement from HealthWatch organisations

Statement on North Lincolnshire and Goole NHS Foundation Trust Quality Account for 2014/15

121 Annex 1.3: Statement from local council overview and scrutiny committees (OSC)

122 Annex 1.4: Statement from the Trust governors’

123 Annex 2: Statement of directors’ responsibilities in respect of the Quality Report

125 Annex 3: Independent auditor’s report to the Board of Governors on the Annual Quality Report

128 Annex 4: Glossary

131 Annex 5: Mandatory Performance Indicator Definitions


4

PART 1

Statement on quality from the chief executive of the Northern Lincolnshire and Goole NHS Foundation Trust Quality and safety are the overarching priority for Northern Lincolnshire and Goole NHS Foundation Trust (also referred to as ‘the Trust’ throughout the remainder of this report). There can be no compromises to this quest for continuous quality improvement.

In pursuit of this goal, during the 2014/15 financial year (comprising April 2014 – March 2015) the Trust has endeavoured to strengthen its commitment to this as depicted by our visions and values: ‘Together we care, we respect and we deliver’.

I believe passionately that together we can deliver safe, quality services that put our patients, service users and their carers first. It is heart-warming to hear of all the good experiences where we achieved our visions and values, through the hard work and dedication of our workforce.

In cases where we fall short of this aspiration, the Trust Board and I are keen to hear these experiences too, so that we understand where further work is needed and that we can take action to ensure that the same issues do not occur again. To ensure we keep on hearing the good experiences and opportunities for improvement, at each one of our Board meetings we hear from a patient, service user or carer in their own words, what we did well or what we can do better. This is our quest and this is our commitment to ensure that we deliver what is at the very core of our being here.

Within this Quality Account is the detail behind our commitment to focus on continuous quality improvement. You will notice that the first section relates to our performance against our own, internally set quality priorities.

To aid our commitment to quality, you will see that these are not targets we have simply set ourselves that are easy to ‘tick off’ as achieved but rather these are designed to be stretching and focused on areas where we know we can do better – some even as a result of direct patient or service user feedback.

You will see from this that we have not always achieved these targets, and where this is the case we will continue to strive for compliance – committed to achieve and embed quality practice.

You will see from this that we are committed to quality in an open and transparent manner, publishing our self-assessment against these priorities here, annually, but also in our monthly quality report, overseen and scrutinised firstly by the Qualityand Patient Experience Committee (QPEC) and then presented to the Trust Board.

This monthly report is then a public document available on our internet site for all our local population to see and have access to.

Sections two and three of this report are mandated sections that all NHS Foundation Trusts have to report and here again you will see that our performance with these national indicators is reported openly and honestly, with an explanation of what we are doing in these areas to continuously improve.

As a result of these processes and assurance mechanisms, to the best of my knowledge the information contained in this document is accurate.

Our focus on quality and safety development has been supported over the last two years with a number of external scrutiny visits starting with the visit of Sir Bruce Keogh’s team, the Care Quality Commission and Monitor, the Foundation Trust regulator.

These reviews, though challenging at the time, have helped us firm up our plans for quality development and to add pace to their delivery. As a result of all this scrutiny, I am deeply proud of all my colleagues that make the Trust what it is. Instead of giving up in the face of these pressures, the organisation and all its staff have risen to the challenges.

A key outcome of this is the Trust’s Quality Development Plan (QDP) which has become the central place for all improvement plans to be stored, monitored, audited and updated.

This, amongst other assurances we were able to evidence, enabled the Trust to move out of the ‘special measures’ placed on it with regard to quality. This effectively demonstrated our determination and commitment to quality development within the Trust.

This commitment to quality already demonstrated enables me to confidently look to the challenges of the future accepting that there will also be challenges that we have to face together.

5

our many innovative mechanisms to secure permanent staff for our organisation and its patients.

These challenges illustrate that the local healthcare environment in which we operate needs to change to meet these demands and to ensure financial sustainability. To accomplish this, the Trust is working closely with our local healthcare community and commissioners on shaping sustainable services for the future through Healthy Lives and Healthy Futures (HLHF). This review of healthcare services across North and North East Lincolnshire is linked in to similar programmes within the East Riding of Yorkshire and East Lindsey.

This programme of sustainability aims to ensure that health and care systems are in place which provide safe, high quality and affordable services for the future.

The first phase of this programme has now been completed and has resulted in 24/7 hyperacute stroke services being centralised at Scunthorpe hospital and ear, nose and throat (ENT) services being centralised at Grimsby hospital.

While there are no compromises to quality and safety development, the Trust, among many other NHS organisations, faces many challenges ahead in relation to its financial sustainability.

You will note from the Trust’s Annual Report that our commitment to quality development is delivered in a complex and challenging environment. Like other NHS Trust’s we have faced unprecedented demands on our services during the winter and continuing into recent months, affecting our ability to meet A&E targets.

While other Trust’s in the region declared major incidents, effectively closing their doors to patients, the Trust remained open and our staff worked tirelessly to meet these increased pressures. Again, this is a source of pride for the Trust Board and our staff.

Another challenge presently is the availability of skilled doctors and nurses for recruitment to posts within the organisation. As a result of national shortages, this is a constant challenge for us to recruit permanent staff.

This leads to the Trust relying on temporary and agency posts to ensure safe staffing levels are maintained. We will continue with

The work will continue and will result in the need for more changes in the future.

In the midst of this complex and changeable context in which the Trust operates, the Trust Board and I are confident and determined that the Trust’s commitment to quality will aid the Trust go on developing and embedding quality practices, working together to put our patients, service users and carers first.

I look forward to outlining our continuing achievements both throughout the year in the monthly quality report as well as next year in our annual quality account publication and to recognise the pivotal role all our staff have in driving this agenda forward to secure the best care for our patients.

Karen Jackson, Chief executive


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The Trust’s quality targets and priorities – driving continuous improvementIt is worth noting here, that these targets/quality priorities for the most part are not nationally or regionally set, rather they are set locally by the Trust. They are selected as areas of key importance for the Trust to drive and embed continuous quality improvement. These indicators are not chosen for their ease of completion, resulting in a report full of green ‘completed’ ticks. These indicators are instead quality focused, aspirational and stretching. As a result, the executive summary that follows, and the greater detail within part two of this report presents progress so far, not always demonstrating that our internal quality targets have been met. Where these have not been met, an explanation and summary of the work underway are presented and for the most part, these targets have been selected to stay within the quality report to

drive quality development during 2015/16.

About Northern Lincolnshire and Goole NHS Foundation Trust

• Diana, Princess of Wales Hospital in Grimsby (also referred to as DPoW),

• Scunthorpe General Hospital located in Scunthorpe (also referred to as SGH) and

• Goole District Hospital (also referred to as GDH),

• Community and therapy services in North Lincolnshire.

The Trust was originally established as a combined hospital Trust on April 1 2001, and achieved Foundation Status on May 1 2007.

It was formed by the merger of North East Lincolnshire NHS Trust and Scunthorpe and Goole Hospitals NHS Trust and operates all NHS hospitals in Scunthorpe, Grimsby and Goole.

In April 2011 the Trust became a combined hospital and community services Trust (for North Lincolnshire). As a result of this the

Northern Lincolnshire and Goole NHS Foundation Trust (referred to as ‘The Trust’ throughout this report) consists of three hospitals and community services in North Lincolnshire and therapy services in Northern Lincolnshire. In summary these services are:

name of the Trust, while illustrating the geographical spread of the organisation, was changed during 2013 to reflect the Trust did not just operate hospitals in the region.

The Trust is now known as Northern Lincolnshire and Goole NHS Foundation Trust.

Running four services, separated by considerable distances, poses a significant service delivery challenge, but also allows the Trust to serve a wider population. The Trust also provides a range of services delivered outside of hospital settings.

Due to these geographical distances a key way the Trust uses to help measure and monitor quality of care is through site by site breakdowns of performance against various measures. You will see this illustrated throughout the following sections of the report.

Our core business can be defined as: • Delivering a full range of

emergency secondary health care services, including intensive and high dependency care

• Maintaining a comprehensive range of planned and unplanned services, in an environment of patient choice and contestability

• Ensuring a full range of secondary care diagnostic services are available locally.

Unplanned services: statistics at a glance – during 2014/15:• 144,996 people attended one

of our accident and emergency departments, an increase of 7,154 on 2013/14. This equates to 2,788 a week, 397 people a day! This represents the fifth year increase in a row.

• 30,834 of these were admitted as an inpatient to one of our 3 hospitals, an increase of 2,776 seen in 2013/14. This equates to 593 admissions through A&E a week, 84 people a day! While the numbers are increasing, so to is the level of acuity.

Executive summary of the key points from this year’s Quality AccountThe Trust’s Quality Account contains a detailed summary of performance against its quality priorities set for the 2014/15 financial year. This full detail is available within part two of this report.

Performance against these indicators and the relationship of these results to next years (2015/16) quality priorities is significant, therefore these two key highlights are presented as part of this executive summary.

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Clinical effectiveness – performance at a glance 2014/15The following ‘at a glance’ overview of performance is viewed continually throughout the year, and reviewed within the monthly quality report, as a result these are constantly changing based on the real time nature of these indicators. For full explanation of the data behind these indicators, see section two of this report.

Comment:

• Mortality indicators have been partially met throughout 2014/15 with the Trust’s ‘official’ SHMI being ‘within expected range’. More recently, following national improvements in mortality and the subsequent rebasing of this relative ratio, the Trust according to the ‘provisional’ HED SHMI indicator has moved slightly into the ‘higher than expected’ range. This is for the period November 13 – October 14. Due to the importance of this area, this remains a quality priority for next year’s monitoring in the monthly quality report and the monthly mortality report

• National Institute for Health and Care Excellence (NICE) guidance is another indicator that has not yet been met, despite good progress having been made. This is another indicator that remains a part of the quality priorities for next year

• During 2014/15 a mid-year review of the Trust’s Quality Priorities was held, as a result, a new indicator to do with transfer of patients for non-clinical reasons was set to aid the Trust’s understanding of this important area. To date, the results from this are aiding the Trust’s Discharge and Transfer working Group. As a result this area will remain a quality priority for 2015/16

• Transfer and discharge target. No established way of monitoring this important indicator has been available. To navigate around this issue, the Trust has developed a way of monitoring this area using one of the central administration systems. While a step in the right direction, the data output and reported here has recently been validated and found to be inaccurate. Work is underway to resolve these data concerns, however in the meantime, this information should be regarded with caution.

Quality indicators at a glance; March - 20152014/2015 Indicators

Indicator Time period/RAG ComparatorTarget

Clinical effectiveness Most recent data Previous Trends

CE1 Deliver mortality performance within expected range and improving quarter on quarter, until reported SHMI is 95 or lower

Official SHMI (July 13 - June 14) 109 R 108 95

HED data (Dec 13 - Nov 14) 112 R 111 95

Position vs peers Higher than expected range R Within

expected rangeWithin expected range

Indicator Change Feb - 2015 Previous Trends Target

CE2 NEWS - Approriate action taken DPoW 0% 100% G 100%

95%SGH 0% 100% G 100%

GDH 0% 100% G 100%

Feb - 2015 Previous Trends Target

CE3 3.1) Screened for Dementia DPoW 1% 95% G 94%90%

SGH 2% 96% G 94%

3.2) Dementia - screened, appropriate assessment

DPoW 0% 100% G 100%90%

SGH 0% 100% G 100%

3.3) Dementia - appropriate referral to specialist services

DPoW 0% 100% G 100%90%

SGH 0% 100% G 100%

CE4 NICE - Compliance with all NICE guidance0.9% 82.8% R 81.9%

90% by March 2015NICE - Compliance with all NICE TAGs assessed

0.1% 95.8% G 95.7%

CE5 Transfer of patients for non-clinical reasons (capacity) to not exceed 20% of the total 7.6% 33.57% R 26% 20%


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In support of the above commentary, the quality priorities for next year (2015/16 financial year) are illustrated as follows with explanations included. For full detail of how these priorities are set, including consultation with patients and governors, see section 2.1d within this report.

2015/16 Quality priorities – clinical effectiveness

Clinical effectiveness:

CE1Deliver mortality performance within ‘expected range’ and improving quarter on quarter, until reported SHMI is 95 or better.

CE2 NEWS - in 95 per cent of cases with a NEWs score, appropriate action was taken.

CE3.1Dementia – 90 per cent of patients aged 75 and over admitted as an emergency to be asked the dementia case finding question.

CE3.2Dementia – 90 per cent of the above patients scoring positive on the case finding question to have a further risk assessment.

CE3.390 per cent of the patients identified as requiring referral following risk assessment to be referred in line with local pathway.

CE4Evidence based practice - to increase compliance with NICE guidance with 90 per cent compliance achieved by the end of March 2016.

CE5 Transfer of patients for non-clinical reasons (capacity) to not exceed 20 per cent of the total.

(For more information on how these priorities are set, see section 2.1d of this report).

Comment:

• The National Early Warning Score (NEWS) indicator remains for 2015/16, despite the fact that this has been consistently achieved, the rationale for this is to ensure that practice is truly embedded, hence focussed monitoring will remain in place within the monthly report

• As described in the commentary following the 2014/15 ‘at a glance’ view of performance, a new target to focus the Trust’s attention on the important area around transfers has been established. This was enacted during the mid-year review of the indicators. The information is still being evaluated and is supporting the Discharge and Transfer Group’s work in this area

• Despite an improvement in the levels of compliance with NICE guidance, the target to reach 90 per cent has not yet been achieved; as a result, this remains a quality priority for the board’s assurance during 2015/16.

For latest news from Northern Lincolnshire and Goole NHS

Foundation Trust visit our website at: www.nlg.nhs.uk

Follow the Trust on Twitter: @NHSNLaG

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Patient Safety – performance at a glance 2014/15

For full explanation of the data behind these indicators, see section 2 of this report. (For more information on the detail behind this ‘at a glance’ summary, see section two of this report)

Comment:

• Performance for MRSA bacteraemia and C difficile incidence has been in line with the targets set for the year and when compared to other local and national providers, significantly less levels of MRSA and C difficle have been reported

• The Safety Thermometer (methodology and components of this indicator are available in more detail within section two of this report) for the acute Trust have not consistently been achieved, as a result, detailed within the following section, these remain as quality priorities for 2015/16

• Following last year’s strengthening of the targets around falls and pressure ulcers to the elimination of avoidable incidents, this remains an area of progress but requires further monitoring, so it is to remain in the list of quality priorities for 2015/16

• Last year’s establishment of new nutrition and hydration targets have not yet achieved the targets being aimed for, so it is proposed that these will also remain as priorities.



Indicator Change Time period/RAG ComparatorTarget

Patient safety Feb - 2015 Previous Trends

PS1 MRSA bacteraemia incidence (YTD: 1) 1 1 R 0 0

PS2 C. Difficile incidence (YTD: 20) 1 3 G 2 No more than 35

PS3 Safety thermometer (community) -1% 96.% G 97% 95%

PS4 Open and honest initiative - Harm free care - Saftey thermometer (‘New’ and “Old’)

DPoW 0.5% 90.7% R 90.2%

95%SGH -6% 86.5% R 92.5%

GDH 4.2% 100% G 95.8%


PS5 Elimiation of avoidable repeat fallers

DPoW -1 0 G 1 Eliminate ALL avoidable

repeat fallsSGH 0 0 G 0

GDH 0 0 G 0

PS6 Reduction in number of avoidable pressure ulcers (Grades 2, 3 and 4)

DPoW -2 1 G 3 50% reduction (no more than 2 per month)

SGH 0 0 G 0

GDH 0 0 G 0

PS7 Nutrition care pathway was followed

DPoW -1% 95% R 96%

100%SGH 0% 98% R 98%

GDH 0% 100% G 100%

The food record chart completed accurately and fully, in line with care pathway

DPoW 1% 90% R 89%

100%SGH 7% 93% R 98%

GDH 0% 100% G 100%

PS8 The fuild management chart was completed accurately and fully, in line with care pathway

DPoW 0% 97% R 97%

100%SGH 4% 96% R 92%

GDH 0% 100% G 100%


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2015/16 Quality priorities – patient safety

Patient safety:

PS1 MRSA - 0 MRSA bacteraemia developing after 48 hours into the inpatient stay (hospital acquired).

PS2C Difficile - achieve a level of no more than 21 hospital acquired C. Difficile cases over the financial year 2015/2016.

PS3Safety Thermometer - provide harm free community care to 95 per cent or more patients - as measured by the Safety Thermometer.

PS4Safety Thermometer - provide harm free care to 95 per cent or more (acute) patients - as measured by the Safety Thermometer.

PS5Patient falls - Eliminate all avoidable repeat falls (as measured via the root cause analysis undertaken for every repeat faller).

PS6Pressure ulcers - a 50 per cent reduction in avoidable grades 2, 3 and 4 pressure ulcers (as measured via the root cause analysis undertaken for every grade 2, 3 and 4 pressure ulcer).

PS7.1 Nutrition – 100 per cent of patients the care pathway was followed.

PS7.2Nutrition – 100 per cent of patients identified as requiring it will have their food record chart completed accurately and fully in line with the care pathway.

PS8Hydration – 100 per cent of patients identified as requiring it will have their fluid management chart completed accurately and fully in line with the care pathway.

(For more information on how these priorities are set, see section 2.1d of this report)

Comment:

• The above quality priorities for patient safety for 2014/15 illustrate that MRSA, C difficile remain key indicators for continued monitoring. The C difficile target is to be lowered for 2015/16 from 33 to 21

• Following last year’s strengthening of the falls and pressure ulcer targets these remain priorities for continuous monitoring during 2015/16

• Hydration and nutrition, both crucial areas of focus were included last year in the quality indicators, it is proposed to continue to monitor these during 2015/16 until assurance that these are embedded

• While the community element of the Safety Thermometer has been achieved over the last five consecutive months, it has been proposed that this remains to ensure it is embedded.

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Patient experience – performance at a glance 2014/15

For full explanation of the data behind these indicators, see section two of this report.

Comment:

• Trust performance with response rate to the national Friends and Family Test has mainly achieved the targets set for the response rates to the in-patient element. Additional improvements are still needed with regard to A&E response rates. As a result this is a recommendation for remaining as a quality priority for 2015/16

• The various indicators relating to complaints illustrate that the work and focus on this area has resulted in significant improvements in the process measures applied. Due to the importance of this area, and the additional work underway around learning from the themes sitting behind complaints (another quality priority around those dealing with communication) this area will remain a quality priority for 2015/16

• Another change to the quality priorities agreed last year was around the target relating to pain relief. Compliance with this indicator has been 100 per cent across the board. As a result, this target was removed and designed to be replaced with two more detailed indicators relating to omissions in patient medications and ensuring no delays in providing pain relief. These questions are currently being added to the Nursing Dashboard, so it is proposed that these become the targets for focussing on during 2015/16.




Patient experience Feb - 2015 Previous Trends

PE1 Response rate to friends and family test within the top 50%

Inpatient Bottom 50% R Top 50%Top 50%

A&E Bottom 50% R Bottom 50%


PE2 Re-opened complaints to not exceed 20% of total closed complaints 11.5% 17.3% G 5.8% 20%


PE3 Complaints - action plan drafted 0% 100% G 100% 90%

Complaints - action plans implemented8% 100% G 92% 90%

Q3 2014/15 Q2 2014/15 Trends Target

PE4 Complaints - 50 % reduction in complaints relating to communication 28 72 R 44 50%

(max. 33 per qtr)


PE5 Patients should not have any unplanned omissions in providing patient medications

DPoW

No data to report as yet 90%SGH

GDH

Patients should not have a delay of more than 30 minutes in providing pain relief

DPoW


GDH

Oct - 2014 July - 2014 Trends Target

PE6 Staff satisfaction - increase in morale/staff satisfaction -1 5.3 R 6.3 2.5% increase

(min. 6.65)


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2015/16 Quality priorities – patient experience

Patient Experience

PE1 Response rate to friends and family test within the top 50 per cent.

PE2 Re-opened complaints to not exceed 20 per cent of total closed complaints.

PE3Complaints – 90 per cent of action plans following a complaint to be implemented within agreed timescales.

PE4 Complaints – 50 per cent reduction in complaints relating to communication.

PE5a Patients should not have any unplanned omissions in providing patient medications.

PE5b Patients should not have a delay of more than 30 minutes in providing pain relief.

PE6 Staff satisfaction1 – 2.5 per cent increase in morale/staff satisfaction each six months.

(For more information on how these priorities are set, see section 2.1d of this report)

1 Rationale for staff satisfaction indicator: This is based on an indicator of nine per cent improvement achieved between November 2012 and January 2014 and measured through the morale barometer so has some reasoning and rationale while still being stretching. The means of measurement/data source would be the morale barometer.

Comment:

• A reduction in re-opened complaints remains a key priority. Following a review of this indicator during the mid-year review process, the target was tweaked to reflect a more accurate view of this area to a percentage target, not simply a numerical one. As a result, monitoring of this will continue during 2015/16

• While significant progress has been made with the various process measures around complaints, the Trust has set an improvement priority around reducing the underlying ‘themes’ identified following a more detailed ‘deep dive’ assessment of the underlying reasons for the complaint. This target is focussing on what are we doing differently as a result of complaints with a view to learn lessons from. From the review work undertaken, complaints relating to communication are an important area to focus improvement efforts on

• Staff satisfaction remains quality priority based on the work underway to improve staff engagement and morale, recognising that happy staff provide high quality care to patients and service users.

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PART 2:

Priorities for improvement, statements of assurance from the board and reporting against core indicators

2.1 Priorities for improvement: overview of the quality of care against 2013/14 quality prioritiesInformation reported within part 2Due to the timings necessary to compile the Annual Quality Account, the most recent information available presented is not always to the end of the financial year. Despite this at least 12 months trending information is presented where available.

This is overseen primarily by MPAC, before consideration by the Trust Board.

• Section 2.1d Quality priorities for the 2015/16 financial year.

In some cases these new quality priorities have changed from those reported on below. Where this is the case, beneath each indicator, the rationale for the change is explained.

A note on interpretation of the following informationWherever possible throughout this report, unfamiliar terms or acronyms have been explained in the body of the report. Where this has not been possible due to compliance with the national template set for the Trust’s annual quality account submission, every effort has been made to ensure the glossary provides the necessary definition to aid the reader’s interpretation of this information.

Priorities for improvementThis section of the report highlights during 2014/15 progress towards achieving the priorities which we set out in our Annual Quality Account for 2013/14 for this financial year. The quality priorities are divided into three sections:

• 2.1a Clinical effectiveness

• 2.1b Patient safety

• 2.1c Patient experience.

During 2014/15 the following quality priorities were monitored by the monthly quality report which is presented and reviewed on a monthly basis by the Trust’s Quality and Patient Experience Committee (QPEC) and the Trust Board. In addition to this, to ensure oversight of mortality indicators has led to the creation of the Mortality Performance and Assurance Committee (MPAC).

This has meant that while the monthly quality report has reported on all quality indicators, including those around mortality, a separate monthly mortality report is also used to monitor performance against a comprehensive range of indicators.


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15

Clinic

al eff

ectiv

enes

s

Overview of the quality of care against 2014/15 quality priorities:

2.1a Clinical effectiveness (CE)

CE1 Mortality

CE2 National Early Warning Scores (NEWS)

CE3 Dementia

CE4 Evidence Based Practice (NICE)

CE5 Transfer and Discharge


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2.1a Clinical effectiveness

CE1 – Mortality improvement – Summary Hospital Mortality Indicator (SHMI)Introduction to mortality dataDuring 2013/14, mortality indicators and NHS Trusts’ performance against them received a lot of attention. This culminated in NHS medical director Sir Bruce Keogh reviewing 14 NHS Trusts with outlying levels of mortality.

Mortality – how is it measured?In order to report the Trust’s position on mortality, it is worth explaining some of the different mortality measures and how the Trust uses these internally.

There are two primary ways to measure mortality, both of which are used by the Trust:

1. Crude mortality – expressed as a percentage, calculated by dividing the number of deaths within the organisation by the number of patients treated

2. Standardised mortality ratios (SMR). These are statistically calculated mortality ratios that are heavily dependent on the quality of recording and coding data. These are calculated by dividing the number of deaths within the Trust by the expected number of deaths.

• This expected level of mortality is based on the documentation and coding of individual, patient specific risk factors (ie their diagnosis or reason for admission, their age, existing comorbidities, medical conditions and illnesses). This information is combined with general details relating to their hospital admission (ie the

type of admission, elective for a planned procedure or an unplanned emergency admission), all of which inform the statistical models calculation of what constitutes expected mortality.

• As standardised mortality ratios (SMRs) are statistical calculations, they are expressed in a specific format. Based on the average expected mortality within the UK, an average ‘expected level’ of mortality would be expressed as 100. Therefore an SMR of more than 100 would be considered to be a higher than would be expected compared with the UK average. Conversely, an SMR of less than 100 would be a mortality ratio less than would be expected compared with the UK average.

• While ‘100’ is the key numerical value, because of the complex nature of the statistics involved, confidence intervals play a role, meaning that these numerical values are grouped into three categories: “higher than expected”, “within expected range” and “lower than expected”. These categories are based on mortality performance across the UK, and using this statistical data and the confidence intervals for this information, results in SMRs of both above 100 and below 100 being classified as “within expected range”, therefore the level of 100 does not in isolation determine a Trust’s performance in line with mortality SMRs. For this reason, the Trust looks at SMR data using funnel charts,

Interpreting Standardised Mortality Ratios:

Standardised mortality ratios (SMRs) must always be interpreted with caution. As these are ratios of actual deaths against expected levels of mortality they are heavily dependent on data and the accuracy of recording.

Interpretation should be likened to that of a smoke alarm, in the same way as the smoke alarm sounding does not mean there is definitely a fire, an SMR indicator of above 100 does not definitely indicate a problem. However, just as it would be unwise to ignore

a smoke alarms warning and not investigate, so too is it unwise to ignore an outlying SMR. This is the approach that the Trust takes.

A NOTE OF CAUTION

Northern Lincolnshire and Goole NHS Foundation Trust had been aware of its mortality performance and had been acting on this information with a view to understanding and improving the quality of care provided.

This was reported in some detail during the previous 2012/13 and 2013/14 annual quality accounts. Despite this programme of improvement work, the Trust was identified as being an outlier in this area and as a result was one of the 14 Trusts visited by one of Sir Bruce Keogh’s review teams.

While the identification of these Trusts was based on their mortality performance, the review team’s visit focused on the wider quality of care. The Trust welcomed the visit and the review team’s feedback has provided a useful external view on where additional improvement is needed.

More detail regarding the action taken following the Keogh and Care Quality Commission (CQC) visits and the progress made by the Trust is available later on in this report.

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which illustrate the Trust’s relative position against other UK Trusts and its categorisation. More detail regarding the SMRs used is contained in the next section.

Standardised Mortality Ratios (SMRs) – which ones are used by the Trust?There are a number of different standardised mortality ratios (SMR) in use throughout the United Kingdom. Historically, this has made understanding and benchmarking an NHS Trust’s performance against mortality indicators very difficult.

As a result the NHS commissioned an ‘official’ standardised mortality ratio called the Summary Hospital Mortality Indicator or SHMI.

As this is the ‘official’ NHS mortality indicator of choice, it is calculated using a strict methodology which ensures all NHS organisations are measured in the same way using the same indicators. As a result of this, it allows NHS organisations to be ranked according to performance.

The Summary Hospital Mortality Indicator (SHMI) is therefore designed to bring clarity to quality in this area. However, a crucial element of SHMI, which is not immediately obvious, and therefore can confuse, is that although SHMI has hospital in the title, it is not purely an indicator of in-hospital mortality, it includes community mortality up to 30 days following discharge from hospital.

This is the only SMR that includes both in hospital and out of hospital mortality. It can therefore be viewed as a wider healthcare community mortality performance indicator – not solely a reflection of the Trust’s performance.

Another important point to note regarding SHMI is that because it includes community mortality within the indicator, it is based not only on in-hospital recorded data but on information from the Office for National Statistics (ONS).

This introduces a significant delay in publishing information on the healthcare community. As a result, when SHMI information is published each quarter, the time frame included within the report is between six and 18 months out of date.

To illustrate this, in January 2015, the SHMI was published focusing on the time frame of July 2013 to June 2014.

Therefore while the SHMI is a useful tool to aid the Trust’s understanding of this important area, it has struggled to use this effectively in order to monitor ongoing performance due to the significant time lag in reporting.

What is Healthcare Evaluation Data (HED)As a result of the time lag in reporting of SHMI, the Trust has purchased an additional information toolkit from the University of Birmingham Hospitals NHS Foundation Trust, called Healthcare Evaluation Data (HED).

HED uses the same methodology as the official SHMI, but enables a much more recent timeframe to be reported.

The official SHMI publication in January 2015 reported data up to June 2014, the HED information reports data to the end of November 2014.

As it is not the official SHMI indicator, it is treated by the Trust as a ‘provisional’ SHMI indication, but from rigorous reconciliation work, it has proved to be an accurate data source that reflects the official SHMI on publication.

As a result of this, the Trust uses both the official SHMI and the HED provisional SHMI indication as markers of performance.

How is mortality performance monitored within the Trust?The Trust Board monitors performance against mortality indicators through a sub-committee oversight and scrutiny. This sub-committee of the Trust Board is called the Mortality Performance and Assurance Committee (MPAC). It is chaired by the chairman of the Trust Board.

The committee oversees all matters relating to mortality. Its primary form of intelligence is the monthly mortality report, which comprehensively presents a range of different mortality performance measures, utilising the official SHMI, the HED provisional information, crude mortality and an overview of mortality using other SMRs.

Standardised mortality ratios (SMRs) like the SHMI are not automatic markers of poor performance, however, they should not be ignored. The analogy of the smoke alarm is very apt, and the Trust takes the same view meaning that any SMRs of above 100 are not ignored but proactively investigated using a number of methods including more detailed information reports to obtaining the medical records of patients having died and providing assurance that there are no quality of care concerns. The Mortality Performance and Assurance Committee (MPAC) rigorously oversee these areas and assign specific work streams as appropriate.

Now that the key terms of reference have been introduced and explained, the following section looks at how the Trust is performing against these indicators and outlines the work being undertaken to further focus on quality improvement.


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CE1 – Mortality improvement – Summary Hospital Mortality Indicator (SHMI)

• TARGET: Deliver mortality performance (SHMI) within ‘expected range’ and improving quarter on quarter, on a Moving Annual Total (MAT) basis at each quarterly publication date until our reported SHMI is 95 or better.

• Achievement (July 2013 – June 2014): Using the official SHMI indicator, the Trust is currently within the ‘expected range’. Mortality performance the previous quarter was 108, the current official SHMI is 109, so this represents a one point deterioration. The next official SHMI publication is due in April 2015 for the period of October 2013 to September 2014.

The Trust’s official SHMI in national contextThe following chart illustrates the Trust’s most recent SHMI score and ranking in relation to those of all Trusts nationally.

Figure 1 National SHMI score range: January 2015 release (covers July 2013 - June 2014 period)

NLaG120

100

80

60

40

20

0

Source: Information Services based on the Health and Social Care Information Centre’s data

Key to abbreviations: NLAG – Northern Lincolnshire and Goole NHS Foundation Trust

Comment:

• The most recent official SHMI was published in January 2015 and covers the July 2013 to June 2014 time period

• The Trust’s SHMI score was 109 – ranking 119 out of the 137 NHS provider organisations included in data set

• This continues to be officially within the “as expected range”.

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The Trust’s provisional HED SHMI in national contextThe University of Birmingham Hospitals’ Healthcare Evaluation Data (HED) reporting product allows a more up to date view of the provisional SHMI indicator, to the end of November 2014. The following funnel plot graph outlines the Trust’s position in relation to other organisations.

Figure 2

Source: Information Services based on the Healthcare Evaluation Data (HED)

Key to abbreviations: SHMI – Summary Hospital Mortality Indicator

NLAG – Northern Lincolnshire and Goole NHS Foundation Trust

Comment:

• From the most recent information available, using the HED ‘provisional’ SHMI, the Trust’s ranking moves from the “as expected range” just over the boundary into the “higher than expected” grouping

• The Trust’s ‘provisional’ HED SHMI score is 112.1, ranking the Trust as 134 out of 141 NHS provider organisations

• Data in this analysis should be treated as provisional. From reconciliation work, we know that this data source reflects previous SHMI publications

• For a more detailed overview of the actions having been taken to improve the Trust’s mortality position and those being taken now, see section 2.3a of this report.

Has the quality indicator been changed during the year from that set in last year’s (2013/14) Quality Account? No, there has been no change to this quality priority during the 2014/15 reporting period.

Rationale for changing this quality priority for 2015/16: Not all elements of this indicator have at present been met. Therefore no change is going to be made to this indicator and it will continue to be measured during the 2015/16 financial year.

125

120

115

110

105

100

95

90

85

80

75

70

65

60

National SHMI - 12 months to November 2014Higher than expected

Lower than expected

Within expected range

Line from column values;99.8% upper limit

Line from column values;99.8% lower limit

Line from column values;95% upper limit

Line from column values;95% lower limit

Colour by banding

500 1000 1500 2000 2500 3000 3500 4000

SHM

I

Expected deaths

NLaG


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CE2 – National Early Warning Score (NEWS)Introduction to the National Early Warning Score (NEWS)

An important element of providing effective and safe care is monitoring a patient’s condition, identifying any markers of deterioration and taking appropriate action to ‘rescue’ them from further deterioration, preventing mortality.

This important facet of clinical care has been one of the many areas of work focussed on as part of the Trust’s work to improve mortality performance.

When a patient’s condition deteriorates, there are a number of markers that can identify this, and when appropriately monitored, these markers can trigger effective action to prevent further deterioration. These markers are often combined together as a risk calculator. The National Early Warning Score (NEWS) is a nationally developed deteriorating patient score which the Trust has used since November 2012.

This has led to the Trust’s large scale investment in electronic equipment to enable all previously handwritten bedside observations to be now recorded electronically on a variety of handheld devices by clinical staff.

This is then displayed on electronic computer screens at the nurses’ station which enables all patient observations, including the crucial NEWS score, to be viewed ‘at a glance’ by all healthcare professionals involved in the patient’s care.

Crucially, any NEWS scores that are outside of normal limits are clearly discernible and ensure that no matter how hectic the ward environment, appropriate action is taken to prevent further deterioration.

The electronic system also enables the clinical team to be reminded on the frequency of such observations.

The use of the National Early Warning Score (NEWS) within the TrustThe National Early Warning Score (NEWS) was implemented during November 2012 within the organisation. Since then the Trust has gone on to embed this as standard practice which has led to great innovations at the patients’ bedside and on ward areas. The Trust has long provided a clinical system called Web V which has historically provided clinicians with electronic access to pathology and laboratory results.

This system has over time been developed to include a range of other useful functions. As part of this, the system has evolved to become an Electronic Patient Record (EPR).

One of the first elements of this EPR was the development of the NEWS scoring system as part of the patient’s bedside documentation.

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CE2: National Early Warning Score (NEWS) – appropriate action takenIn 95 per cent of cases with a NEWs score, appropriate action was taken

• TARGET: 95 per cent of patients with a NEWS score, an appropriate clinical response was actioned.

• Achievement (January 2014 – February 2015): The following chart illustrates that this target has been achieved in the main, with the overall trend showing continued improvements.

Figure 3 In 95% of cases with a NEWS score, appropriate clinical response actioned

Source: Information services, nursing dashboard

Key to abbreviations: DPoW – Diana, Princess of Wales Hospital SGH – Scunthorpe General Hospital

GDH – Goole District Hospital

NB: As Trust performance with this indicator has been consistently high, for optimal viewing of this information at individual site level, the above charts axis starts at 93 per cent.

Comments:

• The appropriateness of this assessment is judged by nursing staff undertaking this audit on a monthly basis, using a standard procedure to ensure a consistent approach

• Performance against this indicator at all sites achieved the 95 per cent target and demonstrated an improvement on previously reported performance

• Where 100 per cent compliance has not been achieved this is due to the observations not being recorded within the exact timeframe recommended in accordance with the NEWS score criteria. Observations recorded outside of this timeframe are marked as a ‘no’ when audited regardless of whether the appropriate escalation has taken place (ie observations undertaken and recorded at one hour 15 minutes instead of at one hour). There has not been a failing in escalation to a senior nurse/clinician


Rationale for changing this quality priority for 2015/16: As this is an important indicator supporting the Trust’s focus on continued mortality improvements, this indicator will remain a priority for 2015/16.

93

94

95

96

97

98

99

100

Aug 13

Sept 13

Oct 13

Nov 13

Dec 13

Jan 14

Feb 14

Mar 14

Apr 14

May 14

Jun 14

Jul 14

Aug 14

Sept 14

Oct 14

Nov 14

Dec 14

Jan 15

Feb 15

Trustwide 100 99 97 99 98 99 99 99 99 99 100 100 99.7 99.7 100 96 98 100 100

DPoW 99 99 100 99 99 99 99 100 100 99 99 100 100 100 100 100 99 100 100

SGH 99 99 95 98 98 98 99 98 97 99 100 100 100 99.4 100 94 97 100 100

GDH 100 100 100 100 100 100 100 100 100 100 100 100 93.8 100 100 94 100 100 100

Threshold 95 95 95 95 95 95 95 95 95 95 95 95 95 95 95 95 95 95 95

Perc

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eted


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CE3 – DementiaIntroduction to dementia

Dementia is a significant challenge for the NHS with an estimated 25 per cent of acute beds occupied by people with dementia, their length of stay is longer than people without dementia and they are often subject to delays on leaving hospital.

Dementia affects an estimated 670,000 people in England, and the costs across health and social care and wider society are estimated to be £19 billion – both figures are set to rise with the ageing of the population.

Timely diagnosis can greatly improve the quality of life of the person with dementia by preventing crises (and thus care home and hospital emergency admission) and offering support to carers (who are invariably under stress).

To aid the NHS focus on dementia, a series of dementia process measures have been set which aim to improve dementia risk assessment allowing for an effective foundation for appropriate management.

This is designed to bring significant improvements in the quality of care and substantial savings in terms of shorter lengths of stay. To assist this approach, a Commissioning for Quality and Innovation (CQUIN) target has been set.

This CQUIN approach is designed to incentivise the identification of patients with dementia and other

causes of cognitive impairment alongside their other medical conditions and to prompt appropriate referral and follow up after they leave hospital.

The dementia CQUIN payment is triggered in three stages:

1. The case finding of 90 per cent of all patients aged 75 and over following admission to hospital, using the dementia case finding question and identification of all those with delirium and dementia

2. The diagnostic assessment and investigation of 90 per cent of those patients who have been assessed as ‘at-risk’ of dementia from the dementia case finding question and presence of delirium

3. The referral of 90 per cent of those for specialist diagnosis of dementia and appropriate follow up.

(Source: DH, 2013, Using the Commissioning for Quality and Innovation)

Data quality issuesThis indicator was reported on within the 2013/14 indicators. However, due to issues in identifying a reliable monitoring system, performance reported throughout the year was not in line with the 90per cent target set. Issues with the monitoring of this indicator were confirmed through the use of an audit assessing this area in more detail, from the patient’s medical records.

Due to this, performance against this target, reported prior to March 2014, was based on the paper based monitoring system which was found to contain inaccuracies. Therefore results reported prior to March 2014, presented over the next few pages, should be interpreted with caution.

Since March 2014 the Trust has moved the monitoring of this important area to an electronic based monitoring system, housed in the Trust’s Web V electronic patient record.

The advantages of this is it ties in more closely with day-to-day electronic patient records and provides visual reminders to ward staff of the need to undertake appropriate dementia screening.

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CE3.1: Dementia case screening question

• TARGET: 90 per cent of patients aged 75 and over admitted as an emergency to be asked the following dementia case finding question: “Have you been more forgetful in the last 12 months to the extent that it has significantly affected your daily life?”

• Achievement (January 2014 – February 2015): Following some initial problems in ensuring a robust data collection method for this area between September 2013 and March 2014, since then compliance has been routinely in line with the target set for this national CQUIN.

NB. Please note earlier comments regarding data quality issues throughout 2013/14.

Figure 4

Source: NLAG CQUINS data, intranet, information services team

Key to abbreviations: DPoW – Diana, Princess of Wales Hospital SGH – Scunthorpe General Hospital CQUIN – Commissioning for Quality and Innovation

NB: The above chart’s data labels refer to the number of patients, not the percentage of patients, as illustrated in the chart axis.

Comments:

• The above chart illustrates that compliance with all eligible patients having a dementia screening question has exceeded the 90 per cent target set with 94 per cent compliance at both SGH and DPOW

• Performance at both sites is being monitored, in both medicine and surgery and critical care groups. The main reason for this seeming non-compliance appears to be that nursing staff are not completing the screen in the required initial 72 hour time period despite the flagging on the Web V system.

This concern has been raised by the quality matron with the lead for dementia, with appropriate nursing colleagues in the groups to manage the non-compliance with required escalation to the general managers, deputy chief operating officer and the chief operating officer.

0

10

20

30

40

505560

70

80

90

100

Sept 13

Oct 13

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Dec 13

Jan 14

Feb 14

Mar 14

Apr 14

May 14

Jun 14

Jul 14

Aug 14

Sept 14

Oct 14

Nov 14

Dec 14

Jan 15

Feb 15

Target 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%

DPoW 36% 41% 30% 5% 57% 50% 68% 99% 96% 94% 93% 91% 88% 93% 88% 92% 94% 95%

SGH 49% 58% 55% 11% 86% 81% 83% 96% 95% 96% 98% 95% 95% 94% 97% 94% 94% 96%

Perc

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108 121 118

176 169161

229 258 239 222 230 214 241 251 95 280 259

24

7989

59

132 164

125

227 231 204 196 203 181 222 184 60 295 251

13


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CE3.2 – Further risk assessment as a result of positive screening question

• TARGET: 90 per cent of patients scoring positive on the case finding question to have a further risk assessment.



Figure 5



CQUIN – Commissioning for Quality and Innovation

NB: The above chart’s data labels refer to the number of patients, not the percentage number of patients. Also, the axis starts at 70 per cent.

Comments:

• Since embedding the new system using Web V from March 2014, significant improvements are noted in all areas of this indicator around dementia

• For this part of the indicator, DPoW and SGH both reported 100 per cent since September.

70

75

80

85

90

95

100

Sept 13

Oct 13

Nov 13

Dec 13

Jan 14

Feb 14

Mar 14

Apr 14

May 14

Jun 14

Jul 14

Aug 14

Sept 14

Oct 14

Nov 14

Dec 14

Jan 15

Feb 15

Target 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%

DPoW 100% 100% 100% 100% 100% 100% 95% 100% 100% 100% 100% 92% 100% 100% 100% 100% 100% 100%

SGH 100% 100% 100% 100% 96% 100% 75% 100% 100% 100% 90% 100% 100% 100% 100% 100% 100% 100%

Perc

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16 16 26

27

18

22 19 21 19

9

7 13 17 12 3 12 1224

23 28 13

17

18

2014 5 17

9

12

15 17 18 4 16 2117

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CE3.3 – Identified patients at risk to be referred in line with local pathway

• TARGET: 90 per cent of the patients identified as requiring referral following risk assessment to be referred in line with local pathway.



Figure 6



CQUIN – Commissioning for Quality and Innovation

NB: The above chart’s data labels refer to the number of patients, not the percentage number of patients.

Comments:

• Since embedding the new system using Web V from March 2014, significant improvements are noted in all areas of this indicator around dementia.

0

20

40

60

80

100

Sept 13

Oct 13

Nov 13

Dec 13

Jan 14

Feb 14

Mar 14

Apr 14

May 14

Jun 14

Jul 14

Aug 14

Sept 14

Oct 14

Nov 14

Dec 14

Jan 15

Feb 15

Target 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90

DPoW 100 100 100 100 100 100 95 100 100 100 100 92 100 100 100 100 100 100

SGH 100 100 100 100 96 100 75 100 100 100 90 100 100 100 100 100 100 100

2

02

11

12

12 8 11 12 7 11 7 10 2 9 6

4

3 10

9

14

4

16 6 11 12 7 9 7 8 2 10 10

5

9


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Figure 7Trust dementia screening benchmarked against NHS England statistics

Indicator Data period NLsGNational average

Better / worse

Local peer

Better / worse

Dementia - identification Jul 14 - Sep 14 93.5% 88.4% Better 85.9% Better

Dementia - Further assessment Jul 14 - Sep 14 97% 93.2% Better 85.3% Better

Dementia - Referral Jul 14 - Sep 14 100% 96.3% Better 97% Better

Source: Trust Information Services, derived from NHS England Statistics

Key to abbreviations: NLAG – Northern Lincolnshire & Goole NHS Foundation Trust (The Trust)

National average – performance in other NHS organisations in the UK

Local peer –select group of NHS Trusts with similar characteristics to the Trust

Better / worse – Trust performance compared to peer

Comments:

• When compared to the national and peer average, the Trust performs better in connection with the three components which make up the dementia screening process.


Rationale for changing this quality priority for 2015/16: Until the release of the latest CQUIN scheme to focus on dementia, the current targets will remain unchanged for 2015/16.

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CE4 – National Institute for Health and Care Excellence (NICE) evidence-based practice Introduction to National Institute for Health and Care Excellence (NICE) guidelines

The National Institute for Health and Care Excellence (NICE) provides national guidance and advice to improve health and social care. NICE was originally set up in 1999 to reduce variation in the availability and quality of NHS treatments and care.

NICE guidance takes several forms:

• Clinical guidelines (CGs): provide advice on the management of individual conditions. They are systematically-developed statements to assist professional and patient decisions about appropriate care for specific clinical circumstances. These may be as diverse as antenatal care, breast cancer or schizophrenia. They are developed in association with the Royal Medical, Nursing and Midwifery Colleges

• Technology appraisal guidelines (TAGs): assess the clinical and cost effectiveness of health technologies, such as new pharmaceutical and biopharmaceutical products, but also include procedures, devices and diagnostic agents. This is to ensure that all NHS patients have equitable access to the most clinically and cost-effective treatments that are available

• Social care guidance: provide practical support to practitioners working in children’s and adult’s social services, and people that use these services and their carers

• Cost-saving medical technologies (MTGs) and diagnostic agent (DGs) reviews help facilitate speedy and consistent access to and use of these technologies

• Interventional procedures guidance (IPGs): recommends whether interventional procedures, such as laser treatments for eye problems or deep brain stimulation for chronic pain, are effective and safe enough for use in the NHS

• Public health guidance (PH): covers disease prevention, health improvement and health protection and has influenced policy and practice in the NHS and local government on many of the big issues in today’s society.

(Source: NICE, 2014, About NICE (www.nice.org.uk)

Introduction to the Trust’s implementation of National Institute for Health and Care Excellence (NICE) guidelines

The process by which NICE guidance is assessed and compliance determined contains a number of key steps and requires effective communication from a wide variety of Trust staff including frontline staff who deliver services. A bespoke system is used to monitor all steps of the process, which can be divided into two elements:

1. Process measures – an overview of compliance against statutory imposed timescales (in the case of technology appraisal guidelines) and those outlined in the local Trust NICE policy. This process is designed to ensure

compliance with NICE guidance is clinically assessed and determined locally by relevant clinical staff ie is clinically led

2. Outcome measures – an overview of all NICE guidance and the individual clinical specialties compliance against each component part that is of relevance to them. This is designed to ensure the Trust knows centrally areas of non-compliance and can have an overview on the action necessary to ensure compliance.

The Trust’s Implementation of NICE guidance policy outlines the process for the implementation of new guidance. This is briefly summarised below:

• NICE/Quality Administrator identifies new guidance and lead groups with the Medical Director (monthly)


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• Risk and Governance Facilitators present new guidance to governance group to establish relevance and where guidance is relevant for the group to identify the lead clinician to take forward implementation of the guidance (within two weeks of guidance being issued)

• The Trust’s Gap Analysis Toolkit/baseline assessment is distributed to lead clinicians (to be returned within six weeks. The intention behind this step is

to determine the current level of compliance and any additional actions required to ensure full implementation and adherence to NICE guidance)

• Returns are monitored and followed up by the NICE/qQuality administrator (reminder sent after three weeks)

• NICE database updated accordingly to confirm compliance, action plans monitored via governance groups.

ReportingDue to the nature of the timescales involved in guidance implementation, the Trust’s Governance and Assurance Committee receive a comprehensive update on NICE guidance on a quarterly basis and the Trust’s Quality and Patient Experience Committee receive this monthly summary contained within the Quality Report. Quarterly/monthly reports are also provided to all directorates/groups.

CE4 – Compliance with NICE evidenced based practice

• TARGET: To increase compliance with NICE guidance to 90 per cent by the end of March 2015.

• Achievement (January 2014 – March 2015): The Trust has not yet achieved this quality priority, and this will therefore remain as an area of focus during 2015/16 as a quality indicator for oversight by the Trust Board.

Overall Trust compliance – NICE technology appraisal guidance (TAGs)As at March 30 2015, Trust compliance with those NICE TAGs that had been assessed using the Trust’s Gap Analysis Toolkit is as follows:

Colour Compliance statusCompliance

numbersCompliance

(%)

Green Full compliance 182 95.8%

Amber Partial compliance 2 1.1%

Yellow Non-Compliant, deviation approved by TG&AC 1 0.5%

Blue Not yet assessed – OVERDUE 5 2.6%

Red Non-Compliant 0 0.0%

Total 190 100.0%

Source: Trust NICE database

Key to abbreviations: Full compliance – fully compliant as declared by teams assessing guideline relevance

Partial compliance – some elements of the guideline not yet compliant with

Non-compliant, deviation approved by TG&AC – not compliant with the NICE guideline, and rationale for this presented and approved by the Trust’s Governance and Assurance committee

Not yet assessed – overdue – compliance not yet assessed and deadline missed

Non-compliant – fully non-compliant at present with NICE recommendations

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Overall Trust compliance – all NICE guidanceAs at March 302015, overall Trust compliance is as follows:

Colour Compliance statusCompliance

numbersCompliance

(%)

Green Full compliance 337 82.8%

Amber Partial compliance 33 8.1%

Yellow Non-Compliant, deviation approved by TG&AC 2 0.5%

Blue Not yet assessed – OVERDUE 32 7.9%

Red Non-Compliant 3 0.7%

Total 407 100.0%

Source: Trust NICE Database

Key to abbreviations: Full compliance – fully compliant as declared by teams assessing guideline relevance

Partial compliance – some elements of the guideline not yet compliant with

Non-compliant, deviation approved by TG&AC – not compliant with the NICE guideline, and rationale for this presented and approved by the Trust’s Governance and Assurance committee

Not yet assessed – overdue – compliance not yet assessed and deadline missed

Non-compliant – fully non-compliant at present with NICE recommendations


Rationale for changing this quality priority for 2015/16: As a result of not yet meeting this quality indicator, this will remain a quality priority for 2015/16, and therefore be monitored in the monthly quality report by the Quality and Patient Experience Committee (QPEC) and the Trust Board.


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CE5 Transfer and discharge

Transfer of patients for non-clinical reasons (capacity) to not exceed 20 per cent of the total transfers.

commenced in February 2015

• Multi-agency initiatives across the health and social care communities to manage demand for unplanned care services.

1. Development and monitoring of key indicatorsWork has been underway since December with the information team to develop the suite of information which supports the transfer and discharge programme.

The most recent reports (which cover the 12 month period to the end of December 2014 and January 2015) have been expanded to include more indicators and a summary dashboard. New information which is now included in the monthly report covers weekend discharge rates, delayed transfers of care, number of consultant episodes in a single spell and throughput by ward.

This report is being shared with key staff within the Trust and will form the main agenda item for the next Transfer and Discharge Working Group to convert it into a working knowledge base.

The ‘at a glance’ dashboard providing an overview of these key data items is included on the following page.

2. Stocktake of current position

The Trust received an internal audit report in January 2014 giving limited assurance in terms of the management of the transfer of care and discharge arrangements.

An internal stocktake is being undertaken against the original issues which were identified in the report and which, in turn, led to a 39 point action plan being put together by the Trust.

This stocktake will take into account good practice from other Trusts in terms of patient flows and will be a key element of the KPMG review.

Transfer and discharge is a crucial element of an effective and efficient system – one of the measures of an effective system will be to achieve a reduction in the number of patients who are transferred for capacity reasons.

As such a transfer and discharge group is in place to oversee this area and work this month is focussing on:

• Development and monitoring of key indicators – including length of stay, benchmarked delayed transfers of care and transfers between wards (split by site and reason for transfer). The work underway now is to convert this data into usable intelligence which has an impact on practice

• Stocktake of our current position against the original East Coast Internal Audit (Jan 2014)

• Support for the KPMG internal audit work on the bed management/review of operations centre which

NB: – Data quality concerns:“3. Transfers with a reason of capacity”

On the table opposite (Transfer and discharge working group - Summary Dashboard), you will see this indicator presented in the third column.

There has been no established way of monitoring this important indicator. To navigate around this issue, the Trust has developed a way of monitoring this area using one of the central administration systems.

While a step in the right direction, the data output reported here has recently been validated and found to be inaccurate. Work is underway to resolve these data concerns, however in the meantime, this information should be regarded with caution.

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3. Bed management/review of operations centresThe KPMG internal audit review has been agreed in order to support the Trust’s work on the transfer of patients between wards and to address the question of whether the operations centres are able to work effectively. This work includes a review of the policies and procedures underpinning transfer of care (and whether they are used in practice) and follow up of the actions from the previous audit.

4. Multi-agency initiatives

• In addition to managing the significant levels of activity which have continued through January and February (and which has been made more difficult by outbreaks of diarrohea and vomiting), the chief officer of the operations directorate has been undertaking various workstreams to promote the timely discharge of patients from acute care and, where appropriate, support the management of care outside an

acute hospital setting with the aim of reducing unplanned care activity:

• The business case for a frail elderly assessment and support team (FEAST) at SGH (part of the Better Care Fund) was approved at the joint board of North Lincolnshire Health and Social Care Partners at the end of February. This proposal includes significant investment into establishing a multi-disciplinary team

• A significant feature of the FEAST team proposal is the proactive discharge of older patients at various key points - ie prior to admission from A&E, within a short stay facility or from specialty wards

• The next stage is to begin getting the team in place with an implementation plan being put together.

• Home from Home – the Trust is working with NAViGO to develop a facility on the DPoW site for the management of patients with confusion who also require acute care for their physical conditions.

Plans are in place for this new service to be established from April 2015

• The Trust continues to work in partnership with other organisations to support the management of patients outside of an acute setting where this is appropriate. East Midlands Ambulance Service (EMAS) has been supported to undertake a detailed analysis of calls received by them for North Lincolnshire residents who live in care homes

• Working with the Trust’s community services, they have been able to review the ambulance calls for more than 350 people. A report on the findings is due to be shared imminently and will highlight where different pathways could support alternatives to bringing patients for hospital based care.

• The outcomes of this work for North Lincolnshire will also be shared with North East Lincolnshire colleagues in order to consider their relevance for the population who access DPoW.

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Managing increased demand on the Trust’s servicesAs well reported within the media over the last few months, pressure on Acute NHS Trusts has been building as demand for A&E and unplanned services has increased year on year.

As referred to during the chief executive introduction, this pressure during 2014/15 winter months resulted in a number of Trusts implementing their major incident plans due to the demands on their services. The Trust was no different and faced an increase in demand on both the A&E and admission units.

When looking at the Trust’s average demand, 397 people a day attend our A&E departments, with approximately 84 people a day requiring admission to the Trust. How is this managed to best effect? To provide context in how on a day to day basis this constant, often unplanned demand is managed, we asked our operations centre team for their perspective on what steps are in place to manage this demand and prevent patients being transferred unnecessarily, for non-clinical reasons.

The operations centre was established in 2011 and provides a centralised resource where operational teams work from to optimise patient flow throughout all hospital sites in the Trust. They have access to the very latest information to do with the number of beds available and aim to use these most effectively and efficiently. They are always looking for innovative ways to increase patient flow throughout the acute Trust ensuring the finite numbers of beds available are used to best effect possible. Actions taken routinely in this quest for most effective and efficient management include:

• To support patient flow through the winter months and even now, a seven-day hospital social work team was introduced with close working links to the operations centre to help minimise delays in transfers of care between the acute Trust and community services

• Outliers on non-specialty wards are regularly reviewed as part of the medical handover processes so that medical teams are able to discuss any concerns they have resulting in appropriate medical management of these patients

• Routine and regular meetings are held with a standardised agenda to ensure that emergency, elective admissions, staffing issues, gaps requiring staffing redeployment, barriers to pathway progress or discharge can be discussed and acted upon

• Introduction and regular reviews of the escalation and surge approaches to managing capacity are in place with clear roles and actions identified

• Weekly meetings regarding winter pressures are held with local commissioners (CCGs), social care, mental health and ambulance services

• Work to ensure that business presence is available at operations meetings to have access to accurate elective data to support decision making regarding when and where more extreme action has to be taken ie cancellation of elective surgery to ensure that patients on cancer or other priority pathways are treated where possible

• The operations centre works closely with the infection control teams to support management of outbreaks considering high level of demand for capacity. This results in robust information sharing with community outbreaks to minimise risk if residents admitted from these areas.


34

35

Patie

nt Sa

fety


2.1b Patient safety (PS)

PS1 MRSA Bacteremia Incidence

PS2 C. Difficile

PS3 Safety Thermometer (Community)

PS4 Safety Thermometer (Acute)

PS5 Falls

PS6 Pressure Ulcers

PS7 Nutrition

PS8 Hydration


36

Source: Trust infection control database, information services team

• February 2015: 0 cases reported at Grimsby hospital

• February 2015: One case reported at Scunthorpe hospital

In 2013/2014 the Trust had five cases of hospital acquired MRSA bacteraemia (post 48 hours)

In 2012/2013 the Trust had two cases of hospital acquired MRSA bacteraemia (post 48 hours)

In 2011/2012 the Trust had four cases of hospital acquired MRSA bacteraemia (post 48 hours)

In 2010/2011 the Trust had eight cases of hospital acquired MRSA bacteraemia (post 48 hours)

Comments:

• Compliance during 2013/14 exceeded the Department of Health target of 0 hospital acquired MRSA Bacteraemia, but did not exceed the Trust’s regulator, Monitor, target of no more than six

• Since the beginning of the 2014/15 financial year, one hospital acquired MRSA bacteraemias has been identified

• While disappointing to report one case at the end of the reporting period, the Trust’s performance in connection with infection control indicators has been excellent and performs better than local and national peer benchmarking.


Rationale for changing this quality priority for 2015/16: Due to the important nature of this quality indicator, this will remain a quality priority for 2015/16, and therefore be monitored in the monthly quality report by the Quality and Patient Experience Committee (QPEC) and the Trust Board.

PS1 MRSA bacteraemia incidence

TARGET: 0 MRSA bacteraemia developing after 48 hours into the inpatient stay (hospital acquired).

Achievement (April 2014 – February 2015): One case reported in February 2015.

Figure 8 Hopsital acquired MRSA bacteraemias (post 48 hours)

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37

PS2 C. difficile incidence

• TARGET: Achieve a level of no more than 33 hospital acquired C difficile cases over the financial year 2014/15

• Achievement (April 2014 – February 2015): 20 cases. The Trust has achieved this quality priority as illustrated graphically below.

Figure 9 Hospital acquired Clostridium Difficile infections


• Three cases of C difficile were identified in February 2015, bringing the cumulative total of 20 confirmed cases since April 2014. This is significantly less than the maximum target set, the Trust’s performance against this important area is also illustrated compared with other organisations, nationally and the local peer

• The Trust’s performance against infection control indicators has been excellent and compares favourably to both the national and local benchmarking, this is illustrated over the page.

Figure 10 Trust performance versus Public Health England and NHS England statistics

Indicator Data period NLaGNational average

Better / worse

Local peer

Better / worse

MRSA bacteria rate per 100,000 bed days (ii) Jul 14 - Sep 14 0.0 0.7 Better 0.8 Better

C. Difficile infection rate per 100,000 bed days (iii) Jul 14 - Sep 14 11.2 11.2 Better 12.9 Better

Source: Trust information team, derived from Public Health England and NHS England Statistics

Key to abbreviations: NLAG – Northern Lincolnshire and Goole NHS Foundation Trust (the Trust)


Local peer –select group of NHS Trusts with similar characteristics to the Trust

Better / worse – Trust performance compared to peer

Comments:

• When comparing the Trust to the national and peer average, the Trust performs better in these important areas

• As referred to earlier within this report, the Trust has faced significant increases in demand on its services. While this will inevitably place additional stresses on the system, it is reassuring to see excellent achievement of these infection control targets, in this context, and compared with local and national peers.

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38

To support the Trust’s focussed work around adhering to this quality indicator, the following tables detail the number of C difficile cases by site that were not preventable, possibly preventable, and preventable.

This assessment and categorisation is based on the director for infection prevention and control (DIPC) review of the case and the evidence recorded, from this the preventability of the case is decided. Due to the timescales involved for these DIPC reviews, there will be a delay in reporting the outcomes when compared with the monthly data provided within this report, therefore the numbers below may differ from the total number of cases detailed on the graph above. Where data is unavailable, this will be reported at the earliest opportunity in subsequent quality reports.

Figure 11 C. difficile – preventable, possibly preventable and not preventable

Diana, Princess of Wales Hospital, Grimsby

Q1 2013/14

Q22013/14

Q3 2013/14

Q4 2013/14 Ap

r - 14

May -

14

Jun -

14

Jul -

14

Aug -

14

Sep -

14

Oct -

14

Nov -

14

Dec -

14

Jan - 1

5

Feb -

15

Total

No. of cases eligible for DIPC review 2 4 3 3 0 1 3 1 1 0 1 2 1 1 2 25

No. of DIPC reviews outstanding 0 0 0 0 0 0 0 0 0 0 1 1 0 1 2 5

Not preventable 1 2 2 1 0 1 3 1 1 0 0 1 1 0 0 14

Possibly preventable 1 2 0 1 0 0 0 0 0 0 0 0 0 0 0 4

Preventable 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 2

Scunthorpe General Hospital Q1 2013/14

Q22013/14

Q3 2013/14

Q4 2013/14 Ap

r - 14

May -

14

Jun -

14

Jul -

14

Aug -

14

Sep -

14

Oct -

14

Nov -

14

Dec -

14

Jan - 1

5

Feb -

15

Total



Not preventable 2 2 1 0 0 0 0 2 0 0 0 1 0 1 0 9


Preventable 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Goole and District Hospital Q1 2013/14

Q22013/14

Q3 2013/14

Q4 2013/14 Ap

r - 14

May -

14

Jun -

14

Jul -

14

Aug -

14

Sep -

14

Oct -

14

Nov -

14

Dec -

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Jan - 1

5

Feb -

15

Total



Not preventable 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1


Preventable 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1



GDH – Goole District Hospital DIPC – director of infection prevention and control

Comments:

• It should be noted that the numbers in the above tables show a site specific breakdown of the same information reported on the previous page for C difficile at Trust level, therefore the numbers may appear to differ.


Rationale for changing this quality priority for 2015/16: This indicator will remain, however in line with national guidance, the target will be reduced from 33 to 21.

39

PS3 Safety Thermometer – increase in harm free care (community)

During 2013/14 the Trust used the NHS Safety Thermometer methodology to monitor the incidence of harm as a result of their acute and community care (community care in North Lincolnshire area only, which became a part of the Trust from April 2011).

• VTE – risk assessment, prophylaxis and treatment of DVT or PE

For the community Safety Thermometer, VTE is not relevant as an indicator. In community practice, patients are not routinely risk assessed for VTE and any concerns regarding a patient in this matter would be referred to the patient’s GP or to the acute Trust via A&E attendance.

In the same way, prophylaxis, unless prescribed by a doctor, would not routinely be commenced by community staff.

Due to these differences, the individual elements of this indicator have been classed as not applicable to the community care Safety Thermometer results.

As a result, VTE is not included in the following section pertaining to community care Safety Thermometer results.

• TARGET: Provide harm free community care to 95 per cent or more patients – as measured by the Safety Thermometer

• Achievement (April 2014 – February 2015): 96 per cent. The Trust has achieved this target for five consecutive months in a row.

The following table illustrates the total community cumulative percentage of harm free care by month since April 2013.

Figure 12 Cumulative % of Harm Free Care

SiteQ1

13/14Q2

13/14Q3

13/14Q4

13/14Q1

14/15Q2

14/15Oct 14

Nov 14

Dec 14

Jan 15

Feb 15

Community Care Total 93% 91% 93% 94% 94% 95% 95% 95% 95% 97% 96%

Source: NLAG Safety Thermometer data, intranet, information services team

Key to abbreviations: Total – average performance within North Lincolnshire community care

Old harms – treatment commenced with a pre-existing ‘harm’ ie a pressure ulcer

New harms – identified following commencement of treatment

Comments:

• From an analysis of the community data, ‘old’ pressure ulcers have been consistently reported, lowering the cumulative percentage, and making it difficult to ascertain and report problem areas.

The NHS Safety Thermometer provides the ability for ‘a temperature check’ of harm to be recorded. It did this by auditing on a point prevalence basis the care provided to patients on a given date each month. This point prevalence audit provided a ‘snapshot’ view of harm on that given day each month.

It focusses on harm in four key areas:

• Pressure ulcers grades 2,3 and 4

• Falls – all falls reported, even if no harm occurred

• Catheter associated UTIs – those treated with antibiotics


40

Overall percentage of harm free care – EXCLUDING ‘old’ pressure ulcersThe following table illustrates the overall percentage of harm free care, excluding ‘old’ harms (specifically – excluding ‘old’ pressure ulcers).

The table below outlines performance since January 2014.

Figure 13

PeriodQ4

13/14Q1

14/15Q2

14/15Oct 14 Nov 14 Dec 14 Jan 15 Feb 15

Community Care Total 98.5% 98.8% 98.5% 99.3% 98.4% 98.5% 99.2% 99.5%





Comments:

• Community harm free care (‘new’ harms only) was 99.2 per cent during January 2015, and has remained consistently high since monitoring began.

To enable further action to be taken, the overall percentage for community has been broken down into the four component parts that comprise this indicator.

(Source data for the following tables: NLAG Safety Thermometer data, intranet, information services team)

Figure 14 Pressure ulcers (grades 2, 3 and 4) – INCLUDING both old and new:

PeriodQ1

13/14Q2

13/14Q3

13/14Q4

13/14Q1

14/15Q2


Community Care Total 97.0% 96.7% 97.0% 97.0% 97.2% 95.3% 98.9% 96.6% 96.6% 98.0% 95.8%


Key to abbreviations: Total – average performance within North Lincolnshire community carE



Figure 15 Pressure ulcers (grades 2, 3 and 4) – New only:

PeriodQ4

13/14Q1

14/15Q2


Community Care Total 98.8% 98.9% 99.0% 99.4% 98.7% 98.9% 99.8% 99.3%


Key to abbreviations: Total – average performance within North Lincolnshire community carE



41

Figure 16 Falls percentage - Harm Free Care

PeriodQ1

13/14Q2

13/14Q3

13/14Q4

13/14Q1

14/15Q2


Community Care Total 99.3% 98.5% 99.0% 99.3% 99.5% 98.1% 100% 99.4% 99.6% 99.6% 99.2%





Figure 17 Catheter associated UTIs: percentage - Harm Free Care

PeriodQ1

13/14Q2

13/14Q3

13/14Q4

13/14Q1

14/15Q2


Community Care Total 99.1% 99.3% 99.0% 99.6% 99.6% 98.5% 99.3% 99.4% 99.7% 98.9% 98.6%


Key to abbreviations: Total – average performance within North Lincolnshire community carR




Rationale for changing this quality priority for 2015/16: As patient safety is such an important indicator to the Trust, this will remain as a quality priority for 2015/16 to ensure that practice has become embedded.


42

PS4 Increase in harm free care (acute)

During 2013/14 the Trust used the NHS Safety Thermometer methodology to monitor the incidence of harm as a result of their acute and community care (community care in North Lincolnshire area only, which became a part of the Trust from April 2011).

The NHS Safety Thermometer is based on a point prevalence analysis of the care provided to patients on a given date each month. This point prevalence audit provided a ‘snapshot’ view of harm on that given day each month. It focussed on harm in four key areas:

• Pressure ulcers grades 2,3 and4

• Falls – all falls reported, even if no harm occurred

• Catheter associated UTIs – those treated with antibiotics

• VTE – ‘new’ resulting in treatment being commenced after admission.

In November 2013, the Trust was involved in another important milestone project – the Transparency project, now known as the Open and Honest Care initiative.

This initiative, led by NHS England is designed to allow a mechanism for NHS organisations to publish information on the rates of harm, patient and staff experience and staffing levels in ‘real time’, in this case information pertaining to the care provided during the preceding month.

This publication pulls together information from existing data allowing for data relating to all patients, not purely relying on a snapshot sample, to guide the Trust in its quest for continuous improvement around quality and safety, but also enabling greater patient choice. This information, amongst other data, also contains the previously focussed on Safety Thermometer information reporting point prevalence data.

Therefore, in changing the focus of this following section, the following benefits are realised:

• All patient harm is now encapsulated in this report – an improvement over the previously used snapshot sample only approach

• ‘Real time’ information reporting, providing most recent information enabling board to ward assurance.

The following section will report harm following care commencement in the Trust, for the preceding month for the following key indicators:

• NHS Safety Thermometer (four key areas – pressure ulcers (‘new’ and ‘old’), falls, catheter associated UTIs and ‘new’ VTEs) – outcomes of point prevalence data collection

• Pressure ulcers – all incidences within the preceding month (hospital acquired)

• Falls – all incidences within preceding month that led to either moderate or severe harm.

PS4 Provide harm free acute care to 95 per cent or more patients – as measured by the Open and Honest Initiative

• TARGET: Provide harm free acute care to 95 per cent or more patients – as measured by the Open and Honest Initiative

• Achievement (April 2014 – February 2015): 91.5 per cent. From recent monitoring the number of patients who did not experience harms has not met the target set, this will remain a quality priority target throughout 2015/16.

43

Open and Honest Initiative: Safety Thermometer (‘new’ harms only) Headline figures – Performance as a Trust (‘new’ harms only included):On one day each month we check to see how many of our patients suffered certain types of harm, some old harms are present when the patient is admitted so acquired prior to the patient’s care commencing in hospital, others are new, acquired following admission.

Whilst the headline Open and Honest Care data includes Safety Thermometer data which includes old and new harms, the chart below excludes old harms – or those a patient presents with prior to admission to the Trust. This section therefore focusses solely on providing the Trust information on where it needs to ensure continuous quality focus/improvement, post admission.

Figure 18 Trust headline figure: Percentage who did not experience any ‘new’ harms

Source: NLAG Safety Thermometer data, information services

Key to abbreviations: No harms percentage - percentage of patients without any ‘new’ harms identified, those identified whilst the patient was in hospital.

Comments:

• The trend line in the above chart illustrates that since January 2014 Trust performance has gradually improved in connection with increased levels of harm free care

• The overall percentage has risen this month to 97.5 per cent.

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Feb 14

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Feb 15

No Harm 94.3% 94.7% 96.3% 97.2% 98.1% 96.4% 97.6% 94.6% 96.9% 96% 95.4% 95.1% 96.6% 97.5%

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Perc

enta

ge %


44

Open and Honest Initiative: Safety Thermometer (all harms)

Figure 19 Headline figures – Performance as a Trust (‘new’ and ‘old’ harms included):The chart below shows the percentage of patients who did not experience any harm (‘new’ or ‘old’), since October 2013.

Source: NLAG NHS Safety Thermometer, as reported within the open and honest initiative, NHS England

Key to abbreviations: No harms percentage – reported levels of patients not having any new or old harms

Comments:

• Harm free care within the acute Trust was provided to 91.5 per cent of patients, this was below the 95 per cent target set. The trend line demonstrates that performance has been declining

• The above information includes both new and old harms. When considering new harms only (presented on the previous page) those acquired following admission to the acute Trust has consistently been above 95 per cent. The Trust does not view it simplistically that old harms are outside of our control, and work is underway to understand what and where ‘old’ harms, specifically pressure ulcers, present from and what the acute Trust and the community and therapy services element of the Trust in North Lincolnshire can do to prevent ‘old’ harms. This work is underway and will be reported and updated on within the monthly quality report.

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No Harm 90% 91.7% 97.2% 94.3% 89.5% 96.4% 93.2% 95.3% 93.2% 93.9% 90.2% 89.3% 89.1% 89.3% 87% 91.5% 89.1%

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

45

Figure 20 Headline figures – Performance at site level (‘new’ and ‘old’ harms included): The following chart breaks down the overall ‘headline’ figure to site specific detail. This information is for ‘new’ and ‘old’ harms, reported since October 2013.

Source: NLAG Safety Thermometer data, as reported within the open and honest initiative, Information Services

Key to abbreviations: DPoW – average performance within North Lincolnshire community carE

SGH – Scunthorpe General Hospital

Goole – Goole and District Hospital

Any harms – ‘new’ or ‘old’ harms, as defined by NHS Safety Thermometer

Comments:

• Goole performance is 100 per cent. As Goole has small numbers of patients compared with the larger hospitals, it is very susceptible to small number variation

• DPoW and SGH percentage of those who did not experience any harms were 90.7 per cent and 86.5 per cent during February.

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Nov 14

Dec 14

Jan 15

Feb 15

DPoW 89.1% 91.2% 96.1% 95.6% 86.9% 95.9% 94.8% 95.6% 94.6% 93.7% 92.6% 88.2% 85.4% 93.8% 87.1% 90.2% 90.7%

SGH 90.4% 93.3% 97.2% 93.1% 91.5% 96.6% 92% 94.7% 91.9% 93.8% 87.1% 89.8% 92.9% 85.4% 86.5% 92.5% 86.5%

GDH 91.3% 76.5% 96% 91.3% 96.4% 100% 83% 96.3% 88.9% 100% 100% 100% 91.7% 72.2% 91.3% 95.8% 100%

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%


46

DPoW:

• 97.8 per cent had no ‘new’ pressure ulcers, 95.2 per cent had no ‘old’ pressure ulcers

• 96.9 per cent were UTI free

• 97.5 per cent had no falls

• 5.9 per cent ‘new’ VTEs requiring treatment following admission.

SGH:


• 93.7 per cent were UTI free

• 95.9 per cent had no falls


Goole:


• 95.2 per cent had no falls (one patient had a fall, but suffered no harm as a result),


Performance with additional indicators relating to Venous Thromboembolism (VTE) are also captured by the Safety Thermometer, these are illustrated below for the month of February and also performance trends over time.

Month of February:

Contributing to overall performance in February were the following harms identified:

DPoW:

• 81.1 per cent VTE risk assessment completed, 64.6 per cent VTE prophylaxis given

SGH:

• 97.7 per cent VTE risk assessment completed, 97.1 per cent VTE prophylaxis given.

Figure 21 Trend over time – VTE risk assessment completion:

Source: NLAG NHS Safety Thermometer, VTE risk assessment completion as reported within the Open and Honest Iinitiative, NHS England

Key to abbreviations: DPoW – Diana, Princess of Wales Hospital

SGH – Scunthorpe General Hospital

VTE risk assessment completed – from the information recorded as part of the dataset for the NHS Safety Thermometer, at the time of the audit, the number of patients with a completed VTE risk assessment form

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May 14 Jun 14 Jul 14 Aug 14 Sept 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15

DPoW 85.5% 91.7% 92.3% 83% 91.7% 84.2% 74.5% 88.5% 78.1% 81.1%

SGH 96.7% 96.3% 96.4% 97.3% 96.6% 96.6% 93.4% 93.7% 99.1% 97.7%

47

Action now being taken:

• VTE performance, as monitored by the Safety Thermometer tool methodology, has been monitored for some months now in the quality report. As a result of previously reporting gaps, appendix 1 of the monthly quality report now includes a focussed version of this information, presented at individual ward level

• For ease of reference regarding the work underway to improve the quality of care for patients with pressure ulcers, please see section PS6 within this report.

Safety Thermometer – harm free care benchmarking derived from the Health and Social Care Information Centre (HSCIC)

The following indicators derived from HSCIC give an indication of the quality of care through a defined measure of harm free care (Safety Thermometer).

Figure 22

Source: Information services, derived from HSCIC

Key to abbreviations: NLAG – Northern Lincolnshire and Goole NHS Foundation Trust (the Trust)


Local peer –select group of NHS Trusts with similar characteristics to the Trust Better / worse – Trust performance compared to peer

Comments:

• The period of time presented in the above table, compared with the national average differs to that reported in the body of the quality report, over the preceding pages

• As illustrated already, performance, measured by harm free care, in the community is performing well, exceeding the national average

• The acute Trust performance, again as already illustrated, has been declining. Compared with the national average, and local peer, the Trust performs worse.

Indicator Data period NLaGNational average

Better / worse

Local peer

Better / worse

Safety thermometer Harm free care - Acute hospital

Jul 14 - Sep 14 91.2% 93.7% Worse 92.7% Worse

Safety thermometer Harm free care - Community

Jul 14 - Sep 14 94.5% 93.5% Better - -


48

Open and Honest Initiative: FallsHeadline figures – Performance as a Trust (new harm only): The following chart illustrates the number of falls, identified from all reported incidents, since October 2013, including the level of harm and the falls rate per 1000 bed days. The chart also illustrates the trend over time.

Figure 23

Source: NLAG Specific Findings from Open and Honest Initiative, NHS England

Key to abbreviations: Cumulative number of falls (n=) – cumulative numbers of falls of all harm severity

Moderate – moderate harm resulting from the fall (see glossary for full definition)

Severe – severe harm resulting from the fall (see glossary for full definition)

Death – death resulting from the fall

Falls rate per 1000 bed days – the number of falls expressed as a percentage rate per 1000 bed days toallow for comparison

Comments:

• The above chart reports the harm classifications following falls, specified by the Open and Honest Initiative, specifically resulting in moderate, severe harm, or harm leading to death

• The falls rate per 1000 bed days allows comparison, despite differing numbers of patients. This peaked in December at 0.13 per 1000 bed days. This was driven by three patients identified as having a fall resulting in death, as the classification of harm. All three patients were at SGH.

• In January, an additional patient was also identified as having a fall that resulted in death. This has been grouped with the three cases from December and all have been escalated as Serious Untoward Incidents (SUIs) for further investigation. This work is now underway. To date three out of the four are completed and have been submitted to commissioners for their comments and approval of the investigative work undertaken. Once all are completed, a meeting will be organised to assess all the incidents, however from each reviewed to date, all were deemed to be accidents with no common themes arising.

• Action now being taken:

• For ease of reference regarding the work underway to improve the quality of care for patients at risk of falling, please see section PS5 within this report.

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Moderate Severe Death

Falls rate per 1000 bed days

49

Open and Honest Initiative: Pressure ulcersHeadline figures – Performance as a Trust (new harm only): The following chart illustrates the number of pressure ulcers since October 2013, including the level of harm and the pressure ulcers rate per 1000 bed days. The chart also illustrates the trend over time.

Figure 24

Source: NLAG Specific Findings from Open and Honest Initiative, NHS England

Key to abbreviations: Cumulative number of pressure ulcers (n=) – cumulative numbers of all grades

Hospital acquired grade 2 – grade 2 pressure ulcer (see glossary for full definition)



Rate per 1000 bed days – the number of pressure ulcers expressed as a percentage rate per 1000 bed days to allow for comparison

Comments: • The pressure ulcer rate per 1000 bed days demonstrates an increasing trend over time

• In February the overall number of pressure ulcers was 30 in total, made up of one grade 4 pressure ulcer, 10 grade 3 pressure ulcers and 19 grade 2 pressure ulcers

• In December and January an increased number of grade 2 pressure ulcers can be seen, however this has reduced in February.

Action now being taken:• The above chart illustrates the numerical side of this story whilst a more detailed clinical

narrative of the work around this area is contained in section PS6 within this report, to avoid duplication of key work streams throughout this document.


Rationale for changing this quality priority for 2015/16: As patient safety is such an important indicator to the Trust, this will remain as a quality priority for 2015/16.

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Rate per 1000 bed days (percentage %)

Cum

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) Hopsital acquire Grade 2 Hopsital acquire Grade 3 Hopsital acquire Grade 4

PU rate per 1000 bed days


50

National CQUIN Target: Maintain pressure ulcer rate at or below the baseline Another CQUIN (Commissioning for Quality and Innovation) relates to the area of pressure ulcers, as reported within the NHS Safety Thermometer (and reported as part of the Open and Honest Initiative, referred to on the preceding page). The previous summary of this data has concentrated on new harms resulting from pressure ulcers, for the CQUIN target, all harms resulting from pressure ulcers are focussed on. The financial value of this CQUIN is £397,277.

This National CQUIN is based on local trending information. The target, as a result of this, is based on the Trust’s previous median value. When worked out this equated to 5.99 per cent. This has been used to base the target on, specifically that five consecutive months to the end of March 2015 are lower than 5.99 per cent. The following chart illustrates the Trust’s current performance against this target.

Figure 25 NLaG Pressure ulcer rate (per month)

Source: NLAG Specific Findings from NHS Safety Thermometer, NHS England

Comments:

• In September 2014, the Trust’s rate of ‘old’ and ‘new’ pressure ulcers increased above the 5.99 per cent target being aimed for. This has continued above the target till December 2014. The February 2015 rate was 6.65 per cent. This CQUIN target is currently not being attained

• NB: It should be noted that this information is based on the Safety Thermometer information, a snapshot sample in time, whereas the preceding page outlined the open and honest dataset, containing all pressure ulcers. This explains any difference in reported data.


• For ease of reference regarding the work underway to improve the quality of care for patients with pressure ulcers, please see section PS6 within this report.

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Jan 15

Feb 15

Pressure ulcers 4.82% 4.43% 5.22% 5.10% 4.99% 7.04% 6.04% 7.06% 7.64% 5.47% 6.65%

Target 5.99% 5.99% 5.99% 5.99% 5.99% 5.99% 5.99% 5.99% 5.99% 5.99% 5.99%

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PS5 Patient fallsAn introductionAnother element of the NHS Safety Thermometer is patient falls. The indicator breaks down degrees of harm resulting from a patient falling within the Trust.

Using this information, the Trust is able to discern both the rate of patient falls including trends over time, while also being able to determine if the work being

undertaken to reduce falls and repeat falls is making a difference to the degrees of harm resulting.

To aid this approach, each repeat fall reported within the Trust is assessed

using an approved root cause analysis (RCA) process culminating in a meeting with ward staff to determine if the patients fall could have been avoided or not. Using the outcomes of this information, enables us to track progress with avoiding future falls.

PS5 – Patient falls – eliminate all avoidable repeat fallers• TARGET: Eliminate all avoidable repeat falls as measured via the root cause analysis undertaken for every repeat faller

• Achievement (April 2014 – February 2015): This target has been met in five months over the last 10 months, this is graphically illustrated below.

Falls has been an area of focus for some time within the Trust. The lead quality matron for falls is supporting proactive work to prevent falls occurring within the acute Trust.

To achieve this, for every repeat fall a RCA is performed to identify lessons that can be learnt to prevent future patients falling. As part of the RCA work undertaken, each fall is determined to have been either avoidable or unavoidable. From April 2014, reported below, the target has been amended to eliminate all avoidable repeat fallers.

The following table provides a summary of performance per month against this target.

Figure 26

Q1

2013 /14Q2

2013 /14Q3

2013 /14Q4

2013 /14Q1

2014 /15 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15

Number of Repeat Fallers 65 65 56 60 56 22 22 15 19 19 24 21 18

Avoidable14 11 3 5 4 0 1 0 2 0 0 1 0

22% 17% 5% 8% 7% 0% 5% 0% 11% 0% 0% 5% 0%

Unavoidable51 54 53 20 20 22 21 15 17 19 24 20 18

78% 83% 95% 33% 36% 100% 95% 100% 89% 100% 100% 95% 100%

Data Source: RCA Records kept by lead quality matron

Key to abbreviations: Avoidable – fall deemed to be avoidable as a result of the Root Cause Analysis (RCA)

Unavoidable – fall deemed to be unavoidable

Comments:

• In February, no falls were deemed to be avoidable following the root cause analysis process.


• The care rounds form has been amended and now uploaded ready for trial period from April 2015. Utilisation of care rounds to be discussed at matron weekly meeting to ensure compliance

• The NED challenge meetings continue to be held with one single joint meeting being held with all four quality matrons in attendance to review progress against falls, dementia, hydration/nutrition and pressure ulcers. This is a comprehensive meeting which enables the team to share ideas across all key lead areas


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• Root Cause Analysis (RCA) meetings continue to be held monthly at SGH and DPoW while Goole meetings are held quarterly. Ward sisters/charge nurses and ward staff attend to review patient cases. RCA meetings to also capture multiple patient moves as a potential factor to aid understanding of the context

• Medical electronics have been contacted regarding finding available space for the sensor pads to be stored in a central location for ease of access and stock take purposes to ensure these are available for all ward areas when a patient’s risk factors merit the use of falls sensors

• Patients with alcohol/drug dependency have been identified as providing challenging issues for both nursing and medical staff. This is to be escalated further by deputy chief nurse. Ward C6 at DPoW has had seven repeat fallers, six of whom were related to alcohol

• Ward 23 at SGH has had 27 repeat fallers, 15 of whom were related to alcohol. Parkinson’s, dementia, delirium and sepsis featured as other related themes

• Charitable Funds Committee has approved the purchase of a further 19 low level beds

• Training on falls prevention continues. This was achieved through a combination of online, face-to-face and work booklet training.


Rationale for changing this quality priority for 2015/16: As patient safety is such an important indicator, the Trust will continue to monitor this quality priority monthly within the quality report.

PS6 Pressure ulcersAn introductionPatient safety – the Trust’s open and honest approachAs part of the Open and Honest dataset, the Trust publishes the number of grade 2, 3 and 4 pressure ulcers and undertakes a root cause analysis on all of these.

A transparent culture builds public confidence in the nursing care patients receive and ensures organisational accountability for care.

PS6 Pressure ulcers – 50 per cent reduction in avoidable grade 2, 3 and 4 pressure ulcers

• TARGET: Reduction by 50 per cent avoidable grade 2, 3 and 4 pressure ulcers as measured via the root cause analysis undertaken

• Achievement (April 2014 – February 2015): This target has not yet been met, therefore this target will remain for 2015/16.

Avoidable grade 2, 3 and 4 hospital acquired pressure ulcers – RCA outcomes – 50 per cent reduction in avoidable grade 2, 3 and 4 pressure ulcers The Trust has actively been focussed on reducing hospital acquired pressure ulcers. The following table focusses on the number of potentially avoidable grade 2, 3 and 4 pressure ulcers.

This is first time the root cause analysis work will include grade 2 pressure ulcers as well as previously reported grades 3 and 4. This results in a strengthened quality improvement focussed target.

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The information below is taken from records kept by the lead quality matron as a result of the RCA work taking place for patients with grades 2, 3 and 4 pressure ulcers.

In order to determine the local target metrics, total numbers of avoidable grade 2, 3 and 4 pressure ulcers were identified for quarter one, which resulted in 12 that were deemed to be avoidable following the root cause analysis work undertaken.

Based on this, setting a 50 per cent reduction target, equates to no more than six pressure ulcers per quarter. Six per quarter, divided by three months, equates to no more than two avoidable pressure ulcers per reported month.

Figure 27

Q1 Total

Q2 Total

Oct

14

Nov

14

Dec

14

Q3 Total

Jan

15

Feb

15

February’s breakdown

Number of Grades 2, 3 & 4 Pressure Ulcers

87 85 28 32 43* 85 50# 30^Grade

2Grade

3Grade

4

Avoidable12 24 6 8 1 24 3 1 19 10 1

13% 28% 21% 25% 4% 28% 9% 5%

Unavoidable75 61 22 23 27 61 33 21

87% 72% 79% 72% 96% 72% 91% 95%

Source: RCA records kept by lead quality matron

* 15 were not reviewed prior to discharge by tissue viability nurses, due to insufficient capacity in the team.# 14 were not reviewed prior to discharge by tissue viability nurses, due to insufficient capacity in the team.

^ Three grade 2 pressure ulcers were unverified (two due to patient discharge, prior to being seen, and one patient died), five grade 3s require additional information and RCA meetings to be held.

Comments:

• During February the number of pressure ulcers reported was 30, a reduction on the previous month’s total of 50

• To understand this area in more detail a focussed meeting with the chief nurse is being organised alongside a number of focussed pieces of work are being initiated to assess the relationship between Trust services and ‘old’ pressure ulcerations, reviewing the information available at each site for trends in relation to bed pressures and the necessity to transfer patients and the effect of recent Dragon’s Den initiatives to do with pressure ulcer ‘Pressure Ulcer Grading’ wheels and mirrors.


• A piece of work is underway to ensure all RCAs are received and reviewed in a more efficient manner. Some ward areas are not returning RCA information in a timely manner so this will be addressed as part of this

• A consultation paper is being written to explore options around delivery of the tissue viability service across the Trust including the in hospital and community teams

• Ward sisters/charge nurses continue to receive support in completing RCAs in a timely manner and RCA meetings continue monthly with Ward sisters/charge nurses bringing along staff members to ensure lessons are learned for the ward teams. Where needed extraordinary RCA meetings are arranged within the same month to capture any themes and trends

• Process for investigating a grade 3/4 pressure ulcer has been reviewed and updated (by the deputy chief nurse) which has resulted in greater clarity, specifically:

- If a cluster of pressure ulcers are reported within the same week from one area, this will trigger a multi-disciplinary team review to consider urgent actions to be taken, including tissue viability nurses/quality matrons/operational matrons


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- If two avoidable pressure ulcers are identified within a two month time frame, this will trigger escalation to the chief nurse for a detailed review of the ward and any contributory factors/risks. Due to this new process the first escalation meeting was arranged in December for a ward at DPoW

• All dynamic mattresses have to be cleaned off site after each patient. The current contract cannot cope with the demand for mattress cleaning, the Trust has invested in additional dynamic mattresses but we are not feeling the benefit as mattresses are waiting for transportation, cleaning and return which can put a mattress out of action for up to one week. A business case is currently being developed by medical engineering to enable them to process and clean mattresses; this would require relocation of the medical engineering team/department to give them the space to clean mattresses

• The small hand-held mirrors have now been received into the Trust and have been launched, these were purchased from the Dragons Den work and will aid with the inspection of hard to assess pressure areas.


Rationale for changing this quality priority for 2015/16: As patient safety is such an important indicator to the Trust, and as this target has not yet been met, the Trust will continue to monitor this within the monthly quality report.

PS7 Nutrition PS7.1 Nutrition – for 100 per cent of patients the nutrition care pathway was followed: PS7 is a new indicator for 2014/15. It has been included as a quality priority for the Trust Board to ensure patients while in hospital have this, a crucial element of their care, focussed upon, that of their nutrition. This focussed quality improvement project relates to the Trust’s continued work to understand quality related issues affecting patient safety.

In September 2013 the Trust moved away from its local screening tool for nutrition to a nationally validated tool – the Malnutrition Universal Screening Tool (MUST).

This was implemented within all adult inpatient ward areas (excluding maternity, day surgery and investigations unit).

With a change in screening tool new documentation was required which led to the opportunity to incorporate

both nutrition and hydration into one care pathway.

The MUST screening tool is used to identify those patients who are at risk of malnutrition – depending on the MUST score – a management plan is then followed for the duration of the patients stay.

The total MUST score for a patient is worked out from their BMI, the amount of unplanned weight loss they may have and the ‘acute disease

effect’ (if the patient is acutely ill and there has been or likely to be no nutritional intake for >5 days).

The MUST score triggers appropriate action, as described below:

• MUST score of 0: Low risk and require screening weekly

• MUST score of one: Moderate risk and require screening weekly, commencement and completion of a food record chart, to be encouraged to have fortified meals from the food menu, offered snacks from the Trust wide snack list

• MUST score of two or more: High risk and require the same management as those patients scoring one plus a referral to the dietician for a dietetic review.

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PS7.1 – Nutrition – for 100 per cent of patients the nutrition care pathway was followed:

• TARGET: In 100 per cent of patients, the nutrition care pathway was followed


The following chart illustrates current levels of compliance with using the care pathway following rollout of the MUST scoring system in September 2013.

Figure 28


Key to abbreviations: Trustwide – Northern Lincolnshire and Goole NHS Foundation Trust overall DPoW – Diana, Princess of Wales Hospital; SGH – Scunthorpe General Hospital GDH – Goole District Hospital

NB: The above charts axis starts at 80 per cent.

Comments:

• Performance against this indicator at all DPoW and SGH has not yet achieved the 100 per cent target set

• Compliance in February in SGH has remained at 98 per cent and DPoW has dipped slightly to 95 per cent. Goole have achieved 100 compliance.

• The trend line demonstrates improvement across all three sites.


• Introduction of volunteers at mealtimes on some wards to assist patients with eating/drinking

• Expectation that all patients have a MUST screen entered electronically from November 1

• Additional support has also been agreed by allowing further scrutiny and challenge from a non-executive director who will join the nursing teams overseeing this area, providing a fresh pair of eyes to this area with a view to supporting the team make further improvements

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86

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90

92

94

96

98

100

Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sept 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15

Trustwide 84% 92% 93% 88% 93% 95% 94% 90% 94% 93% 93% 95% 97% 97%

DPoW 81% 94% 88% 87% 91% 95% 94% 90% 93% 93% 90% 92% 96% 95%

SGH 85% 89% 96% 88% 95% 95% 94% 90% 94% 93% 94% 98% 98% 98%

GDH 100% 100% 100% 100% 100% 100% 100% 94% 100% 100% 100% 100% 100% 100%

Threshold 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

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• Information for patient leaflet on Eating and Drinking Whilst in Hospital approved and uploaded – to be circulated to wards

• Information for patient leaflet on Helping Yourself to Eat Well Whilst in Hospital for patients identified as at risk of malnutrition written and circulated for comments prior to approval at Information for Patient Group

• Creation of an approved nutrition screening tool for paediatrics (PYMS) – implemented during December within inpatient areas

• Creation of a nutrition and hydration care pathway for implementation with the PYMS screening tool within paediatrics

• The week commencing March 16 2015 was the international nutrition and hydration week. To coincide, a number of local activities within the Trust to raise awareness were held, these included:

- Nutrition information stands to raise awareness on making correct food choices which included leaflets, word searches along with hydration products being given out to improve hydration

- Staff, patients and public had a chance to make their own smoothies by pedalling a bike to produce a tasty drink

- Colourful children’s ‘Alice in Wonderland’ themed tea party on Rainforest and Disney wards along with ‘change for life’ information, colouring sheets

- Members of the senior management and nursing teams visiting wards, serving tea and cakes, supported by information for patients

- Information on gluten free options

- Information offered on dental hygiene/care

- Experiential feeding was provided by the speech and language team which offered members of the public the chance to attend and become involved.


Rationale for changing this quality priority for 2015/16: As nutrition and hydration are crucial indicators to the Trust, and as this target has not yet been met, the Trust will continue to monitor this within the monthly quality report.

PS7.2 Nutrition PS 7.2 is also a new indicator for 2014/15 and continues the nutrition theme, this time focussing on ensuring that those patients who are identified as moderate to high risk (MUST score >1) have a food record chart commenced and completed fully in line with the management plan.

PS7.2 – Nutrition – for 100 per cent of patients the food record chart was completed accurately and fully in line with the care pathway

• TARGET: In 100 per cent of patients, the food record chart was completed accurately and fully in line with the care pathway


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The following chart illustrates the current compliance with ensuring the food record chart was used fully and appropriately.

Figure 29 In 100% of patients the food record chart was completed accurately and fully, in line with the care pathway


Key to abbreviations: Trustwide – Northern Lincolnshire and Goole NHS Foundation Trust overall DPoW – Diana, Princess of Wales Hospital; SGH – Scunthorpe General Hospital GDH – Goole and District Hospital


Comments:

• Performance against this indicator has not yet achieved the 100 per cent target set. The trend line no longer shows an improving performance since January

• During February, compliance at DPoW has improved slightly to 90 per cent from a sharp dip to 86 per cent in December

• SGH compliance has risen to 93 per cent. Performance at Goole has gone back to 95 per cent.


• As a result of previous drops in compliance in this area, all the quality matrons have focused on ensuring that those patients who are identified as moderate to high risk (MUST score >1) have a food record chart commenced and completed fully in line with the management plan.

During the nursing dashboard audits throughout the month it was agreed to specifically identify all patients who have a high MUST score and focus on the food record charts as well as fluid charts where applicable and use the opportunity to educate staff on the importance of completing these records. This focussed work will continue for the foreseeable future.



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100


Trustwide 93% 95% 95% 88% 97% 94% 96% 93% 94% 96% 94% 90% 88% 92%

DPoW 95% 97% 96% 87% 96% 95% 97% 94% 93% 96% 97% 86% 89% 90%

SGH 90% 93% 93% 88% 98% 93% 95% 92% 96% 94% 91% 93% 86% 93%

GDH 100% 90% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 95% 100%

Threshold 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

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PS8 Hydration

PS 8 is also a new indicator for 2013/14. This illustrates the Trust’s focus on ensuring both nutrition and hydration needs are met for patients admitted to the Trust.

Effective and consistent fluid management is recognised nationally as being an area of weak practice as demonstrated in the National Patient Safety Agency (NPSA) (2008) and the National Reporting and Learning System (NRLS) (2008) evidence.

Accurate fluid balance monitoring is an essential tool in the early identification of a patient whose condition is deteriorating (NPSA 2008) and is strongly recommended by both the NPSA and the National Institute for Clinical Excellence (NICE, 2007).

Monitoring the hydration status of patients by using fluid management charts is imperative to reducing the risks of dehydration and the associated complications it can bring.

Progress against this indicator will be monitored throughout the year.

PS8 Hydration – for 100 per cent of patients the fluid management chart was completed accurately and fully in line with the care pathway.

• TARGET: In 100 per cent of patients the fluid management chart was completed accurately and fully in line with the care pathway


Figure 30 In 100% of patients the fluid management chart was completed accurately and fully, in line with the care pathway


Key to abbreviations: Trustwide – Northern Lincolnshire and Goole NHS Foundation Trust overall DPoW – Diana, Princess of Wales Hospital; SGH – Scunthorpe General Hospital GDH – Goole and District Hospital


80

82

84

86

88

90

92

94

96

98

100


Trustwide 87% 86% 88% 88% 88% 89% 91% 88% 89% 86% 87% 96% 95% 96%

DPoW 86% 84% 83% 87% 84% 89% 88% 83% 83% 85% 89% 96% 97% 97%

SGH 87% 87% 91% 88% 90% 88% 94% 91% 94% 84% 83% 95% 92% 96%

GDH 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Threshold 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

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Comments:

• Performance at SGH has risen to 96 per cent. Performance has remained at 97 per cent at DPoW and at 100 per cent at Goole.


• Working towards electronic fluid management charts

• Hydrant drinking system, now available to all ward areas with stock held on one ward at each sit,

• Working towards dementia friendly drinking glasses

• Amendment to the fluid management chart to incorporate registered nurse signatures – Following further amendments and trial on one surgical ward trial to be undertaken within medicine prior to further discussion and approval at NMAF.




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2.1c Patient experience (PE)

PE1 Friends & Family Test

PE2 Reduction in Re-Opened Complaints

PE3 Complaints Action Plans Implemented

PE4 Complaints Themes Reduction in Incidence

PE5 Pain Management

PE6 Staff Satisfaction

Patie

nt Sa

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PE1 Friends and Family Test

PE1 Friends and Family Test – To have a response rate that achieves a response rate in the top 50 per cent.

• TARGET: Have a response rate that achieves a response rate in the top 50 per cent.

• Achievement (April 2014 – February 2015): This target has not yet been met, although significant progress is clear from the inpatient element of the survey. This target will remain for 2015/16.

The Trust has participated in the Friends and Family Test since it was launched across the country. Within 48 hours of receiving care or treatment as an inpatient or visitor to A&E, patients are given the opportunity to answer the following question:

“How likely are you to recommend our ward/A&E department to friends and family if they needed similar care or treatment?”

Service users are then asked to answer how likely or unlikely along a six-point scale they would answer the above question. There is also an opportunity to elaborate on the reasons for their answer and all feedback will be encouraged whether positive or negative.

This target measures the response rate for patient and service user feedback. When comparing the Trust to the national landscape, the following charts illustrate the response rate compared to that of other providers.

Figure 31 Response Rate: A&E Friends and Family – broken down by site

Northern Lincolnshire and Goole A&E Friends and family response rate in national context by sites - February 2015

DPW - 19.2%

SGH - 13.9%

NLaG Trust - 16.6%National Average - 21.9%

70%

60%

50%

40%

30%

20%

10%

0%

Source: NHS England, Friends and Family Test data

Key to abbreviations: NLAG Trust – Northern Lincolnshire & Goole NHS Foundation Trust overall DPoW – Diana, Princess of Wales Hospital; SGH – Scunthorpe General Hospital National average – the national average response rate Bars within graph: Each bar represents NHS organisation participating in the friends and family test, providing a league table of performance

Comments:

• The response rate at DPOW is close to the national average however the response rate at SGH has dropped to 13.9 per cent.

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Figure 32 Response Rate: Inpatient Friends and Family – broken down by site


Key to abbreviations: NLAG Trust – Northern Lincolnshire and Goole NHS Foundation Trust overall DPoW – Diana, Princess of Wales Hospital; SGH – Scunthorpe General Hospital National average – the national average response rate Bars within graph: Each bar represents NHS organisation participating in the friends and family test, providing a league table of performance

Comments:

• During July and August, the Trust moved from the bottom 50 per cent to the top 50 per cent of reporting Trusts. This was maintained in the subsequent months, until December 2014, where the response rate again dipped below the national average. In February 2015, the Trust moved into the bottom 50 per cent of reporting Trusts, with a Trust response rate of 43.1per cent compared to the national average of 46.1per cent.

Greater clarity and action to support Friends and Family Test response rate:

• To bring further clarity to individual ward level performance, with a view to identifying exemplar wards, a new addition to the monthly quality report, is the league table for ward areas, presented in appendix 2 of the monthly quality report. This report is available on the Trust’s internet site.

• For a further summary of action being taken, see the end of this section for a full summary.

Northern Lincolnshire and Goole inpatient Friends and family response rate in national context by sites - February 2015

DPW - 38.1%

SGH - 44.7%

NLaG Trust - 43.1% National Average - 46.1%

GDH - 83.1%

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%


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Figure 33 Response rate and feedback summary by site and survey

A&E In-patient

DPoW SGH DPoW SGH Goole

Tota

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Posi

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Tota

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Posi

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Q1 13/14 115 97% 82 74% 235 99% 283 97% 48 100%

Q2 13/14 121 92% 44 82% 238 97% 270 97% 47 100%

Q3 13/14 121 97% 40 82% 208 97% 425 95% 35 97%

Jan-14 24 96% 88 83% 133 96% 192 93% 18 100%

Feb-14 128 93% 82 91% 264 98% 358 95% 23 96%

Mar-14 252 96% 84 88% 286 95% 433 94% 27 100%

Apr-14 194 96% 148 88% 196 95% 447 95% 32 100%

May-14 137 97% 169 91% 362 92% 454 96% 24 100%

Jun-14 381 98% 230 90% 368 93% 451 96% 29 100%

Jul-14 286 95% 564 91% 460 95% 608 97% 31 100%

Aug-14 236 94% 233 96% 385 95% 487 100% 40 95%

Sep-14 254 96% 173 91% 409 92% 485 97% 60 100%

Oct-14 274 91% 465 84% 474 93% 496 95% 46 100%

Nov-14 732 90% 534 86% 363 92% 509 95% 46 98%

Dec-14 463 88% 498 84% 309 92% 514 93% 49 98%

Jan-15 409 89% 508 87% 341 95% 548 95% 54 100%

Feb-15 481 84% 346 81% 371 94% 505 96% 64 100%

Source: Information services team

Key to abbreviations: DPoW – Diana, Princess of Wales Hospital, SGH – Scunthorpe General Hospital, Goole – Goole District Hospital, A&E – Friends and Family Test returns from A&E department, Inpatient – Friends and Family Test returns from in-patient wards.

* ‘Positive feedback’ defined as the percentage of patients/service users answering ‘extremely likely’ and ‘likely’ to the question:

“How likely are you to recommend our ward/A&E department to friends and family if they needed similar care or treatment?”

Key to RAG ratings: Positive feedback > 90 per cent

Positive feedback > 80 per cent and < 90 per cent

Positive feedback < 80 per cent

For more information regarding the Friends and Family Test, please follow this link to the NHS England site:

www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/

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Feedback from the Friends and Family Test: A&E – broken down by siteNHS England is no longer providing a Friends and Family Test score and so the charts presented as follows mirror the national changes in the analysis of this information, by comparing the percentage of responses which would recommend the Trust by site with the other UK comparators.

Figure 33b



Comments:

• A&E feedback for the Trust is 83 per cent which is lower than the national average of 88.4 per cent.

• The percentage recommending has dropped to 84 per cent at DPOW and 81 per cent at SGH.

DPW - 84%

SGH - 81%

NLaG Trust - 83%National Average - 88.4%

Northern Lincolnshire and Goole A&E percentage recommended in national context by sites - February 2015


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Feedback from the Friends and Family Test: Inpatient Percentage Recommended – broken down by site As already introduced, NHS England are no longer providing a Friends and Family Test Score, therefore the following mirror the national changes in the analysis of this information, by comparing the percentage of responses which would recommend the Trust by site with the other UK comparators.

Figure 34 NLaG inpatient percentage recommeded in national context by sites - February 2015

100%

95%

90%

85%

80%

75%

70%

DPW - 94%SGH - 96%

NLaG Trust - 95%National Average - 96.3%GDH - 100%

Northern Lincolnshire and Goole inpatient percentage recommended in national context by sites - February 2015



Comments: • Goole is above the national average performance line

• The percentage of inpatients responding who recommended the Trust has remained at 95 per cent which is just below the national average of 96.3 per cent. SGH is 96 per cent and DPOW is 94 per cent

For more information regarding the Friends & Family Test, please follow this link to the NHS England site:

www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/

Figure 35: How the Trust compares to peerA summary of the Trust’s performance for the latest quarter (October to December 2014) is shown in the following tables:

Indicator NLaGNational average

Better / worse

Ranking out of 140

A&E recommended 87.1% 86.8% Better 79th

A&E response rate17.6%

(2,966/16,882)18.8% Worse 82nd

Indicator NLaGNational average

Better / worse

Ranking out of 140

Inpatient recommended 93.8% 94.3% Within 1% 108th

Inpatient response rate39.7%

(2,808/7,063)35.8% Better 49th

Source: Information services* Within 1 per cent of the value benchmark. In this case the NLAG rate is within 0.94 per cent of the national average rate.

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Comments:

• In the last quarter, the Trust (A&E) performed well in terms of feedback from the Friends and Family Test and narrowly missed the national average for response rate

• In the inpatient element of the Friends and Family Test the Trust performed within 1 per cent of the national average in terms of feedback and performed above the national average in terms of response rate to the Friends and Family Test.

Action now being taken to improve:

• We are now sending out the quality comments for groups to share and action and are able to pull out themes from data collected

• NETCALL continues to contribute to increased A&E responses. The information services team are doing a piece of work around the completion of patient data on arrival to improve calls, they recognise this is a Trustwide issue which affects any call reminder or automated call service

• A&E now have dedicated stands now at each site to enable a central visual point for the completion of cards

• Engagement with clerical teams and nursing teams continues to help raise awareness of Friends and Family Test

• A Polish version of the friends and family cards is being displayed in A&E to guide one of our larger non English speaking groups enabling them to give feedback if they wish. Translation and easy read versions of Friends and Family Test will be available on the patient experience web page

• The Task and Finish Group continues to discuss issues monthly

• Improvements within Friends and Family Test and patient feedback continue. A web platform has been costed by a local company which would support use via tablets and smart phones

• Process improvements are being considered, these include a more permanent resource for data collection and inputting. Re-useable envelopes for reducing paper waste and improving time management.

Early Implementation for additional Friends and Family Test

• As from January we are now submitting community and minor injuries unit data to NHS England. There remains no targets to attain to only that we provide feedback opportunities for our patients

• The Friends and Family Test was due to roll out to some additional areas nationally from January and April 2015. The Trust was asked by its commissioners to commence an early implementer programme from October 2014

• The areas being included are outpatients, day-case areas and community. Currently cards are being made available in all these areas across site. The emphasis is on ensuring a robust process, capturing all areas and engaging teams to own the principles of Friends and Family Test, which are active use of feedback for service improvement and increasing team morale through positive feedback

• All areas went “live” as from April

• Initial work has given some good evidence of engagement and responses

• Submission for community commenced in January with a good return

• The new paediatric cards are now in use and some of the pictorial feedback is encouraging. The cards enable comments and pictures for the younger children and these seem to be workable

• 2015-2016 Friends and Family Test – Nationally there is no CQUIN attached, and locally the requirements stand at inpatient 30 per cent and A&E 15 per cent.


Rationale for changing this quality priority for 2015/16: As this quality priority has not yet been met, this will remain as a quality priority for 2015/16.


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PE2 ComplaintsIntroductionComplaints are a key source of learning for the Trust and as such much work is underway to ensure that the Trust responds to complaints in a constructive and helpful manner therefore answering a patient, relative or carers concerns appropriately.

Secondly as a result of the complaint, appropriate action including learning lessons as a result is also of importance to the organisation. As part of this, the following sections relating to complaints are designed to ensure the Trust uses this feedback appropriately.

PE2 – Reduction in re-opened complaints

• TARGET: Re-opened complaints to not exceed 20 per cent of total closed complaints.

• Achievement (April 2014 – February 2015): No target was set for this quality priority, until recently, so limited data is available. Since December 2014 this target has been met.

Target – Re-opened complaints to not exceed 20 per cent of total closed complaints Since May 2014, the number of reopened complaints had been on average 14 per month which exceeded the target being aimed for – a 50 per cent reduction, equating to no more than 2.5 per month. This is illustrated in the following statistical process control (SPC) chart.

Figure 36

Num

ber (

n=)

Data Source: DATIX, performance assurance team

Key to abbreviations: Re-opened: Complaints that have been resolved which for any number of reasons require further review. Mean – average number of reopened complaints for the period UCL – upper control limit (see glossary for full definitions regarding SPC terminology)

Over recent months, the number of closed complaints was increased. As a significant proportion of these relate to the older complaints in the system which made up the ‘backlog’ which QPEC and the board is aware of. It should be expected therefore that a proportion of those complaints closed will always be re-opened, as a result of the complainant requiring further assurance.

-5

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To set a numerically based reduction was therefore deemed unrealistic. Instead of a numerical target, a proportional or a percentage target would seem more realistic. The same information above has been re-presented using a percentage indicator below.

Figure 37 Percentage of re-opened complaints

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Percentage re-opened 14.9% 18.9% 12.7% 16.9% 26.7% 22.8% 38.1% 37.5% 27.8% 16.2% 25.5% 19.3% 5.8% 17.3%

Data Source: DATIX, performance assurance team

Key to abbreviations: Percentage of re-opened complaints – the percentage of complaints that have been re-opened Re-opened: Complaints that have been resolved which for any number of reasons require further review.

As a result of this, at the mid-year review of the quality priorities, the Quality and Patient Experience Committee (QPEC) agreed to refine this indicator to read:

“Re-opened complaints to not exceed 20 per cent of total closed complaints”

As illustrated in the above chart, this target has been met during January and February 2015.


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Complaints – contextual information – as at the February 13 2015:To provide further context to the wider complaints management processes within the Trust, the following chart illustrates trends since 2013. The data has been extracted from DATIX as at February 13 2015.

Figure 38 NLaG Complaints resolution January 2013 - present

Data Source: DATIX, Performance assurance team

Key to abbreviations: New – The number of new complaints received in a month regardless of whether or not they were resolved within that month.

Closed – The number of complaints that were resolved within a month regardless of whether they were received within the month or resolved within agreed timescale.

Net open – The total number of complaints currently open; includes new complaints and those unresolved from previous month(s). This includes open ‘on hold’. This includes re-opened complaints.

Comments:

• Since February 2014, the number of closed complaints has exceeded the number of new complaints month on month.

Has the quality indicator been changed during the year from that set in last years (2013/14) Quality Account? Yes. As explained, a numerical target was felt to be an inaccurate way of reliably tracking improvement and performance in general, especially when balanced with the increasing number of complaints being closed.

Rationale for changing this quality priority for 2015/16: No further changes are planned in connection with this indicator since its amendment during the 2014/15 mid-year quality priorities review.

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Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb

2013 2014 2015New 48 66 57 44 49 42 50 55 56 63 73 48 54 40 50 48 23 29 37 31 41 45 44 43 37 35

Closed 37 33 24 45 37 36 26 29 41 41 37 38 47 53 63 65 60 57 42 32 54 74 47 57 52 52

Net open 115 147 169 157 169 169 197 197 195 195 220 221 248 211 202 185 201 170 173 177 172 165 153 158 148 142

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PE3 Complaints – action plans agreed within timescales• TARGET: 90 per cent of action plans following a complaint to be implemented within agreed timescales.

• Achievement (April 2014 – February 2015): Now above 90 per cent. This target has been met.

The policy for the operational management of this area states that where remedial action is identified, an action plan, which records timescales and responsibilities, will be prepared by the relevant directorate/operational group on the closure of a concern or no later than three months after closure of the complaint and will be monitored regularly by the operational group until fully implemented. Whilst this is not a new requirement, the electronic recording of completed actions on DATIX has not been consistent.

The following table illustrates part one of the process, that of drafting an action plan, for those complaints requiring action, since April 2013.

Figure 39 Q1 2013 /14

Q2 2013 /14

Q3 2013 /14

Q4 2013 /14

Q1 2014 /15

Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15

Total number of complaints closed

106 99 116 163 182 42 32 54 74 47 57 52 52

Total number of complaints requiring action plan

49 43 58 47 41 12 13 14 20 16 17 14 17

Number of action plans drafted by Complaints Team

49 43 57 47 41 12 13 14 20 16 17 14 17

% action plans drafted by Complaints Team

100% 100% 98% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Data Source: DATIX, clinical and quality assurance team

Key to abbreviations: Closed complaint – the number resolved within the month,

Action plan – a plan to resolve any areas for improvement identified as a result of the complaint,

Action plans drafted by central team – action plan developed as a result of the complaint,

Percentage of action plans drafted by complaints team – the number of action plans drafted as expressed by a percentage (%).

Comments:

• The above table illustrates that phase one of the process, that of drafting an action plan in response to a complaint (where necessary) by the central complaints team is exceeding the target set for complaint responses.

Step two of the process is implementation by the relevant directorate/operational group of the agreed actions within the agree three month timeframe following closure of a complaint.


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The following table illustrates the number of action plans that required implementation during each month. The table then outlines the number of these actually implemented in practice. Due to the aforementioned three month timescale, the number eligible for completion each month differs from the number drafted in the same month.

Figure 40 Q1 2013 /14

Q2 2013 /14

Q3 2013 /14

Q4 2013 /14

Q1 2014 /15

Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15

Number of complaints action plans requiring implementation within month

2 26 44 55 43 5 1 8 16 7 17 12 11

Number of complaint action plans fully implemented

2 4 14 12 4 0 0 0 9 6 16 11 11

% of action plans fully implemented

100% 27% 32% 19% 9% 0% 0% 0% 56% 86% 94% 92% 100%

Data Source: DATIX, Clinical and quality assurance team

Key to abbreviations: Complaint action plans requiring implementation within month – the number where the action plan deadline agreed ended in this period,

Action plan fully implemented – the agreed plan is fully implemented as a result of the complaint,

Percentage of action plans fully implemented – the number of action plans implemented as expressed by a percentage (%).

Comments:

• This area was one which had been identified as needing to be addressed as a high priority for 2014/15. As described in the June quality report, a more robust process of monitoring/implementation of the complaint action plans was introduced and a complaints assistant identified to work with directorates/groups co-ordinate these arrangements. All complaints closed from July 1 2014 have followed this process.

• As detailed previously significant improvements were expected to take effect from October 1 2014. Since October 2014 the percentage of action plans fully implemented has risen significantly with compliance in February 2015 reaching 100 per cent.


Rationale for changing this quality priority for 2015/16: As this quality priority is of key importance to the organisation, this will remain as a quality priority for 2015/16.

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PE4 Complaints• TARGET: To achieve a 50 per cent reduction in complaints relating to the specific theme of communication (reported

quarterly)

• Achievement (April 2014 – December 2014): This target has not met been during the 2014/15 financial year. This will remain a priority for 2015/16 to continue the Trust’s focus on learning from complaints.

In order to understand the ‘themes’ arising from complaints, to enable the Trust to set an improvement trajectory, a detailed assessment of closed complaints during two separate periods of time was undertaken. The periods of time chosen were both during quarter 2 (July-September), but separate years:

• Quarter 2, 2012/13,

• Quarter 2, 2013/14 – during which time the Keogh review team visited resulting in increased media publicity.

From this analysis, communication was identified as one of the most predominant reasons for the complaint to be made (55-60 per cent of formal complaints analysed). As a result of this, the Trust has set an improvement trajectory for complaints relating to communication.

Based upon Q2 2013/14 data as a baseline identified 65 formal complaints over a 3 month (1 quarter) period related to this theme of communication. Projecting this over the remainder of the year (3 remaining quarters) would equate to 260 complaints per year. A 50 per cent improvement trajectory based on this would be a maximum of 130 complaints per year. This breaks down to a quarterly target of no more than 32.5, rounded up equals 33.

In this month’s report, the second quarterly information is able to be analysed, this is presented as follows:

Figure 41 Q1 2014/15 (Apr - Jun)

Q2 2014/15 (Jul - Sep)

Q3 2014/15 (Oct - Dec)

Total number of formal complaints received 158 115 132

TARGET BEING AIMED FOR (50% Reduction) – Maximum Per Quarter of: 33 33 33

Total where the theme was determined to be around communication 33 (21%) 44 (38%) 72 (55%)

Comments:

• During quarter 3, a total of 72 complaints relating to communication were received, this is significantly above the target of “no more than 33 per quarter”.

Action being taken and further theme analysis:After the detailed analysis reported previously (deep dive review of complaints) further work is ongoing to provide more detail on the themes arising from that analysis. This work includes reviewing those complaints falling into “general” categories (eg general medicine, surgery etc) to obtain more understanding of the underlying themes and raising the issues through various focus groups, governance meetings, study days etc.

In addition a small working group reporting to the Patient Experience Group (PEG) has been formed to also look at these themes and options which can be considered and implemented both short and long term.

The aim of this is to increase awareness of the themes in order to get those issues addressed at the point of care and the results of this work will be reported on a quarterly basis with a view to reducing themes such as “communication” to 50 per cent (or less) than the 2013/14 period.


Rationale for changing this quality priority for 2015/16: This indicator will remain the same for the 2015/16 monitoring period.


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PE5 Pain management

• TARGET: Patient felt staff did everything to help control pain/improve comfort.

• Achievement (April 2014 – February 2015): This target was consistently met with 100 per cent reported compliance.

Since this indicator was included within the monthly quality report, compliance has been 100 per cent each month. On the back of recent reflections following ‘patient’s stories’, some of which related to management of pain and administration of pain relief, this illustrated that the measure being used for this area requires further refinement.

At the same time, the recent guidelines issued by NICE on nursing staffing levels included a number of nursing ‘red flags’ to help trigger areas for greater nursing scrutiny/management. Two of these ‘red flags’ related to this area, specifically:

• Unplanned omission in providing patient medications,

• Delay of more than 30 minutes in providing pain relief.

Based on this greater guidance, and listening to local patient’s experiences, a proposal was submitted to the Quality Patient and Experience Committee (QPEC) during the mid-year review of quality priorities to widen PE5 relating to pain management to include the following two indicators:

• PE5a: 90 per cent of patients should not have any unplanned omissions in providing patient medications,

• PE5b: 90 per cent of patients should not have a delay of more than 30 minutes in providing pain relief.

As a result of this agreement, the nursing dashboard process by which levels of nursing quality are measured on a monthly basis, evaluating 10 patients on every ward within the Trust, will be amended to have these questions included. As soon as this information begins to filter through, this will be reported within the monthly quality report.

Has the quality indicator been changed during the year from that set in last year’s (2013/14) Quality Account? Yes. As the target set was being met consistently, it was decided at the mid-year review to change the target to more comprehensively assess pain management. Work is now underway to develop data collection systems to enable these new indicators to be reported within the monthly quality report.

Rationale for changing this quality priority for 2015/16: This amended indicator will remain the same for the 2015/16 monitoring period.

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PE6 Staff satisfaction: culture change and the morale barometer

Introduction - Culture change Following the launch of the ‘Together …’ vision and values in September 2012 much activity has taken place on a corporate level to weave the values into appropriate business practices. In summary the work to date has focused on:• Human resources and

organisational development activities – linking the vision and values to the recruitment, induction, contract of employment and appraisal processes

• Patients and our values –how we use and learn from patient stories that have value related compliments or complaints. The vision and values group presently has two patient representatives as permanent members to assist with this

• Marketing and branding – focusing on the on-going rollout and development of the ‘Together…’ brand

• Reward and recognition – how we recognise staff and teams who are excelling at delivering their services through the values. Here we aim to learn from them, share and disseminate best practice and in doing so contribute to increase in holistic team working practices.

The vision and values group recognises that, as important as the above activities are, the vision and values must be ‘lived’ at an operational level through day-to-day working practices. To this end the launch of the values champions network took place via its inaugural workshop on February 18 2014. To date 57 staff have stepped forward as champions. The above workshop aims to:

• Equip them with a thorough knowledge of the values, how to sell these and techniques

This has been achieved through significant investment in staff engagement, staff suggestion schemes and increased internal communications to increase awareness of Trust activities (to name just a few of the organisational development (OD) work streams).

Culture change measured via the morale barometerThe workstreams to operationally weave the Vision and Values (V&V) into Trust policies and procedures continue, but in many cases have been completed. From this work of particular note is as follows:

• Personal appraisal and development review (PADR):

Following a successful pilot the vision and values PADR policy and revised documentation, a review has taken place to fine tune the processes. The revised documentation firmly links the PADR process with the pay progression policy (presently in draft pending ratification and implementation). The next stage to bolster the impact of the vison and values PADR process is to link staff high performers into an internal talent pool for recruitment and workforce planning purposes.

to overcome any resistance or apathy the may encounter

• Assist them in identifying how, in many ways, they are already ‘living’ the values’ and for these practices to the shared and disseminated amongst the group

• Identify new ways that they could deliver the values in their work place and support them in taking these back to their areas, and

• Introduce initiatives such as NHS Change Day, #hellomynameis etc as means of driving positive behaviour changes and innovation in their teams and areas.

Morale barometer incorporating the Friends and Family TestTo date four morale barometer surveys have been completed, the last taking place in January 2014.

These results from these surveys reveal that from Trust embarking on its culture transformation plan:

• Staff job satisfaction and morale has increased by c.10 per cent

• Staff: managerial working relationships, and staffs sense of ‘engagement’ and ‘voice to suggest change’ have increased by nine per cent, eight per cent and eight per cent respectively.


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Next steps in vision and values activity/rollout:

• Collective leadership linked to vision and values management/leadership style:

The review into medical staff and management team relationships has been completed and this, together with a series of recommendations to introduce ‘Collective Leadership” and build effective medical:management relationships has been provided to the chief executive officer, medical director and director of organisational developement and workforce for consideration.

Morale barometer incorporating the Friends and Family Test

• The seventh morale barometer survey took place in October 2014. All 6,500 staff were invited to take part and participate in this quarterly survey. Response rates to date are illustrated in the table below:

Feedback from staff is that the surveys are being run too frequently. As such the surveys will now be run six monthly. This will also provide for time between the surveys for recommendations to be acted upon. The next survey is scheduled for April 2015.

These survey findings seek to evaluate the progress being made on its culture transformation plan and the mood of staff. The key findings are displayed in the table overleaf (please note a score of one equates to 10 per cent unless the

value is displayed as a percentage in its own right).

The target being aimed for this indicator is based on an indicator of 17.5 per cent improvement achieved between November 2011 and October 2014 and measured through the morale barometer so has some reasoning and rationale whilst still being stretching.

The following page contains the results of the most recently run morale barometer in October 2014 and presents this compared to previous surveys recorded in April.

Nov 2011 May 2013 Sept 2013 Jan 2014 Apr 2014 July 2014 October 2014

Response rate 87 340 545 356 330 496 286

Source: Morale barometer findings, directorate of organisation development and workforce

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Engagement and WorkloadTotal

changeQuarterly

changeOct-14 Jul-14 Apr-14 Jan-14 Sep-13 May-13

Reflecting back over the last 3 months: How engaged do you feel with you ward/departments activities and future developments?

-0.1 -1.1 4.3 5.4 5.4 5.2 4.6 4.4

How well do you feel you can influence service developments or decision making processes on your ward/department?

-0.2 -1.2 3.4 4.6 4.6 4.4 3.8 3.6

How well do you feel you can influence decision making processes in the Trust?

0.1 -0.7 2.6 3.3 3.3 3.1 2.7 2.5

How well do you feel you are able to cope with your current workload?

0 -0.5 5.3 5.8 6.1 5.8 5.2 5.3

Value and satisfactionTotal

changeQuarterly

changeOct-14 Jul-14 Apr-14 Jan-14 Sep-13 May-13 Nov-11

As a member of your ward/department’s team how valued do you feel?

-0.3 -1 4.7 5.7 5.9 5.7 5 5 -

As a member of the Trust how valued do you feel? -0.3 -1.1 3 4.1 4.2 3.7 3.4 3.3 -

How much satisfaction do you get from working with your immediate colleagues?

-0.2 -0.6 7 7.6 7.7 7.4 7.2 7.2 -

How much satisfaction do you get from working with your management team?

0.1 -0.9 4.3 5.2 5.6 5.1 4.6 4.2 -

How much personal satisfaction do you get from coming to work?

0.1 -1 5.3 6.3 6.4 6.1 5.7 5.5 5.2

CommunicationsTotal

changeQuarterly


How well informed do you feel about what’s happening within the Trust?

0.3 -1.1 4.3 5.4 5.6 5.3 4.6 4

Appraisal and developmentTotal

changeQuarterly


Reflecting back over the last twelve months have you had an appraisal?

11% -9% 77% 88% 92% 68% 70% 67%

Did you see your appraisal as a positive experience which let you plan how you are going to meet your objectives over the forthcoming year?

13% -15% 48% 63% 69% 65% 67% 35%

From your appraisal did you and your manager create an achievable meaningful development plan which will help you do your job?

15% -10% 50% 60% 68% 53% 66% 35%

Have you been provided with the time, or support, to start carrying out the actions on this development plan?

7% -12% 34% 46% 56% 86% 51% 27%


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Summary: Measurement of the quality improvement target around this areaTo measure this quality improvement target, the key question highlighted on the previous page, will be used to measure progress in this area. The question asks:

“How much personal satisfaction do you get from coming to work?”

While all the questions asked as part of the morale barometer are designed to help gauge and measure morale and staff satisfaction, this key question is designed to measure the workforce job satisfaction which is widely recognised as the definition of morale.

In order therefore to measure this indicator throughout the 2014/15 year, the baseline for measuring quarter on quarter progress will be the April 2014 response to this question – 6.4. This weighted score represents a 1.1 improvement on the same question asked from November 2011 to July 2014 morale barometer.

Using the October 2014 morale barometer information therefore yields a result of 5.3, a reduction of -1.0. This appears on face value to be a big step backwards akin to the workforce mood found in November 2012. The reasons for this are being currently investigated by the organisational development team with a report pending.

Has the quality indicator been changed during the year from that set in last years (2013/14) Quality Account? No, there has been no change to this quality priority during the 2014/15 reporting period.

Rationale for changing this quality priority for 2015/16: During 2015/16, this important area of staff morale and organisational culture has served as a quarterly update for the Quality and Patient Experience Committee (QPEC) and the Trust Board. Due to a change in the reporting methodology of the morale barometer, this will be reported in future on a six monthly basis.

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2.1d: Quality priorities for 2015/16 Rationale for quality priorities:The quality priorities for 2015/16 have been identified as a result of the Trust’s concentrated monitoring of the previous year’s priorities and are linked to its continuing focus on ensuring patients and service users are provided with safe and effective care and treatment. A number of the indicators relate to the Trust’s areas of focus during and throughout 2014/15.

How agreed:The priorities for 2015/16 have been agreed by the Trust Board and by the Quality and Patient Experience Committee (QPEC). They have been identified via a number of mechanisms including the following:-

• Discussions with the governors

• Discussions with the commissioners

• The findings from the national surveys (out-patient and in-patient)

• The findings from the staff survey

• Findings from patient satisfactions surveys that are undertaken by the Trust

• Feedback from patients using the ‘patient story’ video approach (played at QPEC and Trust Board meetings) alongside face to face patient stories

• The results that are published within our nursing dashboard

• The data provided by our clinical systems where we are identified as being an outlier

• Information from the Care Quality Commission intelligent monitoring report

• Information from incidents and complaints

• Comments received from local HealthWatch organisations as a result of discussions around last year’s Quality Account

• Feedback received and work undertaken to improve as a result of the Keogh review’s findings and now included within the Trust’s Quality Development Plan (QDP)

Taking into account the wider public views:The quality indicators are agreed following discussions with governors who represent the interests of their constituents following their election to this role from public members of the Trust. The findings from the in-patient and out-patient surveys are also considered when developing these proposed indicators to take into account the views of the wider public.

Feedback and comments from the local overview and scrutiny committees, made up of elected councillors who represent their constituents, is also taken into account when formulating the proposed new quality indicators.

During 2014/15 another powerful way of representing the local public and learning from their experiences was the ‘patient story’ model, using video interviews with local patients explaining their ‘journey’ through the Trust’s services.

These recordings and also the use of face to face stories from patients and the public are a regular feature at both the Quality Patient and Experience Committee (QPEC) and Trust Board meetings and have had an impact on the quality priorities chosen.

How progress will be monitored and measured:Progress against these indicators will be reported monthly using the monthly quality report. The indicators include improvement targets to allow for on-going measurement.

A selection of methods will be employed to measure this area including statistical process control (SPC) charts, tables and graphs. The Quality and Patient Experience Committee (QPEC) and the Trust Board will receive this report.

To ensure our governors are involved in the Trust’s the monthly quality report features as part of the quarterly Governors Quality Review Group (QRG). This report is also shared with the Trust’s commissioners.

The companion to the monthly quality report is the monthly mortality report, this also features an overview of the organisation’s focus on mortality and provides the Mortality Performance and Assurance Committee (MPAC) and in turn the Trust Board with up to date intelligence charting the Trust’s progress against these quality focussed indicators.


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CE1Deliver mortality performance within ‘expected range’ and improving quarter on quarter, until reported SHMI is 95 or better

CE2 NEWS - in 95 per cent of cases with a NEWs score, appropriate action was taken

CE3.1Dementia - 90 per cent of patients aged 75 and over admitted as an emergency to be asked the dementia case finding question

CE3.2Dementia - 90 per cent of the above patients scoring positive on the case finding question to have a further risk assessment

CE3.3Dementia - 90 per cent of the patients identified as requiring referral following risk assessment to be referred in line with local pathway

CE4Evidence based practice - to increase compliance with NICE guidance with 90 per cent compliance achieved by the end of March 2016

CE5Transfer and discharge - Transfer of patients for non-clinical reasons (capacity) to not exceed 20 per cent of the total

Patient safety:

PS1 MRSA - 0 MRSA bacteraemia developing after 48 hours into the inpatient stay (hospital acquired)

PS2C. difficile - achieve a level of no more than 21 hospital acquired C. difficile cases over the financial year 2015/2016

PS3Safety Thermometer - provide harm free community care to 95 per cent or more patients - as measured by the Safety Thermometer

PS4Safety Thermometer - provide harm free care to 95 per cent or more (acute) patients - as measured by the Safety Thermometer

PS5Patient falls - eliminate all avoidable repeat falls (as measured via the root cause analysis undertaken for every repeat faller)

PS6Pressure ulcers - a 50 per cent reduction in avoidable grades 2, 3 and 4 pressure ulcers (as measured via the root cause analysis undertaken for every grade 2, 3 and 4 pressure ulcer)

PS7.1 Nutrition - 100 per cent of patients the care pathway was followed

PS7.2Nutrition -100 per cent of patients identified as requiring it will have their food record chart completed accurately and fully in line with the care pathway

PS8Hydration - 100 per cent of patients identified as requiring it will have their fluid management chart completed accurately and fully in line with the care pathway.

2015/16 Quality priorities:

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Patient Experience

PE1Friends and Family Test - to have a response rate that achieves a response rate in the top 50 per cent which also improves in the quarter one response rate

PE2 Complaints - Re-opened complaints to not exceed 20 per cent of total closed complaints

PE3 Complaints – 90 per cent of action plans following a complaint to be implemented within agreed timescales

PE4 Complaints – 50 per cent reduction in complaints relating to communication

PE5a Pain management2 - Patients should not have any unplanned omissions in providing patient medications

PE5b Pain management2 - Patients should not have a delay of more than 30 minutes in providing pain relief

PE6 Staff satisfaction3 – 2.5 per cent increase in morale/staff satisfaction each six months

2 Rationale for pain management indicator: Pain management and patient comfort is a subjective very personal measure. From a recent patient story, more emphasis on this area has been placed by the inclusion of two more detailed quality priorities, based on the NICE guidance on Safe Staffing levels which outlined a number of ‘red flags’ for nursing concern, these were both listed.

3 Rationale for staff satisfaction indicator: This is based on an indicator of nine per cent improvement achieved between November 2012 and January 2014 and measured through the morale barometer so has some reasoning and rationale whilst still being stretching. The means of measurement/data source would be the morale barometer.

The Trust’s quality targets & priorities – driving continuous improvementIt is worth noting here, that these targets/quality priorities for the most part are not nationally or regionally set, rather they are set locally by the Trust. They are selected as areas of key importance for the Trust to drive and embed continuous quality improvement.

These indicators are not chosen for their ease of completion, resulting in a report full of green ‘completed’ ticks. These indicators are instead quality focussed, aspirational and stretching. As a result, the executive summary that follows, and the greater detail within part two of this report presents progress so far, not always demonstrating that our internal quality targets have been met.

Where these have not been met, an explanation and summary of the work underway are presented and for the most part, these targets have been selected to stay within the quality report to drive quality development during 2015/16.


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2.2 Statements of assurance from the Board

2.2a Information on the review of services

During 2014/15 Northern Lincolnshire and Goole NHS Foundation Trust provided and/or sub-contracted 25 relevant health services.

The Trust has reviewed all the data available to them on the quality of care in 25 of these relevant health services.

The income generated by the relevant health services reviewed in 2014/15 represents 100% of the total income generated from the provision of relevant health services by the Trust for 2014/15.

2.2b Information on participation in clinical audits and national confidential enquires

During 2014/15, 33 national clinical audits and four national confidential enquires covered relevant health services that Northern Lincolnshire and Goole NHS Foundation Trust provides.

During that period the Trust participated in 100 per cent of the national clinical audits and 100 per cent 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 Trust was eligible to participate in during 2014/15 and those in which it participated in are as follows:

NB: The following tables list:

• The name of the national clinical audits and national confidential enquiries listed in HQIP’s quality account resource

• Which ones the Trust were eligible to participate in

• The number of cases submitted for each audit against the number required, also expressed as a percentage (%)

• If action planning is taking place or has been completed to improve processes and practice following publication of findings.

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National clinical audits 2014/15

National clinical audit titleEligible for

NLAGNLAG

participated

Number of cases

submitted

% of number required

Action planning

Acute care

Adult Community Acquired Pneumonia Yes YesOn-going

Deadline May 2015

On-going Deadline May

2015N/A

Case Mix Programme (CMP) Yes Yes 915 100% Yes

Major Trauma: The Trauma Audit & Research Network (TARN)

Yes Yes 332/471 70% Yes

National Emergency Laparotomy Audit (NELA)

Yes Yes 232 100%Awaiting

Publication

National Joint Registry (NJR) Yes Yes 693 100%Awaiting

Publication

Pleural Procedures Yes Yes 32 100% Yes

National Complicated Diverticulitis Audit (CAD)


Publication

Blood and Transplant

National Comparative Audit of Blood Transfusion programme

Yes Yes On-going On-going On-going N/A

1. 2015 Audit of Patient Blood Management in Scheduled Surgery;


2. 2015 Audit of the use of blood in Lower GI bleeding;


3. 2016 Audit of the use of blood in Haematology (submitted for all)


Cancer

Bowel cancer (NBOCAP) Yes Yes 262

Awaiting publication

for comparison

with HES

Yes

(13/14)

Head and neck oncology (DAHNO) Yes Yes 50

Lung cancer (NLCA) Yes Yes 269

National Prostate Cancer Audit Yes Yes 201

Oesophago-gastric cancer (NAOGC) Yes Yes 107


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NLAGNLAG

participated

Number of cases

submitted


Action planning

Heart

Acute Coronary Syndrome or Acute Myocardial Infarction (MINAP)

Yes Yes267/425

(deadline not until June)

63%Yes

(13/14)

Cardiac Rhythm Management (CRM) Yes Yes 410/439 93%Awaiting

Publication

Congenital Heart Disease (Paediatric cardiac surgery) (CHD)

N/A N/A N/A N/A N/A

Coronary Angioplasty/National Audit of PCI

Yes (SGH) Yes 296 100%Awaiting

Publication

National Adult Cardiac Surgery Audit N/A N/A N/A N/A N/A

National Cardiac Arrest Audit (NCAA) Yes Yes 228/250 91% Yes

National Heart Failure Audit Yes Yes270/470

(deadline not until June)

57% Yes

National Vascular Registry N/A N/A N/A N/A N/A

Pulmonary Hypertension (Pulmonary Hypertension Audit)

N/A N/A N/A N/A N/A

Long term conditions

Chronic Kidney Disease in primary care N/A N/A N/A N/A N/A

Diabetes (Adult) Yes Yes

14/15 Deadline May

2015

14/15 Deadline May 2015

Yes (13/14)

Diabetes (Paediatric) (NPDA) Yes Yes14/15

Deadline June 2015

14/15 Deadline

June 2015

Yes

(13/14)

Inflammatory Bowel Disease (IBD) programme

Yes Yes 42/52 81% Yes

National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme

Yes Yes 191/314 61% Yes

Renal replacement therapy (Renal Registry)

N/A N/A N/A N/A N/A

Rheumatoid and Early Inflammatory Arthritis


Publication

National Pregnancy in Diabetes Audit YesYes DPOW

ONLY6 100%

Awaiting publication

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NLAGNLAG

participated

Number of cases

submitted


Action planning

Mental health

Mental health (care in emergency departments)


Publication

National Confidential Inquiry into Suicide and Homicide for people with Mental Illness (NCISH)

N/A N/A N/A N/A N/A

Prescribing Observatory for Mental Health (POMH)

(Prescribing for substance misuse: Alcohol detoxification)

N/A N/A N/A N/A N/A

Older peopleFalls and Fragility Fractures Audit Programme (FFFAP)

National Hip Fracture Database (submitted for all)

Yes Yes 470 100% Yes

Older people (care in emergency departments)


Publication

Sentinel Stroke National Audit Programme (SSNAP)

SSNAP Clinical Audit

Yes Yes 893/928 96% Yes

Other or TBCElective surgery (National PROMs Programme)


National Audit of Intermediate Care N/A N/A N/A N/A N/A

British Society for Clinical Neurophysiology (BSCN) and Association of Neurophysiological Scientists (ANS) Standards for Ulnar Neuropathy at Elbow (UNE) testing

N/A N/A N/A N/A N/A


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NLAGNLAG

participated

Number of cases

submitted


Action planning

Women and Children’s

Epilepsy 12 audit (Childhood Epilepsy) Yes Yes 26 100% Yes

Fitting child (care in emergency departments)

Yes Yes 100/100 100%Awaiting

Publication

Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE-UK)

Yes Yes 29 100% Yes

Neonatal Intensive and Special Care (NNAP)


Paediatric Intensive Care Audit Network (PICANet)

N/A N/A N/A N/A N/A

Total: 44

Eligible for NLAG participation: 33

NLAG Participated in: 33

National confidential enquires 2014/15

Confidential enquiryEligible for

NLAGNLAG

participatedOrganisational Questionnaires

Number of cases

submitted


Action planning

Sepsis Yes Yes 2 9 100%Awaiting Report

Gastro Intestinal Haemorrhage Yes Yes 2 4 100%Awaiting Report

Lower Limb Amputation Yes Yes 2 N/A N/A Yes

Tracheostomy Care Yes Yes 2 14 100% Yes

Total: 4 4

Eligible for NLAG participation:

4

The reports of 17 national clinical audits were reviewed by the provider in 2014/15 and the Trust intends to take the following actions to improve the quality of healthcare provided:

Increased information to patients/carers

• (Epilepsy 12) To ensure patients and carers have a documented discussion in clinics regarding water safety in line with national recommendations.

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Increased awareness and education of staff

• (National Neonatal Audit Programme) Increase awareness of the NNAP results to midwifery and paediatrics to help improve the communication process between staff

• (National Neonatal Audit Programme) Increased focus for all NICU Staff on the referral process for babies regarding retinopathy of prematurity (ROP) Screening and to ensure this is being undertaken within the screening window

• (UK TARN Trauma Audit) Results to be disseminated to staff and raise awareness amongst staff of recording all data, especially injury data, in order to obtain accurate assessment of mortality

• (UK TARN Trauma Audit) Staff submitting data to UK TARN audit shown how to run accreditation reports in order for them to review cases for any data that may have been omitted and potentially take correcting action

• (UK TARN Trauma Audit) Data collection and submission staff attended a training session provided by UK TARN

• (MINAP) To develop ‘guidance sheets’ for staff collecting the data to increase he accuracy of data collection

• (National Hip Fracture Database) Presented key findings at Trust surgery and critical care quality and safety days and orthopaedics audit meetings to raise awareness of any problem areas

• (Elective surgery (National PROMs Programme) Present key findings at the general surgery and orthopaedics audit meetings to raise awareness of any problem areas

• (National Hip Fracture Database) visited to hospital cited in hip fracture database 2013 report who have improved time to surgery and performed well (Harrogate) to discuss how improvements have been made in best practice tariff targets and look at what lessons may be transferred to NLAG

• (Paediatric diabetes) Diabetes nurses have held training events to inform families of the ‘upbeat’ website and encourage them to register for easy access to information regarding management of diabetes

• (Paediatric diabetes) To review files of all patients with HBA1c above 80mmols to ensure HBA1c levels for these patients is the best it can be

• (National Prostate Cancer) Cancer team met with clinical team to discuss minimum dataset and data collection to improve data validity and consistency as well alleviate concerns form the clinical lead regarding data submission due to suspected issues with somerset cancer registry

• (BAUS PCNL and Nephrectomy) Training offered to consultant leads and audit liaisons to show how to upload data on to the BAUS system, including downloading our own data and editing, validating and changing follow up settings

• (BAUS PCNL) Downloaded our own data from BAUS and analysed and presented findings to urology audit group to help data validation and action planning

• (ICNARC Case Mix Programme) Presented findings at quality and safety day to raise awareness

Identified need for further evaluation/patient surveys

• (National Hip Fracture Database) To obtain and review all patients documented as having hospital acquired pressure sores to ensure data accuracy

• (National Cardiac Arrest Audit) To perform root cause analysis on a sample of in-hospital cardiac arrests on a monthly basis to ensure any learning points are maximised.

Changes to service/process

• (National Neonatal Audit Programme) To understand and assess the current methods at both sites for NICU staff when referring babies for retinopathy of prematurity (ROP) Screening, as this can now be completed in the first instance as an inpatient or if unable to, as an outpatient (within the appropriate screening time period)

• (UK TARN) To ensure all the data required for the UK TARN forms part of the trust-wide emergency trauma form currently being developed for use

• (BTS Pleural Procedures Audit) A change to the documentation for chest drains has been proposed, combining two separate forms into one and ensuring more pertinent data is recorded, including prompts for written consent

• (National IBD Audit) Treatment pathway document to be developed


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• (National Bowel Cancer Audit) In order to improve laparoscopic operation rates the Trust has recruited a new laparoscopic colorectal surgeon

• (Paediatric diabetes) Number of clinics and consultation time increased to 30 minutes (regular visit) and 45 minutes

• (BAUS percutaneous nephrolithotomy - PCNL) In an attempt to reduce length of stay the consultant lead communicated to all that following an operation on a Wednesday, earlier nephrostomy removal can take place in order to discharge patients prior to the weekend if no post-operation bleeding is present

• (BAUS percutaneous nephrolithotomy - PCNL) Consultant lead to ensure mid-stream specimen of urine is undertaken at pre-assessment of all PCNL cases to ensure patient in infection free before operation takes place

• (BAUS percutaneous nephrolithotomy – PCNL) Consultant lead to look at business case for a machine that involves using x-rays (high-energy radiation) or ultrasound (high-frequency sound waves) to pinpoint where a kidney stone is and break it in to smaller pieces so it can be passes, therefore reducing the need for more radical surgery

• (National emergency laparotomy – NELA) Consultant leads at each site have started drafting an acute abdomen pathway to ensure risk scoring is completed for all patients and all steps of the pathway are met within certain timeframes (pre-publication of results)

• (NCEPOD Tracheostomy) New tracheostomy surgical safety checklist has been constructed by consultant leads and audit department in order to comply with NCEPOD recommendations within the findings and self-assessment checklist for trusts.

Collaborative/MDT working to be improved/discussed

• (Neonatal National Audit Programme) Data validation continues to be completed every quarter during the reporting year to ensure that all appropriate information has been completed, with special focus on antenatal steroids and ROP screening

• (National Hip Fracture Database) Introduced additional lists for hip fracture on Tuesdays at DPOW and weekends at SGH in order to try to improve time to theatre

• (National Prostate Cancer Audit) Cancer team constructed a data collection form for specific use at MDT in order to aid documentation and submission of staging to national audit and improve quality and validity of data.

The reports of 11 local clinical audits were reviewed by the provider in 2014/15 and the Trust intends to take the following actions to improve the quality of healthcare provided:

Increased awareness and education of staff

• (Homebirth) Staff awareness sessions to be delivered on updated home confinement guideline and the importance of documentation

• (Use of customised growth charts) Refresher training to be given to staff regarding when to commence the growth chart and the process to be followed depending on measurements taken.

• (Goole deliveries) development of new guideline, community staff inducted in to the Goole suite and made aware of the processes and staff refreshed in protocols in place for high risk women

• (CQUINS sepsis) Sepsis screening tool (SST) to be included as part of the junior doctor induction, and reminders for its use to be rolled out as screen savers. Refresher teaching sessions for A&E/ECC staff to be carried

• (CQUINS sepsis) Copies of the SST are stored in the triage room so that the triage nurse can place the SST in the notes if he/she believes it to be a case of sepsis.

Changes to service/process

• (WHO Checklist – Maternity) Maternity checklist to be reviewed and revised to better reflect maternity practice

• (Management of third and fourth degree tears) Face to face follow up clinics now reinstated following an audit showed the previously agreed telephone appointments were not taking place and evidence of the benefits to the patient of having a face to face appointment

• (CQUINS medicine discharge summaries) The discharge letter template has been amended so that the ‘procedures and treatments’ section is now mandatory. The date of discharge section is now auto-populated with a confirmation message for the completing clinician

• (CQUINS medicine discharge summaries) The list of consultant specialties which auto-populates the specialty field on the discharge summary has been reviewed and updated.

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• (Monthly and rapid cycle prescribing audit) The trust are currently re-designing the drug prescription charts in order for it to be more conducive to meeting national standards and aid clearer documentation for both daily and prophylactic scripts

• (WHO surgical safety checklist) Pre-list briefing introduced for both morning and afternoon lists

• (WHO surgical safety checklist) Associate medical director of surgery and critical care to undertake spot checks on the delivery of the checklist on a continuous basis

• (NICE TA49 - ultrasound locating devices for placement of CVC’s) clinical lead for anaesthetics working with vascular access

specialists to introduce a booklet with a checklist in order to improve documentation of CVC placement

• (NICE – CG99 Constipation in children and young people) New paediatric clinic set up by consultant and nursing lead to ensure compliance with NICE guideline and attempt to reduce inpatient admissions.

2.2c Information on participation in clinical research

The total number of patients receiving relevant health services provided or sub-contracted by the Trust in 2014/15 that were recruited during that period to participate in research approved by a research ethics committee is not known as this data is not collected.

However, those patients recruited to NIHR adopted research studies was 1306 as of end January 2015

NB: It should be noted that all studies opened within the Trust are subject to rigorous governance checks which includes submission to a research ethics committee where required. Thus additional patients will be involved in research studies where by the actual patient accrual is not reported through R&D as a core expectation of the Trust at this time i.e. in house/academic studies that are not NIHR adopted.

The Trust takes part in clinical research, this is because it believes that research is important because it helps to improve healthcare by finding out which treatments work best for patients.

It also gives patients the opportunity to access novel and innovative treatments and therapies. Within the department we have adopted the

Within the research and development department, our aims are:

• To increase the number of research studies open within the Trust, including industry studies that may also generate income. Such income is then re-invested within the Trust in the areas of further research and professional development,

• To increase the number of patients recruited to studies within the Trust thus increasing the opportunities for patients to access new and cutting edge treatments which may not be offered through routine care delivery,

• To improve the time that it takes to open a research study within the Trust.

NIHR strapline of ‘Today’s research is Tomorrow’s Treatment’ which captures the essence of what our service is about.

The research and development department offers a central corporate function within the Trust and takes an organisational-level lead in ensuring that research is conducted and managed to high scientific, ethical and financial standards.

The Research and developement department function is delivered from two offices based at the Scunthorpe and Grimsby sites and is led and managed by the head of research and professional development supported by a team of 11 research nurses, two data coordinators and a projects coordinator.


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• To continue working with our research partners in Yorkshire and Humber to deliver the National Institute of Health Research (NIHR) high level objectives.

The research and development department is currently supporting a range of research projects. These include:

• National Institute of Health Research (NIHR) Portfolio adopted research

• Non-Portfolio research

• Commercially Sponsored studies

• Academic and In-House research studies.

There are currently 87 studies open to recruitment within the Trust, these include

• 15 of these studies are commercial

• 66 are adopted onto the NIHR (National Institute for Health Research) Portfolio

• 6 account for other studies which are currently open.

How the research and development team help to deliver researchThe team of nurses and data coordinators help to deliver research within our Trust in the following ways:

• By identifying patients suitable for research studies– involvement is entirely voluntary and never undertaken without formal written consent from the volunteers

• By supporting the investigators in delivering the research studies on a day by day basis, including seeing patients in clinics and at home where required

• Following-up of the patients involved in the studies once the actual treatment stage has been completed – this can be for a number of years in some studies

• Collecting the data that contributes to the results of studies. This then goes onto changing practices and treatments in the future.

We currently have research projects open in the following areas:

Oncology Diabetes Dermatology Paediatrics

Haematology Gastrointestinal Rheumatology Nursing

Stroke Obstetrics ITU Management

Cardiology Gynaecology Surgery Neurology

The Research and development department is dedicated to supporting and furthering research, development and innovation within the Trust. The department provides assistance and guidance on how to:

• Check whether projects are research, service evaluation or audit

• Help and advice on protocol development, study design, data management and analysis

• Assist in the setup of a study

• Coordinate a submission to the Research Ethics Committee (REC) and where necessary Medicines and Healthcare Products Regulatory Agency (MHRA) to facilitate approvals

• Undertake the necessary NHS Trust approval process on behalf of Northern Lincolnshire and Goole NHS Foundation Trust.

It also provides information about training courses offered by other training providers in the field of health service research, local and national funding opportunities and research and development publications.

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2.2d Information on the Trust’s use of the CQUIN framework

A proportion of the Trust’s income in 2014/15 was conditional on achieving quality improvement and innovation goals agreed between the Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of relevant health services, through the Commissioning for Quality and Innovation payment framework.

Further details of the agreed goals for 2014/15 and for the following 12 month period are available electronically at:

www.england.nhs.uk/wp-content/uploads/2014/02/sc-cquin-guid.pdf

The areas of care which were included within the CQUIN scheme for 2014/15 included the following:-

• Friends and Family Test

• NHS Safety Thermometer (Pressure ulcer prevalence)

• Dementia

• Patient experience

• Vision & values appraisals

• Implementing sepsis care bundle

• Clostridium difficile

• Quality of electronic discharge summaries

The amount of income in 2014/15 which was conditional upon achieving quality improvement and innovation goals was £6.14 million.

The monetary total value for 2014/15 CQUIN indicators was £6.14 million. The Trust are currently in discussions with commissioners regarding the CQUIN financial value that the Trust will receive.

2.2e Information on Never Events

The Trust reported 0 never events during 2014/15.

2.2f Information relating to the Trust’s registration with the Care Quality Commission

Northern Lincolnshire and Goole NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is ‘requires improvement’. The Trust has no conditions on its registration.

The Care Quality Commission has not taken enforcement action against the Trust during 2014/15.

The Trust has not participated in any special reviews or investigations by the Care Quality Commission during the reported period.

Themes arising from the CQC visit of the Trust:The CQC visit to the Trust during the 2014/15 period identified a number of themes. These have all become a central part of the Trust’s Quality Development Plan (QDP) and are monitored by the Trust Board. As this is a board paper, the full QDP is available for viewing on the Trust’s Internet site. A high level summary of these themes are presented below:

• Hydration and feeding,

• Care of the deteriorating patient,

• Patient falls,

• Staffing levels,

• Implementation and consistency of clinical strategies and pathways,

• Mixed sex accommodation,

• Dementia care,

• Friends and Family test,

• Improved patient flow,

• Senior medical involvement out of hours,

• Improved clinical leadership,

• Improved record keeping and clinical documentation,

• Complaints and PALS,

• Mandatory training and appraisal,

As you can see many of these areas are reported within this annual account and form the basis of the Trust’s focus on Quality during 2015/16.


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2.2g Information on quality of data

The Trust submitted records during 2014/15 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:

• 96.4 per cent for admitted patient care

• 99.8 per cent for outpatient care

• 98.3 per cent for accident and emergency care.

- Which included the patient’s valid General Practitioner Registration Code was:

• 100.0 per cent for admitted patient care

• 100.0 per cent for outpatient care

• 100.0 per cent for accident and emergency care.

2.2h Information governance assessment report

The Trust’s information governance assessment report overall score for 2014/15 was 66 per cent and was satisfactory.

2.2i Information on payment by results clinical coding audit

The Trust was not subject to the payment by results clinical coding audit during 2014/15 by the Audit Commission.

2.3 Trust performance against core indicators

Since 2012/13 NHS foundation trusts have been required to report performance against a core set of indicators using data made available by the Health and Social Care Information Centre (HSCIC).

For each of these indicators, the number, percentage, value, score or rate (as applicable) is reported for at least the last two reporting periods (last two years).

As the information has been made available from the Health and Social Care Information Centre, where possible a comparison has been made for each of the Trust’s indicators with:

a). The national average for the same;

b). Those NHS Trusts and the NHS Foundation Trusts with the highest and lowest of the same.

For each of these indicators, the Trust is required to make an assurance statement in the following format:

Some of those indicators were not relevant to the Trust; therefore the following indicators reported on are only those relevant to the Trust.

This information has been presented as follows in table or graphical format, as most suited to the type of information being presented.

The Trust considers that this data is as described for the following reasons [insert reasons].

The Trust [intends to take or has taken] the following actions to improve the [indicator/percentage/score/data/rate/number], and so the quality of its services, by [insert description of actions].

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2.3a: Summary Hospital-Level Mortality Indicator (SHMI)

The data made available to the Trust by the Health and Social Care Information Centre with regard to:

• The value and banding of the summary hospital-level mortality indicator (“SHMI”) for the Trust for the reporting period;

Figure 42

Source: Health and Social Care Information Centre (HSCIC)

Key to abbreviations: Trust – Northern Lincolnshire and Goole NHS Foundation Trust, UK average – The United Kingdom average, commonly expressed as 100 – ‘expected mortality’, UK best – The lowest SHMI scoring Trust/hospital/unit, UK worst – The highest SHMI scoring Trust/hospital/unit.

Comments:

• The above table illustrates the Trust’s performance against the Summary Hospital Mortality Indicator (SHMI). The SHMI is a Standardised Mortality Ratio (SMR). SHMI is the only SMR to include deaths outside of hospital in the community (within 30 days of hospital discharge). This inclusion of community mortality means the information needed to ascertain this comes from the Office for National Statistics, this results in delay in the reporting of the SHMI. To illustrate the most recently available SHMI reports performance July 2013 to June 2014

• This delay in reporting makes it difficult for the Trust to continuously in real time monitor this area using SHMI alone, hence why the Trust uses this in collaboration with the ‘provisional SHMI’ indicator from the Healthcare Evaluation Data (HED). Using this ‘provisional indicator’ the Trust has access to more timely information which demonstrates further improvements with mortality performance, illustrated graphically as follows.

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114 112 116 116 117 118 115 115 111 109 109 109 108 109


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Figure 43 NLaG - Moving Annual Total (MAT) provisional SHMI

Source: Healthcare Evaluation Data (HED), information services team

Key to abbreviations: NLAG – Northern Lincolnshire and Goole NHS Foundation Trust, Moving Annual Total (MAT) – A moving annualised average, each months data includes that month plus the 11 months preceding, providing a more reliable presentation of trends over time,

National average – The United Kingdom average, commonly expressed as 100 – ‘expected mortality’,

DPoW – Diana, Princess of Wales Hospital, SGH – Scunthorpe General Hospital, GDH – Goole District Hospital,

Provisional SHMI – The Healthcare Evaluation Data (HED) product provides a provisional SHMI on a monthly basis by which the Trust can report mortality in various internal reporting,

Official SHMI – the ‘official’ SHMI publication, published quarterly, illustrates that the ‘provisional’ HED data is a reliable indicator to monitor Trust performance on a monthly basis.

Comments:

• The above chart illustrates that the Trust’s mortality performance has improved at pace. During the past few months however, the rate of improvement previously seen has slowed at both sites, resulting in a steady trend of at or around a SHMI score of 108-109. As this is a relative score, benchmarking the Trust to the rest of the UK, if other Trusts improve at a faster rate, the likelihood the Trust will move back towards the ‘higher than expected’ grouping. The provisional HED SHMI information has provided the Trust with an insight that this might be happening

• There has been and are still slight differences between the Trust’s individual hospital sites, and there is a significant difference between the in-hospital element of the SHMI ie deaths taking place at the hospital, and the out of hospital part of the indicator, ie those deaths that take place within 30 days of discharge home or into the community. Both of these important elements are monitored monthly by the Trust’s mortality report and the Trust’s Mortality Performance and Assurance Committee (MPAC) and ultimately by the Trust Board. The Board recognises that the mortality position is a community wide issue and there needs to be a healthcare community wide focus on this to enable further improvements to the overall SHMI. The Trust is focusing on working with colleagues from general practice and other community services to understand this further and take action to improve the out of hospital SHMI

• While 100 is the national average and is commonly defined as ‘expected’ mortality, it is recognised that this statistical measure is not an absolute indicator of performance. As a result of this, the Health and Social Care Information Centre (HSCIC) publish an organisation’s position nationally, determining the national best and worst, as well as a Trust banding, which illustrates if an organisation is statistically an outlier, using 95 per cent confidence intervals. This banding is illustrated as follows.

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Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

2012 2013 2014 2015

NLaGNational averageOfficial SHMI

DPoWSGHGDH

95

Figure 44Publication date Sample time frame Trust value

Trust banding

October 2011 April 2010 – March 2011 1.14 1

January 2012 July 2010 – June 2011 1.12 2

April 2012 October 2010 – September 2011 1.16 1

July 2012 January 2011 – December 2011 1.16 1












Key to abbreviations: Trust value – The Trust’s SHMI score, Trust banding – The Trust’s banding – determining if it is an outlier using statistically calculated levels of confidence (95 per cent confidence intervals).

Banding numbers are based on a 95 per cent control limit. The bandings mean:

• 1 – higher than expected

• 2 – as expected

• 3 – lower than expected

As a result of being identified as an outlier between the periods of October 2010 and December 2012, the Trust was one of 14 inspected by a team from the NHS medical director, Sir Bruce Keogh. This ultimately led to the Trust being placed in a form of ‘special measures’ with greater level of scrutiny and assistance provided by a partnering arrangement between the Trust and Sheffield Teaching Hospitals NHS Foundation Trust and a member of Monitor’s executive team working alongside the Trust. More details from this period are summarised later in this report.

Overseen by the Mortality Performance and Assurance Committee (MPAC) the focussed work ongoing prior to the Keogh team’s visit, but further strengthened as a result, saw steady improvements illustrated in previous pages charts resulting in the table above charting the Trust’s steady performance within the ‘as expected’ banding. More work is still needed and this is underway currently, more detail of this provided in the later section of this report.

a). The percentage of patient deaths with palliative care coded at either diagnosis or speciality level for the Trust for the reporting period.


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Figure 45


Key to abbreviations: Trust – Northern Lincolnshire and Goole NHS Foundation Trust,

UK average – The United Kingdom average,

UK best – The Trust/hospital/unit reporting highest percentage levels of palliative care,

UK worst – The Trust/hospital/unit reporting lowest percentage levels of palliative care.

Comment:

• The above chart illustrates the percentage of patients with a palliative care code used at either diagnosis or specialty level

• Palliative care coding is a group of codes used by hospital level coding teams to reflect palliative care treatment of a patient during their hospital stay. Different statistically calculated Standardised Mortality Ratios (SMR) have treated this group of patients differently depending on the indicator. Some previously employed SMR indicators including the Risk Adjusted Mortality Index (RAMI) that the Trust used to use exclude patients with a palliative care code from the mortality indicator. To ensure this was not exploited for minimising an organisation’s mortality, Trusts are required to meet strict rules that govern the use of such codes to only those patients appropriately seen and managed by a specialist palliative care team

• The SHMI does not exclude this group of patients, rather they are included and the appropriate risk factor for each is statistically determined according to the model. As palliative care coding is a key mortality indicator, the SHMI on publication each quarter include the above breakdown of data for Trusts to see the proportion of palliative care codes being used versus the national average

• The above table illustrates the percentage of patients each quarter where palliative care codes have been used in either the patient’s specific diagnosis or at the specialty team level of those caring for the patient. It is noticeable during successive quarters of a gradual increase in the level of palliative care codes being used, this demonstrates some of the work undertaken within the Trust to ensure appropriate palliative care support is provided as and when needed and improving recording systems to ensure when the palliative care specialist team are involved this is accurately captured within the hospital coding.

Northern Lincolnshire and Goole NHS Foundation Trust considers that this data is as described for the following reasons:

• The Trust has been actively pursuing an improvement programme looking at all elements of data related and quality care related factors that make up the Trust’s overall SHMI. A number of improvements have been made in these areas, which is demonstrated as helping reduce the Trust’s mortality ratio since reporting of this information in the 2012/13 and 2013/14 Quality Accounts

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• The Trust Board, supported by the Mortality Performance Committee, recognises that the mortality position is a community wide issue and there needs to be a healthcare community wide focus on this to enable further improvements to the overall SHMI. The analysis of the SHMI indicator within the monthly mortality report includes a specific breakdown of the SHMI between the in-hospital and out of hospital component parts. This greater understanding has illustrated a significant gap between the in-hospital ie deaths within the Trust and the out of hospital ie those deaths that take place within 30 days of discharge home or into the community. This difference is illustrated in the following chart.

Figure 46 Trust provisional SHMI : Full, in hospital and out of hospital Moving Annual Totals (MAT)

Source: HED Information, CHKS

Key to abbreviations: NLAG Full SHMI – The Trust’s full combined SHMI (including both in-hospital and out of hospital deaths (within 30 days)

NLAG In-hospital SHMI – The in-hospital death rate

NLAG out of hospital SHMI – The out of hospital (within 30 days following discharge) death rate

National Average – the UK average SHMI score, always represented as 100

• There has been and are still slight differences between the Trust’s individual hospital sites, and there is a significant difference between the in-hospital element of the SHMI ie deaths taking place at the hospital, and the out of hospital part of the indicator, ie those deaths that take place within 30 days of discharge home or into the community. Both of these important elements are monitored monthly by the Trust’s mortality report and the Trust’s Mortality Performance and Assurance Committee (MPC) and ultimately by the Trust Board. The Board recognises that the mortality position is a community wide issue and there needs to be a healthcare community wide focus on this to enable further improvements to the overall SHMI. The Trust is focusing on working with colleagues from general practice and other community services to understand this further and take action to improve the out of hospital SHMI.

The Trust has taken the following actions to improve the indicator and percentage in a and b, and so the quality of its services by:

• The improvements seen during 2013/14 and 2014/15 are a result of a number of improvement projects assessing both data quality and clinical care. These improvement projects have been focused and guided by the monthly provision of the latest data in the comprehensive mortality report, presented and then scrutinised by the Mortality Performance and Assurance Committee (MPAC). This is then in turn provided to the Quality, Patient Experience Committee (QPEC) for their assurance of MPAC’s actions, before finally being presented to the Trust Board and then becoming publically accessible.

• Another source of valuable information regarding the clinical care and quality thereof was the use of the ‘mortality trigger tool’ review process which screened out all deaths

90

100

110

120

130

Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

2012 2013 2014

National averageNLaG Full SHMI

In hospital SHMI Out of hospital SHMI


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and ensured clinical review of cases with triggers, both from a nursing and medical standpoint. This provided recent quantitative and qualitative data on clinical practice. It provided ‘themes’ requiring further focus

• From these two sources of information (1) the monthly mortality report and (2) the ‘mortality trigger tool’ review process, the Trust developed a focused and targeted quality evaluation and improvement programme. As part of this, the following areas where prioritised for improvement projects:

Clinical areas – where the data illustrated highest levels of mortality:• Stroke services

• Respiratory medicine

• Gastroenterology

• Sepsis

• Haematology/oncology

• Diabetes and endocrine

• Acute kidney injury/renal failure

‘Themes’ identified as areas relating to poor quality:• Hospital acquired pneumonia

• Fluid management

• Cardiac arrests

• Venous thromboembolism (VTE)

• Safe staffing.

Each of these quality improvement project teams were asked to scope out the problem, using anecdotal observations of the teams working in these areas, the feedback from the ‘mortality trigger tool’ review process and the monthly mortality report.

Once they had identified the main issues, they began to develop ways of targeting these issues with a view to improvement. Each project was monitored by the centrally held

mortality action plan. As a result of these projects the following improvements were made:

• Centralisation of the hyperacute stroke service on the Scunthorpe site to ensure that the specialist and finite resource was fully able to deliver 24/7 hyperacute stroke care. As a result mortality performance in stroke, looking at the service as a whole, has seen significant improvements

• Development and roll-out of respiratory pathways to enable admitting teams to prescribe evidenced-based treatment, reducing delays to crucial medications and investigations

• In collaboration with the respiratory pathways, a sepsis pathway, a more generic series of protocols, was designed and implemented to ensure that patients on admission with sepsis receive potentially lifesaving antibiotics sooner and more consistently

• Work has begun to redesign access for emergency patients requiring urgent endoscopic assessment with the drafting of a joint rota between medics and surgeons

• An AKI guideline, protocol and improved guidance on the Web V system, based on abnormal blood work, have been developed and are currently being approved for use

• Increased joint working is the objective behind new guidelines to help feed those patients unable to eat to reduce patient deterioration but also to lessen the risk of patients developing hospital-acquired pneumonia

• Improved guidance, in line with recently published NICE guidance, and a bespoke fluid prescription sheet have been drafted and are currently being approved for use

• An improved tool to help get to the root cause behind in-hospital cardiac arrests has been developed and is currently being piloted. It is hoped this will provide effective ‘real time’ information demonstrating the aspects of care that could be improved in this area to reduce the number of cardiac arrests or to work to improve end of life care planning still further.

The work going forward into 2015/16

• While these improvement projects have made good progress, further improvement is still possible. As such, recent changes in the assurance mechanisms around mortality, leading to the renaming and repositioning of the Mortality Performance Committee (MPC) to the Mortality Performance and Assurance Committee (MPAC), has led to a stocktake in the plans around mortality improvement and a refreshed approach

• The fundamental use of the monthly mortality report has not changed. What has changed however within the report is the increased use and reliance of the crude mortality indicator, and less use and reporting from the statistical standardised mortality ratios (SMRs)

The reason for this in part was the usefulness front line clinicians found in using these indicators, and most importantly how much access they had using these to access the individual patient records in order to scrutinise the level of quality provided to them from their services

Using the previously relied upon data, access to patient level information to facilitate case

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note review was a protracted process leading to delays and resulted in their efforts to review and improve care being a project, rather than a day to day part of their management process arrangements

• The new refreshed mortality report will be included alongside the traditional report to begin with to ensure all users of the report both internal and external have access to the information they have been familiar with receiving, but, supporting this, with a view to this being the report of the future, the refreshed report will be more concise and focused primarily on crude mortality

An additional benefit of crude mortality is the timeliness of the data, being only a month behind the present day. To further simplify both the process in reporting this material, but also the data available to front line teams, the information each improvement team will receive is the refreshed mortality report with embedded links to enable them to access the patient specific information that makes up the area’s crude mortality performance for any given month

This strategic change moves the ownership of the data from corporate support team members to the frontline clinical teams who ‘own’ the service, thus enabling them to access information when it suits them and their work plans.

• This refreshed mortality report and the focus on crude mortality, shows six key clinical groupings have the greatest levels of mortality. This is not to imply these six areas have the highest levels of ‘excess’ death, rather, simply these areas are those that have the highest numbers, so

using the Pareto 80:20 principle, these are the areas where greatest levels of improvement, to the maximum benefit of local service users, can be gleaned.

• The six areas are unsurprisingly areas where mortality would likely be expected and are as follows:

• Cardiology

• Gastroenterology

• Stroke

• Cancer/end of life care

• Infection/sepsis

• Respiratory

• The fundamental approach to take now in these areas again is nothing new. Each have been asked to ensure they have a medical lead, nursing lead, therapy lead and any other multidisciplinary team involvement, relevant to their specific area

Using the refreshed mortality report and embedded links to the patient specific detail, each of these groups is asked to reflect on the previous actions taken (for those groups who have operated previously ie respiratory) ensure that any outstanding actions are factored into their new plans and using the also refreshed ‘mortality trigger tool’ review process, now renamed as the ‘quality of care outcomes tool’ to illustrate the process is all about quality not specifically mortality, review cases of mortality and determine which areas of quality could be improved

• Each of the six groups will be supported to undertake these projects and to further support them in unblocking any obstacles they face during the course of their improvement work, each will be invited on a regular

basis to attend the Mortality Performance and Assurance Committee (MPAC) to feed back on their progress.

External scrutiny and the Trust’s supportAs referred to in the 2013/14 Quality Account, the Trust had been selected as one of 14 NHS Trusts to be visited by a team led by Sir Bruce Keogh. While the review was sparked as a result of the Trust being an outlier in connection with mortality rates, the review was very much focused on overall care quality, not just mortality. The Trust welcomed this visit which took place in June 2013 and fully supported the review team.

Arising from the Keogh review, Monitor, the regulator of Foundation Trusts, found the Trust in breach of its licence (specifically the requirement to secure economy, efficiency and effectiveness) and in August 2013 the Trust was placed in ‘special measures’.

The Trust has also received a number of external reviews and visits since, including a revisit by some of the original Keogh team in November 2013 and a re-visit by the CQC in December 2013. The Trust also received a CQC visit by the Chief Inspector of Hospitals in April 2014.

Following the Keogh and CQC reviews, the Trust commissioned an external review of the Trust’s governance arrangements using KPMG, an external company providing professional services including audit.


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Following these visits and the additional support provided to the Trust, in July 2014 the Trust was the second of the 14 ‘Keogh sites’ to be removed from special measures. This was following the assurances gleaned from the site visits but also from the assurance provided by the Trust’s rigorous monitoring of the improvement areas identified via the various visits, using the centrally held Quality Development Plan (QDP).

The QDP is a comprehensive action plan that includes in one central place all the recommendations and actions now being taken following the Francis Report, and visits by the CQC and other external bodies visits ie the Deanery, facilities ‘safe and secure’ accreditation.

The QDP is further sub-divided into the various sub-committees of the Trust board best placed to oversee and seek assurance on delivery of the action plans sitting under them. These sub-committees take regular delivery of the QDP actions relevant to them. This is also reported on a regular basis to the Trust Board.

2.3b: Patient Reported Outcome Measures (PROMS)

The data made available to the Trust by the Health and Social Care Information Centre with regard to the Trust’s patient reported outcome measures scores for:

a) Groin hernia surgery

b) Varicose vein surgery

c) Hip replacement surgery

d) Knee replacement surgery.

during the reporting period.

Type of surgery Sample time frameTrust adjusted

average health gain

National average

health gain

National highest

National lowest

Groin hernia

April 2010 – March 2011 0.121 0.085 0.156 -0.020

April 2011 – March 2012 0.084 0.087 0.143 -0.002

April 2012 – March 2013 0.083 0.085 0.157 0.015

April 2013 – March 2014 0.051 0.085 0.139 0.008

Varicose vein

April 2010 – March 2011

Not available

0.091 0.155 -0.007

April 2011 – March 2012 0.094 0.167 0.047

April 2012 – March 2013 0.093 0.175 0.023

April 2013 – March 2014 0.093 0.150 0.023

Hip replacement

April 2010 – March 2011 0.438 0.405 0.503 0.264

April 2011 – March 2012 0.405 0.416 0.532 0.306

April 2012 – March 2013 0.461 0.438 0.538 0.369

April 2013 – March 2014 0.426 0.436 0.545 0.342

Knee replacement

April 2010 – March 2011 0.316 0.299 0.407 0.176

April 2011 – March 2012 0.317 0.302 0.385 0.180

April 2012 – March 2013 0.357 0.319 0.409 0.195

April 2013 – March 2014 0.332 0.323 0.416 0.215

Source: Health and Social Care Information Centre (HSCIC), primary data used

Comment:

• The above table shows the Trust’s reported adjusted health gain, which is a measure of the patient’s own reported outcome following surgery within the Trust.

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• The Patient Reported Outcome Measure (PROM)s is a national initiative designed to enable NHS trusts to focus on patient experience and outcome measures

The four areas listed above are nationally selected procedures of which the Trust has no power to influence. This is illustrated in varicose vein surgery, which the Trust does not provide hence why no data is available.

Northern Lincolnshire and Goole NHS Foundation Trust considers that the outcome scores are as described for the following reasons:

• The Trust monitors its participation rates and response rates in relation to the completion of pre-operative and post-operative PROMs questionnaires. Lower than average participation rates were noted for groin hernia but significantly high participation rates were noted for both Hip and Knee Replacement at 92.5 per cent and 92.4 per cent respectively

• Quarterly reports are received from the Health and Social Care Information Centre that provide progress updates on both the participation rates and the overall health gain reported by patients.

The figures noted above evidence the positive performance of the Trust in relation to overall health gain with health gain scores for groin hernia falling slightly below the national average. Health gains for all other clinical procedures are above the national average for 2013-2014.

The Trust has taken the following actions to improve these outcome scores, and so the quality of its services by:

• Discussing the results at the surgery and critical care clinical governance group and presenting to clinicians at the general surgery clinical audit meetings. The Trust has access to patient level data which is analysed in house and used to drive further improvements in patient reported outcomes

• Continuing to review participation rates for each clinical procedure with a particular focus on groin hernia, and making improvements in the internal monitoring of pre-operative questionnaire returns to ensure all eligible patients are given the opportunity to participate.


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2.3c Readmissions to hospital

The data made available to the Trust by the Health and Social Care Information Centre with regard to the percentage of patients aged:

a) 0 to 15; and

b) 16 or over,

Readmitted to a hospital which forms part of the Trust within 28 days of being discharged from a hospital which forms part of the Trust during the reporting period.

Age group Time frameTrust Emergency readmissions (%)

National re-admissions (%)

National highest (%)

National lowest (%)

0 to 15

2011/2012 8.56% 10.01% 14.94% 0.00%

2010/2011 8.19% 10.15% 25.80% 0.00%

2009/2010 7.93% 10.18% 31.40% 0.00%

2008/2009 7.59% 10.09% 22.73% 0.00%

16 or over

2011/2012 9.47% 11.45% 17.15% 0.00%

2010/2011 9.18% 11.42% 22.93% 0.00%

2009/2010 8.92% 11.16% 22.09% 0.00%

2008/2009 8.64% 10.90% 29.42% 0.00%


Comment:

• The above table outlines the percentage rate of emergency re-admissions to the Trust within two primary age groups (1) 0 – 15 years and (2) 16 years or over. The table also provides peer data with which the Trust can benchmark itself. The table illustrates that the rate of emergency re-admissions within the Trust has been consistently lower than that of the national average

• You will notice the above table does not hold the most recent years information. Following consultation with the Health and Social Care Information Centre (HSCIC), this data is unlikely to be available before the Quality Account deadline. The work has been taken back in-house from an external agency and the methodology is currently being reviewed. Any updates will be announced on the HSCIC indicator portal.


• The Trust has been consistently below the national rates for re-admissions.

The Trust intends to take the following actions to improve these percentages, and so the quality of its services by:

• The Trust continues to monitor its readmission rates on a monthly basis and compares these to the national rates in order to benchmark our performance

• For the 12 month period to September 2014, the Trust continued to perform well – overall, the Trust’s rate of admission within 30 days was 6.1 per cent compared to a national rate of 6.6 per cent. However, this rate is for the Trust as a whole but it is not consistent across our two main hospital sites with one site (DPoW) performing better than the other (SGH)

• Therefore, the Trust intends to do further analysis to understand the reasons for the differences between the sites and to share effective practice where this will improve the quality of our services.

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2.3d Personal needs of patients

The data made available to the Trust by the Health and Social Care Information Centre with regard to the Trust’s responsiveness to the personal needs of its patients during the reporting period.

Time frameAverage weighted

score of 5 questionsNational average National highest National lowest

2013/2014 64.4 68.7 84.2 54.4

2012/2013 68.5 68.1 84.4 57.4

2011/2012 69.0 67.4 85.0 56.5

2010/2011 67.8 67.3 82.6 56.7

2009/2010 67.6 66.7 81.9 58.3


Comment:

• The table above highlights the average weighted score for five specific questions. This information is presented in a way that allows comparison to the national average and the best and worst performers within the NHS

• The above figures are based on the adult inpatient survey, which is completed by a sample of patients aged 16 and over who have been discharged from an acute or specialist trust, with at least one overnight stay. The indicator is a composite, calculated as the average of five survey questions from the inpatient survey. Each question describes a different element of the overarching theme:

“responsiveness to patients’ personal needs”.

1. Were you involved as much as you wanted to be in decisions about your care and treatment?

2. Did you find someone on the hospital staff to talk to about your worries and fears?

3. Were you given enough privacy when discussing your condition or treatment?

4. Did a member of staff tell you about medication side effects to watch for when you went home?

5. Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital?

• Individual questions are scored according to a pre-defined scoring regime that awards scores between 0-100. Therefore, this indicator will also take values between 0-100

• For each provider an average weighted score (by age and sex) is calculated for each of the questions. Trust scores are calculated from a simple average of the question scores. National scores are calculated by a simple average of the trust scores.

The Trust considers that this data is as described for the following reasons:

• The Trust has continued to achieve results that are above the national average and has made positive progress each year. Performance against the first four questions noted above has been monitored on a monthly basis by the quality matrons who have surveyed 10 patients on each ward per month, the outcome being published on the monthly nursing dashboard. This has enabled wards and departments to review progress and identify areas for improvement.


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The Trust has taken the following actions to improve this data, and so the quality of its services by:

• The quality matrons will continue to review the Trust’s performance in relation to the personal needs of patients and will also develop systems to ensure that appropriate contact information is given to patients on discharge.

• The Patient Experience Group has been progressing a number of actions to aim to improve general communication and the provision of information to patients

• The assistant director of nursing/head of quality has been reviewing the provision of private spaces for use by staff to support confidential conversations being held with patients and visitors

2.3e Staff recommending Trust as a provider to friends and family

The data made available to the Trust by the Health and Social Care Information Centre with regard to the percentage of staff employed by, or under contract to, the Trust during the reporting period who would recommend the Trust as a provider of care to their family or friends.

Staff Survey YearTrust performance

(%)National average (acute Trusts) (%)

National highest (acute Trusts)

(%)

National lowest (acute Trusts) (%)

2014 55% 67% 93% 38%

2013 48% 67% 94% 40%

2012 55% 65% 94% 35%

2011 54% 62% 89% 33%

2010 54% 63% 89% 38%


Comment:

• The above table illustrates the percentage of staff answering that they “agreed” or “strongly agreed” with the question: “If a friend or relative needed treatment, I would be happy with the standard of care provided by this Trust”.


• Feedback from staff is that they would recommend the Trust as a healthcare provider through their perceptions that the Trust delivers highly quality, compassionate care and has excellent patient facilities

• Staff feel that they work in an environment that is predominantly free from physical or verbal aggression from patients, their relatives and/or carers and from other member of staff

• Concerns regarding the Friends and Family Test (FFT) relate to perceptions over staff numbers and the sense that they are not engaged and therefore are unable to influence service developments.

• The Trust has taken the following actions to improve this percentage, and so the quality of its services by:

• The organisational development and workforce culture transformation plan aims to directly increase staff engagement and stimulate a culture where staff feel they can come forward with service improvement ideas.

• To date work on a Trustwide perspective to increase staff voice has included two very successful internal ‘dragon den’ events with 10 service improvement ideas being taken forward, and many receiving national media attention.

• Further work is on going and remains to increase staff engagement at ward/departmental level through a drive towards a collaborative, inclusive leadership and management style.

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2.3f Risk assessed for venous thromboembolism

The data made available to the Trust by the Health and Social Care Information Centre with regard to the percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the reporting period.

Quarter / YearTrust performance

(%)

National average (Acute providers)

(%)

National highest (Acute providers)

(%)

National lowest (Acute providers)

(%)

Q3 2014/15 96.2% 95.9% 100% 81.2%

Q2 2014/15 95.7% 96.1% 100% 86.4%

Q1 2014/15 95.7% 96.1% 100% 87.2%

Q4 2013/14 95.8% 95.9% 100% 78.9%

Q3 2013/14 95.9% 95.8% 100% 77.7%

Q2 2013/14 95.1% 95.7% 100% 81.7%

Q1 2013/14 95.2% 95.4% 100% 78.8%

Q4 2012/13 91.8% 94.2% 100% 97.9%

Q3 2012/13 94.4% 94.1% 100% 84.6%

Q2 2012/13 93.2% 93.8% 100% 80.9%

Q1 2012/13 92.8% 93.4% 100% 80.8%

Q4 2011/12 90.8% 92.5% 100% 69.8%

Q3 2011/12 81.0% 90.7% 100% 32.4%

Q2 2011/12 82.5% 88.2% 100% 20.4%

Q1 2011/12 80.1% 84.1% 100% 15.7%

Q4 2010/11 51.2% 80.8% 100% 11.1%

Q3 2010/11 42.9% 68.4% 100% 0%

Q2 2010/11 38.5% 52.5% 100% 0%


Comment:

• The above table illustrates the percentage of patients admitted to the Trust and other NHS acute healthcare providers who were risk assessed for venous thromboembolism (VTE) since quarter two, 2010/11. As illustrated in the above table the Trust has consistently achieved above 90 per cent since quarter four, 2011/12 and is now performing on par with the national average for this indicator.


• The Trust is striving to oversee compliance with VTE risk assessments and prophylaxis prescribed. This is accomplished through monthly reporting within the quality report, ward level performance with the VTE indicators collected as part of the Safety Thermometer.

The Trust has taken the following actions to improve this percentage, and so the quality of its services by:

• The Trust reports VTE prophylaxis rates by ward and had action plans to improve those wards with lower rates. These are constantly monitored and re-visited as required.


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2.3g Clostridium difficile infection reported within the Trust

The data made available to the Trust by the Health and Social Care Information Centre with regard to the rate per 100,000 bed days of cases of C. difficile infection reported within the Trust amongst patients aged two or over during the reporting period.

Time frameTrust performance

per 100,000 bed days

National average per 100,000 bed

days

National highest per 100,000 bed

days

National lowest per 100,000 bed days

April 2013 – March 2014 9.7 14.7 37.1 0

April 2012 – March 2013 17.1 17.3 30.8 0

April 2011 – March 2012 19.8 22.2 58.2 0

April 2010 – March 2011 19.7 29.7 71.2 0

April 2009 – March 2010 19.2 35.3 92.0 0


Comment: • The above table illustrates the rate of Clostridium difficile per 100,000 bed days for specimens taken from patients

aged two years and over. The downward trend from the first available data in 2009 is discernible from this table and the Trust compares favourably to the national average for this indicator.

Northern Lincolnshire and Goole NHS Foundation Trust considers that this data is as described for the following reasons:• The Trust continues to make significant progress in reducing the number of Clostridium Difficile cases and remains

below the national average. A trend reported previously of cases deemed unavoidable continues to significantly outnumber those cases felt to be at least partially avoidable. Nevertheless, work continues to reduce these still further.

The Trust has taken the following actions to improve this rate, and so the quality of its services by:• The Trust has an evidence based Clostridium difficile policy and patient care pathway

• Multi-disciplinary team meetings are held for inpatient cases to identify any lessons to be learnt and root cause analysis is conducted for every hospital acquired case and a director of infection prevention and control (DIPC) review is held where there has been a breach in practice or the patient has died

• For each case admitted to hospital, practice is audited by the infection prevention and control team using the Department of Health Saving Lives’ audit tools

• Embedded Trustwide Clostridium difficile prevention action plan which is monitored monthly by the Trust Board and Infection Control Committee

• Monthly meetings of site specific Clostridium difficile action groups whose remit is to review each case and monitor site specific trends and themes. Local action plans are produced and monitored

• Production of a dash board to monitor compliance with the routine deep clean schedule reviewed by the site specific Clostridium difficile action group

• Embedded training programme that purely focuses on Clostridium difficile issues and care. To support this a monitoring and feedback mechanism to managers regarding the number of staff attending these sessions

• Use of an alert sticker for patient medical notes and to fit in with the Trust direction of travel in connection with the development of the electronic patient record, ensured that a Clostridium difficile alert icon has been built in to the system being used to host this development

• Use of a specific Clostridium difficile discharge letter that is sent to GP’s informing them of the patients result and informing them of the potential future risks for the patient

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• Existing antimicrobials steering group to monitor the antibiotic side of the Clostridium difficile agenda

• Development and implementation of a rolling programme of antibiotic prescribing audits reviewed by the steering group and the site specific Clostridium difficile action groups

• Appointed non-executive director (NED) lead for the Infection Control Committee

• An embedded infection prevention and control zero tolerance framework for improved quality and safety

• Embedded policies and communication aids for the admission, outlying and transferring of patients with infectious diseases

• To ensure the right level of challenge the Infection Control Committee is formally a sub-committee of the Board

2.3h Patient safety incidents

The data made available to the Trust by the Health and Social Care Information Centre with regard to:

a) The number and, where available, rate of patient safety incidents reported within the Trust during the reporting period,

Time frame

Trust number of patient

safety incidents reported

Trust rate of patient safety

incidents reported per 100 admissions

Large acute Trust national rate of patient safety

incidents reported per 100 admission

Large acute national highest rate per 100

admissions

Large acute national lowest

rate per 100 admissions

October 2014 – March 2015 5,358* Not Available Not Available Not Available Not Available

April 2014 – September 2014 5,163* Not Available Not Available Not Available Not Available

October 2013 – March 2014 4,574 8.76 7.25 12.46 1.72

April 2013 – September 2013 4,866 9.32 7.08 11.06 3.85

October 2012 – March 2013 4,720 9.20 7.22 12.73 3.04

April 2012 – September 2012 4,487 8.78 6.69 13.61 1.99

October 2011 – March 2012 4,217 8.41 6.22 9.75 1.93

April 2011 – September 2011 4,033 8.04 5.99 10.08 2.75

October 2010 – March 2011 3,733 7.25 5.62 9.91 1.79

April 2010 – September 2010 3,626 7.04 5.25 8.65 1.71

October 2009 – March 2010 3,069 5.92 5.49 9.19 2.10

Source: April 2010 – March 2013, Health and Social Care Information Centre (HSCIC), April 2013 – March 2014, DATIX

* For the purposes of this report, as national comparative data is unavailable on the NHS Information Centre’s Portal for the most recent period (April 2014 – March 2015) local data from DATIX has been used to indicate the number of patient safety incidents. As the national data is unavailable, only the actual number of incidents reported by the Trust is available.


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Comment: The above table demonstrates the total number and rate per 100 admissions of patient safety incidents reported within the period of October 2009 – March 2015.

• The Trust’s average rate of patient safety incidents reported is above the average of other large acute NHS organisations (illustrated in the table above). Within the Trust staff are encouraged to report all incidents. NHS England state “Organisations that report more incidents usually have a better and more effective safety culture. You can’t learn and improve if you don’t know what the problems are”, therefore this number should be seen as encouraging that concerns regarding patient safety are reported for appropriate escalation and investigation and for remedial action to be taken to ensure any concerns are learnt from thus reducing the chance of these incidents replicating themselves and leading to patient harm

• The Trust is continuing to actively encourage and promote incident reporting, and therefore expects the number of incidents reported to remain high and potentially increase in number in order to continue the work streams focussing on learning from incidents. The emphasis continues on reducing harm from patient safety incidents, the number and percentage in figure b) below demonstrates this. This approach is recommended by the National Patient Safety Agency (NPSA): “Organisations that report more incidents usually have a better and more effective safety culture. You can’t learn and improve if you don’t know what the problems are.”

b) and the number and percentage of such patient safety incidents that resulted in severe harm or death.

Time frame

Trust number of patient

safety incidents reported

involving severe harm or death

Trust rate of patient safety

incidents reported involving severe harm or death

(%)

Large acute Trust national average of patient safety

incidents reported involving severe harm

or death (%)

Large acute Trust national highest

rate involving severe harm or

death (%)

Large acute Trust national lowest

rate involving severe harm or death

(%)

October 2014 – March 2015 13* Not Available Not Available Not Available Not Available

April 2014 – September 2014 13* Not Available Not Available Not Available Not Available

October 2013 – March 2014 9 0.20% 0.61% 2.64% 0.03%

April 2013 – September 2013 13 0.27% 0.71% 2.97% 0.05%

October 2012 – March 2013 10 0.21% 0.79% 3.46% 0.00%

April 2012 – September 2012 8 0.17% 0.71% 2.50% 0.00%

October 2011 – March 2012 10 0.24% 0.75% 3.26% 0.00%

April 2011 – September 2011 8 0.20% 0.77% 2.88% 0.10%

October 2010 – March 2011 5 0.13% 0.92% 4.01% 0.05%

April 2010 – September 2010 6 0.17% 0.75% 2.95% 0.02%

October 2009 – March 2010 9 0.29% 0.64% 1.63% 0.05%

Source: April 2010 – March 2013, Health and Social Care Information Centre (HSCIC), April 2013 – March 2014, DATIX

* For the purposes of this report, as national comparative data is unavailable on the NHS Information Centre’s Portal for the most recent period (April 2013– March 2014) local data from DATIX has been used to indicate the number of patient safety incidents. As the national data is unavailable, only the actual number of incidents reported and the Trust’s rate is available.

Comment:

• The above table demonstrates the total number and rate per 100 admissions of patient safety incidents involving severe harm or death reported within the period of October 2009 – March 2014. The Trust has a lower than national average of patient safety incidents reported involving severe harm or death.

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• The Trust undertakes regular analysis of incident data, producing a wide range of monthly, quarterly and annual analysis reports which are shared throughout the organisation via a number of committees/groups/forums. These reports enable aggregate analysis of data, along with analysis of particular hot-spots and trends. The relevant group/committee review the reports, and consider recommendations, which look to improving patient safety and addressing known risks identified in these reports.

The Trust has taken the following actions to improve this number and/or rate, and so the quality of its services by:

• The Trust has formed a number of multi-disciplinary groups focussing on prevention initiatives to reduce the harm from patient safety incidents, and also to reduce the number of incidents. Examples of these work streams are the Safer Medication Group which has a formal work programme in place which is taking forward a number of initiatives and is reviewed on an annual basis to ensure these remain relevant and targeted against known risks

• The Trust falls prevention group has in place an action plan incorporating and integrating patient safety preventing harm from falls initiatives, environmental risk assessments and health and safety risk management initiatives, all targeted on reducing risk and preventing harm to patients.

• A key focus group is the Learning Lessons Review Group which had developed a formal action plan incorporating a number of patient safety initiatives, including actions to address patient mis-identification, with regular reporting to the Trust Governance and Assurance Committee.

• The Trust has also developed a programme of quality and safety half day sessions that run at least quarterly in each of the Directorate groups. The idea behind these sessions is to enable clinical staff providing the service to be able to have time to present cases of learning for discussion of lessons learnt and to disseminate good practice.

2.3i Ambulance handover timesIn order to understand the patient experience of patients arriving in the Trust’s A&E departments via ambulance, the Trust have access to information provided to it from the East Midlands Ambulance Service regarding the length of time it takes for the ambulance crew to handover the care of the transported patient to the receiving team in the Emergency department.

From undertaking local benchmarking, however, through the use of observational audits in the emergency department, concerns have been raised with regard to the accuracy of this information recorded and collected by the Ambulance service. To gain assurance regarding the process undertaken to compile this information, the Trust have selected this as its local indicator for external review by PWC, an external auditor, to assess how the ambulance service data compares to data collected from the Trust’s systems. The findings from this external audit will help guide future collaborative work with the ambulance service to improve the reliability and quality of this information.

To set the scene for this improvement project, the following chart illustrates the currently provided data from the ambulance service in connection with the percentage of cases where the ambulance handover exceeds 15 minutes.

NB: As stated above, this information should be interpreted with caution, as it is invalidated data from the ambulance service.


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Figure 47 Percentage (%) of patients having a delayed ambulance handover > 15 minutes

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Source: Ambulance Service Data, East Midlands Ambulance Service (EMAS)

Key to abbreviations: DPoW – Diana, Princess of Wales Hospital, Grimsby, SGH – Scunthorpe General Hospital Peer average – Other local Trusts in Lincolnshire and East Midlands (n=23)Comment: The above chart demonstrates the percentage of patients having a delayed ambulance handover of 15 minutes or more. The following chart illustrates the currently provided data from the ambulance service in connection with the percentage of cases where the ambulance handover exceeds 30 minutes. NB: As stated above, this information should be interpreted with caution, as it is invalidated data from the ambulance service.

Figure 48 Percentage (%) of patients having a delayed ambulance handover > 30 minutes

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Source: Ambulance Service Data, East Midlands Ambulance Service (EMAS)Key to abbreviations: DPoW – Diana, Princess of Wales Hospital, Grimsby, SGH – Scunthorpe General Hospital Peer average – Other local Trusts in Lincolnshire and East Midlands (n=23)Comment: The above chart demonstrates the percentage of patients having a delayed ambulance handover of 30 minutes or more.

Northern Lincolnshire and Goole NHS Foundation Trust considers that this data requires further validation and accuracy checking. To establish the accuracy of this information and if the Trust can use this to monitor and improve quality in the future, an external audit has been undertaken as part of the external assurance process on the annual quality account, to look into this data in greater detail. The findings of this review work will be available in the near future and as a result further work will be initiated in response.

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Part 3

Other information

An overview of the quality of care based on performance in 2013/14 against indicators

3.1 Overview of the quality of care offered 2014/15Parts 2.1a, 2.1b and 2.1c of this report outlined progress during 2014/15 towards achieving the priorities for this financial year just ended which the Trust set out in its previous Annual Quality Account for 2013/14. The quality priorities in part two were presented in three distinct sections: clinical effectiveness (2.1a), patient safety (2.1b) and patient experience (2.1c).

The Trust’s quality targets & priorities – driving continuous improvementIt is worth noting here, that these targets/quality priorities for the most part are not nationally or regionally set, rather they are set locally by the Trust.

They are selected as areas of key importance for the Trust to drive and embed continuous quality improvement.

These indicators are not chosen for their ease of completion, resulting in a report full of green ‘completed’ ticks. These indicators are instead quality focussed, aspirational and stretching.

As a result, the executive summary that follows, and the greater detail within part two of this report presents progress so far, not always demonstrating that our internal quality targets have been met.

Where these have not been met, an explanation and summary of the work underway are presented and for the most part, these targets have been selected to stay within the quality report to drive quality development during 2015/16.

For these indicators selected by the Trust, the full report, contained within parts 2.1a, 2.1b and 2.1c refer to benchmarked data, where available, to enable performance compared to other providers. References to the data sources used are also stated within these earlier parts of this report and where relevant this includes whether the data is governed by standard national definitions.

This information, presented in part two of this report also illustrates historical data for comparison and trending purposes. If the basis for calculating data has changed from that of historical data, this is explained in full detail within section two of this report.

During 2014/15 the following quality priorities were monitored by the monthly quality report which was presented and reviewed on a monthly basis by the Trust’s Quality and Patient Experience (QPEC) Committee and the Trust Board. The ‘at a glance’ overview of performance that follows is viewed continually throughout the year, and reviewed within the monthly quality report, as a result these are constantly changing based on the real time nature of these indicators.

A summary of the Trust’s performance against these key indicators (outlined within part 2 in full) are summarised below:


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Patient safety Feb - 2015 Previous Trends

PS1 MRSA bacteraemia incidence (YTD: 1) 1 1 R 0 0

PS2 C. Difficile incidence (YTD: 20) 1 3 G 2 No more than 35

PS3 Safety thermometer (community) -1% 96.% G 97% 95%

PS4 Open and honest initiative - Harm free care - Saftey thermometer (‘New’ and “Old’)

DPoW 0.5% 90.7% R 90.2%

95%SGH -6% 86.5% R 92.5%

GDH 4.2% 100% G 95.8%


PS5 Elimiation of avoidable repeat fallers

DPoW -1 0 G 1 Eliminate ALL avoidable

repeat fallsSGH 0 0 G 0

GDH 0 0 G 0

PS6 Reduction in number of avoidable pressure ulcers (Grades 2, 3 and 4)

DPoW -2 1 G 3 50% reduction (no more than 2 per month)

SGH 0 0 G 0

GDH 0 0 G 0

PS7 Nutrition care pathway was followed

DPoW -1% 95% R 96%

100%SGH 0% 98% R 98%

GDH 0% 100% G 100%

The food record chart completed accurately and fully, in line with care pathway

DPoW 1% 90% R 89%

100%SGH 7% 93% R 98%

GDH 0% 100% G 100%

PS8 The fuild management chart was completed accurately and fully, in line with care pathway

DPoW 0% 97% R 97%

100%SGH 4% 96% R 92%

GDH 0% 100% G 100%

Patient safety:


Indicator Time period/RAG ComparatorTarget

Clinical effectiveness Most recent data Previous Trends

CE1 Deliver mortality performance within expected range and improving quarter on quarter, until reported SHMI is 95 or lower

Official SHMI (July 13 - June 14) 109 R 108 95

HED data (Dec 13 - Nov 14) 112 R 111 95

Position vs peers Higher than expected range R Within

expected rangeWithin expected range

Indicator Change Feb - 2015 Previous Trends Target

CE2 NEWS - Approriate action taken DPoW 0% 100% G 100%

95%SGH 0% 100% G 100%

GDH 0% 100% G 100%


CE3 3.1) Screened for Dementia DPoW 1% 95% G 94%90%

SGH 2% 96% G 94%

3.2) Dementia - screened, appropriate assessment

DPoW 0% 100% G 100%90%

SGH 0% 100% G 100%

3.3) Dementia - appropriate referral to specialist services

DPoW 0% 100% G 100%90%

SGH 0% 100% G 100%

CE4 NICE - Compliance with all NICE guidance0.9% 82.8% R 81.9%

90% by March 2015NICE - Compliance with all NICE TAGs assessed

0.1% 95.8% G 95.7%

CE5 Transfer of patients for non-clinical reasons (capacity) to not exceed 20% of the total 7.6% 33.57% R 26% 20%

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Patient experience Feb - 2015 Previous Trends

PE1 Response rate to friends and family test within the top 50%

Inpatient Bottom 50% R Top 50%Top 50%

A&E Bottom 50% R Bottom 50%


PE2 Re-opened complaints to not exceed 20% of total closed complaints 11.5% 17.3% G 5.8% 20%


PE3 Complaints - action plan drafted 0% 100% G 100% 90%

Complaints - action plans implemented8% 100% G 92% 90%

Q3 2014/15 Q2 2014/15 Trends Target

PE4 Complaints - 50 % reduction in complaints relating to communication 28 72 R 44 50%

(max. 33 per qtr)


PE5 Patients should not have any unplanned omissions in providing patient medications

DPoW


GDH

Patients should not have a delay of more than 30 minutes in providing pain relief

DPoW


GDH

Oct - 2014 July - 2014 Trends Target

PE6 Staff satisfaction - increase in morale/staff satisfaction -1 5.3 R 6.3 2.5% increase

(min. 6.65)

Patient experience:


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Monitor compliance framework summaryPerformance against key thresholds for the period 1st April 2014 to 31st March 2015

TargetW

eight

ing

2014/15 Qtr 1

2014/15 Qtr 2

2014/15 Qtr 3 Threshold Jan 15 Feb 15 Mar 15

Qtr 4 Actual to date W

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1. Infection control*

Clostridium Difficile 1.0 G G G 33 2 3 0 20 G

2. Referral to treatment waiting times

Admitted - maximum waititng time of 18 weeks 1.0 G R R 90% 91.64% 90.50% 90.74% 90.95% G

Non-admitted - maximum waititng time of 18 weeks 1.0 G G G 95% 95.21% 95.28% 95.44% 95.31% G

Incomplete - maximum waititng time of 18 weeks 1.0 G G G 92%1.0 95.86% 95.98% 96.68% 96.18% G

3. Cancer***

31 day wait diagnosis to treatment 1.0 G G G 96% 99.29% 100% 98.54% 99.26% G

i 31 day wait subsequent treatments - Surgery 1.0 G G G 94% 100% 100% 100% 100% G

ii 31 day wait subsequent treatments - Anti cancer drugs G G G 98% 100% 100% 100% 100% G

i 62 wait consultant screening service intervals 1.0 G G G 85% 86.74% 95.33% 84.57% 88.84% G

ii 62 day wait referral to consultation G G G 90% 100% 80% 100% 94.74% G

i 2 week wait referral to consultation 1.0 G G G 93% 98.54% 98.11% 98.43% 98.36% G

ii 2 week wait brest symptom referrals G G G 93% 95.31% 97.62% 94.74% 95.80% G

4. A&E

A&E 4 hour wait compliance 1.0 G G R 95% 87.21% 90.75% 92.92% 90.40% R

5. Data completeness community services **

i Referral to treatment information 1.0 G G G 50% 80% 99% 99% 92% G

ii Referral information G G G 50% 80% 99% 99% 92% G

iii Treatment activity information G G G 50% 78% 77% 77% 77% G

Access**

12 Access to healthcare for people with learning disability 0.5 G G G Y/N Y Y Y Y G

* Cumulative figures Total monitor compliance 1.0

** Forecast position Monitor compliance rating G

*** Provisional data Monitor over ride rating R

3.2 Performance against relevant indicators and performance thresholds

Performance against the relevant indicators and performance thresholds set out in Appendix B of the Compliance Framework.

For full details and technical specifications from Monitor guiding NHS Trusts how compliance with the above is to be calculated, please see annex 5.

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3.3 Information on staff survey reportSummary of performance – NHS staff surveyThe Trust’s staff survey results for 2014, as in previous years; reassuringly shows that staff work in a safe working environment that is predominantly free from harassment, bullying or abuse from patients or their colleagues.

Perhaps most reassuring is that staff feel that their individual and collective roles make a true difference to patients and that they are satisfied with the quality of the care they and the Trust delivers. This is considered a major achievement since these indicators featured within the bottom five ranked scores in the previous year’s survey results.

Focusing on the concerns emerging from the survey the Trust aims to focus on three main areas, namely; the quality and content of appraisals, increasing the impact of listening to patient and staff voice in improving services and the reporting of incidents.

Detailed performance – NHS staff survey

Response rate is compared with that of the previous year: 2013/14 2014/15 Trust

improvement/ deterioration

Response rateTrust

National average


37% 49% 30% 45% -7%

Top four ranking scores: 2013/14 2014/15 Trust improvement/ deteriorationTop four ranking scores Trust

National average


Percentage of staff experiencing harassment, bullying or abuse from patients relatives or the public in last 12 months

23% 29% 27% 29% +4%

Percentage of staff experiencing physical violence from staff in last 12 months 2% 2% 1% 3% -1%

Percentage of staff agreeing that their role makes a difference to patients 86% 91% 93% 91% +7%

Percentage of staff feeling satisfied with the quality of work and patient care they are able to deliver 77% 78% 83% 77% +6%

Bottom 4 ranking scores: 2013/14 2014/15 Trust improvement/ deteriorationBottom four ranking scores Trust

National average


Percentage of staff able to contribute towards improvements at work 65% 67% 61% 68% -4%

Effective team working3.71

indicator3.73

indicator3.64

indicator3.74

indicator-0.7 indicator

Percentage of staff reporting errors, near misses or incidents witnessed in the

last month74% 84% 87% 90% +13%

Percentage of staff having well-structured appraisals in the last 12 months 30% 38% 30% 38% No change


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Action plans to address areas of concerns:Regarding the bottom ranked score the Trust has ongoing action plans and monitoring tools in place to address the issues relating to appraisals. Since the staff survey the current appraisal rate holds at c.93 per cent for the workforce. This work continues to be supported by dedicated training courses for staff and managers with the delivery of appraisals monitored centrally within the Trust. This work not only aims to ensure all staff receive an appraisal but that the structure and quality of the appraisal is meaningful.

Concerns relating to effective teams is already a feature of on going activities which strive to equip leaders with the skills to manage through an inclusive collaborative style.

To address the concern that 61 per cent of staff feel they can contribute toward service improvements the organisational development team is preparing for a major piece of engagement work to listen to staff and understand the barriers they feel to coming forward with

service improvement ideas. This piece of work form one of the three core oragnisational development objectives for 2015/16.

In addition to this patient and staff voice has become a key work stream and quality indicator through the newly created ‘Patient and Staff Experience Group’, a sub-group of QPEC, which seeks to implement initiatives that improve the patient experience and working lives of staff through listening to their collective experiences and service improvement ideas.

Work remains on-going through the Trust’s risk management department to encourage staff to come forward and report incidents, and for managers to feedback to staff on the outcome of the investigated incident.

Future priorities and targets:Appraisals, the quality of appraisal and then the time for staff to carry out both their objectives and training requirements remains an on-going priority for the Trust.

Significant investment in training was made during 2013/14; this work must now be seen to improve the perceptions of staff regarding the quality of their appraisal.

The other main priority is, as outlined above, to make significant inroads into addressing staff concerns regarding staff voice and engagement. The action plan that will be developed by the organisational development team into how to improve staff voice must be owned and delivered by the executive team and Trust Board. It is expected that this action plan with recommendations will be available at the start of quarter 2 2015/16.

Beyond the above two priorities the Trust remains committed to the rollout and deliverables with the Trusts culture transformation plan. These will directly impact on improving the effectiveness of team working whilst providing the platform to ensure staff remain happy with the quality of care they deliver to our patients.

3.4 Information on patient survey report

IntroductionTo improve the quality of services that the NHS 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 their local health services to tell us about their experiences Northern Lincolnshire and Goole NHS Foundation Trust took part in the national survey for 2013.

Response rate compared with previous year:

2013 2014

Response rateTrust National average Trust National average

44% 49% 51% 45%

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Actions to be taken as a resultThis year the survey showed improvement within a number of areas from the previous year and this remains our focus, that we are looking at our own results and targeting improvements. Whilst it is always good to compare ourselves to other Trusts it is our own development that remains our priority.

Some areas of excellent patient experience are 97 per cent found the ward, toilets and bathrooms clean, 77 per cent of patients always had confidence and trust in the doctors and felt they were treated with respect and dignity and 90 per cent of patients were always given privacy when being examined.

Areas we have improved in from previous year :-• Mixed sex accommodation

• Pain management

• Information giving pre and post operatively

• Offering feedback

• Providing information regarding complaints process.

These may not necessarily be better than other Trusts within the survey Trusts but internally we are moving forward and that is our ultimate intention.

This inpatient survey provides us with a wealth of feedback from a large group of our patients and our commitment to them is to use that information to shape our actions for this coming year.

These areas will be:• Ensuring we look at cancellation

rates

• Nurses and doctors talking over patients

• Staff on duty

• Staff providing consistent information

• Staff providing emotional support

• Discharge medication information.

Equally the inpatient survey provides one area of feedback for us and we triangulate this with other areas of patient feedback to ensure our direction remains clear.

Work has already begun on some of the issues above based on that triangulation process.

Patient stories, which capture personal patient and relative experiences are being used to highlight to staff the impact of their behaviours have on.

Gill’s Story is a key story which has been viewed at Trust Board and shared across many forums. It will continue to be used for training purposes as we recognise the value of this very emotive type of learning lessons.

A focus on communication will be a priority for the Experience Group this year, this will feed back to QPEC as the sub-group of the Trust Board. The goal is to design an action plan which is very active and frontline focussed. The group involves patients to encourage the patient voice to be present in the setting of our priorities with this.

Our recruitment team continue to rise to the challenge with regards to staffing, we know that nationally this is problem for many Trusts. Overseas recruitment and off-site recruitment fairs are just some of the initiatives being undertaken.

The twice yearly morale barometer and findings from the staff Friends and Family Test help us understand further how our staff feel, as we know this is linked to retention of staff. A report and plan has been developed from these findings.


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Annex 1: Statements from commissioners, local Healthwatch organisations and overview and scrutiny committees

Annex 1.1: Statements from Commissioners Feedback from:

• NHS North Lincolnshire Clinical Commissioning Group

• East Riding of Yorkshire Clinical Commissioning Group

• North East Lincolnshire Clinical Commissioning Group

• East Lincolnshire Clinical Commissioning Group

This statement has been prepared in collaboration with NELCCG, NLCCG, ERYCCG and Lincolnshire East CCG. Commissioners welcome this opportunity to provide feedback to the Trust on the work already undertaken in relation to quality throughout 2014/15, and areas of work identified for further development in 2015/16.

Positive Assurance The Quality Account clearly demonstrates the progress made and challenges encountered by Northern Lincolnshire & Goole Foundation Trust during 2014/15.

As Commissioners, we are pleased to note the Trusts on-going commitment to the reduction of hospital acquired pressure ulcers, compliance with the dementia screening indicator, compliance with the NEWS indicator, improved friends and family response rate (in-patient indicator and A&E indicator), improved compliance with the nutrition and hydration care pathways and innovative national and international recruitment campaigns.

Evidence of the Trusts commitment to improving performance against the quality indicators (some of which are defined above) has been demonstrated as part of the new NL&G Quality Contract Review (QCR) meeting. The NL&G QCR meeting was established in December 2014, the meeting oversees achievement of the national quality standards in line with the Trusts contract and supports Commissioners to achieve national and local quality standards with the provider, and identify priority measures that benefit patients and partner organisations’ business plans.

The QCR meeting has been instrumental in improving communication between the Trust and its Commissioners and raising the profile of a variety of initiatives undertaken by the Trust in relation to the quality agenda. For example; the improved nutrition care pathway and revised menu option, implementation of the Pressure Ulcer Group (PUG) and associated pressure ulcer mascot, the pressure ulcer identification wheel and the Pressure ulcers In Paediatrics (PIP) initiative. Commissioners would like to note that the work undertaken in relation to pressure ulcer management is exemplary. All of these initiatives provide Commissioners with positive assurance.

Areas Requiring Further Assurance Commissioners remain concerned with the Trusts performance against its mortality indicator, the number of reopened complaints and the number of complaints made in relation to communication (this links with patient experience) and the Trusts approach to the care of adults who are considered to be vulnerable. E.g. lack capacity to make decisions around their care and support needs, people with a learning disability and people with a mental health condition.

Commissioners would like to see further information in relation to the local population’s requirements, in order to establish whether this report meets the population’s needs. In terms of format, Commissioners feel that it may be difficult for patients and the public to work through the document and understand what it means in relation to the quality of care being provided by the organisation. There don’t appear to be any patient reported outcome measures as part of the account or details of how the Trusts staff have been engaged in development of this report; these would have been a

useful references for commissioners.

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ConclusionOverall, the Quality Account is well presented and the information included in the report provides a balanced view of the Trusts performance against it quality indicators for 14/15. The report provides commissioners with useful insights and assurances on how the Trust delivers its services in line with national and local quality indicators. However, Commissioners note that the Trusts priorities for 2015/16 are similar to those for 2014/15, suggesting that steady rate of progress has been made but there is room for further development.

Finally, we confirm that to the best of our knowledge, the report is a true and accurate reflection of the quality of care delivered by Northern Lincolnshire & Goole Foundation Trust and that the data and information contained in the report is accurate.

Commissioners remain committed to working with the Trust and its regulators to improve the quality of services available for the population of each CCG area in order to improve patient outcomes.

Annex 1.2: Statement from HealthWatch organisationsFeedback from:

• North East Lincolnshire HealthWatch

• North Lincolnshire HealthWatch

• East Riding of Yorkshire Healthwatch

Statement on North Lincolnshire and Goole NHS Foundation Trust Quality Account for 2014/15

Healthwatch North Lincolnshire and Healthwatch North East Lincolnshire welcome the opportunity to make a statement on the Quality Account for Northern Lincolnshire and Goole NHS Foundation Trust and have agreed to provide a joint statement. Healthwatch North Lincolnshire & North East Lincolnshire recognise that the Quality Account report is a useful tool in ensuring that NHS healthcare providers are accountable to patients and the public about the quality of service they provide. The following is the joint response from North and North East Lincolnshire Healthwatch.

Progress on Priorities for 2014-15We note that although mortality indicators had been partially met throughout 2014/15, more recently the provisional data shows some comparative deterioration in the position. Healthwatch is pleased that the target to deliver within the ‘expected range’ remains a quality priority for the Trust over the coming year.

We are pleased to see that the Trust has continued to demonstrate willingness to hear the experiences of patients and carers and identify opportunities for improvement.

ComplaintsIt was noted by Healthwatch that complaints about poor communication continue to be high and it appears to need a lot more work across all levels of staff. It is encouraging that the Trust aims for a 50% reduction in complaints about communication as poor communication remains a key theme in feedback Healthwatch get from patients and carers. Healthwatch North Lincolnshire are pleased to note that issues regarding


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communication that were raised during the recent Enter and View visits to Scunthorpe General Hospital are being addressed and improvements are being monitored by the Trust though their Quality Development Plan.

Friends & Family TestIt is noted that the FFT response rate continues to be comparatively low and it is pleasing to see that it remains a priority to raise this to within the top 50%. However, Healthwatch would like to see the data reported in more detail in the Quality Account including some analysis of the wealth of qualitative data generated from the open question on the FFT form.

Quality StandardsHealthwatch welcome the additional patient safety measures covering nutrition, feeding and fluid management. We are pleased to see that the administration of pain medication is being monitored.

There appears to be no quality standard around numbers or percentage of cancelled appointments or length of wait until first appointment. This is something people draw to our attention and although delays and cancellations may turn into complaints, not everyone chooses to complain. However, Healthwatch NL and NEL welcome the addition of a quality measure on the transfer of patients as this will capture any delays in discharge or transfer of patients.

We also note that information on pressure ulcers does not clearly indicate that the majority of patients are found to have pressure ulcers on admission.

Presentation of NLAG AccountsThe Quality Accounts document was again a very lengthy document and although it fulfils the requirements and guidance from the DoH and presents a wealth of statistical information, Healthwatch do not perceive it to appeal to the public. Bearing this in mind, the extraction of the summary into a separate document and compilation of an `easy read’ version is suggested.

ConclusionHealthwatch has a key role, backed up by statutory powers, to strengthen the voice of local patients and public in all aspects of commissioning and delivery of health care services. We therefore support the priorities for 2015-2016 in strengthening performance across all the three areas of clinical effectiveness, patient safety and patient experience.

We look forward to continuing to work more closely with Northern Lincolnshire and Goole NHS Foundation Trust in the future and seeing how their priorities are developed in 2015-16.

Comments from Healthwatch East Riding of YorkshireWe are concerned about the low response rate to the Friends and Family Test and urge the Trust to continue to increase the response rate Trust-wide.

We have formally raised concerns about the cost of parking at Goole District Hospital compared to parking in Goole; we would also urge the adoption of a pay on exit model.

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Annex 1.3: Statement from local council overview and scrutiny committees (OSC)Feedback from: North Lincolnshire Council – Health Scrutiny Panel

North East Lincolnshire Council – Health, Housing and Wellbeing Scrutiny Panel

Lincolnshire County Council – Health Scrutiny Committee

East Riding of Yorkshire Overview & Scrutiny Committee

North Lincolnshire Council – Health Scrutiny Panel’s Quality Accounts comments for Northern Lincolnshire and Goole Hospitals NHS Foundation TrustNorth Lincolnshire Council’s Health Scrutiny Panel welcomes the opportunity to comment as part of Northern Lincolnshire and Goole NHS Foundation Trust’s (NLG) Quality Account. NLG are a key partner and provider of local services, and members have built a valuable working relationship with Trust personnel over the previous fourteen years.

The panel conducted a site visit to Scunthorpe General Hospital in September 2014, where members had an opportunity to visit key wards and clinical areas, and to talk to staff, patients and their families. Feedback was widely positive regarding professionalism and helpfulness of staff, quality of care and cleanliness. Any issues that were raised by patients and carers were responded to swiftly and appropriately.

The panel notes with some concern a lack of progress on reducing the SHMI rate. At the time of writing, the HSCIC has yet to publish their latest data, although we anticipate that the Trust will remain just within the ‘as expected’ category. This performance has been largely static over the previous year. However, we note the Trust’s latest Mortality Report, which incorporates more recent Hospital Evaluation Data system provisional figures. This suggests that local performance would increase into the ‘higher than expected’ range. The panel is, of course, aware of the inexact methodology in this area, the local ‘in-hospital’ and ‘out-of-hospital’ performance, and also that reducing the SHMI rate requires a wide ownership of co-ordinated actions. However, as the key acute provider, and an important community provider, we share NLG’s view that this should remain the highest priority for 2015/16 and beyond. We signal our intent to hold all relevant partners to public account for improvements in this area. We also welcome NLG’s decision to retain this as a priority.

The panel is encouraged by a refreshing drive to reinvigorate the Healthy Lives, Healthy Futures programme. Clearly, we acknowledge NLG’s key role within this, working with commissioners and other partners. We note an improved willingness to address the very real need for reform and integrate Health and Social Care across the South Bank of the Humber, and potentially within a wider footprint. We share NLG’s view that this is vital to ensure future sustainability, whilst driving up quality standards. Clearly, we have significant concerns about the current and short-to-medium financial situation within the local NHS.

The panel very much welcomes each of the clinical effectiveness, patient safety, and patient experience priorities agreed by the Trust and set out within this document. In particular, we are glad to see priorities aimed at improving services for those with dementia, and also to assist in reducing the number of problems associated with discharge – possibly the most common complaint that the panel receives. In addition, we are aware of the link between transfers and the SHMI rate.

Over the previous year, we have expressed concerns raised by local people about several wards at SGH. Whilst we are aware that the Trust has internal processes in place to set improvement plans and monitor progress, we intend to continue to ask for evidence of local improvements.

On work-related issues, the Chief Executive and key officers pro-actively provide regular, constructive updates to the panel on ongoing and developing activities, answering members’ questions in a frank and open manner. Each contact between the Trust and the panel through the year has been positive and any queries have resulted in a swift and comprehensive response, and we thank the Trust for this.


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North East Lincolnshire Council – Health Scrutiny Panel’s Quality Accounts comments for Northern Lincolnshire and Goole Hospitals NHS Foundation TrustUnfortunately, no comment on the quality accounts has been received.

East Riding of Yorkshire Council – Health Scrutiny Panel’s Quality Accounts comments for Northern Lincolnshire and Goole Hospitals NHS Foundation TrustUnfortunately, no comment on the quality accounts has been received.

Lincolnshire Council – Health Scrutiny Panel’s Quality Accounts comments for Northern Lincolnshire and Goole Hospitals NHS Foundation TrustThe Health Scrutiny Committee for Lincolnshire recognises the importance of services provided by the Trust to the residents of Lincolnshire. Unfortunately, the Committee is unable to make a statement on the Quality Account for 2014-2015, but will continue to work with the Trust and looks forward to participating in the Quality Account process in future years.

Annex 1.4: Statement from the Trust governors’

The Quality Review Group appreciates the quality of data provided in the Quality Report which enables an accurate assessment of performance. The SHMI position having been reduced and remained in the “as expected” range for six consecutive quarters has started to deteriorate which has prompted the Trust to renew and refocus its mortality improvement work. The impact of these refocused projects will not be reflected in the SHMI position until the end of the year as the SHMI position is a measure of mortality 6 months previously. Governors will maintain their focus and robust challenge on this important issue.

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Annex 2: Statement of directors’ responsibilities in respect of the Quality ReportThe directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 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 NHS 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 2014/15;

• 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 2014 to March 2015 (the period);

• Draft Board minutes from the meeting on 28 April 2015;

• Papers relating to Quality reported to the board over the period April 2014 to March 2015;

• Feedback from commissioners; NELCCG, NLCCG, ERYCCG and Lincolnshire East CCG for 2014/15 dated 04/05/2015;

• Feedback from governors dated 20/05/2015;

• Feedback from Local Healthwatch organisations; Healthwatch North Lincolnshire and Healthwatch North East Lincolnshire dated 01/05/2015;

• Feedback from Overview and Scrutiny Committee; North Lincolnshire Council – Health Scrutiny Panel dated 05/05/2015;

• The trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009 for Q1 – Q3 and Trust’s Quality Report to the Board ,dated 28/04/15;

• The 2014 national patient survey;

• The 2014 national staff survey;

• The Head of Internal Audit’s annual opinion over the trust’s control environment dated 13/05/15;

• Care Quality Commission Intelligent Monitoring Report dated March 2014, July 2014 and December 2014;

• the Quality Report presents a balanced picture of the NHS foundation trust’s performance over the period covered;

• the performance information reported in the Quality Report is reliable and accurate;

• 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 that 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, 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.gov.uk/annualreportingmanual) as well as the standards to support data quality for the preparation of the Quality Report (available at www.monitor.gov.uk/annualreportingmanual).

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


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Annex 3: Independent auditor’s report to the Board of Governors on the Annual Quality Report


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Annex 4: Glossary Benchmark Peer Group: Calderdale and Huddersfield NHS Foundation Trust, Chesterfield & North Derbyshire Royal Hospital NHS Trust, Countess of Chester NHS Foundation Trust, County Durham and Darlington NHS Foundation Trust, Doncaster and Bassetlaw Hospitals NHS Trust, North Cumbria University Hospitals NHS Trust, North Tees & Hartlepool NHS Trust, Rotherham NHS Foundation Trust, Royal Bolton Hospital NHS Foundation Trust, The Pennine Acute Hospitals NHS Trust, University Hospitals of Morecambe Bay NHS Trust

Commissioning for Quality & Innovation Framework (CQUIN): The CQUIN payment framework enables commissioners to reward excellence, by linking a proportion of English healthcare providers’ income to the achievement of local quality improvement goals. Since the first year of the CQUIN framework (2009/10), many CQUIN schemes have been developed and agreed. This is a developmental process for everyone and you are encouraged to share your schemes (and any supporting information on the process you used) to meet the requirement for transparency and support improvement in schemes over time.

Common Cause Variation: an inherent part of the process, stable and “in control”. We can make predictions about the future behaviour of the process within limits. When a system is stable, displaying only common cause variation, only a change in the system will have an impact.

Complaints: The NHS Complaints Regulations (England) 2009 require that an offer to discuss the complaint with the complainant is made on receipt of all complaints; the discussion to include the response period (the period within which the investigation is likely to be completed and when the response is likely to be sent to the complainant). The requirement is to investigate the complaint in an appropriate manner, to resolve it speedily and efficiently and to keep the complainant informed as to progress. The response should be within 6 months or a longer period if agreed with the complainant before the expiry of that period.

The Complaints Regulations permit extensions to the agreed timescale where this becomes necessary and in agreement with the complainant. The Trust (as outlined within the Policy for the Management of Complaints) expects

that any delay to the agreed response time is communicated to the complainant, the reasons explained and an extension agreed.

In respect of monitoring, the Regulations require (amongst other points) that the Trust maintain a record of the response periods and any amendment of that period and whether the response was sent to the complainant within the period or any amendment of that period.

KEY DEFINITIONS TO INTERPRET COMPLAINTS DATA:

NEW: The number of new complaints received in a month regardless of whether or not they were resolved within that month.

CLOSED: The number of complaints that were resolved within a month regardless of whether they were received within the month or resolved within agreed timescale.

NET OPEN: The total number of complaints currently open; includes new complaints and those unresolved from previous month(s). This includes open ‘on hold’. This includes re-opened complaints.

RE-OPENED: Complaints that have been resolved which for any number of reasons require further review.

Control Limits: indicate the range of plausible variation within a process. They provide an additional tool for detecting special cause variation. A stable process will operate within the range set by the upper and lower control limits which are determined mathematically (3 standard deviations above and below the mean). These consist of an upper control limit, a lower control limit and a mean (average).

Crude Mortality Rate: The crude mortality rate is based on actual numbers. Unlike Standardised Mortality Ratios (SMRS) i.e. SHMI and HSMR which features adjustment based on population demographics and related mortality expectations. Crude mortality is calculated by using as the numerator the number of patients who have died divided by the denominator which in this case is the total population. Times this figure by 100, equals the crude mortality percentage (%).

Fall: A sudden, unintended, uncontrolled downward displacement of a patient’s body to the ground or other object. This includes situations where a patient falls while being assisted by another person, but excludes

falls resulting from a purposeful action or violent blow.

Unavoidable Fall: Impossible to avoid the fall(s) from happening. Describes an event that could have been anticipated and prepared for, but that occurs because of an error or other system failure

Avoidable Fall: The fall(s) could have been avoided. Recognises that some of these events are not always avoidable, given the complexity of healthcare; therefore, the presence of an event on the list is not an a priori judgment either of a systems failure or of a lack of due care

Patient Experience: This Trust has set the goal of being the hospital of choice for our local patients. Being the hospital of choice is a far different thing than being the hospital of convenience, proximity or default. We measure patient experience using methodologies employed by the NHS National Patient Experience Survey against two key indicators to help us determine that our hospitals are the ones our patients would choose if the practical factors were removed.

The Trust uses The Menu Card Survey which asks five questions relating to patient experience and is attached to inpatients’ menu cards. It measures the patients’ experience in real time. The questions asked are all derived from questions that feature in all National Patient Surveys.

The scores depicted in the graphs reflect an absolute figure generated by this methodology (in short – high score is good, 100% would be the maximum achievable score).

Pressure Ulcer: Definition of Avoidable and Unavoidable Pressure Ulcer

The Department of Health (DH) has been asked to clarify what an avoidable pressure ulcer is in regards the nurse sensitive outcome indicators. The DH researched the availability of definitions, finding that there are a limited number of definitions in existence to draw from.

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The Wound, Ostomy and Continence Nurses Society of the US have produced a position paper which points to a clear definition of “avoidable” pressure ulcer (WOCNS) March 2009. However, the DH are using a modified version of the Avoidable d Unavoidable pressure ulcers definitions from the Centre for Medicare and Medicaide (CMS) 2004, to keep with the UK policy Terminology.

The modified definitions are:

AVOIDABLE PRESSURE ULCER:

“Avoidable” means that the person receiving care developed a pressure ulcer and the provider of care did not do ONE of the following:

• Evaluate the person’s clinical condition and pressure ulcer risk factors

• Plan and implement interventions that are consistent with the persons needs and goals and recognised standards of practice within the Trust

• Monitor and evaluate the impact of the interventions

• Revised the interventions as appropriate

UNAVOIDABLE PRESSURE ULCER:

“Unavoidable” means that the person receiving care developed a pressure ulcer even though the provider of the care had done ALL of the following

• Evaluated the persons clinical condition and pressure ulcer risk factors

• Planned and implemented interventions that are consistent with the persons needs and goals and recognised standards of practice within the Trust

• Monitored and evaluated the impact of the interventions

• Revised the interventions as appropriate

• The individual person refused to adhere to prevention strategies in spite of education of the consequences of non-adherence and this was documented.

Pressure ulcer gradings from the European Pressure Ulcer Advisory Panel (EPUAP):

Category/Grade 1: Non-blanchable redness of intact skin

Intact skin with non-blanchable erythema of a localized area usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness or pain may also

be present. Darkly pigmented skin may not have visible blanching.

Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons.

Category/Grade 2: Partial thickness skin loss or blister

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister.

Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. This category/stage should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation.

Category/Grade 3: Full thickness skin loss (fat visible)

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough may be present. May include undermining and tunnelling.

Further description: The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

Category/Grade 4: Full thickness tissue loss (muscle/bone visible)

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining and tunnelling.

Further description: The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable.

Rate per 1000 bed days: So we can know if we are improving even if the number of patients we are caring for goes up or down, we also

calculate an average called ‘rate per 1,000 occupied bed days’. This allows us to compare our improvement over time, but cannot be used to compare us with other hospitals, as their staff may report in different ways, and their patients may be more or less vulnerable than our patients.

Readmission Rate (RA): This measure shows the percentage of patients who were readmitted to hospital as an emergency within one month of being discharged. It can serve as an indicator of the quality of care provided and post-discharge follow up. A low readmission rate is an indicator of the quality of care in that it reflects a healthy care balance. Where rates are low, patients are not having to come back to the Trust for care of the same complaint. Conversely, a high readmission rate potentially signals that an organisation is releasing patients home too soon or otherwise not addressing all elements of their clinical condition.

Safety Thermometer methodology:

Harm:

• Catastrophic harm: Any patient safety incident that directly resulted in the death of one or more persons receiving NHS funded care.

• Severe harm: Any patient safety incident that appears to have resulted in permanent harm to one or more persons receiving NHS-funded care.

• Moderate harm: Any patient safety incident that resulted in a moderate increase in treatment and which caused significant but not permanent harm, to one or more persons receiving NHS-funded care. Locally defined as extending stay or care requirements by more than 15 days; Short-term harm requiring further treatment or procedure extending stay or care requirements by 8 - 15 days

• Low harm: Any patient safety incident that required extra observation or minor treatment and caused minimal harm, to one or more persons receiving NHS-funded care. Locally defined as requiring observation or minor


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treatment, with an extended stay or care requirement ranging from 1 – 7 days

• None/ ’Near Miss’ (Harm): No obvious harm/injury, Minimal impact/no service disruption.

Harm Free Care:

• Safety Thermometer enables the calculation of the proportion of patients who received harm free care. This is calculated by dividing the number of patients receiving harm free care (as the numerator) by the total number of patients surveyed (the denominator).

• Patients with more than one of the harms listed, will not be classified as harm free care and are thus not counted in the numerator. Patients recorded as having multiple harms are removed from the numerator in the same way as those with only one harm.

Proportion of patients with ‘harm free’ care:

• Those patients without any documented evidence of a pressure ulcer (any origin, category 2-4), harm from a fall in care in the last 72 hours, a urinary infection (in patients with a urinary catheter) or a new VTE (treatment started after admission).

Proportion of patients with ‘harm free’ care – new harms only:

• Those patients without any documented evidence of a new pressure ulcer (developed at least 72 hours after admission to this care setting, category 2-4), harm from a fall in care in the last 72 hours, a new urinary infection in patients with a urinary catheter which has developed since admission to this care setting, or a new VTE (treatment started after admission).

Sigma: A sigma value is a description of how far a sample or point of data is away from its mean, expressed in standard deviations usually with the Greek letter σ or lower case s. A data point with a higher sigma value will have a higher standard deviation, meaning it is further away from the mean.

Summary Hospital Mortality Indicator (SHMI): The SHMI is the NHS ‘official’ Standardised Mortality Ratio (SMR). It is a method of comparing mortality levels in different years, or between different hospitals. As a result, the SHMI is used as a performance tool to rank NHS organisations within a league table. The ratio is calculated by using as a numerator the number of deaths divided by the denominator, in this case, the number of ‘expected’ deaths, multiplied conventionally by 100. Thus, if mortality levels are higher in the population being studied than would be expected, the SHMI will be greater than 100. This methodology allows comparison between outcomes achieved in different trusts, and facilitates benchmarking. The outcomes of the SHMI are reported in three bandings: (1) higher than expected, (2) as expected and (3) lower than expected. The SHMI includes not only in-hospital deaths, but also includes deaths within the community, occurring within 30 days of hospital discharge. As a result, it is dependant not only on in-hospital coded information, but also on Public Health data, this results in a delay in reporting. As a consequence, the quarterly data published by the Health and Social Care Information Centre reports on historic information ranging from 18 months to 6 months. To illustrate this point, the SHMI information release in April 2015 reports performance from October 2013 – September 2014.

Special Cause Variation: the pattern of variation is due to irregular or unnatural causes. Unexpected or unplanned events (such as extreme weather) can result in special cause variation. Systems which display special cause variation are said to be unstable and unpredictable. When systems display special cause variation, the process needs sorting out to stabilise it. This is most commonly reported using two types of special cause variation, trends and outliers. If a trend, the process has changed in someway and we need to understand and adopt if the change is beneficial or act if the change is a deterioration. The outlier is a one-off condition which should not result in a process change. These must be understood and dealt with on their own (i.e. response to a major incident).

Identifying Special Cause Variation – agreed rules:

• Any point outside of the control limits,

• A run of 7 points all above or below the central line, or all increasing / decreasing,

• Any unusual patterns or trends within the control limits,

• The proportion of points within the middle 1/3 of the region between the control limits differs from 2/3.

Standard Deviation: Standard deviation is a widely used measurement of variability or diversity used in statistics and probability theory. It shows how much variation or “dispersion” there is from the “average” (mean, or expected/budgeted value). A low standard deviation indicates that the data points tend to be very close to the mean, whereas high standard deviation indicates that the data are spread out over a large

range of values.

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Annex 5: Mandatory Performance Indicator DefinitionsThe following indicators:

• Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways,

• Cancer 31 day, 62 day waits.

Have been subject to external audit in line with the following criteria:

Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways:

• Detailed descriptor: The percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the period;

• Numerator: The number of patients on an incomplete pathway at the end of the reporting period who have been waiting no more than 18 weeks;

• Denominator: The total number of patients on an incomplete pathway at the end of the reporting period.

Accountability: Performance is to be sustained at or above the published operational standard. Details of current operational standards are available at: www.england.nhs.uk/wp-content/uploads/2013/125yr-strat-plann-guid-wa.pdf (see annex B: NHS Constitution Measures).

• Indicator format: Reported as a percentage.

Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers:

• Detailed descriptor: Percentage of patients receiving first definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer;

• Data definition: All cancer two-month urgent referral to treatment wait;

• Numerator: Number of patients receiving first definitive treatment for cancer within 62 days following an urgent GP (GDP or GMP) referral for suspected cancer within a given period for all cancers (ICD-10 C00 to C97 and D05);

• Denominator: Total number of patients receiving first definitive treatment for cancer following an urgent GP (GDP or GMP) referral for suspected cancer within a given period for all cancers (ICD-10 C00 to C97 and D05);

Accountability: Performance is to be sustained at or above the published operational standard. Details of current operational standards are available at: www.england.nhs.uk/wp-content/uploads/2013/125yr-strat-plann-guid-wa.pdf (see Annex B: NHS Constitution Measures).

2014/2015 · 35 diagnostics, therapeutics and central operations group 42 path links nhs pathology...

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